Inspection on 05/06/08 for Ashlands Care Home

This inspection was carried out on 5th June 2008.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Ashlands Care Home 41 Main Street Methley Leeds Yorkshire LS26 9JE Lead Inspector Denise Rouse Key Unannounced Inspection 5th June 2008 08:30 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 Ashlands Care Home DS0000071511.V365920.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. Ashlands Care Home DS0000071511.V365920.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashlands Care Home Address 41 Main Street Methley Leeds Yorkshire LS26 9JE 01977 515823 01977 517130 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) Roche Healthcare Limited Susan Coleclough Care Home 50 Category(ies) of Dementia (50), Mental disorder, excluding registration, with number learning disability or dementia (50) of places Ashlands Care Home DS0000071511.V365920.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: Dementia - Code DE, maximum number of places: 50 Mental Disorder, excluding learning disability or dementia - Code MD, maximum number of places: 50 The maximum number of service users who can be accommodated is: 50. New service. 2. Date of last inspection Brief Description of the Service: Ashland’s provides 50 places for people who require nursing care with dementia or mental health needs. The home stands in its own grounds and has accommodation provided over three floors. There is a passenger lift, small gardens and some car parking available at the home. The home is situated in Mickletown an area of Methley, a former mining village between Castleford and Leeds. There are local village shops and a good transport link to both towns. Information about the home is available in the statement of purpose and service user guide. The last inspection report is also available for people to look at. Fees charged on the day of the site visit ranged from £519.00 to £574.00 plus the Registered Nurse Care Contribution. Extra charges were made for private chiropody and hairdressing. Ashlands Care Home DS0000071511.V365920.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate, quality outcomes. The accumulated evidence used in this report has included: • A review of the information held on the home’s file since registration. • Information submitted by the registered provider in the Annual Quality Assurance Assessment. • Surveys received from one person living at the home, three relatives, one health care professional and three staff. • An unannounced visit to the home which lasted six hours, undertaken by one inspector, which included a full tour of the premises. • Evidence was gained by direct observation during the site visit which involved talking with people living at the home, the manager, deputy and other members of staff. Inspection of records, including care profiles, medication administration records, staff files and some of the home’s policies and procedures. • What the service does well: What has improved since the last inspection? Ashlands Care Home DS0000071511.V365920.R01.S.doc Version 5.2 Page 6 This report is the first one to be produced since Roche Healthcare acquired Ashland’s Care Home. What they could do better: Information about the home should be available in different formats that are easy for people to understand. Contracts should be provided for all people living in the home, so that they, or their chosen representative are aware of the terms and conditions of occupancy. Some care profiles require more detail, especially in relation to special equipment currently being used, to ensure that peoples current care needs are being met. Medication storage requires monitoring to ensure that medications are stored within the correct temperature range, to ensure medications are safe to be used. Medication administration records must have prescribed nutritional drinks recorded on them when they have been taken by the individual, to ensure accurate records are kept. Activities and social stimulation should be provided for people being nursed in their bedrooms to ensure they do not feel isolated. Drinks should be accessible to people and not be placed on people’s chair backs. Training for staff about safeguarding people should be provided to ensure staff know what action to take if abuse were to occur. Improvements to the décor of the home are required to help stimulate people’s memory and assist them in identifying different areas of the building. Health and safety of people working and living in the home must be protected in relation to fire safety and in relation to the humid atmosphere found in the upper floors of the building. The home should continue to encourage staff to undertake and complete their National Vocational Qualification in Care to enhance the care being provided Personal allowance monies should be held at the home for those who have this facility, monies should be sent through from head office to ensure people can have access to all of their allowance if they wish. Clinical waste bin lids should be kept locked and the kitchen yard should be cleared of items waiting for disposal, so that people’s health and safety is protected. Ashlands Care Home DS0000071511.V365920.R01.S.doc Version 5.2 Page 7 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. Ashlands Care Home DS0000071511.V365920.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 Ashlands Care Home DS0000071511.V365920.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): Standards 1 3 (6 Not applicable) People who use this service experience good outcomes in this area. People are fully assessed before being offered a place within the home to ensure their needs can be met. Information is available about the home, however this should be provided in different formats to help people understand what is available to them. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Prospective residents have a full assessment of their needs undertaken which includes gaining information about their state of mind as well as their physical and mental health needs. They are invited along with their family or chosen representatives to look round. Management consider the skills of the staff and admissions are not made if staff cannot meet people’s needs. Consideration is given to how new people will fit in with the existing client group, so that people admitted settle in well. Ashlands Care Home DS0000071511.V365920.R01.S.doc Version 5.2 Page 10 People considering living in the home are able to spend time there and move in for a trial period. This ensures that they can experience the services the home has to offer. Staff get to know their individual special needs and ensure that these needs can be met. Information is available in the service user guide and statement of purpose, which is combined and has been updated to reflect the homes recent change in ownership. This ensures people have enough information to make an informed choice about if it is the right place for them. However some people would benefit from this information being provided in different formats, so that people who have special needs can understand what is available to them. Contracts of residency with terms and conditions of occupancy were evident for some of the people who were case tracked, however not everyone had this information on file. This should be provided to ensure people understand what is to be provided for them. Intermediate care is not undertaken. Ashlands Care Home DS0000071511.V365920.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): Standards 7 8 9 10 People who use this service experience adequate outcomes in this area. People have their health care needs met and their privacy and dignity is respected. However some medication practices place people at potential risk. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: People have personalised care plans in place, which reflect their health care and special needs. Care plans reflect what people can do for themselves and say what help staff need to provide to support individuals. However some of the care plans inspected required a little more detail to ensure that staff knew peoples full needs. Four out of the five care profiles inspected provided evidence that nearly all care plans were reviewed monthly or as the individuals needs changed. However one persons care plan had not been updated to reflect the type of pressure relieving mattress they were currently being nursed upon and this information must be reviewed and updated so that the care plan is accurately reflecting this person’s current needs. Ashlands Care Home DS0000071511.V365920.R01.S.doc Version 5.2 Page 12 Risk assessments are in place for individuals, they include information about people’s special needs to help ensure people can maintain their independence whilst their safety is maintained. Special equipment is provided to ensure that people’s special health care needs can be met, to improve people’s independence or their quality of life. Advice is sought from health care professionals to ensure peoples special need, relation to diet and skin care are met. People are accompanied to appointments at dentists and hospitals outside the home. The health care needs of people not able to leave the home are managed by visiting health care professionals. Staff know people well and information is passed at handover so that all staff are aware of any changes in peoples conditions. These are then acted upon to ensure that people’s needs are known and can be are met. The medication systems in operation in the home were inspected. Medication records are completed and provide a record of medications given to each person. Controlled medication is handled correctly to ensure people’s safety is maintained. However prescribed nutritional supplements are not recorded when given on the Medication Administration Record (MAR), these are recorded on a fluid balance chart when being given out by care staff. These prescribe supplements must be recorded on the MAR chart when they are given, to ensure a full record is kept of all medications prescribed and given to people in the home. The medication fridge was found not to be working and a fridge from a different area of the home had to be utilized for medications. Fridge temperatures were not recorded daily, so it was not possible to tell when this situation arose. These issues must be addressed to ensure medications for cold storage are safe to be used. The treatment room also felt quite hot and management must monitor the temperature of this room to ensure that medications are stored at a safe temperature so that they remain effective for people who receive them. Staff treat people with dignity and respect, addressing people by their preferred name. Staff knock on bedroom doors before entering. Double bedrooms have screens provided in between the beds to ensure personal care being given is not witnessed by the other person sharing the room. Management have introduced specific care pathways for people who are near to death, to ensure that the care provided is individual and people are well supported at the end of their life. Ashlands Care Home DS0000071511.V365920.R01.S.doc Version 5.2 Page 13 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): Standards 12 13 14 15 People who use this service experience good outcomes in this area. People have their social needs recorded so these needs are known and can be met. However the social needs of people who are nursed in their rooms are overlooked. People receive a nutritious diet, which meets their needs. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Peoples preferred social activities are recorded in “ working and playing” care plans. They also have their Life and family history recorded on a “ Map of Life” so that staff can help people reminisce if they want to. However one person who was case tracked was nursed in bed, their working and playing care plan required updating to ensure that they had access to activities and could gain social stimulation, to suit their needs. One comment received was “There is no stimulation for residents, especially for my husband who is in his room alone with the TV on”. Ashlands Care Home DS0000071511.V365920.R01.S.doc Version 5.2 Page 14 At the time of the site visit the home had no full time activities co-ordinator in place, but were recruiting for this post to be filled. Staff are providing some activities until this post is filled. These include playing with beanbags, large dominos, reminiscence cards, and paints and batting a balloon with a bat. Activities usually available are included in the service user guide. There is music and television available in the lounge areas and a small quiet lounge provided downstairs. Staff spend time talking with people and hold their hands if this is appropriate. Trips are undertaken over the year and entertainers are provided for people at the home and their relatives to enjoy. They especially enjoy singers “Young at Heart” who bring tambourines and flags for people to wave so they can join in. Reminiscence boxes are hired from Kirstall Abbey and the home has created one of their own for people to use to help them remember things from the past. A snoozelam has been recently created with a relaxing chair, dimmed lights, coloured lights and music to aid people’s sensory stimulation and relaxation. New activities equipment has been purchased and there is plenty of things to be used to create a good programme of activities once the new activities coordinator takes up their position. Visiting is open and people go out with their relatives if they are able to do so. Staff also take people out for walks in good weather when they are able to do so. People’s religious preferences and needs are recorded and acted upon. The Roman Catholic priest visits the home monthly or as required. Other Local clergy can visit the home as people request. People can go to the local church services and coffee mornings if they wish, escorted by staff. People’s dietary needs are known and catered for. The chef knew their special needs. They can choose where to eat, either in their bedroom, lounge or the dining room. Meals provided are balanced and nutritious with home baking provided. People who require help with feeding are assisted by patient staff and they are gently reminded to eat and encouraged. Plate guards and adapted drinking cups and cutlery is available to increase people’s independence to feed themselves. However feeder beakers of squash were placed on the back of people’s chairs, the manager did not know why this was occurring other than the person may have been prone to knocking the drink over. This practice did not look nice and people’s drinks should be put in a more appropriate place. People with weight loss are monitored and supplement drinks are prescribed. Foods are fortified and records are made of what food and drink people take to ensure their health is maintained. Specialist advice is sought where necessary to ensure people’s dietary needs are met. Ashlands Care Home DS0000071511.V365920.R01.S.doc Version 5.2 Page 15 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): Standards 16 18 People who use this service experience adequate outcomes in this area. People feel concerns raised would be dealt with. However the lack of safeguarding training for staff could place people at risk. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: There have been two complaints received at the home since the last inspection. Complaints are dealt with appropriately. People indicated that they know how to raise issues with the home, and those spoken with said felt issues would be dealt with. Staff said “ If residents are concerned about anything we try our best to solve their problems and pass on the information to the nurse in charge as well”. There has been one safeguarding referral made since the last inspection. This was made directly to the Commission for Social Care Inspection and there were issues to be addressed by the home. Once these were addressed care for the individual concerned improved. Information about safeguarding people is covered at induction for new staff. There are varying policies in place, which help protect people, including a whistle blowing policy. Staff questioned about what to do if an allegation of abuse was received knew what action they must take to protect people. However it would be helpful to staff to have a flow chart to with information of whom to contact if an allegation of abuse where to be made. Ashlands Care Home DS0000071511.V365920.R01.S.doc Version 5.2 Page 16 Some staff have received safeguarding training but this has not been updated for all staff in the last two years. Safeguarding training is scheduled to commence and all staff must receive this training as soon as possible, to ensure that the vulnerable client group continues to be protected. Ashlands Care Home DS0000071511.V365920.R01.S.doc Version 5.2 Page 17 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): Standards 19 26 People who use this service experience adequate outcomes in this area. People live in a safe and well-maintained environment but it does not always meet the needs of the specific client group. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The home is purpose built there are two passenger lifts allowing people to have access to all areas of the home. There is a small car parking at the front of the home and a small garden with garden furniture, accessible by a ramp. There is a very small patio area outside the downstairs dining room. In reception the floor covering had been replaced to make the entrance more inviting. The lounge areas downstairs have brown carpet fitted, which on the day of the site visit was seen to be being cleaned. However it was badly stained in some areas and requires replacing. The range of chairs used for Ashlands Care Home DS0000071511.V365920.R01.S.doc Version 5.2 Page 18 people to sit in were varied in design to suit peoples complex needs, however some were in a bad state of repair and required replacing. In the last few months improvement s have been made to the top floor by creating a “snoozelam room”. The corridor at the side of this new room is about to have pictures put up to make it more homely. A refurbishment plan has commenced which has started with redecorating an upstairs lounge with patterned wallpaper with curtains and flooring to be ordered in bold patterns to help people with dementia identify this area of the home. There is a plan to continue to redecorate throughout the home from the top floor to the ground floor. This is required as at present all areas of the home are decorated in bland colours and most areas have lino flooring. This does not help orientate people with dementia or memory problems. Decoration being undertaken in future will be chosen from specialist decorating companies, which have the needs of people with dementia in mind. There is no distinction by way of signage or colour, between each floor of the home to enable people to get their bearings. This must be addressed. A programme of routine maintenance is undertaken to ensure that the home remains comfortable for people to live in. People have their names on their bedroom doors; some have a personal photograph to help remind them which bedroom is theirs. However generally Bedroom doors are all the same colour and do not have memory boards to help stimulate people to remember that they have reached their own room. One shower room upstairs has a wheelable seat in it. A new bath is ordered and about to be fitted in another bathroom to enhance the bathing facilities available to people. On the day of the site visit bedroom doors were being held open by bedside cabinets on the upper floors. If people did not have their bedroom doors open where there were no windows in the corridors airflow was not occurring. This was discussed with management and these items were removed and staff spoken with about this unsafe practice. The environment for staff to work in on the upper floors was hot and management must look at how they can safely ensure bedroom doors can be kept open if people request this, or need this to occur for staff to be able to easily observe them whilst in bed and to gain airflow. Some upstairs lounges had ceiling fans available to help the air flow; however these were just blowing the hot air around. This issue must be addressed. Hand wash facilities are available throughout the building. Alcohol hand rub is available at the entrance and people are invited to use it and contribute towards effective infection control. The laundry was inspected, staff take pride in their work and systems of handling soiled and infected linen are in place, to help ensure infection control is maintained. There were no unpleasant aromas in any area of the home. Ashlands Care Home DS0000071511.V365920.R01.S.doc Version 5.2 Page 19 Outside the laundry and kitchen areas there was a variety of items in the yard, which were being stored there to be discarded. One clinical waste bin did not have the lid closed and a yellow bag was hanging out of it. Clinical waste must be placed in bins and the lids must be closed to ensure peoples health and safety is protected. Comments received included “The home appears a little shabby and would probably benefit from a refurbishment”. Ashlands Care Home DS0000071511.V365920.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): Standards 27 28 29 30 People who use this service experience good outcomes in this area. People receive care from adequate numbers of staff who receive training to help them give good care. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Staff are provided in sufficient numbers to meet peoples needs. People receive timely care from patient staff who worked to ensure peoples privacy and dignity is respected. When sickness or absence occurs, sometimes if this happens at short notice and agency staff cannot be found then there can be less staff in the home however staff work hard to ensure this does not impact negatively on the care they give to people. One member of staff stated when this occurred the manager thanks the staff at the end of the shift and has been known to put a thank you card in the staff room with chocolates. This helps to keep the staff morale up and lets them know they are appreciated. A thorough recruitment process is followed which includes recording the outcome and responses from potential staff at interview, as well as undertaking all necessary references and criminal checks. Staff do not commence work at the home without these checks being undertaken. Ashlands Care Home DS0000071511.V365920.R01.S.doc Version 5.2 Page 21 Ongoing training is provided for all staff, a training matrix ensures that staff can receive training at appropriate intervals which keeps their knowledge and skills up to date, and helps them provide good care to people living in the home. All new staff receive induction training, which includes information about abuse. However safeguarding training was required for the other staff. Roche Healthcare Limited now operates the home. Some staff have felt unsettled by this change. Some issues raised related to how annual leave has to be accrued yearly before it is taken. Also about annual leave granted by the previous owners being unclear to the new owners. These issues should be resolved to ensure staff remain positive. One comment received was “ before Ashland’s was bought by Roche Healthcare I thought the atmosphere and care was good. Since then the atmosphere has changed and the staff don’t seem to be as warm and friendly as they were either with residents or visitors” The home has less than 50 of care staff who currently hold a National Vocational Qualification in Care al level 2 or 3 undertaking this training helps to ensure that people are looked after by well-trained staff. Staff meetings are held to gain the views of people working in the home. Any issues raised are felt to be listened to by the management in the home and further support has been provided from the higher management team. Ashlands Care Home DS0000071511.V365920.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): Standards 31 33 35 38 People who use this service experience good outcomes in this area. People live in a home that has an effective manger. However there are some issues with personal allowance accounts and health and safety to be addressed. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The manager is newly appointed and has a lot of experience from working in the home. There is support for her provided by the deputy manager and wider management team from Roche Healthcare Ltd. She operates an open door policy so that people can speak with her at any time. She has a clear understanding of the key principles and focus of the service, and works to ensure these are met. Ashlands Care Home DS0000071511.V365920.R01.S.doc Version 5.2 Page 23 Equal opportunities are promoted. The manager updates her skills regularly and has completed her further qualifications in management. The views of people living at the home are always considered. This ensures that their wishes are reflected in decisions made about how the home runs and what improvements they make to the service. Staff spoken said that the manager was approachable and listens to them. They said they value the time that the Estates Manager spends walking round the building talking with the staff. Some stated they would like to have more contact in this manner with the wider management team so that everyone can share their views and discuss issues that require some clarification. Quality assurance audits are carried out for the kitchen, medications, accidents, care plans pressure sores and housekeeping. This ensures management are constantly monitoring how the home is running and act to address any shortfalls found. Staff and people living in the home are asked in a yearly survey for their views of the services the home provides. The management team analyse the information and act upon it to ensure that the home delivers the services people want. Care plan review meetings are held with people and their relative or representative, so that people are fully informed about the care people receive and they can sign the documentation. This has been put in place because no one attended relative and resident meeting felt at the home for a number of months and this system was the best way to gain peoples views. Personal allowance accounts inspected for three people were correct this ensures people are protected from financial abuse. However there have been no personal allowance monies received for these people in the last few months from head office. This issue should be forwarded to the home so these people may have access to these funds. Health and safety checks are undertaken for hot water temperatures in people’s bedrooms, and fire alarm checks weekly. As well as hoist and lift maintenance contracts being in place. Gas and electric services are maintained and certificated as required. Health and safety issues relating to fire doors being held open (see environment) by inappropriate means must be addressed. The issues about the humidity on the upper floors (see environment) and shortfalls with medication storage (see health and personal care) must also be addressed, to ensure peoples health and safety is continues to be protected. Ashlands Care Home DS0000071511.V365920.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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 1 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 3 17 X 18 2 1 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 2 X X 1 Ashlands Care Home DS0000071511.V365920.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? N/A 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 Standard OP9 OP38 Regulation 12 (1) (a) 13 (2) (4) (a) Requirement All prescribed medications must be recorded when given on the medication administration record. To ensure an accurate record is maintained. The medication fridge must be replaced and the fridge temperature must be recorded daily, to ensure medications remain safe to use. The treatment room temperature must be recorded daily and action taken if the room is found to be too hot to store medication within the required range. 12 (1) (a) The décor in the home must be 01/08/08 13 (4) (a) improved to ensure it meets 23 (2) (a) people’s individual and collective (b) (d) (p) needs in a comfortable and homely way to help them identify where they are. The lounge carpet downstairs and worn easy chairs must be replaced. The humid atmosphere upstairs must be monitored and action Ashlands Care Home DS0000071511.V365920.R01.S.doc Version 5.2 Page 26 Timescale for action 01/08/08 2 OP19 OP38 taken as required to addresses this issue and make it comfortable fro people living in the home and for the staff working there. Fire doors must not be held not open by inappropriate means 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 Refer to Standard OP1 Good Practice Recommendations Information about the home should be provided in different formats to help people understand what is available to them. All people living in the home or their chosen representative should have a copy of their contract/ terms and conditions of occupancy, so that they are aware of what the home has to offer them. People who are nursed in bed should have their working and playing care plan updated to ensure that they have access to activities and are socially stimulated. Feeder beakers should not be placed on the back of people’s chairs, drinks should be accessible to people. Safeguarding training should be provided to all staff to ensure people continue to be protected. Staff would benefit from a flow chart with the action to be taken, and agencies to be contacted if a safeguarding issue were to be raised 5 OP28 The home should strive to have 50 of care staff that hold a National Vocational Qualification (NVQ) in Care at level 2 or 3. Staff undertaking their NVQ should be encouraged to continue with this. The higher management team should ensure issues raised by staff are discussed and resolved, to ensure staff morale DS0000071511.V365920.R01.S.doc Version 5.2 Page 27 2 3 4 OP12 OP15 OP18 6 OP31 Ashlands Care Home 7 8 OP35 OP38 is not adversely affected. Personal allowance monies for the three individuals who hold a personal allowance account should have the balance of these monies sent to the home from head office. Clinical waste bins should have their lids closed and locked to ensure peoples health and safety is protected. Items stored for disposal in the kitchen yard should be removed and this area should be kept tidy. Ashlands Care Home DS0000071511.V365920.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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. 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