Inspection on 31/08/05 for Ashlands

This inspection was carried out on 31st August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Ashlands 17/11/08

Ashlands 08/01/07

Ashlands 02/12/05

Ashlands 03/10/05

Ashlands 01/03/05

Ashlands 09/08/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Ashlands 152 Southwell Road East Rainworth Mansfield, Nottinghamshire NG12 0EH Lead Inspector Jayne Hilton Unannounced 31 August 2005 at 10:30 am st 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 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. Ashlands C03 C53 S60714 Ashlands V245912 310805 Stage 2.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Ashlands Address 152 Southwell Road East Rainworth Mansfield Nottinghamshire NG21 0EH 01623 792711 01623 792711 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs M Wragg Emma Lidster Care Home (CRH) 21 Category(ies) of Old Age (OP) - 21 (Twenty One) registration, with number of places Ashlands C03 C53 S60714 Ashlands V245912 310805 Stage 2.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 10/03/05 Brief Description of the Service: Ashlands is a two storey detached building converted and adapted to provide care for older people. There is sufficient space for dining and lounge for the number of people the home is registered for. The home is sufficiently adapted to meet the needs of service users with a physical disability. Adaptations/equipment include bath hoists, mobile hoists, handrails, grab rails and a passenger lift. The home has large pleasant gardens, which are secure and well maintained. The home is Registered for 21 beds, with bathrooms being located on both floors and some rooms having en-suite facilities. Ashlands C03 C53 S60714 Ashlands V245912 310805 Stage 2.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was undertaken by Regulation Inspector Jayne Hilton on 31st August 2005 at 10.30am. The Registered Manager was on leave and the Inspector wishes to thank the deputy manager and other staff who assisted the inspection process in the absence of the manager. The methodology used included a tour of the building, the examination of two care plans and associated records. Medication procedures, the examination of staff files, the Statement of Purpose, Health and Safety records, policies and procedures etc and the staff rota were examined. Four staff were spoken with and two service users. The main focus of the inspection was to check whether the previous inspection requirements and recommendations had been met and to cover those standards not covered at the previous inspection where possible. What the service does well: What has improved since the last inspection? A copy of the inspection report is displayed in the home. There was now evidence of a written activities programme in the home. The menu does now offer an alternative option for lunch and teatime and a record is now kept of what choices service users have made. There was evidence that service users could access their personal records in accordance with the Data Protection Act 1998. The religious and cultural needs of service users are now included in the documentation held in the files. Ashlands C03 C53 S60714 Ashlands V245912 310805 Stage 2.doc Version 1.40 Page 6 What they could do better: 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. Ashlands C03 C53 S60714 Ashlands V245912 310805 Stage 2.doc Version 1.40 Page 7 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 Standards Statutory Requirements Identified During the Inspection Ashlands C03 C53 S60714 Ashlands V245912 310805 Stage 2.doc Version 1.40 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,3, 4, Prospective service users have much of the information they need to make an informed choice about where they live but minor amendments are required to the statement of purpose and service user guide. The registration certificate is not fully displayed. Service users have their needs assessed, but care is needed to ensure these are updated as required. The needs of the service users appear to be met. EVIDENCE: The homes Registration certificate was not displayed fully as only half of the details were visible. It is a legal requirement to display the registration certificate which details the service user categories of registration that the home can provide a service for. Both parts of the Registration certificate must be displayed clearly. A statement of purpose and service users guide is provided. There needs to be a section in the service users guide informing the reader of how they can access a copy of the last inspection report. The inspection reports were displayed on the notice board. Ashlands C03 C53 S60714 Ashlands V245912 310805 Stage 2.doc Version 1.40 Page 9 Two care plan files were examined. The care package documentation includes a pre assessment document, which is completed prior to admission. The owner or the manager goes out to undertake the pre assessment or sometimes they go together. A further assessment and care plans are implemented on the day of admission, which covers all issues as Required by St 3.3. Service users have locks on their doors, but there was no evidence of a key being offered or issued in the care assessment. A section for issuing of keys to bedroom doors and lockable facilities should be included. The assessment documentation provides a personal history and medical profile, social and recreational needs profile, which included the likes and dislikes of service users. There was no evidence of signature of service users or their representatives evident within the care package documentation examined that service users involved in their assessment and plan of care. A section has been devised for service users and their representatives to complete regarding this, however none have yet been completed. One service users assessment was, found, not to have been, updated with changed needs. Service users reported that they were happy with the care offered and say they are well looked after. Ashlands C03 C53 S60714 Ashlands V245912 310805 Stage 2.doc Version 1.40 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8, 9, 10, 11 Service users health, personal and social care needs are set out in a comprehensive care package with some minor areas to address particularly in updates of the changing needs of service users and regarding challenging behaviour of service users. Medication administration was generally satisfactory, however the system for controlled drugs is still not robust. Service users feel they are treated with respect and their right to privacy is upheld. Information for dealing with dying and death still requires updating. EVIDENCE: As reported in Standard 3 of this report the pre-assessment, care plans and reviews provide a total package, which meets the requirement of the standard. The inspectors overall assessment was that the care that was being provided was satisfactory. The manager writes detailed paragraphs of service users progress on a monthly basis. Service users and relatives reported that they were aware of care plans; there was evidence of service user involvement within the care plan but no signature of agreement. Service users and relatives spoken with were happy with the care provided. Risk assessments were evident for mobility and the prevention of falls and stated if the service user had a history of falls recorded in the care plan. Daily records were observed to be neat and holistically written. One service user was noted to Ashlands C03 C53 S60714 Ashlands V245912 310805 Stage 2.doc Version 1.40 Page 11 have some challenging behaviour, however there was no risk assessment or care plan for dealing with this. Staff, need to have clear direction in how to be consistent with managing the behaviour. The healthcare needs of service users appear to be well met with good detailed records of health checks, weight and nutritional screening. Medication systems were assessed. The medication record sheets [MAR] were completed satisfactorily. Staff reported that they have undertaken medicines management distant learning training however there was no evidence of competency assessments being carried out. There was a tablet counter evident, however a check was made on the controlled drugs held in the home and the balance of tablets did not correspond with the balance recorded in the Controlled Drugs record book. On further investigation it was found that an entry for the previous days administration had been omitted. This also demonstrated that the procedures for controlled drugs had not been followed regarding balancing/counting or the error would not have occurred. The deputy manager reported that they are changing to the Boots blister pack system next month. The trolley was secured to the wall. Service users and staff confirmed that all aspects of privacy and dignity are promoted and practiced within the home. Observations made on the day supported this. There is a payphone provided in the hallway, but staff reported that service users are able to use the telephone in the office for private calls. Policies and procedures are in place for dealing with dying and death. The manager obtains information from service users/relatives where possible on their wishes for the end of life. The religious and cultural needs of service users are included in the documentation held in the files. The policy for palliative care should include that the home is not registered to care for terminally ill service users and where medical/nursing input is required, that service users may wish to remain in the home, however a commitment from the GP will be needed that he will provide support from the primary Care services to support the staff in the home in caring for the dying individual. There should be an addition that care plans will be reviewed and that care charts will be implemented. These recommendations were made at the previous inspection but have not been met. Ashlands C03 C53 S60714 Ashlands V245912 310805 Stage 2.doc Version 1.40 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 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 are helped to exercise choice and control over their lives and enjoy a nutritional and balanced diet. EVIDENCE: The documentation in the care package format does assess service users preferences and choices about their daily routines. Service users confirmed they could get up and go to bed when they choose. There was evidence of a written activities programme in the home. A staff on duty board is provided in the hallway to inform service users of who is on duty each shift, which is good practice, photos would be a useful addition for those service users who are unable to read Service users and care plans provided evidence that service users preferences and choice was respected, and the menu does now offer an alternative option for lunch and teatime. A record is now kept of what choices service users have made. Bedrooms that were examined were observed to be well personalised. There was evidence that service users could access their personal records in accordance with the Data Protection Act 1998. Ashlands C03 C53 S60714 Ashlands V245912 310805 Stage 2.doc Version 1.40 Page 13 The menus were devised over a 4 weekly cycle. The menu appeared to be nutritious and varied. Service users reported that the food was nice and was presented well. No liquidised diets are required currently. It was reported that drinks are available on request as well a regular drinks trolley round 6 times a day. The inspector was not able to observe the actual lunchtime due to time being spent on other aspects of the inspection. A chalk, board informs service users what is provided each day, although this was not completed on the day of the inspection. The provision of menu cards on the tables would be a bonus. Service users praised the quality of the meals. Ashlands C03 C53 S60714 Ashlands V245912 310805 Stage 2.doc Version 1.40 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 17, 18 Service users know how to make a complaint, however there are issues with the complaints policy and record folder to be addressed. Service users right to participate in the civic process must be upheld. Policies are in place for protecting service users from abuse, however staff have not yet been provided with training in this area. EVIDENCE: A complaints procedure was displayed in the entrance and copies included in the service user guide, however these need updating with CSCI. Staff, were not able to locate any complaint records on the day of the inspection. All records must be made available for inspection. Service users spoken with confirmed that they felt able to make a complaint if they had reason to do so. There was no evidence regarding whether service users were able to use their right to participate in the civic process. Staff recalled postal voting information being seen in the office, but they were not aware of these being completed by service users. On speaking with service users they could not recall using their vote. It is recommended that documentation be kept within the care package regarding this, which the service user could sign. Relevant policies and procedures were noted to be in place. A copy of the Nottinghamshire Committee for Vulnerable Adults Procedures [NCVAP] guidance manual was observed in the office. Staff have not undertaken training in abuse awareness and this should be provided. The deputy manager reported that this is planned and the home does have a video for staff. The deputy manager was advised that it would be good practice for the manager Ashlands C03 C53 S60714 Ashlands V245912 310805 Stage 2.doc Version 1.40 Page 15 and herself to attend one of the adult protection training courses initially. A sample of service users personal monies and their financial records were not examined at this inspection. Policies for restraint and dealing with violence and aggression were seen in the policy file. Ashlands C03 C53 S60714 Ashlands V245912 310805 Stage 2.doc Version 1.40 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19-26 Overall the environment appears well maintained, safe, clean and comfortable, with service users needs being met by the facilities provided. Bedrooms appear personalised, adequately furnished and pleasantly decorated. There are some areas to address regarding the regulation and monitoring of water outlet temperatures and infection control. EVIDENCE: The home appeared well furnished and comfortable on the day of inspection and the building appeared to be maintained to a satisfactory level. A new handyman has been employed and the inspector was able to ascertain if that there was a programme of routine maintenance or for renewal of the fabric and decoration. There is some damp and crumbling plaster noted in the staff toilet, steps have been taken to remedy this but the work is not yet finalised. Communal areas comprise of a small lounge, large lounge and dining room, which appear to be adequate in meeting space requirements. The lounge areas have large windows almost ceiling to floor, which enable good views of the extensive and well - maintained gardens, from all seating areas. Dining tables were sufficient and were pleasantly adorned with pretty tablecloths. Ashlands C03 C53 S60714 Ashlands V245912 310805 Stage 2.doc Version 1.40 Page 17 There are assisted bathing facilities on each floor, 3 contain toilets and there are 3 other separate toilets as well as some en-suites in rooms. All bathrooms and toilets appeared clean and smelled fresh on the day of the inspection. Bathrooms were nicely personalised and homely touches were evident. As stated at the previous inspection, towels and toiletries should not be stored openly in bathrooms. Where cupboards are provided for toiletries these should be kept locked. The home is sufficiently adapted to meet the needs of service users with a physical disability. Adaptations/equipment include bath hoists, mobile hoists, and handrails; grab rails and a passenger lift. Call alarms were in place and reported to be working ok. Bedrooms examined on the day of inspection were decorated to a satisfactory standard personalised, clean and smelled fresh. Bedrooms had lockable doors but there was no evidence that service users were provided with keys. Lockable facilities are provided but there was no evidence that service users had keys for these. Water in the bedroom outlets were tested for temperature and found to be 43 degrees or below. Lighting is domestic in character. There was evidence that water storage temperatures were monitored for prevention of legionella. Records showed that water outlets in the home were monitored at 50 degrees centigrade throughout. Service users room numbers are indicated however and individual temperatures of each room must be specified and where tested as above 43 degrees centigrade the action taken to remedy the situation, documented also. This was recommended at the previous inspection. There was evidence that some radiators had been covered but there was evidence of risk assessments for surface temperatures. All the central heating radiator risk assessments should be regularly reviewed as part of health and safety monitoring. The laundry systems appear to be satisfactory, however there was no policy in place for infection control. Staff reported that aprons and gloves are always provided. Ashlands C03 C53 S60714 Ashlands V245912 310805 Stage 2.doc Version 1.40 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29, 30 Service users needs appear to be met by the number of staff provided, although the provision of catering staff in the afternoon would be beneficial. The training provision needs to be improved to meet current standards. Recruitment practices are poor and the legislation has been seriously breached in this area. Service users are being put at risk because of the poor standards of recruitment practices. EVIDENCE: The home appears to be adequately covered during the day and night to care for the number of service users the home is registered for. There are 3 care staff on morning and afternoon alongside the manager who works 40 hours supernumery. The manager was on leave on the day of the inspection. 2 waking staff support service users through the night. A handyman works 8 hours a week and there are 42 domestic and 42 catering hours provided. Review afternoon staffing to allow for catering hours to be provided. An immediate requirement was set at the previous inspection regarding poor recruitment practices and which, was found to be met at a follow up visit. At this inspection a sample of staff personal files for eight newly employed staff since the previous inspection was examined and found to be in serious breach of the current legislation. Staff had been employed before obtaining Ashlands C03 C53 S60714 Ashlands V245912 310805 Stage 2.doc Version 1.40 Page 19 satisfactory CRB’s and two satisfactory references and there are some additions required, such as photos, copy of birth certificate/passport, proof of address etc. There was also evidence that CRB’S had been accepted which were obtained for previous employers of staff and which are not acceptable as CRB’s are not transferable. In light of the fact that there was once again evidence that two written references and POVA First checks and CRB’s had not been obtained prior to employment of staff, the inspector spoke with the registered provider by telephone. The Inspector agreed for the staff concerned to remain on duty as not to leave the home deficit of staff cover, however the inspector requires that she be kept informed about every stage of the process of collation of documentation and the home will be closely monitored. The registered provider was also informed of the issue of an immediate requirement notice and that enforcement action will be taken should the regulation be breached again. The Inspector also advised the Registered Provider that the fitness of the registered provider and the registered manager is also questioned in relation to poor recruitment practices, and their registration is at risk should this notice not be complied with. There was evidence of a satisfactory CRB disclosure for the hairdresser. The documentation required by schedule 2 of the regulations must be complete in the staff personal files within seven days of the inspection. By 8/9/05. There was still no evidence of Skills for work Standards being used for induction. Induction and foundation standards need to be addressed and training programmes developed for staff to include regular updates of mandatory training and in meeting the needs of individual service users, such as diabetes, mental health issues and complex needs of older people. Staff reported that the manager, the owner and the deputy manager had attended training in dementia care and that all staff had undertook training in first aid. A training programme for all staff should be devised for 2004/2005 and 2005/2006, which should be available for inspection and which details the training that staff have attended and where training needs to be arranged. Evidence of staff attendance at training must be kept. Staff should undertake training in dealing with challenging behaviour. Ashlands C03 C53 S60714 Ashlands V245912 310805 Stage 2.doc Version 1.40 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34, 36, 37, 38 Evidence regarding the management systems for the running of the home are not satisfactory and therefore not seen to be in the best interests of service users. Staff, are not being appropriately supervised and there are some health and safety issues to address. The homes record keeping and policies and procedures are assessed as unsatisfactory. EVIDENCE: The quality monitoring systems in the home is still currently being developed. Service users surveys have been carried out, however there was no evidence in the home of audits and Regulation 26 provider visits are all required. The registered provider reported that these have been completed but not kept at the home. Copies must be expeded to the CSCI to avoid enforcement action, as this was an outstanding requirement from the previous two inspections. Ashlands C03 C53 S60714 Ashlands V245912 310805 Stage 2.doc Version 1.40 Page 21 As neither, the manger or provider were not available at the inspection standard 34 could not be assessed. The Inspector requires evidence of the financial management systems to demonstrate financial viability of the home. Staff reported that the formal supervision programme had not been maintained. A sample of records was examined as part of the inspection, including medication charts, accident records, staff personal files, fire safety records, care plans and associated records. Some were not satisfactory and have been covered in detail within the report. The requirements of Regulation 37 have been met. Service users individual personal files were stored securely. Policies and procedures for health and safety were in place apart from for infection control. Generic risk assessments were also seen. The COSHH file [Control of substances hazardous to health. The accident records were examined but the manager should obtain the new tear out record book, which complies with the Data Protection Act 1998. Fire alarm test records were not in order, and the handyman explained that the testing was complicated as the home is linked up to the fire station. The inspector requires the home to ensure that they are up to date with the fire authority regulations and to seek advice from the fire officer in how to manage the fire tests. There were no fire safety risk assessments seen in the home. The manager has sought advice from the fire officer regarding a fire door in the lounge but there was no evidence of the response regarding this. Gas and electrical safety certificates were seen in the home. Ashlands C03 C53 S60714 Ashlands V245912 310805 Stage 2.doc Version 1.40 Page 22 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 1 x 2 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 2 3 3 3 2 2 STAFFING Standard No Score 27 3 28 x 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 1 2 x x 1 1 x 1 1 2 Ashlands C03 C53 S60714 Ashlands V245912 310805 Stage 2.doc Version 1.40 Page 23 Yes Are there any outstanding requirements from the last inspection? 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 OP1 Regulation CSA 2000 4,5 Requirement The Registration Certificate must be displayed appropriately as specified in the report. There must be information in the statement of purpose/service user guide of how the inspection report can be accessed by service users or relatives. This is an outstanding requirement. Ensure the changing needs of srevice users are addressed in the review of assessments Ensure care plans and risk assessments are in place where service users present challenging behaviour Ensure that controlled drugs are counted at every administration and appropriate counting practices are implemented. This is an outstanding requirement Update the complaints procedure as specified in the report. Ensure the implementation of safe procedures for infection control. Ensure staff do not commence employment without the receipt of a satisfactory CRB disclosure and POVA Check and two Timescale for action 31st September 05 31st September 05 3. 4. OP3 OP7 OP7 14,15 14,15 31st September 05 31st September 05 31st September 05 31st September 05 31st September 05 31st August 2005 2.30pm Page 24 5. OP9 12,13, Medicines Act 17 12, 13, 16, 23 7,9, 19 6. 7. 8. OP16 OP26 OP29 Ashlands C03 C53 S60714 Ashlands V245912 310805 Stage 2.doc Version 1.40 9. OP29 7,9, 19 10. 11. 12. 13. 14. OP30 OP33 OP34 OP36 OP37 18 26 24, 25 19 17,26, satisfactory references. Should the regulation not be complied with again, Enforcement action will be taken. Ensure that all staff personal files contain the required documentation, as required by schedule 2 of the regulations. Ensure training records are available for inspection Past Copies of regulation 26 visit reports and audits must be sent to CSCI. Submit the business plan and evidence of financial viability to CSCI Ensure formal supervision is provided fopr all staff 8th September 2005 31st September 05 31st September 05 31st September 05 31st September 05 31st September 05 31st September 05 31st September 05 15. 16. OP38 OP38 Ensure all records required to be kept by regulation are available for inspection including complaints, fire safety tests, training records, Reg 26 etc 12,13, 16, Ensure fire risk assessments are 23 carried out. 12, 13, 16, 23 Ensure fire safety checks are routinely carried out and recorded. 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. Ashlands Refer to Standard OP3 OP3OP7 OP9 Good Practice Recommendations Ensure documentation is evident in care plans to demonstrate service users have the opportunity to have a door key and to their lockable facility. Ensure service users or their representative sign to agree the care plan. The regsistered manager should ensure staff are assessed for competencey in medicines administration and that this C03 C53 S60714 Ashlands V245912 310805 Stage 2.doc Version 1.40 Page 25 4. OP11 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. OP11 OP17 OP18 OP19 OP21 OP25 OP25 OP27 OP30 OP30 OP30 OP38 OP38 is documented. Ensure that the policy on palliative care is clear that the home is not registered to care for palliative care and that service users may remain in the home with the full support of the GP and Primary Care Team Services. Ensure that policy for dealing with dying includes the revising of care plans and implementation of care charts. Ensure there is evidence that service users right to participate in the civic process is upheld. Provide training in abuse awareness for all staff Complete the repair damage in the laundry room Towels and toiletries should not be stored openly in bathrooms and toiletries should be kept locked in cupboards. Ensure that the water temperature records are completed as specified in Standard 25 of the report. Regularly review the risk assessments of surface temperatures Review the afternoon staffing hours to provide catering hours. Training should be provided in diabetes care, mental health issues, abuse awareness and the complex needs of older people. Training programmes should be devised for 2004/2005 and 2005/2006 Provide training in dealing with challenging behaviour. Seek advice from the fire officer regarding the on line service and fire safety tests. Obtain an appropriatye and up to date[Data Protection Act 1998] accident record book Ashlands C03 C53 S60714 Ashlands V245912 310805 Stage 2.doc Version 1.40 Page 26 Commission for Social Care Inspection Edgeley House Riverside Business Park, Tottle Road Nottingham NG2 1RT National Enquiry Line: 0845 015 0120 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 Ashlands C03 C53 S60714 Ashlands V245912 310805 Stage 2.doc Version 1.40 Page 27 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!