Inspection on 29/11/06 for Ashwood Care Centre

This inspection was carried out on 29th November 2006.

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

Ashwood Care Centre 03/11/08

Ashwood Care Centre 09/10/08

Ashwood Care Centre 19/05/08

Ashwood Care Centre 06/11/07

Ashwood Care Centre 12/07/05

Ashwood Care Centre 25/01/05

Ashwood Care Centre 19/01/05

Ashwood Care Centre 05/07/04

Ashwood Care Centre 30/09/03

Ashwood Care Centre 20/05/03

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Ashwood Care Centre 1a Derwent Drive Hayes Middlesex UB4 8DU Lead Inspector Mrs Clare Henderson Roe Key Unannounced Inspection 29th November 2006 10:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ashwood Care Centre DS0000010923.V319870.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. Ashwood Care Centre DS0000010923.V319870.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashwood Care Centre Address 1a Derwent Drive Hayes Middlesex UB4 8DU 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) 020 8573 1313 020 8573 1124 Life Style Care Plc Mrs Rosina Skelton Care Home 70 Category(ies) of Dementia - over 65 years of age (0), Old age, registration, with number not falling within any other category (0) of places Ashwood Care Centre DS0000010923.V319870.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 32 Elderly Frail, of which 24 beds are for nursing and 8 are personal care or nursing 15 Elderly Personal Care 23 Older people with dementia - personal care. Minimum Staffing notice. Date of last inspection 12th July 2005 Brief Description of the Service: The home is situated between Uxbridge and Hayes. It is made up of 4 units and can accommodate a total of 70 service users. There are 68 single rooms and one double room, all with en suite facilities. There are local shops, bank and post office facilities nearby. The Beck Theatre is near the home, as are local pubs and restaurants. The home can be accessed by bus and main line train services. There is a full time Activity co-ordinator and a planned and advertised programme of activities. Outings are also arranged. The hairdresser visits 6 times a month. The home has one GP practice and there are weekly visits to the home, and other healthcare services are accessed by the home for service users. A Devotional Meeting is held every two weeks and religious and clergy visits are arranged as required. The home has a Registered Manager, plus a Deputy Manager who is in charge of the training programmes for staff and also works as a registered nurse within the home. The Support Manager provides supervision of staff on the personal care units. The fees range from £394 to £820 per week, dependent on assessed need. Ashwood Care Centre DS0000010923.V319870.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the regulatory process. A total of 20 hours was spent on the inspection process. A tour of each unit was carried out, and service user plans, management records, training records, staff employment records, administration records, maintenance and servicing records were viewed. The CSCI pharmacist Inspector carried out a medication inspection on 12/12/06 and a separate report is available. The requirements and recommendations from the pharmacist inspection have been incorporated in this report. 16 service users, 14 visitors and 12 staff were spoken with as part of the inspection process. It must be noted that it is sometimes difficult to ascertain the views of service users with dementia care needs. The pre-inspection questionnaire and comment cards sent to the home prior to the inspection have also been used to inform this report. What the service does well: The home is being effectively managed. Service users and their representatives are provided with information about the home and encouraged to visit prior to admission, allowing them to make an informed choice. Written contracts of terms & conditions are in place. Information in respect of the service users care needs is well documented and kept up to date. Staff care for service users in a gentle, courteous and professional manner, respecting their privacy and dignity. End of life care is planned for and is being well managed. The activities provision in the home is varied, interesting and encompasses all the service users, and is commendable. The home has an open visiting policy and visiting is encouraged. Visitors spoken with said they are made very welcome at the home and offered refreshments. Information regarding advocacy services is freely available in the home. The food provision is good, offering variety and choice. There are robust systems in place for the management of complaints and POVA, and service users and visitors spoken with said that any concerns are promptly addressed. Overall the home is well maintained, providing service users with an attractive, homely environment to live in. Equipment is available to meet service users needs, to include moving & handling. The home is clean and fresh and there are good systems in place for infection control. The training provision in the home is good and incorporates induction training, health & safety, dementia care, NVQ in care and topics relevant to the needs of the service users and for the provision of effective care. There are good systems in place for quality assurance and for the management of any service users monies. Health & safety is being well managed in the home. Ashwood Care Centre DS0000010923.V319870.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. 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. Ashwood Care Centre DS0000010923.V319870.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 Ashwood Care Centre DS0000010923.V319870.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, 4 & 5. The home does not provide intermediate care. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and their representatives are provided with the information about the service, thus allowing them to make an informed choice about the home. Written contracts are in place, thus ensuring information regarding the homes terms and conditions are understood and agreed. Service users are fully assessed prior to admission to the home, to ascertain that the home is able to meet their needs. Staff have the skills to care for service users with specialist care needs. Service users and their representatives are encouraged to visit the home prior to admission, thus giving them the opportunity to make an informed choice. EVIDENCE: The home has a Statement of Purpose and Service User Guide. Both are available in the reception area, plus copies of the Service User Guide are also in each service users room. For some service user on the dementia unit these have been given to their representatives. The information is up to date and Ashwood Care Centre DS0000010923.V319870.R01.S.doc Version 5.2 Page 9 gives a good picture of what services the home provides. Some representatives spoken with said that they had been given or sent a copy of the Service User Guide prior to visiting the home, and others said that they had been made aware of the document and that it is available to them. The Borough of Hillingdon contracts the majority of the beds. Service users and/or their representatives are given or sent copies of the homes Terms and Conditions, which they sign a copy of and return it to the home. Several people spoken with were aware of this practice and had signed on behalf of their relatives. Contracts are also in place for privately funded service users. Pre-admission assessments were available in each of the service user plans viewed. These were thorough and gave a clear picture of the service users needs. The Registered Manager or the Residential Care Co-ordinator carry out these assessments and speak with the service user as a major part of the assessment. Copies of Social Services client assessments were also seen in some service users files. The home has a 23 bedded dementia care unit. The Residential Care Coordinator is in charge of this unit and has undertaken relevant dementia care training courses. Staff working on the unit had also received training in dementia care, providing them with the skills and knowledge to care effectively for the service users. The activities co-ordinator has also undertaken relevant training for service users with dementia care needs. Representatives spoken with said that they had been encouraged to visit the home prior to their relatives’ admission to the home, and some visits had been unannounced. They had been shown around the home and been able to ask questions regarding the care provision. It is acknowledged that it is not always easy for service users who are unwell in hospital or at home to visit prospective care homes. Ashwood Care Centre DS0000010923.V319870.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 & 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall the service user plans are well completed and maintained up to date, thus giving a good picture of the service users needs and how these are to be met. Medications are generally being well managed at the home, however some shortfalls need addressing to fully safeguard service users. Staff care for the service users in a gentle and courteous manner, thus respecting their privacy and dignity. Work is being done to enhance end of life care, thus ensuring service users needs and wishes in this area are respected and met. EVIDENCE: Service user plans were sampled on each floor. Overall these were up to date and gave a clear picture of the individual service users needs and how these were to be met. Risk assessments for falls had been carried out and all relevant documentation to include the risk assessment had been updated following any falls. Risk assessments had also been completed for any areas of risk identified. The service user plans had been reviewed monthly. Where a Ashwood Care Centre DS0000010923.V319870.R01.S.doc Version 5.2 Page 11 new need had been identified, new care plans had been formulated. There was evidence of input from service users and/or their representatives in the service user plans. One service user plan on the ground floor personal care unit had not been fully completed following an admission some 3 weeks previously. The need to ensure all documentation is completed promptly following admission was discussed. Wound care documentation was in place, and the progress of each wound had been clearly recorded. Audits of pressure sores and wounds are carried out. Pressure relieving equipment was seen in use in the home, and the specific equipment in use for each service user had been recorded in the service user plan. Nutritional assessments had been carried out and monthly weights recorded. Where a problem with a service users weight had been identified, the service user had been promptly referred to the GP. Moving & handling assessments were in place and identified the specific equipment required to assist individuals with their moving & handling needs. For service users with continence care needs, assessments and care plans were in place. For service users on the personal care unit receiving input from the District Nurse, this had been clearly cross-referenced in the service user plan. On the dementia care unit, reference to the service users mental health problem had been incorporated into the care plans for each need, however where a specific mental health problem had been identified, for example, challenging behaviour, a separate care plan had been formulated for this. There was evidence of input from the GP, Tissue Viability Nurse Specialist, Chiropodist, District Nurse and other healthcare professionals. On the first day of inspection the Inspector viewed the medication management on the ground floor units. Some shortfalls were identified, and as a result a full audit by a CSCI Pharmacist Inspector was requested. This was carried out on 12/12/06 and a separate report is available. The requirements and recommendations resulting from that inspection have been incorporated into this report. The abbreviation ‘MAR’ stands for medication administration record. Staff were seen caring for and conversing with service users in a courteous, gentle and professional manner. Service users spoken with said that they were being well cared for at the home. Service users clothing is individually labelled, and service users were well dressed, showing individuality. Service users can bring in personal possessions in line with fire safety. The home has introduced documentation in line with the ‘Gold Standard Framework’ for end of life care. This enables service users and their representatives to discuss and agree the care the service user would like during their final days, and this is recorded. This documentation can be updated at any time, and provides staff with clear information as to the wishes of the service user and their families. Ashwood Care Centre DS0000010923.V319870.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 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The activity input for the home is good and incorporates the interests of the service users, thus ensuring their individual wishes are respected. The home has an open visiting policy, thus encouraging service users to maintain contact with family and friends. Advocacy arrangements are in place, thus ensuring the service users rights and opinions are heard and respected. The food provision in the home is good, offering variety and choice, to meet the service users needs. EVIDENCE: The home has a full time activities co-ordinator. There is a wide range of activities provided and it was clear from speaking with service users and their visitors that the activities provision is good and varied, and caters for service users needs. Activities are offered to all service users, to meet their interests and abilities. Should a service user choose not to join in a specific activity, their wishes are respected. The activities programme is on display in the home, and an additional list of many activities and events taking place over the festive season was also on display. Care plans for social and leisure interests had been completed and were individualised. The home has recently introduced a new document to record each service users life history. Some had Ashwood Care Centre DS0000010923.V319870.R01.S.doc Version 5.2 Page 13 been completed, either with the service user or by their representatives. These provide staff with an insight into the service users past. The activities coordinator has great enthusiasm for her work, and service users benefit from outings, entertainments and activities to meet their own interests. The home has an open visiting policy and visiting is encouraged. If visitors wish to visit very early or late in the day, then the home ask that they ring ahead and inform them for security purposes. Visitors spoken with said that they are made very welcome at the home and representatives spoken with said that they are kept up to date with any relevant information. The home has information on display in the reception area for two advocacy services, Age Concern and RETHINK. Some service users do have input from advocacy services and these can be accessed freely. The home has a 4 week menu with choices available. Service users spoken with generally expressed satisfaction with the food provision and said that they are offered a choice. Food in the kitchen was being appropriately stored and there was evidence of stock rotation. Fridge, freezer, food delivery and cooking temperatures were being recorded. The Inspector discussed food preparation to meet the needs of service users requiring pureed or soft diets, and it was clear that this is carefully considered during the preparation process. Records of each service user choice for all 3 meals are kept. Snacks are provided overnight, and the specialist needs of service users who are awake and wandering during the night had been considered and appropriate snacks provided. The Inspector sampled the lunchtime meals and these were tasty and well presented. Staff were available to assist service users with their meals where required, and were conversing well with service users. Ashwood Care Centre DS0000010923.V319870.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 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has clear complaints procedures in place to address any concerns raised by service users and their visitors. There are robust systems in place for the safeguarding of service users from abuse EVIDENCE: The home has a complaints procedure, copies of which were available in the Service User Guide and also on display in the home. The home had received 14 complaints since the last inspection and these had been clearly documented and responded to. All concerns raised, however minor, are recorded in the complaints register. Service users spoken with said that if they had any concerns they could speak with the manager or staff, and representatives asked said that they were aware of the homes complaints procedure, and that any concerns raised had been addressed promptly. The home has an Adult Protection procedure in place and this dovetails with the London Borough of Hillingdon Safeguarding Adults documentation. Staff had received training in Safeguarding Adults, and those asked were very clear to report any concerns of this nature. The home has had 4 safeguarding adult allegations since the last inspection. Appropriate action had been taken to report, investigate and manage each allegation. Ashwood Care Centre DS0000010923.V319870.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, 21, 22, 24, 25 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was purpose built and overall is well appointed and maintained, thus providing a clean and homely environment for service users to live in. Communal rooms are available on each unit, providing the service users with a choice of venue. Equipment in the home is available to meet the service users needs, thus providing for the service users needs. Clear infection control procedures are in place and being adhered to, thus safeguarding service users. EVIDENCE: The Inspector carried out a tour of the home. There was evidence of redecoration and refurbishment having taken place, for example re-carpeting and redecoration of the second floor corridors, and an ongoing programme is in place. There had been recent replacement of the central heating pipes, and as a result some additional areas have been identified for redecoration, to include bathrooms. The Registered Manager said that the programme was to be updated to reflect this. In the kitchen two issues were noted, one being a Ashwood Care Centre DS0000010923.V319870.R01.S.doc Version 5.2 Page 16 patch of flooring that has been a long standing problem, and the other being an area on the wall in the dry store where the plaster has lifted due to a damp problem. These shortfalls need to be addressed. There are communal rooms on each unit, for dining and sitting. There was evidence some areas had been redecorated and also of some refurbishment. These rooms are homely and provide service users with choices as to where they would like to spend their time. There are assisted bath, shower and toilet facilities on each unit. On the ground floor one problem has been identified with meeting the needs of one service user in this area, and this needs to be addressed. Also, one of the assisted baths required work to remove lime scale and make good a large chip in the enamel. Toilet facilities are available near the communal rooms, and each bedroom has en suite facilities. Rails are in place in all corridors. Grab rails were also seen for the assisted toilet facilities. The home has a selection of moving & handling hoists and equipment to meet the individual needs of the service users, and the equipment to be used is identified in each service users plan. Apart from one double room, all the bedrooms are single. Those viewed had been personalised and the furniture provision was of good quality. Adjustable beds are provided for all service users with moving & handling needs. The home was pleasantly warm throughout. New pipes have been put in for the central heating system. Water temperatures are checked regularly to include storage temperatures, and where any shortfalls are found adjustments are made. Lighting was satisfactory throughout. The laundry was clean and tidy. Good Laundry Practice information was on display. The washing and drying machines are industrial, and the washing machines have sluice programmes incorporated. Protocols were in place for the management of infection control. The home was clean and smelled fresh throughout. Hand washing facilities are available in all areas where service users, staff and visitors may require to wash their hands. Electronic disinfection units are available in each sluice room. Ashwood Care Centre DS0000010923.V319870.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 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is appropriately staffed to ensure that the needs of the service users can be met, and this is kept under review. Systems for vetting and recruitment practices are in place and protect service users. There is a comprehensive ongoing training programme, providing staff with the skills to meet the needs of service users. EVIDENCE: Staffing rosters were available for each unit and for the kitchen and ancillary staff. Overall the home is appropriately staffed to meet the service users needs, however due to an increase in some service user dependencies on the ground floor personal care unit, staff are currently very busy on this unit. The Registered Manager was aware of this and is arranging for re-assessments of the service users concerned, plus was looking to take appropriate action to ensure all service users needs could be met during this period. Agency staff are used on occasion, and the Registered Manager said that they do not have any problems getting cover when required. Just under 50 of the care staff are qualified to NVQ level 2 or 3, or have an equivalent qualification. 10 more staff are commencing NVQ in care training in Ashwood Care Centre DS0000010923.V319870.R01.S.doc Version 5.2 Page 18 the near future. The Registered Manager was very aware of the need for 50 or more of all staff providing care to obtain such a qualification. Employment records for 3 new members of staff were viewed. With the exception of photographs, these contained all the information required under the Care Homes Regulations 2001. In one instance it had been difficult to obtain a reference from the previous employer due to a change in management, however the Registered Manager said that she would continue to pursue this. For two of the staff POVA First checks had been obtained and clear Criminal Records Bureau checks were being awaited. The staff concerned work under supervision until the Criminal Records Bureau check is received. The training records evidence a good provision of training, both in house and also via external training facilities. The induction and foundation training for new care staff covers the Skills for Care common induction standards. Ashwood Care Centre DS0000010923.V319870.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, 33, 35 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Manager has the qualifications and experience to manage the home, and does so effectively. Systems for quality assurance are in place, thus providing an ongoing process of system and practice review. Service users monies are well managed and securely stored. Systems for the management of health and safety throughout the home are good, thus safeguarding service users, staff and visitors. EVIDENCE: The Registered Manager is a first level registered nurse with extensive management experience, and has obtained the Registered Managers Award, NVQ level 4 in management. She has undertaken periodic updates in topics relevant to the needs of the service users and to her role. Staff spoken with said that the Registered Manager is approachable and very supportive. Ashwood Care Centre DS0000010923.V319870.R01.S.doc Version 5.2 Page 20 There are in place very clear systems for quality assurance. This includes an annual audit of the home in line with the National Minimum Standards for Older People, with an action plan to address any shortfalls identified. Regulation 26 visits are carried out monthly and a copy of the reports forwarded to CSCI. Regular staff meetings take place with minutes taken. Weekly tea afternoons are held for service users and their relatives and the Registered Manager operates an ‘open door’ policy. Service users and visitors spoken with said that the Registered Manager is very approachable and any points raised are addressed promptly. Records of the service users monies held by the home were sampled. Small amounts of money are held for some service users, and for 2 service users more significant amounts are held due to the lack of any family to take responsibility for them. Clear computer and written records are maintained for all income and expenditure. Interest is paid on monies accrued. The records viewed were up to date and accurate. Safe facilities are available, and service users have a lockable space in their rooms provided. The maintenance and servicing records were sampled and those viewed were up to date. Data provided by the home showed that all servicing had been carried out and was up to date. The maintenance check records are comprehensive and evidence regular, thorough checks of equipment and systems had been carried out. Staff had received training in health & safety topics, and this is tracked on an ongoing basis to ensure all staff stay up to date with this training. Risk assessments were in place for all equipment and safe working practices, and those specific to the kitchen and laundry were available in those areas. Fire drill training records evidenced that regular drills are carried out, and the need to ensure that these drills incorporate all staff at the required intervals was discussed with the Registered Manager. Overall health & safety is being well managed at the home. Ashwood Care Centre DS0000010923.V319870.R01.S.doc Version 5.2 Page 21 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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 2 3 X 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Ashwood Care Centre DS0000010923.V319870.R01.S.doc Version 5.2 Page 22 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 OP7 OP9 Regulation 17 13(2) Requirement The service user plans must be completed promptly following admission. Medications must be signed for at the time of administration. Where a medication is omitted, the reason for omission must be clearly identified. Previous timescale 20/01/06 not met Fridges must be regularly defrosted and be maintained between 2 and 8 degrees. Records must be made daily Verbal orders must be clear and signed and dated The homes local medication policy must be updated to reflect the current pharmacist supplier and ordering process. The MAR charts must be checked and be accurate and correlate with labels on medication and prescriptions. If a resident is self-medicating then this must be clearly stated on the MAR. Continuous supplies must be maintained The kitchen flooring and area of plaster damage in the kitchen DS0000010923.V319870.R01.S.doc Timescale for action 22/12/06 20/12/06 3. OP9 13(2) 27/12/06 4. 5. OP9 OP9 13(2) 13(2) 27/12/06 01/02/07 6. OP9 13(2) 20/12/06 7. OP19 23(2)(b) 30/04/07 Ashwood Care Centre Version 5.2 Page 23 8. OP21 23(2)(j) & (n) 17 9. OP29 must be made good. There must be assisted toilet facilities to meet the needs of all service users accommodated at the home. Staff records must include all the information required under Schedule 2 of the Care Homes Regulations 2001. Previous timescale of 17/02/06 not met. 31/07/07 01/01/07 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. Refer to Standard OP9 OP9 OP38 Good Practice Recommendations The pharmacist should be requested to update the MAR and delete duplicate and discontinued items. A review of medication management and the appropriate support should be considered on the ground floor residential unit. It is strongly recommended that an of all staff attending fire drills be carried out so that the Registered Manager can ensure all staff on day and night duty have attended fire drills at a frequency in line with Fire safety requirements. Ashwood Care Centre DS0000010923.V319870.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection West London Area Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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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