Inspection on 12/09/06 for Ashfield Nursing and Residential Home

This inspection was carried out on 12th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Ashfield Nursing and Residential... 13/12/05

Ashfield Nursing and Residential... 12/07/05

Ashfield Nursing and Residential... 11/01/05

Ashfield Nursing and Residential... 31/08/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Ashfield Nursing and Residential Home 3 Ashfield Wetherby Yorkshire LS22 7TF Lead Inspector Sean Cassidy Key Unannounced Inspection 12th September 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000047591.V299310.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000047591.V299310.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashfield Nursing and Residential Home Address 3 Ashfield Wetherby Yorkshire LS22 7TF Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01937 584724 01937 583015 info@ashfieldnursing.co.uk Ashfield Nursing Home Limited Mrs Karen Dean Care Home 32 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (32), of places Terminally ill over 65 years of age (4) DS0000047591.V299310.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The place for DE(E) is for the named service user only. Date of last inspection 13th December 2005 Brief Description of the Service: Ashfield Nursing and Residential home was originally registered in 1984 and then re registered as a nursing home in 1991. It provides nursing and personal care and can accommodate thirty-two older people. This home is located in Wetherby; a market town situated approximately twenty miles from Leeds. It is convenient for public transport and a variety of destinations are accessible from the town centre. The building is a detached adapted property that has been extended to provide the current accommodation. There are a number of parking spaces to the front of the house and patio/seating areas are available. The remainder of the garden has borders and paved walkways. Communal areas are two lounges, a dining room and conservatory area. In addition, there are four double bedrooms and twenty-four single. Thirteen bedrooms have en suite facilities. There are a number of communal bathrooms and toilets situated around the home. Specialist equipment is fitted where necessary to assist those service users with mobility problems and other difficulties associated with advancing years. The laundry is sited in an annexe alongside an office/training area. DS0000047591.V299310.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk This was an unannounced inspection; it took place over one day. The inspection was carried out between 9.30am and 17.30pm on 12/09/06. The last inspection of this home took place in December 2005 and a number of concerns were identified, some of which were outstanding from previous inspections. During the inspection all the key standards were assessed. These are identified in the main body of the report. The inspector looked in detail at the care of three residents living in the home. I looked at their care records; spoke to the residents about their care needs and to the staff about how they deliver care. I looked at the environment in which these residents receive care and observed care practices. I also spoke to other residents in the home, carried out a brief tour of the building and looked at other records including maintenance records, staff files and training records. A pre-inspection survey was completed by the home before the visit; the information provided was used during the inspection. Detailed feedback was given to the registered manager at the end of the visit. What the service does well: DS0000047591.V299310.R01.S.doc Version 5.2 Page 6 The service provides residents with an environment that is seen as “relaxed” and “homely”. Residents and relatives commended the staff in the way they spoke and cared for them. They were described as a “good team of carers”. Regular meetings and newsletters provide information to interested parties about the day-to-day operation of the home. The home offers attractive gardens that are accessible when the weather is appropriate. What has improved since the last inspection? What they could do better: The Statement of Purpose and Service User Guide must be reviewed to include all the required information to ensure the residents and prospective residents are correctly informed. The Intermediate care facilities and staff training in this area must improve. Improvements are needed to ensure residents are appropriately assessed and all the care needs are correctly identified and an appropriate care package is provided. Particular attention must be paid to pressure area care, nutrition and continence care. Residents and their representatives must be involved with this process. Laundry services must improve to ensure the risks of losing items when they are sent for cleaning is minimised. Improvements are needed with the record keeping when drugs are being administered. A more appropriate record system is needed to record the controlled drugs stored in the home. Improved assessment and care planning of residents’ social interests and hobbies is needed. Evidence to show how residents have spent their day needs to be improved. The home must ensure that particular effort is made to involve DS0000047591.V299310.R01.S.doc Version 5.2 Page 7 residents with dementia in activities that are suitable for these needs. Training should be provided to an identified activities coordinator. Residents must be provided with an appropriate snack before bedtime as the gap between tea and breakfast is greater than twelve hours. The system for recording complaints needs to be improved to ensure the procedure is correctly adhered to. The complaints procedure needs to be clearly displayed in the home. Adult abuse training provided to staff must improve. Not all staff are trained in this area. Although the feedback with regards to staff attitudes was positive there were concerns raised with regards to the numbers of staff on duty and how busy they are. Therefore, the registered manager must review the staffing system adopted by the home and implement any necessary changes. Improvements are needed with the recruitment procedure adopted by the home. Not all the required information is obtained prior to an employee taking up position. Improvements are needed with the provision of training to staff working at the home. Large gaps were identified in mandatory training, such as, fire and manual handling. Training records showed staff receive little training in the areas that residents have needs. The health and safety systems adopted by the home are in need of review. Some health and safety monitoring is carried out but some areas are not monitored. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000047591.V299310.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000047591.V299310.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6 Quality in this outcome area is adequate. This judgement has been made following a site visit and by checking records. Although residents and prospective residents have access to the Statement of Purpose (SOP) and are provided with a Service User Guide (SUG) more information is needed to ensure they are fully informed about making choices about the home. Residents are appropriately assessed to ensure their care needs can be met. The facilities and staff training in relation to Intermediate Care do not ensure this care need will be met by the home. EVIDENCE: The Statement of Purpose and the Service User Guide were reviewed prior to the inspection. Both documents are reviewed yearly by the management team and contain substantial information to assist the residents to make an informed choice. Both the SUG and SOP need to include more information for the DS0000047591.V299310.R01.S.doc Version 5.2 Page 10 resident and their representatives in relation to the complaints policy. The SOP needs more information contained within it to ensure the prospective resident is informed about the care needs of the resident group that are provided for within the home. The home is registered to take one resident with dementia, however, the manager confirmed that a substantial proportion of the resident group have dementia needs. This should be reflected in the SOP and also how the care home is equipped to meet the care needs of people with dementia.. Information regarding privacy and dignity and emergency admissions should also be included. The SUG’s were seen in residents’ rooms during the inspection. Three resident care files were case tracked and each included an assessment of their care needs, which was used to plan their care whilst living in the home. One resident recently transferred to long stay after Intermediate care was found to be inappropriate. This resident’s care file showed that the care need assessment had been reviewed prior to moving in long term. The home is contracted to provide three intermediate care beds. The manager confirmed that there are no intermediate care facilities available within the home. Staff have not received any training in any area of rehabilitation. This has been identified as a need and the intermediate care team have been contacted regarding the matter. Residents using the intermediate care service are now provided with the SUG on admission. DS0000047591.V299310.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made following a site visit and by checking records. The home is not ensuring the health, personal and social care needs of the residents in the home are being appropriately met. Improvements are needed to ensure the home provides a safe system for the administration of medications. Residents and their families feel the care home respects the main elements of their privacy and dignity. EVIDENCE: All residents had a file that contained information to ensure they are provided with a care package. Evidence was seen to show daily records were made, they were reviewed monthly and records of when the resident had been seen by a health professional were appropriately recorded. The care files for three residents were case tracked and the evidence showed that residents’ health, personal and social care needs were not being met DS0000047591.V299310.R01.S.doc Version 5.2 Page 12 within their individual care plans. The care plans were updated but they were not altered to reflect the changing need of the resident. This was very apparent in the care plans of a resident who had been assessed as terminally ill. This is poor practice. The care files case tracked showed no evidence that the resident or the family had been involved with drawing up the care plans, risk assessments or that they had given consent to the care. This was confirmed when relatives were spoken to. The daily records were filled in but did not give enough information as to what care that resident had received over the course of the day. The care plans and risk assessments contained a poor standard of detail needed to ensure the residents’ needs were being met. Incontinence care plans were vague and did not highlight the type of pads or the correct size that should be used. One resident assessed as having diabetes had no care plan developed in relation to this problem so that staff were aware of his needs. Risk assessments were carried out in areas such as pressure area care, nutrition, falls and moving and handling. One resident identified as being at high risk of malnutrition had not been referred to an appropriate health professional, as laid out in the care files. Residents who required regular turning had turn charts kept in their rooms. Gaps as long as twelve hours were identified in these records. Dementia care needs of residents were not being appropriately planned for. The record keeping of the registered nurses devising these care files were poor as there were many omissions of dates and signatures of when they were written or reviewed. This is poor practice and places the resident at risk of harm. These issues were all highlighted with the manager who confirmed that she has been aware of the problems with documentation and gave assurances that they would be dealt with as a matter of priority. The home has a medication policy in place that includes a risk assessment for those residents wishing to self medicate. A homely remedies policy was also in place. The manager confirmed that there were no residents self-medicating in the home at the time of the inspection. The medication charts for those residents that were case tracked had unexplained gaps identified and it was therefore difficult to identify whether the residents had received their prescribed medication. The Controlled drugs were kept locked and the records kept for these medications were correct and in order. It was recommended that a more appropriate book be obtained that met the Royal Pharmaceutical Guidelines. DS0000047591.V299310.R01.S.doc Version 5.2 Page 13 Residents and relatives contacted during the course of the inspection were happy that they were treated with dignity and respect. Staff were said to be very kind and helpful. The interaction of the staff with the residents and their families were observed to be courteous. Residents and relatives described the staff as “a good team of carers”. Two resident’s relatives spoken to raised concerns about the laundry system adopted by the home as they felt it was unsatisfactory. They said that items of clothing have gone missing and that they have seen their relatives’ clothes being worn by another resident. Slippers have also gone missing. They said that when they spoke to staff regarding these issues they did not feel the answer was satisfactory. These concerns were passed on to the manager who confirmed that they would be investigated. DS0000047591.V299310.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made following a site visit and by checking records. Overall, the home attempts to ensure the lifestyles and activities of the residents match their need. Family and community contacts are promoted. EVIDENCE: The home has a notice board in the entrance area that informs residents and relatives about the entertainment provided during the week and at later dates. Residents and relatives said that entertainment is provided on a regular basis. Two relatives confirmed that they felt the Ashfield had a very “homely” feel to it. Although the programme of events was displayed, the care files and the daily records did not provide evidence to show what the residents had been involved with over a period of time. Those residents case tracked did not have an appropriate record of their social interests and likes or dislikes recorded. No care plan was seen to show how the care staff assisted each individual to meet this particular need. The manager stated that this has been identified and that she is currently working with a member of staff to assist in this area. The home offers an open policy with regards to visiting and residents’ relatives and friends are actively encouraged to maintain their relationships whenever possible. This was confirmed through observation and by speaking to relatives DS0000047591.V299310.R01.S.doc Version 5.2 Page 15 and residents. Residents’ rooms showed evidence that they are enabled and encouraged to take their own personal belongings into the home wherever possible. This was also confirmed by talking to relatives. Relatives also confirmed that meetings are held and they are invited to attend. The lunchtime meal was observed during the inspection and this was observed to be a social event. The dining area was in the process of being redecorated and should be completed quite soon. Those residents needing assistance were seen to receive it from a member of care staff. The feedback from residents and relatives with regards to the quality of the meals was overall positive. The cook keeps a record of any resident that has a specialist dietary need and appropriate meals are provided. The cook and staff confirmed that supper was not consistently offered to residents in the evening time. The gap between tea and breakfast is greater than twelve hours and could place elderly residents at risk from malnourishment. Residents are not appropriately informed with regards to the daily menu. The weekly menu was available on the notice board but it did not correlate with the food that was provided. This was the case for most days. DS0000047591.V299310.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made following a site visit and by checking records. Improvements are needed in both areas of complaints and adult protection to ensure the residents, and others, are appropriately safeguarded. EVIDENCE: Not all residents and relatives are clear about the complaints procedure that should be followed if they need to complain. This was identified from speaking to relatives and residents and also the feedback questionnaires sent to the Commission. The complaints procedure was not displayed in the home on the day of the inspection. The complaints records were seen. The evidence showed that the complaints made to the home are not appropriately recorded and do not contain all the required information. The manager confirmed that the complaint book was missing for fifteen months and the book was not replaced during this time, therefore no complaints could be recorded. This is poor practice. Advice was given as to how the recording of complaints should be made within the home. The complaint procedure displayed in the home and also contained within the SOP and SUG must be altered to ensure they include all the required timescales. The home does have a policy in place to assist with the protection of vulnerable adults. However, staff spoken to were unfamiliar with the content of this policy and procedure. The staff training records show significant gaps in adult protection training. The person providing training in this area has not received recognised adult protection training. The home should review the DS0000047591.V299310.R01.S.doc Version 5.2 Page 17 training provided to ensure residents and others are appropriately protected. Staff spoken to regarding adult protection were able to highlight the appropriate action needed to be taken in the event of an incident being identified. DS0000047591.V299310.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made following a site visit and by checking records. Service users and their relatives felt assured that the home was suitable for their needs and had a homely feel to it. The facilities within the home help to ensure it is clean pleasant and hygienic. EVIDENCE: A brief tour of the home’s environment provided evidence to show that the stated purpose of the home was suitable to meet the needs of the registration. There were suitable gardens surrounding the home that are accessed by relatives and their relatives at regular intervals. Residents and relatives made comments regarding the “homely” atmosphere that is provided. The manager pointed out areas where redecoration had taken place and where it was ongoing. A local fire authority inspection has taken place. The manager said that this has not yet been fully complied with and there are one or two issues they still have with the recommendations. DS0000047591.V299310.R01.S.doc Version 5.2 Page 19 Residents and relatives expressed satisfaction with the cleanliness of the home. There is a laundry room which has a sluicing facility to clean garments that require higher temperature if needed. The home does have policies and procedures that assist the staff in matters relating to infection control. DS0000047591.V299310.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made following a site visit and by checking records. The home needs to review staffing levels and staff training to ensure they are meeting the assessed needs of the residents living there. EVIDENCE: The manager was able to provide a clear rota system that covered both day shifts and night shifts. The home uses an internal bank system to fill any outstanding shifts and agency staff are used when necessary. Staff on duty during the inspection appeared attentive to resident needs and were seen to communicate well with the resident group. Relatives confirmed that the staff were always very pleasant and helpful. Feedback obtained from residents, relatives and staff highlighted that there are staffing issues that need to be looked into from a management perspective. A number of comments highlighted how busy the staff always were. “ They always seem to be rushing around.” “We don’t have much time to sit and have a good chat with the residents as we always have other things to do.” One resident said, “When the staff are putting people to bed in the evening there is no-one around for the residents left downstairs.” Good progress has been made in the area of NVQ training, and over 50 of the carers have now been trained to NVQ level 2 standard or above. DS0000047591.V299310.R01.S.doc Version 5.2 Page 21 The recruitment files of the two most recent recruits to the home were inspected. Both carers were recruited from overseas and the manager had attempted to obtain all the necessary information. However, not all the required information could be obtained. This omission could lead to a possible risk to residents. Carers spoken to confirmed that they received a thorough induction that assisted them with their roles when they started work. Four staff had recently attended palliative care training and four staff are to attend this course at a later date. The training records of four staff were case tracked and the evidence found showed that there were large gaps in the provision of training. Three members of staff had no evidence that they had received any training. Another record showed that the staff member had not received training since 1991. It was agreed with the manager that this standard of training within the home was unacceptable and needed urgent review. No evidence was provided to show the staff were receiving training in areas of resident care need. Discussions were held with the manager about ways that this situation could be improved. This lack of staff training could be detrimental to resident care provision. DS0000047591.V299310.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is adequate. This judgement has been made following a site visit and by checking records. The management the systems and processes adopted by the home to ensure the home is managed more appropriately are not effective. Although quality monitoring does take place, there are a number of areas where the National Minimum Standards are not being met and therefore those quality tools should be reviewed. Residents’ monies are appropriately managed. The health and safety of the residents, relatives and staff are appropriately protected by the systems adopted by the home. DS0000047591.V299310.R01.S.doc Version 5.2 Page 23 EVIDENCE: The manager has achieved the Registered Manager’s Award. She is a qualified nurse who regularly updates her training and working practices. During discussions with service users and relatives it was apparent that she is known to them and is approachable. Staff also confirmed that support in accessing any specialised equipment is available. Staff meetings are held on a regular basis and minutes are made available. Discussions were held with the manager regarding the areas highlighted from the inspection that need improvement. Assurances were given that work would commence on these areas as a matter of priority. The manager would benefit from attempting to access some suitable supervision for herself to assist her in her role. The home has an external body (Investors in People) that comes every 18 months and assesses them in a varied number of areas and provides a written report. It was recommended that this report be made available to all interested parties and be well displayed within the home. The home makes available the most recent inspection report and it is displayed in the entrance hall. A recent resident survey has also been carried out and sent out to relatives. Regular relative meetings are held to ensure they have a say in the running of the home whenever possible. This was confirmed in the feedback from residents and relatives. Only small amounts of resident pocket monies are kept in a safe in an office in the home. All monies were correct for each individual checked. This money is only accessible to residents five days per week. This is not good practice. Health and safety needs to be made more of a priority within the home as the training records available showed large gaps in manual handling and fire training. Evidence was not available to show equipment such as hoists, bed rails and wheelchairs are being appropriately checked to ensure they are in good working order. Hot water temperature checks were not available. Each area of the home is risk assessed and those areas checked were up to date. Regular fire drills take place and the fire alarm system is checked regularly. A trip hazard was identified in the lounge beside the dining room that could have caused an accident to a resident, relative or member of staff. Although the home reacted quickly to rectify this problem when it was highlighted they must be more aware of these hazards and deal with them as soon as possible. DS0000047591.V299310.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X X 1 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 DS0000047591.V299310.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard OP1 OP6 Regulation 4, 5, Sched 1 18, 23 Requirement The registered person must ensure the SOP and SUG contain all the required information. The registered person must ensure that all staff involved with intermediate care have received suitable training and are appropriately supervised. Suitable Intermediate care facilities must be provided to ensure those residents requiring rehabilitation are assisted wherever possible. The service users’ plan must set out in detail the action which needs to be taken by care staff to ensure all aspects of their health, personal and social care needs are being met. The registered person must ensure that the resident or their representative is consulted when planning care and risk assessments. The registered person must ensure those residents identified as being at risk of developing a pressure sore receive the correct care. DS0000047591.V299310.R01.S.doc Timescale for action 30/11/06 30/11/06 3. OP7 15 30/11/06 4. OP8 12,13 30/11/06 Version 5.2 Page 26 5. OP9 13,17 6. OP10 12 7. OP12 14,15,16 The registered person must ensure those residents identified as being at risk of malnutrition receive the appropriate care. The registered person must ensure that the appropriate continence aids are identified and provided for those residents that require them. The community continence nurse should be contacted for assistance where needed. The registered person must 31/10/06 ensure the administration and recording of drugs in the care home is in line with the Royal Pharmaceutical Guidelines. The registered person must 30/11/06 ensure that the laundry facilities used by the home adopt suitable systems that will limit the loss of clothing and prevent residents from wearing other peoples clothes. The registered person must 30/11/06 provide evidence to show structured activities are provided and that access to the outside community is accessible to all residents. Particular consideration must be provided to those residents in the home that have dementia. The registered person must ensure residents social needs are appropriately assessed and recorded in care plans. The registered person must ensure that all residents are provided with a suitable snack at suppertime. The registered person must ensure the complaints procedure is correctly displayed within the home and that it contains all the necessary information required. DS0000047591.V299310.R01.S.doc 8. OP15 16 31/10/06 9. OP16 22 30/10/06 Version 5.2 Page 27 10. OP18 13 11. OP27 18 12. OP29 19 & Schedule 4 18 13. OP30 14. OP38 12 The registered person must ensure all staff receive training in adult abuse by a person trained to do so. The registered manager must review the staffing levels to ensure the correct numbers of staff are on duty at all times. The registered person must ensure all the required information is obtained before a carer can commence work at the home. The registered person must ensure staff receive appropriate training to ensure they are able to meet the care needs of the residents living in the home. The registered person must comply with the requirements made by the local fire authority as a result of its last inspection. The registered person must ensure safe health and safety systems and process are adopted to protect residents, relatives and staff. Records must be appropriately kept as evidence that appropriate checks take place. 31/12/06 31/12/06 30/10/06 31/12/06 31/12/06 DS0000047591.V299310.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard OP9 OP15 OP19 OP29 Good Practice Recommendations The home should ensure that an appropriate Controlled Drug recording book is in place. The home should ensure residents are provided with menus that inform them as to what food is on offer each day. The home should have an annual refurbishment plan in place and appropriate records of this are kept. The registered person should develop a training needs analysis for each individual member of staff. A training matrix for the home should also be developed and kept up to date. The home should ensure the monies held on behalf of residents are accessible at all times and not restricted. 5. OP35 DS0000047591.V299310.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000047591.V299310.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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