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Inspection on 29/06/07 for Ashwood Lodge Care Home

Also see our care home review for Ashwood Lodge Care Home for more information

This inspection was carried out on 29th June 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home provides a pleasant, comfortable and homely environment for the residents. There is suitable equipment, to assist individual residents to be as independent as possible. Staff had time to talk with residents and the relationship between staff residents was very good. One resident said, "I chose this home because it is better than those big places. Staff are lovely and so helpful". Staff said, they sometimes walk with residents to the local surrounding area and to the shops. Resident`s rights are respected and residents live their lives as they wish. Residents are protected recruitment procedures. by the homes complaint`s, safeguarding andStaff completed induction, basic and additional training; to improve upon their knowledge and skills when caring for the residents who live at Ashwood Lodge. More than 81% of care staff had completed training to at least National Vocational Qualification Level 2 and many staff were furthering their training by registering for Levels 3 & 4 of the qualification.

What has improved since the last inspection?

Resident`s Care Plans have been improved, to include details of care needs, but they still need to be further developed by being more detailed. Residents were protected by the home`s recruitment, complaints and medication procedures that had been developed in recent months. There had also been improvements to the records of resident`s finances. Some areas of the home had been redecorated and action had been taken in relation to offensive odours. Staff had completed training for manual handling and Fire Safety and there was an up to date Fire Risk Assessment. All accidents were recorded and the acting manager regularly carried out an analysis of the accidents.

What the care home could do better:

Care Plans must give details of how resident`s needs are to be met. Care Plans must include Risk Assessments and inform how risks are to be managed to an acceptable level, for the safety of the residents. The cleaning rotas that have been introduced, to monitor cleanliness in the home, should be kept up to date. The home did not have a programme of activities or keep a record of activities that were offered to residents. It could not be determined that resident`s interests and recreational preferences were being met. The home must have a permanent registered manager and staff must receive regular one to one supervision, to improve upon the running of the home. The home must keep an up to date record of Risk Assessments for the Control of Substances Hazardous to Health and there must be regular fire drills, for the safety of the residents.

CARE HOMES FOR OLDER PEOPLE Ashwood Lodge Nursing Home Bedale Avenue Billingham Stockton-on-Tees TS23 1AJ Lead Inspector Brenda Grant Unannounced Inspection 29th June 2007 09:30 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 Lodge Nursing Home DS0000066294.V344471.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 Lodge Nursing Home DS0000066294.V344471.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashwood Lodge Nursing Home Address Bedale Avenue Billingham Stockton-on-Tees TS23 1AJ 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) 01642 361122 01642 363710 Nationwide Healthcare Limited Position Vacant Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Ashwood Lodge Nursing Home DS0000066294.V344471.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. That a maximum number of 5 places may be used at any one time for the accommodation of persons who are 50 years and over. 4th July 2006 Date of last inspection Brief Description of the Service: The Haven is a care home registered to provide both personal and nursing care for 27 older people. The home is situated in a residential area of Billingham. All rooms used and occupied by the residents are on the ground floor. The home provides both single and shared bedroom accommodation. Two of the bedrooms have en suite toilet facilities. Both lounge and dining areas are provided for those residents who wish to socialise. The home has a lawned garden, and has external areas accessible to residents. The home provides car-parking facilities for visitors. The previous manager has left and the providers are in the process of recruiting for the position. The previous deputy manager is currently acting up in this role. The fees at this home are £353 and the Primary Care Trust fund resident’s nursing fees. Ashwood Lodge Nursing Home DS0000066294.V344471.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was initially an unannounced inspection. We assessed the information from: the Annual Quality Assurance Assessment and we carried out a ‘site’ visit to the home. The visit took place over one day, six hours fifteen minutes in total. Discussion took place with three residents, two relatives, one staff, the acting manager and the provider. We looked around the home and gardens as well as examining a number of records which included; residents and staff files, health and safety and maintenance checks and complaints and kitchen documentation. The findings from the inspection were of the home adequately providing a personal and nursing care service, with many of the National Minimum Standards being met but there are some areas where improvements need to be made. What the service does well: The home provides a pleasant, comfortable and homely environment for the residents. There is suitable equipment, to assist individual residents to be as independent as possible. Staff had time to talk with residents and the relationship between staff residents was very good. One resident said, “I chose this home because it is better than those big places. Staff are lovely and so helpful”. Staff said, they sometimes walk with residents to the local surrounding area and to the shops. Resident’s rights are respected and residents live their lives as they wish. Residents are protected recruitment procedures. by the homes complaint’s, safeguarding and Staff completed induction, basic and additional training; to improve upon their knowledge and skills when caring for the residents who live at Ashwood Lodge. More than 81 of care staff had completed training to at least National Vocational Qualification Level 2 and many staff were furthering their training by registering for Levels 3 & 4 of the qualification. What has improved since the last inspection? Resident’s Care Plans have been improved, to include details of care needs, but they still need to be further developed by being more detailed. Residents were protected by the home’s recruitment, complaints and medication procedures that had been developed in recent months. Ashwood Lodge Nursing Home DS0000066294.V344471.R01.S.doc Version 5.2 Page 6 There had also been improvements to the records of resident’s finances. Some areas of the home had been redecorated and action had been taken in relation to offensive odours. Staff had completed training for manual handling and Fire Safety and there was an up to date Fire Risk Assessment. All accidents were recorded and the acting manager regularly carried out an analysis of the accidents. 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 Lodge Nursing Home DS0000066294.V344471.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 Lodge Nursing Home DS0000066294.V344471.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards: 3 & 6 Resident’s needs are assessed before moving to the home and they are assured those needs will be met. EVIDENCE: The Annual Quality Assurance Assessment informed, a senior member of the home’s staff visits potential residents, to assess the person’s needs, so that it can be determined whether the needs of the person could be met at Ashwood Lodge. Residents, who are funded by the local authority, have assessments that are carried out by a care manager and those assessments are shared with the home. We examined a sample of the assessments. They included details of: health, social and personal needs as well as social interests, hobbies and religion. Residents said, they were involved with the assessment process and, where necessary, relatives also had the opportunity to give their views. Ashwood Lodge Nursing Home DS0000066294.V344471.R01.S.doc Version 5.2 Page 9 The home does not offer intermediate care therefore standard six does not apply. Ashwood Lodge Nursing Home DS0000066294.V344471.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Standards: 7, 8, 9 & 10 Resident’s health, personal and social care needs are recorded in Care Plans but this information did not always include how care needs would be met. Risk Assessments were not included with Care Plans. Residents are protected by the home’s procedure for managing and administering medicines. Residents are treated with respect and their right to privacy is upheld. EVIDENCE: The home develops Care Plans for each resident, they have improved since the last inspection. There is basic information about the person’s care needs and the plans are regularly reviewed. The Care Plans gave general details about particular areas of need. Not all Care Plans provided specific information about how each resident’s nursing and care needs were to be met. The Care Plans did not record if the views of residents were sought, for the way personal care is delivered. Care Plans did not always include a Risk Assessment or inform Ashwood Lodge Nursing Home DS0000066294.V344471.R01.S.doc Version 5.2 Page 11 how those risks would be managed; to reduce those risks to an acceptable level. There were no Risk Assessments for the use of lap-straps or bed-rails. The home provides nursing care, for those residents who have been assessed as needing nursing input, from the nursing staff at the home. The residents who have been assessed as needing personal care have their nursing care provided by the GP. For all residents there is a record of all visits and appointments with healthcare professionals. The records detailed the regularity of visits for treatment from: opticians, chiropodists, dentists and other healthcare specialists. The home follows the written procedure for managing medicines. The nurse, who administered the medication, was observed administering medicines to residents and this was carried out in a suitable manner. The medication administration record was examined and it was found to be satisfactory. The medicines were seen to be appropriately stored but there was no ventilation to the room. The acting manager said, she was aware the room must be kept to a temperature that is within acceptable limits. Staff were observed being respectful to residents and knocking on bedroom doors before entering the room. The acting manager said, resident’s right to privacy is always respected. Residents spoken with confirmed this and said, “I can do what I want and stay in my room or go to the lounges”, “Staff are always friendly and speak to us in the right way” and “I get on well with all staff and the other people who live here and I am happy with the way I am looked after”. One resident said, “I would sometimes like to be able to lock my door”. The provider said, “Locks on bedroom doors were being considered but we need to make sure we get locks that are appropriate for the residents”. Ashwood Lodge Nursing Home DS0000066294.V344471.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards: 12, 13, 14 & 15 Residents live their lives as they wish and residents maintain contacts with families and friends. Residents have choice and control over what they do. The home provides a varied and balanced menu and there is flexibility when and where residents wish to have their meals. EVIDENCE: Residents spoken with informed, they live their lives as they wish. Staff said they try to find out about residents interests and provide for them at the home. There were a limited number of activities offered to residents. The acting manager said there were plans for residents to be offered more activities on a regular basis. The home does not have a programme of activities or record all of activities that have taken place. On the day of the inspection ‘site’ visit a member of staff went out for a walk with a resident and residents enjoyed music and playing dominoes. Residents said, staff sometimes accompanied them to the local shops or for short walks. One resident said, “It is good to get out in the fresh air”. Ashwood Lodge Nursing Home DS0000066294.V344471.R01.S.doc Version 5.2 Page 13 The acting manager said, the home provides for resident’s religious needs by arranging a religious service each Sunday. There were some residents who had people from their own church visiting them. The home also arranges, on a rota basis, for one of three religious sects to provide a monthly religious service. Residents and staff said, resident’s relatives and friends were always made to feel welcome when they visited the home. Staff said the home has regular contact with resident’s families. One resident’s relative said, “Staff are always friendly and they keep me informed about what is happening at the home”. Residents said, they felt they were in control of their lives. Residents said they got up early or late, stayed in their bedrooms or went to communal rooms and have meals where they chose. Individual bedrooms had resident’s personal possessions and belongings that included small items of furniture, pictures and ornaments. In recent months, some resident’s bedrooms had been redecorated and residents said they had been asked what colour they preferred for their room. The home’s menus were examined, they confirmed there was a good variety of food offered at the home. There was no menu displayed in the dining room, to inform residents of the food they were to be offered for the day. The fresh fruit and vegetables that were delivered, on the day of the ‘site’ visit, were of very good quality. All residents spoken with said, the food was very good. The mealtime, lunch, was observed; the food was well presented and residents were not hurried with eating their food. One resident said, “We have lovely food and it is cooked just right” and another resident said, “The cook always manages to cook me what I want”. There were some residents who had their meal served to them in their bedroom because that is what they preferred. The kitchen records, that were examined, were completed in a satisfactory manner. The cook said, “I attend resident’s meetings and I make every effort to cater for all tastes and diets”. Ashwood Lodge Nursing Home DS0000066294.V344471.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards: 16 & 18 Residents are confident their complaints will be listened to, taken seriously and acted upon. Residents are protected from abuse by the home’s policies and procedures. EVIDENCE: The home has a satisfactory complaint’s procedure. Residents spoken with informed, they did not have anything to complain about and residents were confident any complaint would be appropriately investigated and dealt with. The home has a book for recording complaints but there were no entries, for complaints, within the last 12 months. The home has procedures for protecting residents from abuse. Staff records confirmed staff had completed training for safeguarding vulnerable adults. The acting manager informed, further training was planned so that staff could be updated on the safeguarding procedures. Staff said, they knew of the procedures to follow, if there was an allegation of abuse to a resident. Ashwood Lodge Nursing Home DS0000066294.V344471.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards: 19 & 26 In the main, residents live in a safe and well-maintained environment. The home is clean, pleasant and hygienic and free from offensive odours. EVIDENCE: Ashwood Lodge provides a homely and comfortable environment for the residents. The acting manager informed, parts of the home had been redecorated and residents commented, they thought the home was “Much better now” and “It is light and airy”. The acting manager said that residents were consulted on the colour schemes and residents were involved with choosing some of the furnishings. The garden areas were attractive and well maintained. There were various flowering bushes, flowering plants, a small lawn and seating was available for residents who wished to sit outside. One Ashwood Lodge Nursing Home DS0000066294.V344471.R01.S.doc Version 5.2 Page 16 resident said, “They (the gardeners) always keep the garden nice and tidy and we sit outside when the weather is okay”. One the day of the inspection ‘site’ visit there was a fire exit corridor that had furniture and equipment placed there. This would obstruct people exiting the building in that direction. The acting manager immediately had the items removed. There was also a door that had some broken glass planels, near the rubbish bins, at the side of the home. As this was an area that residents could access it was dangerous for the glass to be unprotected. The provider immediately took action to have the door and glass removed. The home is making plans to accommodate some older people with dementia. This has involved a wing of the building being altered to keep that part of the home as a separate unit. The home will then be divided in to two units. The work has not yet been completed but plans are the new unit should be finished by July 2007. The home was pleasant, hygienic and free from offensive odours. Laundry facilities had washing and drying machines. The home had developed a cleaning rota, so that the acting manager could make sure areas of the home are cleaned on a regular basis. The cook had a separate cleaning rota, for the kitchen. The two rotas had not been kept up to date but the home was seen to be clean. Ashwood Lodge Nursing Home DS0000066294.V344471.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards: 27, 28,29 & 30 Resident’s needs are mostly met by the numbers and skill mix of staff who are trained and competent to care for the residents at the home. Residents are protected by the home’s recruitment procedures. EVIDENCE: On the day of the inspection ‘site’ visit there was sufficient care and nursing staff on duty, to meet the needs of the residents living at the home. There was always a qualified nurse on duty at all times of the day and night. The residents benefit from the home having a high proportion of care staff who have worked at the home for many years. This has created a stable staff group who said, they work well as a team to support the people who use the service. Most of the care staff were qualified to at least National Vocational Qualification Level 2. There were eleven care staff; nine have successfully completed training for National Vocational Qualification Level 2, three of those care staff have enrolled to do Level 4 of the qualification and three to do Level 3. This brings the total of qualified care staff to over 81 ; this is well above the National Minimum Standard of 50 . Ashwood Lodge Nursing Home DS0000066294.V344471.R01.S.doc Version 5.2 Page 18 Staff spoken with and staff files confirmed the home follows the recruitment procedure. The files contained the appropriate checks and references. Staff’s files had information confirming staff had completed basic, induction and further training and many care staff had completed extra training; for dementia awareness. Ashwood Lodge Nursing Home DS0000066294.V344471.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Standards: 31, 33, 35, 36 & 38 A suitably qualified person manages the home but there was no registered manager. Residents and other interested parties views are considered when there are plans to develop the service. Resident’s personal monies were safeguarded by the home’s procedures. In most, but not all, areas the health, safety and welfare of residents and staff are promoted and protected. EVIDENCE: The home does not benefit by having a permanent manager. The acting manager has the appropriate care and management qualifications and experience to run a care home for older people. The home has just appointed a manager who will forward an application, to the Commission for Social Care Ashwood Lodge Nursing Home DS0000066294.V344471.R01.S.doc Version 5.2 Page 20 Inspection, to be a registered manager. Staff said, the acting manager and the providers gave good support when it was needed. The home carried out a quality assurance survey; where residents and/or their relatives complete questionnaires. One relative spoken with said, “They don’t need to make improvements because everything is right here”. The home had devised a report that gave a summary of the survey but the report did not contain details of measures that are to be taken to improve the service. The acting manager said she gave the feedback information, of the survey, to a resident’s meeting. The home does not keep a record of resident’s meetings but there is a record of staff meetings. The minutes of those meetings informed staff of the improvements and developments that are planned for the home. There was no documentation to demonstrate that the home carried out regular self-monitoring checks or internal audits of the service. The acting manager said, “The home holds small amounts of resident’s monies”. That was mainly for resident’s personal allowances. Where the home made a purchase, on behalf of a resident, a receipt was kept and all transactions had signatures. A sample of resident’s finance records were examined and found to be correct. The home’s staff did not get involved with resident’s finances. The acting manager has not had any separate managerial hours to carry out some of the management tasks. The provider said, from 2nd July 2007, the acting was to have some time set aside, for concentrating only on managing the home. One of the management tasks that had lapsed was the formal one to one supervision of staff but most annual appraisals had been completed. Most of the health and safety requirements were met. Staff had completed health and safety training and the home provided protective clothing for staff’s use. The home’s maintenance records were examined and all were up to date. The weekly checks of the fire alarm was recorded, it give details of which fire point had been checked and the Fire Risk Assessment was up to date. Fire drills had not taken place on a regular basis. The home had a record to inform electrical equipment had been checked. There was documentation for Control Of Substances Hazardous to Health but not Risk Assessments for those substances. The home keeps records of all accidents and the acting manager carries out an analysis of the accidents. There were records of checks for the hot water outlet temperatures, in resident’s accommodation, that are controlled by thermostatic valves. Ashwood Lodge Nursing Home DS0000066294.V344471.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 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 2 X 2 X 3 2 X 2 Ashwood Lodge Nursing Home DS0000066294.V344471.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. Standard OP7 Regulation 12 & 15 Requirement Care Plans must include: • How residents care needs will be met • Risk Assessments • Resident’s involvement with reviews and when there are any changes to the plan. This is to make it clear, to residents and staff, how residents care needs will be met. The home must make arrangements to provide, on a regular basis, recreational activities for residents, so that resident’s interests and preferences will be maintained. The home must appoint a permanent manager and submit an application for registration to the Commission for Social Care Inspection. The previous timescale of 01/09/06 has not been met. The home must report what measures are in place to improve the service, as a response to residents of the quality monitoring survey. DS0000066294.V344471.R01.S.doc Timescale for action 31/08/07 2. OP12 16 30/09/07 3. OP31 8 31/08/07 4. OP33 24 30/09/07 Ashwood Lodge Nursing Home Version 5.2 Page 23 5. OP38 13 The home must complete Risk Assessments for the Control of Substances Hazardous to Health. Staff must receive training in fire drills, for the safety of staff and residents at the home. 31/08/07 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. Refer to Standard OP10 OP15 OP26 OP33 Good Practice Recommendations To maintain resident’s privacy, resident’s bedroom doors should have suitable locks. Residents should be informed, each day, of the food that is to be offered at the home. The cleaning rotas, that have been introduced, should be kept up to date; so that the acting manager can monitor all cleaning tasks have been completed. The home should keep a record of: • Resident’s meetings • Self monitoring checks and internal audits. This is so that it can be determined if residents are involved with the running of the home and that the provider regularly evaluates the quality of the service at the home. Staff should receive one to one supervision at least six times yearly and a record of those meetings should be maintained. 5. OP36 Ashwood Lodge Nursing Home DS0000066294.V344471.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS 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 Lodge Nursing Home DS0000066294.V344471.R01.S.doc Version 5.2 Page 25 - 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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