Inspection on 24/04/06 for Ashley Down Nursing Home

This inspection was carried out on 24th April 2006.

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

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

Other inspections for this house

Ashley Down Nursing Home 11/06/08

Ashley Down Nursing Home 03/07/07

Ashley Down Nursing Home 22/01/07

Ashley Down Nursing Home 24/10/05

Ashley Down Nursing Home 02/06/05

Ashley Down Nursing Home 06/12/04

Ashley Down Nursing Home 05/08/04

Similar services:

Springfield House

The Shelley

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Ashley Down Nursing Home 29 Clarence Place Gravesend Kent DA12 1LD Lead Inspector Elizabeth Baker Key Unannounced Inspection 24th April 2006 10:15 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 Ashley Down Nursing Home DS0000061039.V290819.R01.S.doc Version 5.1 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. Ashley Down Nursing Home DS0000061039.V290819.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Ashley Down Nursing Home Address 29 Clarence Place Gravesend Kent DA12 1LD 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) 01474 363638 01474 363638 Ashley Down Care Home Ltd Vacant Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Ashley Down Nursing Home DS0000061039.V290819.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th October 2005 Brief Description of the Service: Ashley Down is a care home providing nursing care for 19 Older People (Old Age), not falling within any other category. Ashley Down Care Home Limited is the registered provider. Mr R Mahomed is a Director of the Company and is the named Responsible Individual for regulatory purposes. Bedroom accommodation comprises 17 singles and one double room. Ten single rooms have ensuite toilet and washbasin facilities. There is an eight-person passenger lift. All rooms used by residents are connected to the nurse call alarm system. Communal accommodation comprises of a day room, a separate dining room and a reception room. The home, which is a Grade II listed building, is located in a conservation area near to the town centre of Gravesend. Shops, pubs, a main post office, banks, places of worship and other amenities are easily accessible. There is a small, secluded patio garden at the side of the property, which is accessible to physically disabled residents. Car parking is limited. Copy inspection reports are kept in the nurses’ office and are available on request. However access information is not publicly displayed. Ashley Down Nursing Home DS0000061039.V290819.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first unannounced visit to the home for the inspection year 2006/07. The inspection took over eight hours and was carried out by lead inspector Elizabeth Baker and inspector Helen Martin. The main purpose of the visit was to check the Provider’s compliance with the two enforcement notices issued in January 2006 in respect of management and staff recruitment. The provider’s compliance against the 28 requirements made at the last additional visit to the home on 2 March 2006 and previous inspections was also inspected. A partial tour of the home took place. Three residents were interviewed in private. A number of residents, one visitor and some members of staff were spoken with. The newly appointed Manager Mrs I Fitzgerald assisted throughout the visit. Mrs Fitzgerald was receptive to advice given. At the time of the visit 16 residents requiring nursing care were residing at the home. Some judgements about the quality of care, life and choices were taken from conversations with residents, the visitor and staff, as well as direct and indirect observations. Some care records were seen as part of case tracking. The Commission has subsequently received three resident survey forms. Comments have been incorporated into the report. What the service does well: What has improved since the last inspection? On the day of the visit a new stair carpet was being laid. Eleven of the 28 requirements outstanding from the last visit have been complied with. The enforcement notices have in the main been complied with, although more recorded detail is required to demonstrate the home operates robust employment practices. Complaints are now handled more efficiently and to the complainant’s satisfaction. Ashley Down Nursing Home DS0000061039.V290819.R01.S.doc Version 5.1 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. Ashley Down Nursing Home DS0000061039.V290819.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Ashley Down Nursing Home DS0000061039.V290819.R01.S.doc Version 5.1 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 the following standard(s): 2, 3 and 6 Quality of this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Contracts lack important details, which may result in residents and or their advocates being confused of what is and what not is included in the fees and charges. EVIDENCE: A review of two resident contracts identified certain pertinent information was missing. The contract for a self-funding resident did not make reference to the actual amount of “nursing contribution” paid for by the local primary care trust. Regulations were amended in 2003 requiring this information be included. This contract referred to a bedroom to be occupied by the resident. However the actual room number was not stated. The contract made reference to fees being subject to annual reviews. However there was no timescale of notification of any fee increase where this was applicable. Regulations require this. Although both contracts invited the signatures of the resident/advocate and the home’s representative, only one contract had been signed by both parties. Contracts inform the resident of what the fees include, for example accommodation, full board, laundering of personal items and nursing care. Ashley Down Nursing Home DS0000061039.V290819.R01.S.doc Version 5.1 Page 9 While this is useful information having detailed information of what actually constitutes additional services and items provided or purchased on residents’ behalf by the home may prevent any misunderstandings. It was apparent from an interview that one resident and their advocates were confused as to what their responsibilities were. The Office of Fair Trading (www.oft.gov.uk) has produced information in respect of care home contracts, which the provider may find useful. Only one of the three survey respondents indicated they had a contract. The pre admission assessment of a recently admitted resident was inspected. However not all prompts had been completed as required by the form. Incomplete forms may result in important information about the residents needs being missed. The home is not registered for intermediate care. Standard 6 is not applicable. Ashley Down Nursing Home DS0000061039.V290819.R01.S.doc Version 5.1 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 the following standard(s): 7, 8, 9, 10 and 11 Quality of this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents remain at risk because care records are not wholly reflective of their current assessed needs. EVIDENCE: Four care plans were inspected as part of case tracking. While there was some evidence that there has been some improvement in the maintenance of care records, not all records were reflective of residents’ current condition. One resident described how their condition had deteriorated significantly since moving into the home. The corresponding care records were not reflective of this. Bedrails were seen to be in use in the resident’s room. However the resident had not been consulted about this provision. There was no protection on the bedrails. Because of the resident’s reduced dexterity, the type of call bell alarms available in the home is not wholly appropriate. The resident is dependent on staff assisting them with all their needs. West Kent NHS and SSD Disablement Services Centre may be able to offer advice as to appropriate equipment for this resident. Care plans have not been compiled with input from the residents. This prevents the home providing care as per residents’ expectations and preferences. Skin integrity assessments were again seen to Ashley Down Nursing Home DS0000061039.V290819.R01.S.doc Version 5.1 Page 11 be inaccurate. There was some confusion as to the correct way of completing the assessment currently in use, which is based on the Waterlow model. For clarity purposes the manager will be contacting the Tissue Viability Specialist Nurse of the local primary care trust for expert advice. Care records did not contain nutritional assessments. The manager expressed an eagerness to ensure all residents are provided with such assessments. It was suggested that the Dartford and Gravesham NHS Trust Nutrition and Dietetic Department might be able to offer assistance in this respect. Oral hygiene assessments were seen in some records. However the information contained therein does not provide the carer with sufficient information with regard to mouth care. A resident described the continued discomfort from pain they experience. The resident’s medication administration record chart indicated regular prescribed analgesia is administered. There was no supporting care plan component or pain assessment chart for this aspect of care. The resident said they were now reliant on staff feeding them and giving them a drink. The care plan did not contain this important information. None of the records contained a social care plan component or biographical details of residents. Records of residents’ involvement in activities are kept collectively and separately from other care records. This situation does not allow for a holistic picture to be obtained of residents’ quality of day and experiences. The practice of recording this information collectively on one page compromises residents’ confidentiality. A number of medication administration record charts were inspected. These were generally maintained in accordance with the requirements of the Nursing and Midwifery Council. However a couple of handwritten transcription entries had not been countersigned by a witness. The clinical room was in a clean and hygienic state. A box of “limited life” eye drops was in use. However there was no date on the box to record when the treatment commenced. Since the last inspection the provider has put a new lock on the clinical room door for security purposes. However the lock states it is a British Standard level 3 lock, where as the type required for the door of this room must be level 5. It was again noted that nursing sundries are stored in a room containing cleaning items. This situation promotes contamination. Details of medication errors are recorded on individual medication administration record charts. However recording this information additionally in a central book would assist the manager and or provider in monitoring administration errors and identifying additional training where this is seen as a need. The new manager was unaware of the important information contained in the Royal Pharmaceutical Society of Great Britain’s guidelines “The Administration and Control of Medicines in Care Homes and Children’s Services”. Contact details were provided. Care records inspected did not contain details of residents’ preferences and wishes in respect of death and dying. While recognising this can be a sensitive Ashley Down Nursing Home DS0000061039.V290819.R01.S.doc Version 5.1 Page 12 subject, this is an important aspect of care and needs to be addressed. Indeed one resident spoke openly of their views on death and dying. This information was not in the corresponding records. Contact details as to how the home may be able to obtain this vital information were provided to the manager. A resident said care staff assist them with their personal care needs in a dignified and respectful manner. Ashley Down Nursing Home DS0000061039.V290819.R01.S.doc Version 5.1 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 of this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Not all residents receive care as per their individual expectations. EVIDENCE: Mixed comments were again received about the quality and variety of meals. Generally residents spoken with were pleased with their meals and said they are always offered a choice. All three comment card respondents indicated they always like the meals at the home. Sadly this is not everybody’s experience. Because meals have been an issue at numerous visits, the Commission handed the provider on 5 April 2006 a copy of new guidance just issued “Highlight of the day? Improving meals for older people in care homes”. Although the new manager was aware of this document, the provider had not left this at the home for the manager’s information. The Commission has subsequently sent an additional copy to the manager, for her ease of reference. Despite the provider responding to the last visit report that all notices pertaining to residents and their advocates had been removed, one notice was still displayed in a particular bedroom. Displaying such notices is an institutional practice. Ashley Down Nursing Home DS0000061039.V290819.R01.S.doc Version 5.1 Page 14 One resident described how they enjoy their bath and that staff assist them appropriately in maintaining their personal hygiene needs. However the resident said they would like to have two baths a week as opposed to one and would prefer it in the evening instead of the morning. Sadly the resident accepted that frequencies and timing of baths fit into the home’s routine and resources as opposed to their own individual choice. Residents said they receive regular visitors, which they very much look forward to. A resident said how much they enjoy their room and described what they like to do throughout the day. The corresponding care records did not contain this information. Some residents were seen enjoying a game of bingo in the lounge. Ashley Down Nursing Home DS0000061039.V290819.R01.S.doc Version 5.1 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 of this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Handling of complaints has improved. Residents are at risk as not all staff may recognise and act on potential abusive situations against residents. EVIDENCE: A review of the home’s complaints book identified a recent complaint had been received, investigated and completed appropriately. This included a thank you from the complainant about the handling of the matter. The new manager could not recall seeing a copy of Kent and Medway MultiAgency Adult Protection Protocols within the home. Contact details were provided in order for the new manager to obtain up to date information on this important subject. Staff including the manager have not received recent adult protection training. Ashley Down Nursing Home DS0000061039.V290819.R01.S.doc Version 5.1 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 of this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The provider continues to provide resources to improve the home’s environment, making it a nicer place to live in. EVIDENCE: Progress continues on improving the home’s environment. At the time of the visit a new stair carpet was being laid. Bedrooms continue to be redecorated and furniture replaced. Although the home does not have extensive external areas, the small gardens are kept neat and tidy for residents’ enjoyment. Window frames have also been repainted. However this has resulted in one resident not being able to have fresh air as they require as the window frames can no longer be properly opened because of the dried paint. The home was clean, tidy and odour free at the visit. However the racking used in sluice rooms to hygienically store clean continence aids remains in a poor condition and prevents effective cleaning. The new manager could not Ashley Down Nursing Home DS0000061039.V290819.R01.S.doc Version 5.1 Page 17 recall seeing a copy of Kent and Medway NHS Infection Control and Health Protection Unit Infection Control guidelines. A copy has subsequently been sent to her, under separate cover, for ease of reference. These guidelines provide important information for care homes, and include action to be taken in the event of reportable or suspected infection outbreaks. Ashley Down Nursing Home DS0000061039.V290819.R01.S.doc Version 5.1 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 of this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Some residents are at risk because staffing levels are not reflective of their current assessed needs. EVIDENCE: Residents again commented on the length of time they sometimes have to wait for staff to respond to their calls. Some of these residents are highly dependent on the support and assistance from staff for the most basic aspects of care. One of the three comment card respondents indicated staff are available when they are needed. Out of the current occupancy of 16, five residents require assistance with their eating and a number of others require prompting. The off duties do not record additional staff are employed for meal times. As stated previously, one resident is resigned to the fact that they may only have one bath a week and that has to be the morning as opposed to evening because of staffing levels. Meaningful dependency assessments are not routinely used to monitor staffing levels. The provider continues to run the home below the minimal staffing levels set by a previous regulatory authority in 1998 for care duties. At that time the home employed separate staff to prepare and or serve breakfasts and evening meals. This is not now the case. At a meeting on the 5 April 2006, the provider inferred an additional healthcare assistant had been rostered for a period of time to support the new manager. The manager commenced on the 13 March 2006. The provider also said that he was advertising for another Registered Nurse. A subsequent letter dated 12 Ashley Down Nursing Home DS0000061039.V290819.R01.S.doc Version 5.1 Page 19 April 2006 from the provider informed the Commission that the new manager had received had two weeks induction and thereafter would be supported by a registered nurse three times a week. A review of off duties covering the period 13 March to 24 April 2006 did not evidence this. Indeed the week commencing 13 March 2006 showed the manager was supported by a registered nurse for four of the five shifts. For the two weeks commencing 20 March 2006 no additional cover is recorded for any of the ten shifts. It was also noted that there had been a number of occasions when the minimum staffing levels had not been met, including one night shift, which was covered by one member of staff only. The Commission has not been informed of these shortfalls. According to the staffing notice issued to the previous provider in 1998 and agreed by current provider as the minimum staffing level requirements of this home, supernumerary time of the manager for administrative duties would be 25 . This figure was set at a time when dependencies of residents entering nursing homes were considerably lower and management duties less. The Commission is aware that insufficient supernumerary time of managers at this home has been a factor in a number of resignations since change of ownership. The Commission will be inspecting this provision at subsequent visits and failure to comply may result in regulatory action being taken. There was no recorded evidence on this visit that a new registered nurse been appointed. To monitor compliance with the enforcement notice issued in January 2006 in respect of staff recruitment, the inspection of two records of newly appointed staff was undertaken and an improvement was noted. The files contained references, criminal record bureau checks, job descriptions, letters of offer and application forms. Although the forms had been completed as required by the application form, the applicants had not been required to state full employment histories. In one case the printed form required the applicant to record employment history for the last five years and the other for ten years. Amendments to schedule 2 of Regulation 9 and 19 effective from 26 July 2004 require a complete history be stated. However neither form contained a complete employment history. Two files inspected at the last inspection were re inspected on this occasion. The missing information had been obtained. One of the new files contained details of the staff induction programme. The other did not. However the staff member confirmed she had undertaken an induction programme. None of the files contained evidence of formal supervision. Only four of the eleven health care assistants are trained in NVQ level II care. Ashley Down Nursing Home DS0000061039.V290819.R01.S.doc Version 5.1 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 of this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The new manager has a good understanding of what needs to be done, but is dependent on the provider for necessary resources to carry out the work. EVIDENCE: To comply with the enforcement notice issued on the home in January 2006 the provider has now appointed a manager to run the home. From conversations with the manager it was evident she is fully aware of the enormity of the task she now has in order to turn the home around, including forging links with specialist clinicians in the community. The manager was receptive to advice given throughout the visit. Although the manager is a Registered Nurse and has experience of working as a staff nurse in nursing homes, she does not hold a requisite management qualification. However she expressed her eagerness to attain this qualification. Residents spoken with Ashley Down Nursing Home DS0000061039.V290819.R01.S.doc Version 5.1 Page 21 were pleased although surprised at the appointment, as they had not been kept informed of the matter. Because of the new manager’s appointment the enforcement notice requirement has been met. However this is the fourth management appointment at the home since the end of 2004. The provider is aware that failure to retain a suitably qualified, competent and experienced manager will result in prosecution. From touring the home there was clear evidence that the provider is endeavouring to ensure the environment is kept to a good standard. The Commission receives regular reports of the provider’s visits to the home as is required. Reports of the Commission’s visits to the home are not easily available to the general public. Indeed the new manager had not had sight of the additional inspection visit to the home on the 2 March 2006. During discussions with staff and management it was established that some training has recently taken place including moving and handling and dementia care. However there was no evidence that care staff have received recent training in respect of Parkinson’s disease, Stroke and Diabetes. The home currently cares for residents with these conditions. Residents and staff spoken openly with the inspectors throughout the inspection process. As stated previously there was no recorded evidence staff are receiving regular formal supervision. Indeed there is no recorded evidence staff have received supervision since the departure of the last registered manager at the end of 2004. However the new manager said documentation is now available and hopes to implement this in the near future. The pre inspection questionnaire form indicates the majority of policies and procedures were issued in 2004 and have not been reviewed since. As clinical and administrative policies and procedures are subject to constant changes, this may result in out of date guidance being available to staff. It was again identified that the Commission is not informed of all events affecting the wellbeing of residents. A notice informing the Commission of a resident’s death was not received until nine days after the event. The requirement is that the Commission is informed within 24 hours. As stated previously the review of off duties identified some shifts, which were not covered as per the minimum levels of the staffing notice. In one case only one person, a registered nurse was on duty for the night shift. The Commission was not informed of this either. A copy of the Commission’s new guidance on reporting events under regulation 37 was handed to the manager, for her ease of reference. A resident described how staff assist them in moving around in bed. The movement described is deemed bad practice. Disappointedly all care staff have only just received moving and handling training. Ashley Down Nursing Home DS0000061039.V290819.R01.S.doc Version 5.1 Page 22 While inspecting the clinical room it was noted some registered nurses resheath sharps prior to disposal in the sharps bin. This practice compromises their own safety and must cease. The accident book was inspected and found to be kept in order. The fire safety logbook evidenced in-house checks of the fire safety equipment is carried out regularly, other than for emergency lighting. This information could not be found. Ashley Down Nursing Home DS0000061039.V290819.R01.S.doc Version 5.1 Page 23 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 2 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X 2 2 STAFFING Standard No Score 27 1 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X X 1 2 2 Ashley Down Nursing Home DS0000061039.V290819.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP2 Regulation 5 Requirement All residents must have a contract, which clearly states the “nursing contribution”, actual room occupied, notice timescales of fee increases and full details of additional charges. All residents must be provided with a comprehensive care plan detailing full current needs, wishes and problems. This must include death and dying and social care. (Timescale 30/06/05, 24/10/05 and 31/03/06 not met). Timescale for action 31/10/06 2 OP7OP11 15 31/07/06 3 OP7 15(2)(c)(d Care plans must be reviewed in ) consultation with the resident and or their representative, revise the plan and notify the resident of any such revision, unless it is impracticable to do so. (Timescale 31/03/06 not met) 17 Care plan components and pain assessment charts must be available for those residents with an assessed need. DS0000061039.V290819.R01.S.doc 31/07/06 4 OP8 31/07/06 Ashley Down Nursing Home Version 5.1 Page 25 5 OP8 17 Care plans must contain full 31/07/06 nutritional details. (Timescale 24/10/05 and 31/03/06 not met) Pressure sore risk assessments must be accurately assessed and recorded. Handwritten transcription entries must be countersigned by a witness; The opening date of limited life preparations must be clearly recorded. A central record of drug areas should be maintained. Nursing sundries must not be stored with cleaning items. (Timescale 31/10/05 and 31/03/06 not wholly met) The door to clinical room to be fitted with a British Standard 5lever lock. Registered Nurse unable to confirm. (Pharmacy Inspector’s report). (Incorrect lock fitted). Residents must be provided with meals as per their individual preferences and needs. (Timescale 30/06/05, 31/10/05 and 31/03/06 not wholly met) 31/07/06 15/05/06 6 7 OP8 OP9 17 13 8 OP9 13 31/08/06 9 OP9 13 31/07/06 10 OP15 16 31/07/06 11 12 OP18 OP27 18 18 All staff must receive adult 31/08/06 protection/abuse training. Staffing levels must be 30/04/06 appropriate to meet the assessed needs of the current residents. (Previous timescales of 31/12/04, 02/06/05, 30/11/05 and 31/03/06 not met) Full employment history details must be sought and recorded in DS0000061039.V290819.R01.S.doc 13 OP29 9 and 19 31/07/06 Page 26 Ashley Down Nursing Home Version 5.1 14 OP30 18 respect of all staff. Staff must be suitably qualified, competent and experienced to ensure all residents assessed needs are met. (Timescale 31/01/06 not met). A quality assurance system must be introduced. (Previous timescales 31/03/05 and 31/08/05 not met). Not inspected Formal supervision must be introduced. (Previous timescales 31/03/05, 31/08/05, 31/12/05 and 31/03/06 not met). All records relating to residents must be complete, up to date and appropriately stored. (Timescale 31/10/05 and 31/03/06 not met) The Commission must be informed of any incident adversely affecting residents, including death details (Timescale 24/10/05 and 02/03/06 not met). Environmental risk assessments must carried out in respect of all bedrooms. Not inspected. Sufficient numbers of staff must be appropriately trained in First Aid. Timescale not expired. 31/08/06 15 OP33 24 31/08/06 16 OP36 18 31/08/06 17 OP37 15 and 17 31/05/06 18 OP37 37(1)(e) 30/04/06 19 OP38 13 31/07/06 20 OP38 13(4) 31/05/06 21 22 OP38 OP38 13(5) 22(4)(c) Residents must be transferred by 30/04/06 staff in accordance with health and safety requirements. Emergency lighting must be 31/05/06 DS0000061039.V290819.R01.S.doc Version 5.1 Page 27 Ashley Down Nursing Home checked inhouse on a monthly basis, and the findings 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 Refer to Standard OP3 OP14 OP15 Good Practice Recommendations Pre admission assessments must be complete of all information. Residents should be able to have baths according to their preferences. Appropriate cookery books must be available in order to ensure nutritional menus are devised. The new manager said a copy of the Caroline Walker Trust publication Eating Well for Older People has been ordered, following receipt of the Commission’s letter dated 18 April 2006. A method of recording food stocks must be introduced. Not inspected. Residents’ windows should be easily openable. Sluice room equipment must be kept in a good condition to allow effective cleaning. 50 of care staff must be trained to NVQ level II care. The Manager must enrol on a relevant management course in order to attain a management qualification equivalent to NVQ level 4. CSCI inspection reports must be easily accessible at all times. Policies and procedures should be reviewed at least annually. 4 5 6 7 8 9 10 OP15 OP25 OP26 OP28 OP31 OP33 OP33 Ashley Down Nursing Home DS0000061039.V290819.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Ashley Down Nursing Home DS0000061039.V290819.R01.S.doc Version 5.1 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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