Inspection on 23/07/07 for Ashurst Park Care Home

This inspection was carried out on 23rd 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

Ashurst Park Care Home 17/05/06

Similar services:

The Shelley

Springfield House

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 Ashurst Park Care Home Fordcombe Road Fordcombe Tunbridge Wells Kent TN3 0RD Lead Inspector Elizabeth Baker Key Unannounced Inspection 23rd July 2007 9:55 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 Ashurst Park Care Home DS0000066424.V345742.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. Ashurst Park Care Home DS0000066424.V345742.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashurst Park Care Home Address Fordcombe Road Fordcombe Tunbridge Wells Kent TN3 0RD 01892 709000 01892 709053 ashurst.park@fshc.co.uk www.fshc.co.uk Four Seasons (DFK) Limited (wholly owned subsidiary of Four Seasons Health Care Limited) Post Vacant Care Home 53 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) Category(ies) of Old age, not falling within any other category registration, with number (53) of places Ashurst Park Care Home DS0000066424.V345742.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Care to be provided to 3 named older people with a diagnosis of dementia (details of the named people held at the CSCI office in Maidstone) 17th May 2006 Date of last inspection Brief Description of the Service: Ashurst Park Care Centre provides care for up to 49 older people who need nursing care. The home is purpose built on two floors, has disabled access and a 13-person passenger lift between the floors. There is one room, which can be used for shared occupancy. The home is situated in large park like gardens, which are accessible by residents. The home is situated in a rural area, approximately half a mile from the village of Fordcombe and three miles from Tunbridge Wells. Infrequent bus services pass at the end of the drive. Car parking is available to the front of the building. The home has a large lounge with separate dining room on the ground floor with a small lounge/dining area on the first floor. A small bar is provided on the ground floor. Bedrooms on the ground floor have ensuite facilities. All rooms used by residents are connected to the nurse call system. There is a separate physiotherapy room. Fees currently range from £459.20 (sponsored) to £950 (private) per week, depending on need and type of bedroom. These fees are exclusive of hairdressing, chiropody, physiotherapy and newspapers/magazines. The current availability of activities includes external entertainers, armchair exercises, religious services and manicuring/grooming. Ashurst Park Care Home DS0000066424.V345742.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 23 July 2007. The visit lasted nine hours. As well as touring the home, the visit consisted of talking with some residents and staff. Six residents, two visitors and two members of staff were interviewed in private. Feedback of the visit was provided to the registered manager. The visit took place prior to the statutory return date of the home’s completed Annul Quality Assurance Assessment (AQAA). No comment cards were received by the Commission at the time of compiling this report. Because of this evidence from these sources has not been used on this occasion. At the time of the visit, 39 residents requiring nursing care were residing at the home. Since the last visit, the Commission has not received any formal complaints about the service. However the Commission was informed of one complaint made directly to the home, which was appropriately investigated. What the service does well: What has improved since the last inspection? All residents are now provided with terms and conditions of staying at the home, promoting equality. The refurbishment of the reception, lounge, dining room, sitting/dining room and corridors has greatly improved the home’s environment for residents to enjoy. The two new refurbished bedrooms provide the occupants with superior accommodation. Although meals do not yet meet all residents’ expectations, some residents have noted an Ashurst Park Care Home DS0000066424.V345742.R01.S.doc Version 5.2 Page 6 improvement. The home now has a special mini bus and designated driver, which should enable more residents to go on external trips. Regular supervision of staff is now taking place, which should help to ensure that staff are appropriately supported in their respective roles. A new method of handling residents’ personal allowances has been introduced, making it safer and fairer for residents using this service. The home manager is receptive to advice given and is eager to address shortfalls identified by visits carried out at the home by different regulatory agencies. The handling of complaints has improved reassuring complainants their concerns are treated appropriately. 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. Ashurst Park Care Home DS0000066424.V345742.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 Ashurst Park Care Home DS0000066424.V345742.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): 1, 2, 3 and 6. Residents who use the service experience adequate quality outcomes. This judgement has been made using a range of evidence including a site visit to this service. Not all residents can be sure their complete needs and expectations will be meet. EVIDENCE: All residents are now provided with a contract of terms and conditions of residence setting out the rules and responsibilities of both parties of staying at this home. Since the last visit a new colour brochure has been produced. This gives prospective residents some insight into the home’s current environment. Included are pictures of two bedrooms, inferring this is the standard of all bedrooms. Sadly this is not the case. This situation may unwittingly mislead prospective residents. The accuracy of brochures is important because not all residents are in a position to actually visit the room to be occupied prior to admission. Ashurst Park Care Home DS0000066424.V345742.R01.S.doc Version 5.2 Page 9 Prospective residents are normally assessed in their current place of occupation prior to a decision of admission being made. Senior nursing staff carry out the assessment visits. The organisation has produced a comprehensive document which staff are expected to use to record all the information gathered at these visits. The purpose of this is to determine whether the needs of residents can be met at the intended home and to inform the corresponding care plan. However not all assessments are completed as is required and do not provide a comprehensive picture of residents complete needs and wishes. The home is not registered for intermediate care. Standard 6 is not applicable. Ashurst Park Care Home DS0000066424.V345742.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 adequate quality outcomes. This judgement has been made using a range of evidence including a site visit to this service. The health and personal care needs of residents are generally met with evidence of multi-disciplinary working taking place on a regular basis. However documentation in support of this is lacking, potentially placing some residents at risk. EVIDENCE: All residents have a plan of care and three were inspected. The home has a range of clinical risk assessments, such as skin integrity (Waterlow), wound charts, pain, nutrition, continence, moving and handling, falls and general risk assessments. These are available to be used to monitor the effectiveness of treatment plans, where there is an assessed need. Whilst acknowledging that the organisation has just issued new care records for the home to complete, the available care records did not adequately evidence that all needs had been assessed and plan components composed. As stated previously some admission assessments were incomplete. The moving and handling and falls risk assessment for a newly admitted resident had not been completed despite there being a need. For a resident involved in two injury incidents the Ashurst Park Care Home DS0000066424.V345742.R01.S.doc Version 5.2 Page 11 corresponding bedroom assessment and general risk assessment had not been updated to reflect the potential hazards. Nor had the fact that an unguarded very hot radiator also presented a potential hazard to this resident. Residents are supported in self-administering medicines. However where this is no longer the case, this does not always trigger a re-write of the resident’s care plan. Where pain is a problem to a resident, not all records contain a pain care plan or accompanying pain assessment. Progress notes are used to monitor the daily condition of residents’ quality of day, including health, personal and social care. While some care staff recorded useful information, others did not. Care staff are required to cross reference numbers on the progress notes to the respective care plan components. However in one particular case staff were commenting on care being delivered to care plan components, which had not yet been written. Some nursing staff use Latin terms and abbreviations on residents care records, which is contrary to their professional body’s guidance on record keeping. Some information was difficult to read because of the poor handwriting. The care plans inspected did not evidence they had been composed with input from the resident and or their advocate. The home has a clinical room in which medicines, nursing aids and sundries are stored. The security of the room is currently compromised because of an unscreened glass door panel. Regular temperature checks of the drug fridge and room are taken and recorded, which should ensure medicines are stored in accordance with manufacturer’s instructions. Waste medicines are disposed of in accordance with regulations affecting care homes providing nursing care. Residents who self-medicate keep some of their medicines in their own bedrooms. In one case an expired use by date preparation was seen, together with a sundry item, which had been prescribed for another person. This room does not contain lockable facilities for such items to be securely stored. The bedroom risk assessment made no mention of the potential hazards of this situation. A stock of dressings and other nursing sundries were also stored in this bedroom, reducing the available useable space for the resident’s personal items. Nursing sundries were also seen in an en-suite room of another bedroom. The en-suite room was not in a “clinical” condition due to a recent leak and resulting damp. Residents said staff treat them with respect when assisting them with personal hygiene needs. Treatments are carried out to residents in the privacy of their own rooms. The home has a separate hairdressing salon, which is much appreciated by residents. Care records inspected still did not contain details of residents’ spiritual and cultural preferences and wishes in respect of death and dying. The home manager recognises the importance of having this sensitive but vital information and is now taking steps to obtain this. Ashurst Park Care Home DS0000066424.V345742.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 quality outcomes. This judgement has been made using a range of evidence including a site visit to this service. Meals and activities offer both choice and variety. Although not all residents are totally satisfied with the quality of some aspects of their meals, the home is actively striving to improve the situation. EVIDENCE: The flexible routines enable residents who enjoy mixing to participate in communal activities, while others prefer the privacy of their own rooms. Some residents are involved in preparations for the forthcoming fete. Since the last visit the activities co-ordinator has left. However interviews are about to take place to find a suitable replacement. Because of the current situation, the usual range of activities has been reduced, but a carer has expressed an interest to provide limited activities until a replacement activities coordinator is in post. Entertainment already arranged with external providers, is still going ahead, including talks about the surrounding areas. Visitors were seen coming and going during the visit. Residents said their visitors are made welcome and come at any time. Some visitors have their meals at the home with their friends/relatives. There is a charge for this. Religious services are held weekly at the home for residents to participate in if that is their wish. Ashurst Park Care Home DS0000066424.V345742.R01.S.doc Version 5.2 Page 13 Bedrooms visited had been individualised with personal possessions. However not all the care records had property details, which could present a problem if an item went missing. Since the last visit two new chefs have been employed. Menus offer a choice of lunch and suppers and residents spoke positively about the breakfast choice and previous Sunday lunch. Residents are provided with daily menus and a member of the hospitality staff speaks to each resident to seek their choice. The home has also received an audit from the organisation’s new Executive Chef/Food Safety Manager. This resulted in the home being congratulated. However despite this not all residents are totally satisfied with their meals, particularly the quality of some of the meat. Residents are able to choose where to eat their meals. Dining room tables had been nicely laid in preparation of the lunchtime meals. Some residents take the opportunity to have aperitifs before their main meal. Ashurst Park Care Home DS0000066424.V345742.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 and 18. Residents who use the service experience good quality outcomes. This judgement has been made using a range of evidence including a site visit to this service. The home has a satisfactory complaints system with evidence that residents feel their views are listened to and acted on. EVIDENCE: The home has a complaints procedure, which is displayed in the main reception on the ground floor. A copy is also displayed on the first floor. All types of complaints are now recorded. The system of recording complaints is in the process of being computerised, which should allow for easy auditing of complaints and subsequent action taken. Residents and visitors spoken with indicated what they would do if they had a concern. The Commission has not received any direct formal complaints about the home since the last visit. However the Commission was copied into a complaint, which the provider investigated to the complainant’s satisfaction. Staff demonstrated the appropriate action they would take if they had a suspicion of abuse. Training details provided at the visit indicates that staff have received Protection of Vulnerable Adult training. Ashurst Park Care Home DS0000066424.V345742.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, 20, 22, 24 25 and 26. Residents who use the service experience adequate quality outcomes. This judgement has been made using a range of evidence including a site visit to this service. Whilst recognising the environmental improvements made to communal areas of the home since the last visit have had a positive effect for residents, further investment in refurbishing bedrooms will improve the environment for all residents. The level of cleaning needs to improve to minimise infection control risks to residents. EVIDENCE: An environmental health inspection was carried out at the home in March 2007. This resulted in a number of recommendations being made. The home has subsequently addressed the matters. The home is surrounded by park like grounds. However it was again noted that some of the paved footpaths are potentially hazardous to residents and visitors, because of covering of moss/weeds, particularly in wet/damp conditions. It is proposed that the home will be landscaping an unused area in Ashurst Park Care Home DS0000066424.V345742.R01.S.doc Version 5.2 Page 16 the near future, which should provide increased outside facilities for residents. Some residents enjoy spending time outside, weather permitting. During conversations with some relatives it was identified that there is no device for residents to use when sitting in the garden to summon assistance. Since the last visit communal areas of the home have been totally refurbished. This certainly has improved first impressions to the home. Residents are very pleased with the changes made to the lounges and dining room. Sadly the scratched condition of many doors throughout the home detracts from the environmental improvements in corridor areas. Many bedrooms require redecorating. Carpets in some of these rooms are stained and give a dirty appearance. The ceiling in one particular bedroom needs repairing, as plaster is about to drop off. At this visit it was noted that because of lack of storage space, equipment and nursing sundries are being stored inappropriately. This included a resident’s bedroom and the en suite of another’s resident’s bedroom. As part of the home’s improvement plan a bathroom is being refurbished, including the installation of a new assisted bath. The home has a range of hoists to assist staff in safely transferring and lifting residents where there is an assessed need. Corridors are wide and fitted with handrails enabling residents to move independently around the home. The home has a limited range of pressure relief/preventative equipment, which is provided to residents on an assessed needs basis. A rubber ring was seen in a sluice room. The provision of such equipment for pressure relief/preventative purposes is now considered poor practice. To minimise scald risks to residents, regular testing of hot water outlets used by residents is carried out and the findings recorded. The majority of heating appliances in use are adjusted to minimise burn risks to residents. However as stated previously, a very hot unguarded radiator was discovered in a particular en-suite room, potentially placing the resident at risk. No unpleasant odours were noted at this visit. Generally the home was seen to be in a clean condition. However the level of detail in some areas was below that expected of a care home providing nursing care. Dusty wheelchairs were seen in a number of bedrooms; spillages were seen on walls around washbasin areas in some bedrooms and the kitchenette on the first floor and dirty bedside bumpers were seen in one room. The home has designated sluice rooms for the safe and hygienic disposal of bodily waste. However the poor decorative state of these rooms does not allow for effective cleaning to minimise cross infection risks. In one room the route to sluicing facilities was impeded because of the number of commodes chairs being stored. It was also noted on this visit that sluice room doors are not lockable to prevent unauthorised access when not in use. This presents potential risks to some residents and young visitors. The home has an appropriately equipped laundry. The laundry is also used as a thoroughfare for staff in accessing the outside break area. On entering the laundry the room was unattended and Ashurst Park Care Home DS0000066424.V345742.R01.S.doc Version 5.2 Page 17 the back door was left wide-open, allowing unauthorised access into the home. This is despite a notice on the door requiring staff not to leave the door open. Ashurst Park Care Home DS0000066424.V345742.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Residents who use the service experience good quality outcomes. This judgement has been made using a range of evidence including a site visit to this service. Residents are cared for by appropriate numbers of care staff. The home’s recruitment and appointment of staff procedures should ensure residents are protected. EVIDENCE: In addition to care staff, staff are employed for administration, reception, cooking, cleaning, laundry, maintenance and transport. Gardens are attended to on a contractual basis. Staff were seen carrying out their duties in an unhurried manner. A number of care records contained dependency assessments, which should assist the home manager in determining staffing levels to meet the assessed needs of the current residents. Residents indicated that staff usually respond to their calls for assistance without too much delay. Currently 21 of unregistered care staff are trained to NVQ level II care or equivalent. This is disappointing as there is an expectation that by now at least 50 would have been. Staff interviewed described their recruitment and appointment experience. This included attending interviews, providing ID evidence, completing forms, and obtaining Criminal Record Bureau clearance before commencing working at the home. This is good practice and should assist in minimising potential risks to residents. Ashurst Park Care Home DS0000066424.V345742.R01.S.doc Version 5.2 Page 19 As part of the home’s initial induction programme, new staff are required to undertake mandatory training, including fire and health and safety. This then leads to a more in-depth induction programme, which continues as long as is required. Staff are provided with and keep workbooks to record the evidence. Subjects cover POVA, infection control, customer care and communication. Not all staff have received communication training. This is an important issue. Indeed an incident where communication had failed was described to the inspector during the visit. Staff receive other training in support of their individual roles and responsibilities, including palliative care, wound care, pressure ulcer care, venapuncture and safe administration of medication. Ashurst Park Care Home DS0000066424.V345742.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37 and 38. Residents who use the service experience adequate quality outcomes. This judgement has been made using a range of evidence including a site visit to this service. The home reviews aspects of its performance through a programme of selfreview and consultations, which include the views of residents and their relatives/advocates. The management of the home is satisfactory overall but records are not well maintained placing residents potentially at risk. EVIDENCE: The home manager has been in post for just over a year. The home manager is a registered nurse, has a Diploma in Social Sciences and a BA Hons (Professional Education). The home manager expects to commence on the Registered Managers Award course next month. Ashurst Park Care Home DS0000066424.V345742.R01.S.doc Version 5.2 Page 21 Residents and staff indicated that the home manager is readily available and approachable. Residents and staff meetings are facilitated, enabling views and opinions of the service to be aired and discussed. The provider recently undertook a satisfaction survey. The results are available on request at the home. The provider has introduced a quality assurance programme, which the home has to follow. The provider’s representatives monitor the progress and compliance through their regular visits to the home. A new system has been introduced for the handling of personal monies on behalf of residents. This is a safer and fairer system and residents and or their advocates have been informed of the changes. Staff supervision now takes place and staff responsible for this have received supervisory training. While acknowledging that care records are about to be changed, residents’ records in use were not of a standard to provide comprehensive and up to date information to demonstrate all needs, risks and preferences had been assessed and recorded. This is disappointing as training details provided in support of this visit indicated that some care staff have attended care planning and documentation courses. As stated previously, residents and or their property are potentially at risk because some staff do not always take the necessary precautions, even though there are some instructions for them to do so to keep the home secure. Despite the home having a range of risk assessments, these are not always appropriately used for the benefit of residents. This includes bedroom, moving and handling and falls risk assessments. The home’s equipment is regularly checked, serviced and maintained in accordance with manufacturers’ guidance. Since the last visit six staff have attended first aid training and another two are due to do the training. Ashurst Park Care Home DS0000066424.V345742.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 2 3 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 X 2 X 2 2 2 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X 3 3 2 2 Ashurst Park Care Home DS0000066424.V345742.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 2 Standard OP3 OP7 Regulation 14(1) 15 Requirement Full details of information gathered at pre admission visits must be properly recorded. Care plans must be complete of all assessed needs; Care plans must be composed and reviewed with input from residents, if they so wish to be involved, and their signatures obtained. Timescale 31/07/06 not met. Facilities for the storage of medicines must be secure and hygienic; Residents must not receive preparations which have exceeded the use by date; Residents must not receive treatments from equipment prescribed for other people. Care plans must be complete of wishes and preferences in respect of death and dying. Timescale 31/08/06 not totally met Contact damage to doors and doorframes in resident areas must be made good. Timescale 30/11/06 not met. DS0000066424.V345742.R01.S.doc Timescale for action 30/09/07 30/09/07 3 OP9 13 31/07/07 4 OP11 12 31/12/07 5 OP19 23 31/12/07 Ashurst Park Care Home Version 5.2 Page 24 6 OP25 13 7 8 OP26 OP37 13 17 9 OP38 13 10 OP38 13 All heating appliances in areas used by residents must be protected to minimise potential risks to residents. The level of cleaning throughout the home must improve to minimise infection control risks. All care records must be maintained in a way to provide a complete picture of the residents’ current assessed needs/wishes, as well as evidence of care actually being delivered. Potential risks to residents must be assessed, properly recorded and made available when there is an assessed need. Residents and or their property must not be put at risk. 31/07/07 31/08/07 30/09/07 15/08/07 31/07/07 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 Refer to Standard OP1 OP8 OP9 OP24 OP12 OP19 OP19 Good Practice Recommendations Published information about the home must reflect the actual situation so as not to unwittingly mislead prospective residents and their advocates. Pressure sore prevention aids must be appropriate to the assessed need. Pain assessments must be provided for residents assessed as needing them. Residents who self-medicate must be provided with appropriate facilities in their rooms for safe storage. Full details of residents’ social interests are sought and recorded. Confirmation that the home’s fire risk assessment complies with the requirements of the Fire Officer must be sent to the Commission, when available. Paths and patio areas must be kept clear of moss and weeds. DS0000066424.V345742.R01.S.doc Version 5.2 Page 25 Ashurst Park Care Home 8 9 10 11 OP22 OP22 OP28 OP31 Excess nursing sundries should be appropriately stored, so not impinge on residents’ storage facilities. A system must be devised allowing residents to summon help when using the gardens. 50 of unregistered care staff must be trained to NVQ level II care. The manager must attain an appropriate management qualification to NVQ level 4 or equivalent. Ashurst Park Care Home DS0000066424.V345742.R01.S.doc Version 5.2 Page 26 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. 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