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Inspection on 14/11/06 for Ashlands Nursing Home

Also see our care home review for Ashlands Nursing Home for more information

This inspection was carried out on 14th November 2006.

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Residents were assessed before admission. This meant that staff understood what care the person needed. The manager made sure that prospective residents had enough information to help them to make a choice about whether the home was right for them. Residents had care plans that told staff what care they needed. Residents and their relatives said they were very well looked after and they received the care and medical attention they needed. One relative wrote that their mother had been at Ashlands for a number of years and the standards had never dropped. Staff had good procedures for looking after residents` medicines, which reduced the risk of medication errors. Residents were very complimentary about the staff. They said that the staff were respectful and treated them well. One resident said the staff were, "a cheerful lot," and another commented that some of the staff were very homely and gave her a hug which she thought was nice. Residents were happy with their lifestyle in the home. One resident said, "I must complement the people who run it, it`s perfect for me." Residents said they were able to make choices about when to get up and how to spend their day. One resident said she liked to spend time in her room and sit quietly and read the paper. There were some organised activities which residents could join if they wished. Residents said they liked the food. They commented that the meals were of a "good standard" and one resident said, I really enjoy the food, there is such a variety." Residents said they knew they could go to the manager if they were not happy about anything and they were confident she would deal with it. One resident said, "she is easy to talk to whether it`s good or bad." Residents had opportunities to tell the manager what they liked or not about the home. They could make suggestions for improvements if they wanted to. One resident said, "I like the way matron (the manager) will listen." Residents, relatives and staff said the home was well managed and praised the skills of the registered person. The home was nicely decorated and furnished. Residents were able to personalise their bedrooms with pictures, ornaments and small pieces of furniture. One resident said, "Having my own things around me has made all the difference."

What has improved since the last inspection?

At the last inspection it was identified that not all complaints were being recorded. This time the records showed that staff were passing on even minor concerns. This meant that the manager was made aware and could deal with the complaints as necessary.

What the care home could do better:

The registered manager must ensure that all risks to a resident`s health and welfare are assessed and recorded on their plan of care. The training records should be kept up to date so that the registered manager can easily identify what training a member of staff has had and what needs to be arranged.

CARE HOMES FOR OLDER PEOPLE Ashlands Nursing Home Turnpike Newchurch Rossendale Lancashire BB4 9DU Lead Inspector Jane Craig Unannounced Inspection 15th November 2006 13:30 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 Nursing Home DS0000022516.V313643.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 Nursing Home DS0000022516.V313643.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashlands Nursing Home Address Turnpike Newchurch Rossendale Lancashire BB4 9DU 01706 217979 01706 226909 ashlandsnh@tiscali.co.uk www.ashlands.org Mrs Anna Mary Marriott 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) Mrs Anna Mary Marriott Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21), Physical disability (21), Terminally ill (4) of places Ashlands Nursing Home DS0000022516.V313643.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Under Annex 2, a maximum of 21 service users who fall in category of either OP or PD A maxium of 4 service users of the category TI within the maximum number of 21. Staffing will be in accordance with the Notice issued dated 21 May 2001 21st February 2006 Date of last inspection Brief Description of the Service: Ashlands Nursing Home is registered to provide care for people over 65 who need nursing care, people who are physically disabled and people who are terminally ill. The home is a family concern with the registered person being a first level nurse. Care is provided in a friendly atmosphere with a small staff team. The home is a former mill owner’s house, which was built in 1863. It is a grade 2 listed building, which has been adapted tastefully whilst retaining many of the original features. It lies in two and a half acres of woodlands and lawns which are well kept and fully accessible to service users. Accommodation is provided on 2 floors. The first floor can be accessed via a passenger lift. Communal areas comprise 1 large lounge and 1 small quiet room. The large dining room also has comfortable seating available. Bedrooms are mainly double, with privacy screening provided. There are no en-suite facilities. Prospective residents are sent a brochure and information about the homes website. Copies of the statement of purpose, service user’s guide and the latest CSCI inspection report are available on request. The range of fees at 15th November 2006 was £470.00 to £523.50 per week. There were no extra charges for residents paying those amounts. Ashlands Nursing Home DS0000022516.V313643.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key unannounced inspection, which included a visit to the home, was conducted at Ashlands Nursing Home on the 15th and 16th of November 2006. At the time of the visit there were 17 residents accommodated. The inspector met with most of the residents and spent time observing interactions between staff and residents. Wherever possible residents were asked about their views and experiences of living in the home and some of their comments are quoted in this report. Nine residents and fourteen visitors had completed questionnaires before the inspection. Their views have also been taken into account when writing the report. Discussions were held with both the registered providers and three members of staff. The inspector also spoke with six visitors. A tour of the premises took place and a number of records and documents were viewed. This report also includes information submitted by the home prior to the inspection visit. What the service does well: Residents were assessed before admission. This meant that staff understood what care the person needed. The manager made sure that prospective residents had enough information to help them to make a choice about whether the home was right for them. Residents had care plans that told staff what care they needed. Residents and their relatives said they were very well looked after and they received the care and medical attention they needed. One relative wrote that their mother had been at Ashlands for a number of years and the standards had never dropped. Staff had good procedures for looking after residents’ medicines, which reduced the risk of medication errors. Residents were very complimentary about the staff. They said that the staff were respectful and treated them well. One resident said the staff were, “a cheerful lot,” and another commented that some of the staff were very homely and gave her a hug which she thought was nice. Residents were happy with their lifestyle in the home. One resident said, “I must complement the people who run it, it’s perfect for me.” Residents said they were able to make choices about when to get up and how to spend their Ashlands Nursing Home DS0000022516.V313643.R01.S.doc Version 5.2 Page 6 day. One resident said she liked to spend time in her room and sit quietly and read the paper. There were some organised activities which residents could join if they wished. Residents said they liked the food. They commented that the meals were of a “good standard” and one resident said, I really enjoy the food, there is such a variety.” Residents said they knew they could go to the manager if they were not happy about anything and they were confident she would deal with it. One resident said, “she is easy to talk to whether it’s good or bad.” Residents had opportunities to tell the manager what they liked or not about the home. They could make suggestions for improvements if they wanted to. One resident said, “I like the way matron (the manager) will listen.” Residents, relatives and staff said the home was well managed and praised the skills of the registered person. The home was nicely decorated and furnished. Residents were able to personalise their bedrooms with pictures, ornaments and small pieces of furniture. One resident said, “Having my own things around me has made all the difference.” What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. Ashlands Nursing Home DS0000022516.V313643.R01.S.doc Version 5.2 Page 7 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ashlands Nursing Home DS0000022516.V313643.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 Nursing Home DS0000022516.V313643.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The admission process ensured that residents had sufficient information to help them to make a decision about moving in and staff had enough information to understand the new resident’s care needs. EVIDENCE: The three residents who were case tracked had been assessed by health and social care professionals prior to their admission to the home. The registered manager had also assessed all three. The assessments provided a strong profile of the resident’s strengths and needs. The resident and their families were fully involved in the process; one resident said they remembered the manager visiting her in hospital. The resident or their relative received written confirmation that their needs could be met at the home. The letter was individual to the resident and identified their assessed needs and the actions to be taken to meet them. Staff said that they had access to the assessments and an opportunity to discuss them with the registered manager before the resident came into the home. Ashlands Nursing Home DS0000022516.V313643.R01.S.doc Version 5.2 Page 10 Ashlands does not provide intermediate care. Ashlands Nursing Home DS0000022516.V313643.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ health and personal care needs were met in accordance with their wishes. Medication practices safeguarded residents. EVIDENCE: The files of three residents were inspected as part of the case tracking process. Although a recently admitted resident did not have a plan to assist staff to manage potentially difficult behaviour, all other care plans to address the residents’ personal and healthcare needs were in place. The residents or their relatives were provided with opportunities to be involved in care planning if they wished, although more than one resident said they were not interested. There was evidence that care plans were reviewed and updated as and when the resident’s needs changed. Care plans included risk assessments for moving and handling, nutrition, pressure sore risk and falls. Plans were in place where a risk of harm was identified. Examples included pressure relieving strategies and directions to assist residents with restricted mobility. Residents’ families had signed their agreement to the use of bed rails but one resident did not have a full risk Ashlands Nursing Home DS0000022516.V313643.R01.S.doc Version 5.2 Page 12 assessment to evidence that this was the best course of action to maintain the resident’s safety. There was evidence that residents’ ongoing healthcare needs, including psychological healthcare needs, were monitored. Residents were referred for specialist treatment when required and advice from other health care professionals was incorporated into their plan. Residents spoken with said that they were very well looked after. Those who filled in questionnaires indicated that they always received the care and medical support they needed and all of the relatives indicated they were satisfied with the overall care provided at the home. Comments on the surveys included; “if my mother is unwell she gets all medical help and we are always told,” and “we are very happy with the care my mother gets, she has been in Ashlands for 7 years and the standard of care has never dropped.” None of the residents administered their own medicines. Two said that they preferred staff to look after them because they took so many. There was a complete set of policies and procedures for managing medication. Records of medicines received and disposed of were complete and up to date. The stock balance of medication was recorded every day, which provided a good audit tool. There were no unexplained gaps on Medication Administration Record (MAR) charts. Handwritten entries on MAR charts were signed and witnessed. Brief criteria for some “when required” medication was recorded on the chart and other residents had care plans in place to assist with pain control. Storage was clean, and secure. There was no excess stock. Storage temperatures were recorded. Storage, recording and administration of controlled drugs were appropriate. Staff received training in care values during their induction programme. One member of staff talked about the importance of maintaining residents’ privacy and dignity and said, “they are probably the most important aspects and part of almost every task.” Staff were seen to speak respectfully to residents and offer help in a discreet manner. One resident said that staff were very careful not to leave them uncovered when they assisted with personal care and another said, “I like to be treated as a person and I usually am.” Ashlands Nursing Home DS0000022516.V313643.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 at least once during a 12 month period. 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 using available evidence including a visit to this service. Residents had choice and control over their daily lives. Daily routines and meals suited residents. EVIDENCE: The registered manager had taken steps to improve opportunities for residents to engage in suitable activities. She had produced a resource for staff to help them to plan and access occupation and activities to meet residents’ individual needs. A member of staff had been identified as taking the lead in activities and part of the plan was to ensure that all residents, including those who preferred to stay in their rooms, were allocated one to one time. One resident had a new daily life and social activity plan on their file, which was part of the initial trial. There were some group activities on offer, such as movement to music and concerts. Some residents said they enjoyed these. Residents’ plans included any specific cultural or religious needs. Ministers from different churches visited the home on a regular basis to provide communion and services. Information about residents’ preferred daily routines, likes and dislikes were recorded on their assessments or care plans. Residents confirmed that there were no set rules in the home and they had choices about where and how to Ashlands Nursing Home DS0000022516.V313643.R01.S.doc Version 5.2 Page 14 spend their time. One resident said, “I’ve never been told I have to get up.” Residents said that even though they needed help they were still given choices about their personal care. One resident said that the staff always opened her wardrobe and asked what she wanted to wear; they didn’t just get something out. Staff said that if they had to make choices on behalf of the less able residents, they would discuss with relatives and consult the care plan. All of the fourteen relatives who returned comment cards indicated that they were consulted if their relative was unable to make a decision about their care. There was an open visiting policy and any special wishes residents had about visiting were recorded on their care plans. All fourteen relatives who completed surveys said they felt welcome in the home and could see their relative in private. One wrote, “Staff make residents and relatives feel at home,” and another commented, “it feels like home from home, you never feel that you shouldn’t be there.” On the day of the visit relatives were seen to visit at various times. The manager said that they were welcome to be as involved in their relative’s care as they wished. Residents who completed surveys indicated that they liked the meals most of the time. Residents spoken with during the inspection were also positive about the food. One said, “I really enjoy the food, there is such a variety.” And another commented, “the standard is good.” The records of meals showed that residents received a balanced diet. The manager and some senior staff had recently completed a course in nutrition. The dining rooms were attractively arranged with full place settings. Alternatively, residents could have their meals in their rooms if they wished. Equipment was available to help residents to maintain their independence and staff were observed giving assistance to residents in a sensitive manner. Ashlands Nursing Home DS0000022516.V313643.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints were taken seriously and acted upon. Staff understood adult protection issues, which safeguarded residents. EVIDENCE: There was a clear complaints procedure on display. The records of complaints showed that staff were passing on information to the registered manager. There had been three complaints since the last inspection, all had been investigated and resolved to the satisfaction of the complainant. Residents and relatives said they knew who to speak to if they were not happy with the service and they all knew how to make a complaint. Those spoken to during the visit were confident that complaints would be dealt with. One resident said that the manager was, “quite easy to talk to whether it’s good or bad,” another said, “I have not made a complaint but if I did I think it would be taken seriously.” Staff were given copies of the adult protection and whistle blowing policies in their staff handbook. New staff received training in safeguarding adults as part of their induction programme but refresher training for other staff was overdue. The registered manager had developed a training package, which incorporated the principles of the No Secrets guidance. She planned to deliver the training to all staff by the end of next month. Staff were aware of the need to report any allegations to their manager. Ashlands Nursing Home DS0000022516.V313643.R01.S.doc Version 5.2 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 the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was clean and well maintained. It provided residents with a safe, comfortable and homely place to live. EVIDENCE: There was a programme of routine maintenance and the home looked to be in a good state of repair. There was a programme for redecoration and refurbishment and some areas of the home had been redecorated and carpeted since the last inspection. Residents were happy with their rooms, some of which were personalised to a high degree with ornaments and pictures. One resident said, “having my own things around me has made all the difference.” Another said, “I am comfortable here.” The home was clean and fresh smelling. Residents who completed surveys said it was always like that and a relative wrote that the home was, “always clean, no unpleasant smells.” The laundry was sited in the basement and away from resident areas. It was adequately equipped for the size of the Ashlands Nursing Home DS0000022516.V313643.R01.S.doc Version 5.2 Page 17 home and on the day of the visit it was tidy and organised. There were no complaints about the laundry. One resident said the laundry service was very good. There was written guidance on infection control procedures and staff were booked onto a refresher training course. Ashlands Nursing Home DS0000022516.V313643.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were sufficient staff and the majority held a relevant qualification. Recruitment practices provided safeguards for residents. EVIDENCE: Duty rosters provided an accurate record of staff on duty. Staff said the their numbers were sufficient to meet the needs of the current residents and the manager said that staffing levels could be increased if residents’ needs changed. Residents who completed questionnaires indicated that staff were available when needed. Thirteen of the fourteen relatives who completed comment cards stated there were enough staff on duty. A resident at the time of the visit said, “help is not instantaneous but I don’t have to wait long.” Residents and relatives made very positive comments about the staff team. A relative wrote, “we, as a family, are very grateful for the love and care that is shown to our mother.” Comments to the inspector included, “the staff are a cheerful lot,” “everyone is so nice,” and staff are very good.” The files of three recently employed staff were inspected. All the required preemployment checks were carried out and the required information and documents were obtained. New staff were appropriately supervised by the registered manager and senior staff. Ashlands Nursing Home DS0000022516.V313643.R01.S.doc Version 5.2 Page 19 All new staff had a very thorough induction training programme. They were mentored through a workbook covering all aspects of care and were then expected to complete an assessment of competency in each area. The induction workbook was based on the previous national induction standards and the registered manager was advised to check the content against the new common induction standards. Staff said there were good opportunities for external training and there were in-house sessions to keep them up to date. More staff had received refresher training in the safe working practice topics than shown on the records submitted by the registered person prior to the inspection. However, it was not clear whether all the training was up to date. Information submitted by the registered person indicated that over 50 of care staff were trained to NVQ level 2 or above. Ashlands Nursing Home DS0000022516.V313643.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefitted from a safe and well managed home and had opportunities to contribute to service development. EVIDENCE: The registered person managed the home on a day-to-day basis. She is a registered nurse who has a palliative care qualification and many years experience of caring for older people and people with terminal illness. The registered person also holds an NVQ level 4 in management. She undertakes short courses in order to keep her practice up to date and fulfil the conditions of her nursing registration. All the residents, relatives and staff spoken to during the visit praised the skills of the registered person. One resident described the registered person as “exceptional.” Another resident commented that she always felt better when the matron was on duty. One relative wrote Ashlands Nursing Home DS0000022516.V313643.R01.S.doc Version 5.2 Page 21 that Ashlands is a “very well run home,” and another relative said, “Anna Mai is lovely and a very good manager.” The home had several systems for monitoring the quality of the service. The Blue Cross Mark of Excellence was used as an annual internal audit. The audit identified areas for improvement and the registered person showed that actions were taken to address these, either through the Business Plan or other means. The home held a current Investors in People Award. Residents or their relatives recently completed surveys based on quality of life outcomes. Results were published and made available to residents and relatives. The results included actions taken to address a concern raised by a resident. The staff did not handle any finances on behalf of residents. Those residents who were able, were encouraged to manage their own money and their families acted on behalf of others. The home did not hold any money for safekeeping. There were health and safety policies and procedures in place. All staff had received fire safety training and practice drills were held during the induction of new staff or every six months. The registered manager kept records of the drills but not the staff who attended. A fire safety inspection was carried out earlier in the year and the fire risk assessment was found to be satisfactory. Servicing and testing of the fire system, equipment and alarms was up to date. Information provided by the registered person indicated that the servicing and maintenance of other installations and equipment in the home was up to date. Ashlands Nursing Home DS0000022516.V313643.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 X X 3 Ashlands Nursing Home DS0000022516.V313643.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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. Refer to Standard OP7 OP8 Good Practice Recommendations Care plans should include any directions for staff to manage difficult behaviour. The registered person shall ensure that unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. This would include risk assessing the use of bed rails. The registered person should bring the staff training records up to date and address any shortfalls identified. The registered person should keep a record of which staff attended a fire drill, the outcome of the drill and any further actions to be taken. 3. 4. OP30 OP38 Ashlands Nursing Home DS0000022516.V313643.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB 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 Nursing Home DS0000022516.V313643.R01.S.doc Version 5.2 Page 25 - 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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