Inspection on 03/07/07 for Ashley Down Nursing Home

This inspection was carried out on 3rd July 2007.

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 22/01/07

Ashley Down Nursing Home 24/04/06

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 3 July 2007 09:40 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.V340252.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. Ashley Down Nursing Home DS0000061039.V340252.R01.S.doc Version 5.2 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@btinternet.com Ashley Down Care Home Ltd Post 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.V340252.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. That from time to time the service may admit service users under the age of 65. 22nd January 2007 Date of last inspection 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. A copy of the latest inspection report is kept in the entrance vestibule. Current fees range from £442.42 per week excluding the NHS registered nursing care contribution (sponsored residents) to £560.62 per week including the NHS registered nursing care contribution (private residents). Additional charges are payable for chiropody, hairdressing, newspapers and toiletries. Activities include board games and quizzes, bingo, monthly motivation sessions and external trips out - transport and weather permitting. Ashley Down Nursing Home DS0000061039.V340252.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first key unannounced visit to the home for the inspection period 2007/08. Link inspector Elizabeth Baker carried out the visit on the 3 July 2007. The visit lasted just over eight hours. As well as touring some parts of the home, the visit consisted of talking with some residents and staff and inspecting some records for case tracking purposes. As number of residents, one visitor and members of staff were interviewed. Feedback of the visit was provided to the home manager at the conclusion of the visit. At the time of compiling the report, in support of the visit, the Commission received survey forms about the service from two residents and three relatives/advocates. At the Commission’s request the home manager completed and returned an Annual Quality Assurance Assessment (AQAA). Some of the information gathered from these sources has been incorporated into the report. At the time of the visit 17 residents requiring nursing care were residing at the home. Since the last visit, the Commission has not received any complaints about the service. What the service does well: What has improved since the last inspection? Ashley Down Nursing Home DS0000061039.V340252.R01.S.doc Version 5.2 Page 6 Under the home manager’s leadership the running of the home has vastly improved, staff morale has increased and residents enjoy a better quality of life. Almost all of the requirements and recommendations made at the last visit have been or are almost complete, demonstrating a commitment to improve the home for the benefit of residents. Care records provide much more detail on residents’ needs, wishes, preferences and abilities. Having this information should ensure residents are better cared for. Staffing is more stable offering a better quality of life for residents. A new version of the contract has been introduced making the terms and conditions of staying at the home more understandable. Additional staffing at lunch and supper times enables residents requiring assistance with their meals to be supported in a more relaxed way. There is more commitment to staff training, which should benefit residents in the quality of care they receive. The home’s current recruitment practices have minimised potential risks to residents. 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. The summary of this inspection report can be made available in other formats on request. Ashley Down Nursing Home DS0000061039.V340252.R01.S.doc Version 5.2 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.V340252.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 and 6. Residents who use the service experience good outcomes. This judgement has been made using a range of evidence, including a visit to this service. The current pre admission process ensures prospective residents are properly assessed prior to a decision of admission being made. EVIDENCE: Since the last visit contracts setting of terms and conditions of staying at the home have been revised. The new version is written in plain English, making it easier to determine the rights and responsibilities of both parties, quickly. All residents and or their advocates are provided with a contract. Prospective residents are usually assessed prior to admission in their current place of occupation. A registered nurse undertakes the process and completes a form of the findings. The information is used to determine whether the home can meet the assessed needs of the prospective client, prior to a decision of admission being made. The information is also used to inform the Ashley Down Nursing Home DS0000061039.V340252.R01.S.doc Version 5.2 Page 9 resultant care plan. The sample inspected contained detailed information, which reflected comments described by residents during the site visit. The home does not provide intermediate care. Standard 6 is not applicable. Ashley Down Nursing Home DS0000061039.V340252.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11. Residents who use the service experience good outcomes. This judgement has been made using a range of evidence, including a visit to this service. The health needs of residents are met with evidence of good multi disciplinary working taking place on a regular basis. Personal care is offered in a way to protect residents’ privacy and dignity and promote independence. EVIDENCE: A review of a sample of care records was undertaken as part of case tracking. Care plans are supported by clinical and health and safety risk assessments, which are used to monitor the effectiveness of the treatment plan. Care plans indicated they had been compiled with input from residents and or their advocates. Where this had not been possible, a statement to this effect was recorded. The level of detail seen in records at this visit had increased. And in accordance with good practice it was noted that care staff no longer use abbreviations. Risk assessments are used where bedrails are in use. These had been signed by the residents and in one case a GP. However these still do not include the contra indications for this provision, such as entanglement and the resident climbing over the top. Evidence was seen that residents receive specialist support from other clinicians when there is an assessed need. GPs Ashley Down Nursing Home DS0000061039.V340252.R01.S.doc Version 5.2 Page 11 visit the home regularly and residents were complimentary about this. An optician had recently undertaken eye tests at the home for a number of residents. Daily records contain more information, giving a better picture of residents’ quality of day experiences as well as their medical condition. Moving and handling assessments are used to instruct staff on how to safely transfer residents. However two of the sample reviewed did not actually include the precise support needed as described by the residents themselves. Care staff were seen explaining to a resident the action being taken during a hoist transfer, reducing the resident’s anxiety. This is good practice. Residents said staff provide appropriate support when assisting them with their personal hygiene needs. The home endeavours to ensure where residents have a gender preference for personal care assistance, this is accommodated. The home has a clinical room in which medicines and nursing sundries and aids are securely kept. Regularly monitoring of the room and fridge temperatures is undertaken and recorded. This should ensure medicines are stored in accordance with manufacturers’ instructions. Registered nurses maintain medicine administration record charts as evidence of medicines administered to residents. A pain assessment chart was seen to accompany a chart to monitor the effectiveness of the treatment plan. The majority of residents admitted into the home, stay there for the rest of their lives. Indeed some of them have lived at Ashley Down for a number of years. The home has endeavoured to obtain information on residents’ preferences in respect of death and dying. However although information was seen in respect of burial preferences, the files did not actual any specific spiritual or cultural preferences and wishes. Ashley Down Nursing Home DS0000061039.V340252.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Residents who use the service experience good outcomes. This judgement has been made using a range of evidence, including a visit to this service. Dietary needs of residents are well catered for and generally meet residents’ tastes and choices. Most residents are able to take part in activities and occupations according to their individual preference and abilities. EVIDENCE: At the time of the visit some residents were enjoying communal games, some were watching television in the lounge and other residents were resting in their rooms watching their own TVs or listening to the radio. Residents are able to choose to have their meals in the dining room, lounge or privacy of their own bedrooms. The new terms and conditions inform the reader that suppertime is between 17.30pm and 18.30pm. This is not the case. Indeed one resident remarked that it could be a long time between supper and breakfast. The home currently serves suppers between 16.45pm and 17.00pm. Hot drinks and snacks are available to residents between supper and breakfast. However not all night staff may be relaying this information to residents. Trips to the nearby theatre are arranged and residents who are able to attend enjoy the shows. Due to the home’s proximity to the town centre, it is intended that some residents will be able to visit the forthcoming French Market, weather permitting. Residents recently enjoyed watching a religious Ashley Down Nursing Home DS0000061039.V340252.R01.S.doc Version 5.2 Page 13 festival procession from the nearby Sikh Temple. A particular favourite of residents is the motivation classes. Sadly because of the cost, this only happens once a month. The home employs an activities co-ordinator on a part-time basis. Since the last visit the activities co-ordinator has attended a specific course and is now trying to develop the activity programme further. Indeed gardening has just been introduced. If carers have an opportunity they now spend quality time with residents. Despite this provision two comment cards returned from residents both indicated there are sometimes activities arranged by the home that they can take part in. Dining room tables are laid out with cloths and fresh flowers. Special days including festivals, saint days and birthdays are now celebrated at the home and residents enjoy these occasions. Soft diets are catered for and are presented in an appetising manner. A dietitian was asked to review the home’s menus for expert advice and was happy with them. Verbal choices for lunches and suppers are available and the chef and or relief cook speak to residents on a daily basis to obtain this information. Residents are able to choose something else if they do not fancy either option. However there appeared to be some confusion about the availability of different supper choices in that the inference was that only one of the three choices could be chosen. The home manager said this is not the case and residents can have what they like from the menu. Sunday lunch is accompanied by a glass of wine if that is the residents’ wish. A full cooked breakfast is available one day a week and some residents take this option up. Generally residents were complimentary about their meals. Comments included “excellent dinners”; “lovely food here” and “very good meals here – have a choice”. Residents spoken with indicated their visitors are made welcome at any time. Religious services do not routinely take place at the home. However a religious visitor provides Holy Communion to those residents who wish to receive it on a regular basis. If there is a request for specific spiritual or religious support the home endeavours to arrange this. Ashley Down Nursing Home DS0000061039.V340252.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 and 18. Residents who use the service experience good outcomes. This judgement has been made using a range of evidence, including a visit to this service. Residents and or their advocates now know their concerns and niggles are listened to and acted upon. EVIDENCE: The home has a complaints logbook, which records details of complaints and action taken. However the manner in which the current book is maintained may jeopardise the confidentiality of residents. The home’s complaints procedure, which is displayed in the entrance vestibule and included information books kept in all bedrooms, has been amended to include the handling of verbal complaints. Residents are on the electoral roll enabling them to vote if that is their wish. The commission is unaware of any investigations having been carried out under the County’s Adult Protection procedures since the last visit. Residents spoken with indicated the action they would take if they were not happy about anything. During an interview with a healthcare assistant it transpired they had not yet received Adult Protection training. However they were able to demonstrate the action they would take if they had a suspicion of abuse. The training schedule produced in support of this visit indicates further Protection of Vulnerable Adults training is due to take place in October 2007. Ashley Down Nursing Home DS0000061039.V340252.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25 and 26. Residents who use the service experience adequate outcomes. This judgement has been made using a range of evidence, including a visit to this service. Further improvements to the environment will enhance the residents’ quality of life. EVIDENCE: The home’s improvement programme initiated by the provider has stalled. Following the provider’s acquisition of the home just over three years ago, improvements were made to the home including decorating communal rooms and installing a new nurse call system. However the last couple of visits have identified the poor decorative state of the reception room and many corridors around the home. Because of the width of some corridors, many doors have been contact damaged by wheelchair and or other equipment. An attempt was made to improve the situation. But the method of touching the paintwork up has actually made the situation worse. Quotes continue to be obtained so that the provider can authorise the work. The decorative state of the double bedroom is poor and gives an institutionalised appearance. Damage to the walls caused by the installation of the new call system in this room has yet to Ashley Down Nursing Home DS0000061039.V340252.R01.S.doc Version 5.2 Page 16 be completed. It was disappointing to see that the decorative state of the provider’s office in the basement, which is only used intermittently, is better than the bedroom, which is used by a resident on a daily basis. A book is kept recording work needing to be done by a maintenance person. The home does not employ a maintenance person and is reliant on the provider arranging this. The provider visits the home once or twice a week. However the arrangement does not guarantee that identified matters are dealt with as quickly as the home manager would always like, resulting in her sometimes having a go herself. The environmental health department of the borough council carried out an inspection of the home’s kitchen on the 25 April 2007. One legal requirement and two recommendations were made. Confirmation that the action required has been completed must now be sent to the Commission. The home has a secluded patio area. A gazebo has just been purchased so residents can sit out and enjoy the small gardens that surround the home. However shrubbery was overgrown in some areas giving a poor outlook for residents. Bedrooms are centrally heated for residents’ comfort. However at the last visit the comfort in the double bedroom was compromised because of window draughts. The home manager said the windows have been measured for secondary glazing. The provider intends to complete the installation by September 2007. The home was clean and odour free. Indeed a resident remarked that there are never any “horrible smells”. Staff should be complimented on the standard of cleanliness seen at the home, particularly as the home is not purpose built and does not lend itself to easy cleaning. Ashley Down Nursing Home DS0000061039.V340252.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Residents who use the service experience adequate outcomes. This judgement has been made using a range of evidence, including a visit to this service. The time afforded the home manager to carry out her management duties must be kept under review to ensure she is properly supported. Staff morale is better resulting in an enthusiastic workforce that works positively with residents to improve their quality of life. EVIDENCE: In addition to care staff, staff are employed for cooking, cleaning, laundry, administration and activities. Staffing levels generally follow the minimum requirements set by the original regulatory authority some years ago. The home manager has supernumerary time to carry out management duties. However because of the enormourity of the task she has faced in turning the home around, this time is not always sufficient, resulting in her working beyond her contracted hours. Indeed on the day of the visit she looked exhausted. During the last twelve months eight members of staff have left and seven have been employed. Additional staff are now rostered at lunch and supper times to support residents who require assistance with their meals. One member of the unregistered care workers is now trained to NVQ level II care. Two are currently working towards achieving the qualification. Since the last visit various members of staff have received training in subjects including infection control, fire training, moving and handling and pureed feeding. Subjects for future training include Parkinson’s disease, diabetes and sight training. These subjects reflect the current needs of some residents. Ashley Down Nursing Home DS0000061039.V340252.R01.S.doc Version 5.2 Page 18 Staff files inspected demonstrated procedures had been followed for the recruitment and appointment of staff. This includes obtaining relevant references, recording full employment histories and obtaining relevant Criminal Record Bureau clearance checks prior to staff commencing employment at the home. This is good practice. New staff undertake an initial induction programme, followed by an in-depth programme. Since the last visit the home manager has obtained information and a CD from the organisation Skills for Care. The home manager now intends to review and revise the current induction programmes to ensure they reflect the Skills for Care training requirements. Ashley Down Nursing Home DS0000061039.V340252.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36, 37 and 38. Residents who use the service experience adequate outcomes. This judgement has been made using a range of evidence, including a visit to this service. The home manager has a clear understanding of what needs to be done to improve the home and her continued commitment has had a positive effect on residents’ quality of life. However she is sometimes prevented in making and taking appropriate management decisions as quickly as she would like because of the current management structure of the home. EVIDENCE: The home manager is a registered nurse and is currently undertaking an NVQ level 4 management course. The home manager endeavours to keep her skills up to date by attending various training sessions. Under the home manager’s leadership there has been a noticeable improvement in how the home is operated. Staff spoke positively about their Ashley Down Nursing Home DS0000061039.V340252.R01.S.doc Version 5.2 Page 20 roles and the support provided by the home manager. The Commission no longer receives calls from concerned relatives and or advocates. Sadly the home manager is still reluctant to proceed with her fit person interview, which she is required to undertake for regulatory purposes. Residents and relatives meetings take place so their views of the home can sought. The home’s inspection report is now kept in the entrance vestibule for ease of access. The returned AQAA records that available policies and procedures were last reviewed in July 2006. The home manager intends to develop policies and procedures currently unavailable. The provider retains overall budgetary control for the running of the home, including authorising repairs and redecoration of the home. However where the home manager has the responsibility and there are limited financial implications, action is quickly taken to address requirements and recommendations identified in reports. There is currently no formal quality assurance programme in place. However since the last visit the provider has obtained “off the shelf” quality assurance manuals. It is intended that the provider and home manager, with external help, will implement a quality assurance programme in the home. The home is responsible for handling personal allowances for the majority of residents. Records are kept of all transactions made and receipts obtained. Residents and or their advocates receive quarterly statements of their individual accounts reminding them of their balances. There are some restrictions to this service and details are now included in the procedure for Residents’ Finances. A copy of the procedure is included in the information books kept in residents’ bedrooms. The home manager has introduced formal supervision, including observing clinical practice. College assessors also observe healthcare assistants in their practice. However it was identified on this visit that the home manager has not had an appraisal or received formal supervision from the provider since commencing employment in April 2006, although they do regularly meet. Records for residents and staff are securely kept. However it was noted on this visit the manner in which complaints are recorded may compromise the confidentiality of individual residents. The home has two separate sluice rooms, one on each floor. However it was identified on this visit that it has not been the home’s practice to keep these rooms locked when not in use, so as to prevent unauthorised access. Ashley Down Nursing Home DS0000061039.V340252.R01.S.doc Version 5.2 Page 21 The training schedule provided in support of this visit detailed staff having received fire training, food and hygiene, infection control and moving and handling. A member of staff is due to attend First Aid training later this month. Maintenance and service records contained up to date information. The passenger lift has just had a major service to check its safety. Ashley Down Nursing Home DS0000061039.V340252.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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 X X X X X 2 3 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 2 3 2 2 2 Ashley Down Nursing Home DS0000061039.V340252.R01.S.doc Version 5.2 Page 23 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 OP25 Regulation 23 Requirement Residents’ bedrooms must be kept draught free and adequately heated at all times. Partially met. The provider must develop an environmental improvement programme for the home. The plan must include specific dates and timescales. The requirement and recommendations identified by the environmental health report dated 25 April 2007 must be complied with within the specified timescales. The home manager must not be expected to regularly exceed her contracted hours in order to carry out management responsibilities properly. A formal quality assurance programme must be initiated. The provider must ensure that the home manager receives appropriate supervision and appraisals. Timescale for action 30/09/07 2 OP19 23 31/08/07 3 OP19 23 31/10/07 4 OP27 18 31/07/08 5 6 OP33 OP36 24 18 31/10/07 31/08/07 Ashley Down Nursing Home DS0000061039.V340252.R01.S.doc Version 5.2 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 6 7 8 9 10 11 12 13 Refer to Standard OP7 OP8 OP11 OP15 OP19 OP26 OP28 OP31 OP33 OP33 OP34 OP37 OP38 Good Practice Recommendations Moving and handling assessment must be complete of all known instructions. Bedrail risk assessments must include details of all contra indications. Care plans in respect of death and dying which include information in respect of residents’ spiritual and cultural preferences and needs. Residents should be consulted on the home’s current meal times. Maintenance support should be readily available at the home. Residents requiring hoist assistance should be provided with individual slings to minimise cross infections. Not discussed on this visit. 50 of care staff must be trained to NVQ level II care. The home manager must successfully complete the Registered Manager Award Course. Policies and procedures should reflect the subjects stated in the AQAA. A formal quality assurance programme should now be initiated to enhance the current arrangements. Budgetary arrangements should be reviewed to ensure the home manager has sufficient available funds to full fill her duties and responsibilities in a timely and proper manner. Records relating to residents must be kept individually. Sluice rooms should be kept locked when not in use to prevent unauthorised access. Ashley Down Nursing Home DS0000061039.V340252.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ashley Down Nursing Home DS0000061039.V340252.R01.S.doc Version 5.2 Page 26 - 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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