Inspection on 06/11/07 for Ashwood Care Centre

This inspection was carried out on 6th November 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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 29/11/06

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 10:15a 6 & 7th November 2007 th 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.V351054.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.V351054.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 ashwood@lifestylecare.co.uk www.schaelthcare.co.uk Southern Cross (LSC) Ltd 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.V351054.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 29th November 2006 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 Manager Designate, 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 fees range from £394 to £820 per week. Ashwood Care Centre DS0000010923.V351054.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 31 hours was spent on the inspection process. Two CSCI Regulation Inspectors and a Pharmacist Inspector carried out the inspection. A tour of the home was carried out, and service user plans, management records, training records, staff employment records, administration records, maintenance and servicing records were viewed. 18 residents, 20 staff and 3 visitors were spoken with as part of the inspection process. The pre-inspection Annual Quality Assurance Assessment (AQAA) document completed by the home has also been used to inform this report. Comment cards for residents, staff, visitors, healthcare professionals and care managers were sent to the home 2 weeks prior to the inspection. Due to a delay in these being given out these had not been returned to CSCI at the time of the inspection, and only 4 have been received following the inspection. Comments have been reflected in general terms. What the service does well: What has improved since the last inspection? What they could do better: Ashwood Care Centre DS0000010923.V351054.R01.S.doc Version 5.2 Page 6 The Service User Guides throughout the home need to be kept up to date so that current information is available. Although staff have worked hard to implement the Southern Cross Healthcare plc care plan documentation, a lack of training has meant that some issues were identified. Shortfalls have again been identified with the medication management and further work is required in this area to ensure that in future medication management is robust and records accurately maintained. Limited information was available for the wishes of residents and their representatives in respect of end of life care. The hours provided for activities throughout the home need to be reviewed to ensure the needs of the residents are being met in this area. In addition, information regarding the budget for the provision of activities, outings and entertainments was not known and has led to a reduction in provision in this area due to a lack of funds. Although the home has a clear complaints procedure this was not always being followed and some information regarding complaints made was not available. Some areas of the home are beginning to look shabby and the home is in need of a full environmental audit from which a redecoration and refurbishment programme can be drawn up. Overall infection control was being managed, however one issue regarding appropriate methods of washing up crockery and cutlery was identified and needs to be addressed. Significant shortages in the staffing were noted, and staffing rosters are not being accurately maintained. Shortfalls were identified in staff training to include care planning, topics relevant to the diagnoses and needs of the residents and areas of health & safety training. The home changed ownership in February 2007 and since then there have been 2 changes in management, and this has all contributed to staff becoming unsettled and low staff morale. The information in the CSCI AQAA document completed and submitted was brief and did not contain all the information required. CSCI surveys were sent out to the home, however there was a delay in giving these out and as a result only 1 was returned to CSCI by the completion of the inspection. Residents’ monies are securely stored and some minor discrepancies found in the records were addressed promptly. However, there have been occasions where money is not available for purchasing toiletries on behalf of residents or for paying bills such as newspapers and hairdressing. There had been some delays in submitting the Regulation 37 notifications for incidents and accidents notifiable to CSCI. It is acknowledged that following discussion with the Responsible Individual and the Regional Manager an action plan was submitted within 24 hours of completion of the inspection to show what action was already being taken to start to address some of the shortfalls identified at this inspection. 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.V351054.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.V351054.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. 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. The Service User Guide had not been updated throughout the home, thus some of the information provided about the home was out of date. Residents and/or their representatives are provided with a contract, thus informing them of the terms and conditions for the home. Prospective residents are fully assessed prior to admission, thus the home ensures they are able to meet each persons needs. EVIDENCE: The copies of the Statement of Purpose and Service User Guide in the reception area had been updated, however the Service User Guide viewed in one bedroom was out of date and referred to the previous owners. All residents must be provided with up to date information about the home. Ashwood Care Centre DS0000010923.V351054.R01.S.doc Version 5.2 Page 9 Hillingdon Social Services and Primary Care Trust have a block contract for the majority of beds at the home. For those purchasing care privately, individual contracts are provided. The home has a pre-admission assessment document that provides a good picture of the resident and their needs. Those viewed had been completed in full. Copies of the Social Services assessment are also obtained. It was noted that some residents with cognitive impairment are accommodated on the general nursing and personal care units, and this situation needs to be monitored. Ashwood Care Centre DS0000010923.V351054.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 adequate. This judgement has been made using available evidence including a visit to this service. Overall the service user plans were being completed to provide staff with the information to meet each resident’s needs. Shortfalls should be easy to address. Shortfalls were identified in the management of medications and this could place residents at risk. Staff have a high regard for the residents, caring for them in a gentle and professional manner, respecting their privacy and dignity. Some shortfalls in identifying end of life care needs place residents at risk of not having there needs fully met. EVIDENCE: 6 service user plans were viewed. Generally these were well completed and gave a good picture of the residents needs. The care planning system in place covers all aspects of daily living, and not all care plans had been completed in all instances. The Southern Cross Healthcare plc documentation has been introduced, however staff have not received any training in the completion of this (requirement under Standard 30). There was evidence of monthly reviews. Risk assessments for falls were in place and had been updated following any Ashwood Care Centre DS0000010923.V351054.R01.S.doc Version 5.2 Page 11 falls. There was no evidence of involvement from residents or their representatives in the formulation and review of the service user plans. Wound care documentation was viewed. Pressure risk assessments and care plans for wounds were in place, plus clear records of wound dressing regimes and changes of dressings were in place. Pressure relieving equipment was seen in use in the home. Assessments for continence, dependency, nutrition and moving & handling were in place and equipment to meet residents moving & handling needs were available. On the residential units there was evidence of input from the District Nurses and this had been cross-referenced in the care plans. There was evidence of input from other healthcare professionals to include GP, optician, chiropodist, tissue viability nurse and dietician. There was some confusion regarding an entry concerning a GP visit, however this was caused by inaccurate information regarding the staff actually on duty that day (see Standard 27). A thorough audit of medication was undertaken in each unit in the home. The recording of receipts, administration and disposal of medication was inspected to determine whether the residents were receiving their medication as prescribed. Just one gap was noted in the recording of administration but it was frequently noted that the records were not accurate. For instance when variable doses of painkillers were prescribed the actual doses given were not documented. The prescriber needs to know the actual dose given to make a correct assessment of pain relief required. If a medicine is not needed regularly then it should be reviewed by the prescriber. When a medicine is stopped temporarily because of pending blood level result then the reason must be given on the MAR (Medication Administration Record). If a resident goes to hospital the code for hospital must be used not the code for ‘on leave’. The recording of medication for disposal was accurate but for receipts into the home it was inconsistent. Sometime records were on the MAR and some on a separate sheet, some on neither. It is important to keep accurate records of medication received into the home, given and disposed of so that an audit can provide evidence that medication is being administered as prescribed. Several medicines audited were correct but in others it was either not possible to audit because of inaccurate records. Of particular concern were the instances identified where medicines were recorded as given but remained in blister packs. All medicines must be recorded on the MAR. One resident was prescribed injections, which were given by the district nurse. This must be clearly indicated on the MAR with records of receipts. At a previous inspection it was identified that many discontinued items were still printed on the MAR by pharmacist. To prevent error and ordering too much stock the home needs to work with the pharmacist to remove these items. Storage of medication in the home was generally secure and good. Medication cupboards must be designated cupboards and not used to store other items. Some attention could be given to cleanliness on the ground floor. Ashwood Care Centre DS0000010923.V351054.R01.S.doc Version 5.2 Page 12 Temperatures were recorded accurately including fridges. On the ground floor the fridge was too cold. There was inconsistent practice of writing dates of opening on oral liquids. Dates of opening both prevent medicines from being used past their expiry date and also allow an accurate audit trail to be maintained. There was good practice in the home of keeping information regarding warfarin with the MAR for reference. This prevents the risk of error. Only the current dose should be kept and previous results archived. It was possible to reference dosage changes back to the GP notes and discharge letters from hospital were kept in the care plans. The GP wrote, signed and dated new medication or dosage changes onto the MAR directly. If residents however are recorded as sleeping and are regularly not awake to take their medication they should be reviewed by the GP. Residents prescribed medication to be administered by a Inspector or enteral tube were well cared for by nurses with input from the dietician. Evidence of feeding protocols and all healthcare professional’s advice was available for reference in the care plan. There was also evidence of good management of residents with diabetes in the home. A nurse was observed reading and learning about a new medication for one of these residents. Overall therefore the residents were generally receiving good healthcare but the home needs to tighten up on accurate recording of medication to ensure that there is evidence that medication is administered as prescribed. The home were auditing medication every month and some of the issues identified above were also noted in an audit carried out in October. They had not been followed up. Staff were seen caring for residents in a gentle, caring and professional manner, respecting residents privacy and dignity. It was clear from speaking with residents and visitors that the staff have a very high regard for the care of the residents throughout the home. Residents looked well cared for and had been dressed to reflect individuality. Several of the bedrooms viewed were personalised and reflected residents interests and past life history. Clothing was labelled and if any clothing is found unlabelled action is taken to try and identify who this belongs to. Residents receive their post unopened unless they are unable to manage it, in which case it will be kept for their representatives to open. Residents can have their own telephones and computers with internet access if they so wish. Some information regarding the wishes of residents and their families in respect of health deterioration and also care in their final days was available. Care plans for this were not in place and the importance of ascertaining this information to ensure the wishes of residents and their families are recorded and respected was discussed with the staff. Ashwood Care Centre DS0000010923.V351054.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 – 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. 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 provision at the home is generally good, however further work is needed in this area to ensure the interests of all residents can be catered for. The home has an open visiting policy, thus encouraging people to maintain contact with family and friends. Information regarding advocacy services was available, thus peoples right to individual representation is respected. The food provision in the home is good, offering variety and choice, thus meeting peoples’ individual needs. EVIDENCE: The home has a full time activities co-ordinator who plans activities for each unit and works hard to provide a variety of activities to meet the residents’ needs. Some comment was received regarding the limitations of activities, and this was discussed with the activities co-ordinator who stated that when an activity takes place on one unit, the residents from other units are invited to go to the unit to join in if they so wish. The home has 70 residents and the importance of activities being provided 7 days a week, with the need to consider additional staff hours for activities provision was discussed with the Ashwood Care Centre DS0000010923.V351054.R01.S.doc Version 5.2 Page 14 Operations Manager (see Standard 27). It was clear that the activities coordinator had not been informed as to the budget available for activities, and as a result some activities had not taken place, for example Halloween celebrations, the purchase of materials for arts & craft sessions and prizes for quiz games. The importance of ensuring that the activities co-ordinator has a clear picture of the budget available for activities and associated events was discussed with the Operations Manager. Input is received from various religious representatives, and the home can arrange input to meet the needs of residents from different religious and cultural backgrounds. The home has an open visiting policy and visiting is encouraged. Residents can receive visitors in their own bedroom or in one of the communal areas, as they so wish. The visitors spoken with said that they are always made very welcome at the home and are offered refreshments. Representatives are kept up to date with any issues. The home has access to the local Age Concern Advocacy service and information on this was clearly displayed on the notice boards. Regular visits from Age Concern representatives had ceased, however the Operations Manager was aware of this and action is to be taken to recommence these visits. Information was also available from other advocacy services who provide advice on financial issues. The kitchen was viewed and this was clean and tidy. The kitchen records were complete and up to date. There is a choice offered at mealtimes and menus are displayed on each unit. Records of each resident’s choices are kept and these lists used at mealtimes to ensure residents are given their choices. One Inspector sampled the lunchtime meal on the second day of inspection and this was well presented and tasty. The home is in the process of introducing the ‘NUTMEG’ nutritional programme and this will clearly identify the nutritional value of all meals and ensure a balanced menu is maintained. A comment was received regarding the nutritional value of the evening meal and this was discussed with the cook. There were some concerns regarding the budgets available for celebrations such as the Christmas party and associated events, and this was discussed with the Operations Manager who said this would be addressed. Ashwood Care Centre DS0000010923.V351054.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 – 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a clear complaints procedure in place, however shortfalls in documentation and recording could lead to complaints not being addressed. Policies and procedures are in place and are followed for safeguarding adults, thus protecting residents. EVIDENCE: The home has a clear complaints procedure and this is on display in each bedroom and on the notice boards. The complaints file was viewed and there had been 6 complaints since the last inspection. During the inspection it became clear that 2 further complaints had been made, however these had not yet been entered into the complaints file. In addition the documentation for 2 complaints identified in the complaints file was not available to view. The Operations Manager has since confirmed that these complaints had been fully addressed and documentation to evidence this has been forwarded to CSCI. The importance of logging all complaints in accordance with Southern Cross Healthcare policy was discussed. Policies and procedures are in place for adult protection and the home also follows the Hillingdon Safeguarding Adults procedures. There had not been any POVA reports since the last inspection. Staff spoken with said that they had received POVA training and were clear on whistle blowing procedures. Ashwood Care Centre DS0000010923.V351054.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21 & 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is being maintained, however redecoration and refurbishment is required to bring the home back to a good environmental standard, to provide residents with a pleasant, homely and well maintained environment to live in. Overall infection control is being managed, however one shortfall identified could place residents at risk. EVIDENCE: A tour of each unit was carried out. Although the home is being maintained, overall the furnishings are old and in places shabby and the home is in need of refurbishment. A full environmental audit must be carried out and a full redecoration and refurbishment plan with timescales for completion drawn up to address the shortfalls identified. The maintenance man does keep a list of the redecoration work carried out. Work had been carried out to repair the plaster damage to the wall in the kitchen, however the problem had reAshwood Care Centre DS0000010923.V351054.R01.S.doc Version 5.2 Page 17 occurred and further work is required. The area of flooring had been sealed however this had not been fully effective and this needs to be done professionally to ensure the floor if fully sealed. The grill in the kitchen had been out of order for several weeks and action must be taken to ensure any equipment is repaired without delay. Since the last inspection action had been taken to convert a bathroom into a shower room and the toileting facilities were appropriate to meet the needs of the residents. The laundry was viewed and was clean and tidy. The laundry person works hard to care for the residents’ personal clothing and all residents looked well dressed. The washing machines have sluice programmes for the management of soiled and infected laundry. Where residents laundry require specialist laundering for any reason, this had been clearly recorded. Protective clothing to include gloves and aprons were available. One issue was identified where some of the crockery was being washed by hand in the sinks in the kitchenette areas. This was discussed and it was agreed that for infection control purposes all crockery and cutlery would be sent to the main kitchen for sanitising in the dishwasher after each use. Staff had received training in infection control, with further training planned. Ashwood Care Centre DS0000010923.V351054.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 & 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Shortfalls were noted with the staffing, thus residents needs were not being met at all times. Systems for vetting and recruitment practices are in place to safeguard residents. There is an ongoing training programme, however shortfalls in the provision of training in some areas could lead to staff not having the knowledge and skills to meet the full needs of the residents. EVIDENCE: The duty rosters were viewed for each unit. On examination of these plus other written information available it became clear that the master roster is not always kept up to date and some of the information was inaccurately recorded. For example, on one day a member of staff who was actually on annual leave had been identified as being on duty. Some of the units had been short staffed on a regular basis, and where night duties had been understaffed people had been asked to stay on until 11pm and then come back on duty at 6am to assist the night staff. This had not been identified on the rosters. The importance of ensuring the worked rosters clearly reflect the actual hours worked by each individual was discussed with the staff on the units and with the management. From viewing trends in residents’ falls it was identified on one unit that additional allocated staff hours were required for one floor in order to ensure that residents could be supervised appropriately. It was also clear that there Ashwood Care Centre DS0000010923.V351054.R01.S.doc Version 5.2 Page 19 had been regular staff shortages over a period of time and when unable to cover the shifts with the homes own staff, protocols for the use of agency staff had not been followed. Following the inspection, an action plan to address the staff shortages was submitted by the Operations Manager. The staffing hours in the laundry had been reduced, and the laundry person no longer had the time to carry out the labelling of clothes and other additional duties in relation to laundry care. The home has over 50 of care staff qualified to NVQ level 2 or 3 in care. One of the kitchen staff is undertaking NVQ level 2 in catering. One Inspector viewed 3 sets of staff employment records for staff recently employed at the home. These contained the information required under the Care Home Regulations 2001. In two instances staff had been employed following POVA first checks and Criminal Records Bureau checks were awaited. The Manager Designate confirmed that these staff were being chaperoned when they worked until the Criminal Records Bureau check was received. Southern Cross Healthcare plc has an induction programme based on the Skills for Care common induction standards and all new care staff complete the booklet. The staff training matrix viewed by one Inspector clearly had not been updated and it was apparent that very little training in topics relevant to the diagnoses and needs of the residents was taking place. As already identified under Standard 7 staff had not received any training in the completion of the Southern Cross Healthcare plc care plan documentation that has been introduced. Following the inspection the Operations Manager has sent through an action plan to include information regarding staff training to be put in place. Ashwood Care Centre DS0000010923.V351054.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 & 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Recent changes in ownership and management, plus lack of information being provided, have led to low staff morale, which in turn has the potential to have a detrimental outcome for the home. Systems are in place for quality assurance, however some shortfalls identified could lead to the quality of care provision not being fully monitored. Residents’ monies are being securely stored, however shortfalls regarding access to residents’ funds to purchase items on their behalf were identified. Staff are not receiving regular formal supervision, thus individual practice, training & development is not being reviewed. Overall health & safety is being well managed at the home, thus protecting residents, visitors and staff. Shortfalls should be easy to address. EVIDENCE: Ashwood Care Centre DS0000010923.V351054.R01.S.doc Version 5.2 Page 21 There has been a change of ownership in February 2007 plus there had been 2 changes in Manager since May 2007. At the time of the inspection the Manager Designate had only been in post for 6 weeks. The AQAA completed for the home was very brief and did not contain the information required under the Care Home Regulations 2001. The Manager Designate needs to ensure she becomes familiar with the systems of working for the home and that the lines of communication with residents, visitors and staff are effective. From discussions with staff it was clear that they did not feel supported and staff morale is low. Lack information about the changes in the Registered Provider plus management changes have also led to staff becoming unsettled. Regular shortages in staffing has not helped with this problem and concerns about ensuring the needs of the residents are met were expressed. The Manager Designate has only been in post for 6 weeks. The concerns were discussed with the Responsible Individual and Regional Manager for the home and action is being taken to meet with staff to clarify issues and to address the concerns they have. Southern Cross Healthcare plc has a comprehensive audit system in place for quality assurance. Regulation 26 visits on behalf of the Responsible Individual are carried out and reports are available. Care plan audits had been carried out and shortfalls identified for addressing by the staff. The home manager audit was last completed on 05/09/07. This was comprehensive and covered all aspects of the home. There had not been any relatives meetings recently and this was to be addressed. One staff meeting had taken place since the change in management. Following telephone contact, CSCI surveys for residents, staff, relatives/visitor/advocates, healthcare professionals and care managers had been sent to the home 2 weeks prior to the inspection. These had not been given out until the evening before the inspection as a result of which no comment card had been received prior to the inspection and 4 received since the inspection. This does not provide enough feedback for an overview of opinion to be gained. Comments have been included in this report in general terms. One Inspector sampled the records for personal monies being held on behalf of residents. Two were correct and where some discrepancy was noted the reason for this was identified and the records corrected. The Operations Manager said that an audit by the Regional Administrator would be arranged and thereafter regular audits will be carried out and recorded. Issues were raised regarding access to residents’ monies for the purchase of items on their behalf. These included purchase of toiletries and payment of newspaper bills and hairdressing bills. It was clear that there had been shortfalls in all these areas and action is being taken to address this robustly to prevent further problems in this area. Staff spoken with had not received formal supervision in recent months. Southern Cross Healthcare plc does have a system for formal supervision for Ashwood Care Centre DS0000010923.V351054.R01.S.doc Version 5.2 Page 22 all staff and this needs to be introduced to provide staff with a system practice review and development planning. One Inspector sampled the maintenance and servicing records and those viewed were up to date, with the exception of the Gas Landlord Certificate. Confirmation that the servicing is up to date has since been received. Fire drills had taken place and the fire risk assessment had been updated in May 2007. Training and updates in health & safety topics to include moving & handling, fire safety, first aid and other subjects was not up to date for all staff. Risk assessments for equipment and safe working practices were in place and up to date. Accidents records viewed were complete and accident audits are carried out. Regulation 37 notifications to CSCI had not been forwarded promptly to CSCI. Ashwood Care Centre DS0000010923.V351054.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X 3 X X X X 2 STAFFING Standard No Score 27 1 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 X 2 2 X 2 Ashwood Care Centre DS0000010923.V351054.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 5 Requirement Up to date copies of the Service User Guide must be available to all residents, to provide them with current information about the home. Input from the resident and/or their representative must be sought for the formulation and review of the service user plans, unless it is impracticable to carry out such consultation. This will ensure the needs and wishes of the resident are clear and can be respected. The care planning must be reviewed to ensure a care plan has been completed for each identified need, so that each persons needs are all being met. Medicines must be recorded accurately when administered. If not administered the correct endorsement must be used. If a variable dose is prescribed then the actual dose administered must be recorded. Medicines must be recorded accurately and consistently when received into the home so that an audit trail can be maintained. DS0000010923.V351054.R01.S.doc Timescale for action 01/01/08 2. OP7 15 01/01/08 3. OP7 15 01/01/08 4. OP9 13(2) 19/11/07 5. OP9 13(2) 19/11/07 Ashwood Care Centre Version 5.2 Page 25 6. OP9 13(2) 7. OP9 13(2) 8. OP9 13(2) 9. OP11 12 10. OP12 16(m)(n) 11. OP16 17(2) Schedule 4 12. OP19 23(2) All current medication must be recorded on the MAR. Clinical rooms must be kept clean to avoid the risk of infection. Medication cupboards and trolleys should be designated cupboards. There must be consistent practices of writing dates of opening on medication to prevent the use of expired stock and maintain stock control. If residents are regularly not able to take their medication because they are asleep they should be reviewed by the appropriate prescriber. The wishes of residents and their representatives must be clearly recorded in respect of their care during their final days. This information must be updated should their wishes change, in order to ensure their wishes are respected and adhered to. The activities co-ordinator must be aware of the budget available for expenditure on all areas of activities, outings and entertainment and the amount available must be appropriate to meet the needs of all the residents in this area. In the event of a complaint being received the homes complaints procedure must be followed and written records maintained in order to evidence that complaints are being appropriately managed. A full environmental audit must be carried out and a redecoration and refurbishment plan drawn up, to reflect all areas requiring work and timescales for completion so that they can be addressed in a timely fashion, providing a good environmental DS0000010923.V351054.R01.S.doc 19/11/07 01/12/07 01/12/07 01/02/08 01/12/07 01/12/07 01/12/07 Ashwood Care Centre Version 5.2 Page 26 13. OP26 13(3) 14. OP27 18 15. OP27 17(2) Schedule 4 16. OP30 18 17. OP31 24(3) 18. OP32 21 19. OP33 24 standard throughout. Cutlery and crockery must be washed up under correct conditions using the dishwasher to minimise any infection risk. Staffing levels throughout the home must be maintained to meet the needs of the residents at all times. Where staff shortages are identified prompt action must be taken to provide staff to cover these shortages. The duty roster on each unit must reflect an accurate record of the hours actually worked by each individual. Any changes to the roster must be clearly identified. Staff must receive training in topics relevant to the diagnoses and care needs of the residents to provide them with up to date skills and knowledge to care for them effectively. An action plan to address this must be drawn up. The CSCI Annual Quality Assurance Assessment must be completed in accordance with the available guidance in order to provide a comprehensive assessment of the home. The person responsible for completion of the AQAA must have a clear understanding of the process. There must be good systems in place for staff to be consulted about the home and to express their views and feel that they have a positive contribution to make to the running of the home. When provided, CSCI questionnaires must be given out promptly to the relevant persons in order to give them the opportunity to express their DS0000010923.V351054.R01.S.doc 16/11/07 09/11/07 16/11/07 01/12/07 01/01/08 01/12/07 08/11/07 Ashwood Care Centre Version 5.2 Page 27 20. OP35 12 21. OP36 18(2) 22. OP38 37 23. OP38 18 views about the home. Clear financial systems must be in place and followed to ensure that any goods or services required by residents are paid for without delay. All staff must receive formal supervision on a regular basis to discuss practice and identify training and development needs. An action plan to address this must be put in place. Regulation 37 notifications must be forwarded to CSCI without delay to keep them informed of any notifiable incidents/accidents. All staff must undertake training and updates in health & safety topics to include moving & handling and infection control, so that practices are up to date in line with current legislation and guidance. 16/11/07 01/02/08 16/11/07 01/02/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations Standard 1. OP9 That when issues are identified during an audit they are followed up on within a limited timescale. To be effective an audit should be carried out on both the monitored dosage system and dispensed packs. 2. OP9 That the pharmacist is requested to remove discontinued item for the MAR to prevent the risk of error. 3. OP15 It is strongly recommended that discussion take place regarding the food provision for parties and festival celebrations to ensure that the provision is appropriate to meet the needs and preferences of the residents and any other people invited to such events. Ashwood Care Centre DS0000010923.V351054.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection West London Local 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. Extracts may not be used or reproduced without the express permission of CSCI Ashwood Care Centre DS0000010923.V351054.R01.S.doc Version 5.2 Page 29 - 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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