Inspection on 06/03/07 for Ashwood Nursing Home

This inspection was carried out on 6th March 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Ashwood Nursing Home 27/04/09

Ashwood Nursing Home 28/10/08

Ashwood Nursing Home 01/05/08

Ashwood Nursing Home 14/09/07

Ashwood Nursing Home 13/06/06

Ashwood Nursing Home 28/02/06

Ashwood Nursing Home 19/09/05

Ashwood Nursing Home 07/03/05

Ashwood Nursing Home 14/01/05

Similar services:

The Shelley

Thorndene

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Ashwood Nursing Home Burwash Common Etchingham East Sussex TN19 7LT Lead Inspector Elizabeth Baker Key Unannounced Inspection 6th March 2007 10:00 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 Nursing Home DS0000013957.V331381.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 Nursing Home DS0000013957.V331381.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashwood Nursing Home Address Burwash Common Etchingham East Sussex TN19 7LT 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) 01435-883434 01435 883091 ashwoodnh4@hotmail.co.uk Ashwood Nursing Home Ltd Miss Ann Elizabeth Morrissey Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19), Physical disability (19) of places Ashwood Nursing Home DS0000013957.V331381.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is nineteen (19). Service users must be older people aged sixty-five (65) or over on admission, and those with a physical disability. Two named service users under sixty-five (65) years on admission with a learning disability only to be accommodated. 13th June 2006 Date of last inspection Brief Description of the Service: Ashwood is a nursing home that provides care up to nineteen older people or those with physical disabilities over the age of 65 years and three residents less than sixty-five years with a learning disability. Ashwood is in the hamlet of Burwash Common and set in grounds with flat access for residents. A wellstocked and managed garden is available to be used by the residents. There is ample off road parking for visitors. The nearest town is Heathfield; the village of Burwash is two miles away. The home is situated on the bus route and there is a railway station in Stonegate a nearby village. The home provides eleven single rooms, and four shared rooms over two floors, situated on the ground and first floors. Eight rooms provide en-suite facilities. Day space consists of a combined lounge/dining room. A passenger lift allows level access throughout the home. The last inspection report is available in the office. At 6 March 2007 current weekly fees range from £550.00 to £950.00 excluding hairdressing, chiropody, physiotherapy, newspapers and aromatherapy. Inhouse activities are limited, but external entertainers provide a range of activities at seasonal times and for a couple of hours one afternoon per fortnight. Ashwood Nursing Home DS0000013957.V331381.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the second key unannounced visit to the home for the inspection period 2006/07. Lead inspector Elizabeth Baker carried out the visit on 6 March 2007. The visited lasted over seven hours. As well as touring the home, the visit consisted of talking with some residents, staff and visitors and inspecting some records for case tracking purposes. Three residents, one visitor and two members of staff were interviewed in private. A number of other residents and staff were also spoken with. Because of personal reasons, the manager was unavailable. However the home’s administrator provided assistance throughout the process, where she was in a position to do so. Feedback was provided to the administrator. Pharmacy Inspector Jeanette Datoo carried out a pharmacy inspection on the 8 March 2007. The findings of that visit have been incorporated into this report. Feedback was provided to the Registered Nurse in charge at the time. At the time of compiling the report, in support of the visit, the Commission received survey forms about the service from 10 residents. At the time of the visit 17 residents were residing at the home. Since the last key unannounced visit, the Commission has not received any complaints about the home. What the service does well: What has improved since the last inspection? Ashwood Nursing Home DS0000013957.V331381.R01.S.doc Version 5.2 Page 6 The re-decorating programme continues and corridors and bathrooms are currently being re-painted. 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 Nursing Home DS0000013957.V331381.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 Nursing Home DS0000013957.V331381.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): 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems are in place to determine prospective residents suitability to be admitted into the home, although more recorded detail would enhance the process further. EVIDENCE: The home endeavours to obtain information about prospective residents prior to admission. Information gathered during the admission process is recorded and transferred to an admission assessment. Where a council or primary care trust sponsors a resident, information is sought from them. However a review of a sample of admission assessments identified they were incomplete of all fields and prompts. This included a resident admitted on an emergency basis. There were no supporting documents from sponsors or health care professionals in this instance. Ashwood Nursing Home DS0000013957.V331381.R01.S.doc Version 5.2 Page 9 The current registration certificate for this home describes three additional conditions of registration, which may no longer comply with new registration guidance issued by the Commission. In order that the matter can be clarified and the certificate “cleansed”, if appropriate, the provider should now contact the Commission’s South East Region Central Registration Team on 020 7979 8079. The home is not registered for intermediate care. Standard 6 is not applicable. Ashwood Nursing Home DS0000013957.V331381.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care records are not wholly reflective of residents’ complete needs, preferences and wishes, potentially placing them at risk. Improvements in medicine management and storage would reduce potential risks to residents. EVIDENCE: Four care records were inspected as part of the case tracking process. As stated previously admission assessments are not always complete of all fields and prompts. As these assessments are used to inform care plans, this could lead to some residents not receiving all the care and support they require. All the records contained a care plan and a number of supporting clinical risk assessments. However not all the care plans and documents provided a comprehensive picture of residents’ needs, support, preferences and wishes. There was no recorded evidence the plans had been composed with input from the resident and or their advocate. It was difficult to establish the author of the plans because not all staff had signed them as required by the form. Ashwood Nursing Home DS0000013957.V331381.R01.S.doc Version 5.2 Page 11 Some risk assessments had been composed in 2005, but there was no recorded evidence they had subsequently been reviewed and updated. It was difficult to establish whether residents are being regularly weighed, because details had not been inserted in the forms where there was a field for this to be entered. Incomplete nutritional assessments were seen. The care records of a recently admitted resident contained a blank moving and handling assessment. The resident requires walking aids to move safely around the home. Where anxiety and pain had been identified in daily records this had not triggered new care plan components. None of the records inspected contained dependency or prevention of falls assessments. The accident forms record incidents of falls. The Commission’s Clinical Trigger – Prevention and Management of Falls in Older People” may prove useful in assisting the home develop such assessments and seeking specialist advice. The document can be obtained from the Commission’s website – www.csci.org.uk. The care plan for a resident with a pressure sore contained a pressure sore component. However there was no recorded evidence it had been reviewed since October 2006. The assessment did not provide evidence of the current grade of the sore or the type of pressure relief equipment provided, although the registered nurse did say the sore was smaller now. No photographs of residents were seen in the care records inspected. This could be a problem if a resident was to wander away from the home. A resident was seen wandering around the home. A review of the daily records identified some staff describing the residents’ day in a meaningless way. For example “due medicines given”, no complaints”, “no change” and “slept well”. Only one of the records reviewed contained a comment about the resident’s quality of day experience. None of the care records contained meaningful social and biographical information on the residents. Residents admitted on a permanent basis usually stay at the home for the rest of their lives. However the records contained no information as the residents’ spiritual and cultural preferences and wishes in respect of death and dying. This is an important aspect of care and needs to be addressed. Medication policies and procedures seen had not been recently updated. A nurse said that no residents self-administered their medicines but lockable storage would be provided for any who wished to do so. The door of the medicines storage room was unlocked but a member of staff said that it was usually kept locked. Inside this room there were locked cupboards, a medicines trolley, fridge and oxygen cylinders. There was no monitoring of the temperatures of the room or fridge. A nurse said the oxygen was not prescribed for current residents but there had been difficulties arranging for the cylinders to be collected. Ashwood Nursing Home DS0000013957.V331381.R01.S.doc Version 5.2 Page 12 Trays in one cupboard held the in use medicines for two residents. The trolley was not used to transport medicines around the home. A member of staff said medicines were removed from their original containers and put into pots, with a resident’s name on each lid and that several pots were carried, in small baskets, to administer to residents. It was discussed that this was not best practice. At lunchtime medicines were prepared, administered and recorded one resident at a time. Records of medicines receipt included date and quantity. Only three of the record sheets seen for disposal of medicines were dated and none provided evidence that unwanted medicines were collected by a waste disposal company. Three inaccuracies were found in the controlled drugs register. A nurse said that she printed the monthly medication administration records (MAR) in the home and that a second nurse checked these, but neither signed for this. On sampling the MAR two doses were different to the prescribed dose, on the dispensing label. For one pain relief tablet printed on a MAR with an ‘as required’ dose, there was no prescribed supply, or a purchased supply as a homely remedy. A nurse said that the home does not use pain management charts. Staff had signed a MAR for administration of two medicines when the resident was not in the home. A nurse said that a carer, not employed by the home had given the doses. The care plan did not include this information and no record was kept of medicines supplied for temporary absence from the home. The Commission’s website contains Professional Advice guidance on medicine management topics including Safe Disposal of Waste Medicines from Care homes (Nursing), which was published in September 2005. The Royal Pharmaceutical Society of Great Britain’s publication The Administration and Control of Medicines in Care Homes and Children’s Services (June 2003) also provides useful information. The publication can be obtained from the society’s website – www.rpsgb.org.uk. Residents spoken indicated staff assist them appropriately when providing personal care support. The home has a number of shared bedrooms. Mobile screens are available to be used when residents’ privacy and dignity is required to be maintained. Ashwood Nursing Home DS0000013957.V331381.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 and 15. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Most residents are supported in exercising their lifestyle preferences with regards to occupation and activities. Residents are offered a choice of meals and where to eat them. EVIDENCE: Although the home does not have structured weekly activity programmes, residents spoken with implied they are happy to spend their days as they currently do. For some residents this means they are able to return home for much of the day and for others it means having lots of visitors coming and going throughout the day. Overseas relatives keep in touch by sending regular email letters and the home prints them out in large print, making it easier for residents to read. Some residents were seen sitting in their rooms reading or watching the TV. One resident now subscribes to a satellite provider as they enjoy watching sport programmes in their own bedroom. Seasonal external entertainers visit the home and residents mentioned how much they had enjoyed the Christmas pantomime. Motivation sessions are facilitated at the home on a fortnightly basis and residents said they look Ashwood Nursing Home DS0000013957.V331381.R01.S.doc Version 5.2 Page 14 forward to these for the quizzes and activity games. However a comment added to a survey form returned by a resident indicated “[they] could do with a few more activities for those that are able. May be a few trips out could be arranged?” and another respondent added, “I perhaps would like a few more activities for [resident] and for the families”. Although meals were not sampled on this visit, comments made by residents throughout the visit included “food is lovely and I can eat what I like” and “food is very good”. Menus do not refer to choices and alternatives, but residents spoken with were aware they could ask for something else if they wanted to. Another resident indicated cooked breakfasts are always available if they want them. A copy of the Commission’s publication Highlight of the day? - improving meals for older people in care homes (March 2006) was provided at the visit, for the home’s information. Some residents require assistance with their meals. During the visit two staff were observed assisting two particular residents. However a third resident in the vicinity also required this level of support. Their meal had been left standing on a unit. The meal was uncovered. Ashwood Nursing Home DS0000013957.V331381.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 and 18. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Arrangements to ensure care staff are appropriately trained and have knowledge of the Council’s adult protection procedures will increase residents’ protection against potential abuse. EVIDENCE: A complaints procedure was seen displayed in a prominent place for the public’s ease of access. Residents and visitors spoken with indicated what they would do if they had a complaint or niggle. Staff interviewed said they had not received adult protection or abuse training. However one staff member described appropriately the action they would take if they had a suspicion of verbal or physical abuse. The home’s policy and procedure file contained an abuse procedure dated 2002. However there was no evidence this had been updated to interlink with the Council’s multi-agency adult protection protocols. To assist the home a copy of the Commission’s publication Better safe than sorry – Improving the system that safeguards adults living in care homes (November 2006) was provided at the visit. The Commission has not received any complaints about the service. Ashwood Nursing Home DS0000013957.V331381.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 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The continued redecorating programme helps to provide a homely environment for residents to live in. EVIDENCE: Because of time constraints only a brief tour of the home was undertaken. As part of the home’s rolling programme of re-decoration, at the time of the visit some corridors and a bathroom were being repainted. Bedrooms vary in shapes and sizes and residents are encouraged to individualise them with personal effects to make them homely. Facilities for staff to wash their hands when supporting residents with personal hygiene needs are available throughout the home. Bed linen and personal clothes are washed on site. The laundry rooms are suitably equipped for this purpose. Residents’ survey forms indicated the home is always fresh and clean. No unpleasant odours were noted. Ashwood Nursing Home DS0000013957.V331381.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are potentially at risk because robust recruitment procedures are not always followed. EVIDENCE: As well as care staff, staff are employed for catering, administration, maintenance and gardening. Staff rotas are maintained and demonstrate the home is staffed 24 hours a day. Residents’ returned survey forms indicated almost all respondents are of the opinion that staff are always available when needed. As mentioned previously a resident’s lunch had been left on the side because there were insufficient care staff to assist all the residents requiring such support at the same time. Dependency assessments were not seen in the care records inspected. Using such assessments may help the home determine the actual staffing levels required at different times of the day. From information provided at the inspection visit, two members of unregistered care staff are now trained to NVQ II or above in care and other care staff are currently doing NVQ training. Two staff files were inspected. This identified that systems are in place for recruiting and appointing staff. However the procedures had not always been rigorously followed. For example “to whom it may concern” references had been accepted, which is contrary to good practice. Where verbal references Ashwood Nursing Home DS0000013957.V331381.R01.S.doc Version 5.2 Page 18 have been obtained it has not been the home’s practice to record details of the findings. There was no recorded evidence that POVAfirst clearance had accessed for an employee who commenced at the home three months ago. Criminal Record Bureau clearance had not been received either. To assist the home in enhancing its recruitment practices, a copy of the Commission’s publications Safe and sound? – Checking the suitability of new care staff in regulated social care services (June 2006) was provided at the visit. Updated Criminal Record Bureau policy and guidance is also available on the Commission’s website. New staff undergo brief induction programmes at the home. Topics cover handbook, policies and procedures, risk assessment, health and safety, fire, accident book, laundry, dishwasher, hoists, emergency lighting and electricity. The Skills for Care website www.skillsforcare.org.uk provides useful information for home managers in the development of induction programmes. There was no recorded evidence that care staff have received recent health and social care training on topics such as dementia and learning disability. The home currently accommodates some older people with dementia and younger people with a learning disability. The staff interviewed said they had not received specific training for these conditions. Ashwood Nursing Home DS0000013957.V331381.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, 37 and 38. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents and advocates expressed satisfaction about the management of the service. However poor record keeping and poor medicine management places residents potentially at risk. EVIDENCE: The manager is a registered nurse, has attained NVQ level 4 management qualification and has run the home since 1986. Although some residents recalled attending residents’ meetings, they said these have not happened for some time. A requirement was made following a visit to the home in September 2005 that the home introduces a quality assurance programme. The February 2006 visit identified the home had Ashwood Nursing Home DS0000013957.V331381.R01.S.doc Version 5.2 Page 20 purchased a quality assurance programme. However the administrator was unable to confirm whether the programme has commenced. Policies and procedures are kept in the office and staff interviewed were aware of them. However a review of the policies and procedures identified that some of them have not been updated for some time. This included the Department of Health guidelines on infection control. The copy is dated 1996. New guidelines were published in June 2006. As stated previously, the home’s abuse policy is dated 2002 and does not interlink with the Council’s multiagency adult protection procedures. Some medicine policies were also noted to be out of date. The situation of not reviewing policies and procedures annually may prevent staff working in accordance with current good practice and indeed current legislation. The home is currently responsible for maintaining personal monies on behalf of one resident. Records are maintained and audited regularly by the home’s accountant. However the monies are held in the home’s business account. Whilst acknowledging the home reluctantly agreed to manage the monies to assist the resident, the current arrangement prevents the resident receiving interest on any credit balances and may not offer adequate protection. Care records did not contain prevention of falls assessments. Accident records identified some residents do endure falls. However there was no recorded evidence that incidents are collated and analysed and subsequent action is taken to minimise potential falls. Not all records relating to residents health and wellbeing are completed as required to ensure all staff have the necessary information to provide care and support to residents. As stated throughout the report not all risk assessments are reviewed and updated on a regular basis to reflect changes in residents’ conditions. A current lift service document was available for inspection. However it was identified during the pharmacy visit that it has not been the home’s practice to ensure medical equipment is routinely checked and serviced. Ashwood Nursing Home DS0000013957.V331381.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 2 9 1 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 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 X 2 2 Ashwood Nursing Home DS0000013957.V331381.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? Yes Ashwood Nursing Home DS0000013957.V331381.R01.S.doc Version 5.2 Page 23 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 OP38 Regulation 18(1)(c)(i ) 15 15 Requirement That each shift has a qualified first aider on duty. Not determined at this visit Care plans must be complete of all needs, preferences, wishes and support of each resident. Care plans must be composed and reviewed with input from the resident and or their advocate, unless the offer is declined. The home must develop a prevention of falls assessment in order that each resident is appropriately risk assessed. All residents must be assessed for their moving and handling requirements, and the findings recorded. To ensure the quality of medicines the temperature of medicines storage must be monitored and medicines stored according to the manufacturer’s directions. In the interests of safety arrangements must be made for the administration of medicines directly from the original dispensed container. Medicines must be administered according to the prescriber’s directions Controlled drugs must be DS0000013957.V331381.R01.S.doc Timescale for action 31/07/07 2. 3. OP7 OP7 31/08/07 31/08/07 4. OP7 13(4) 31/07/07 5. OP7 13(5) 31/05/07 6. OP9 13(2) 05/04/07 7. OP9 13(2) 22/03/07 8. 9. OP9 OP9 13(2) 13(2) 22/03/07 05/04/07 Page 24 Ashwood Nursing Home Version 5.2 10. OP9 13(2) 11. OP9 13(2) 12. OP9 13(2) 13. 14. 15. 16. 17. 18. OP8 OP29 OP29 OP37 12(1)(a) 19 19 17(1)(a), Sch 3(2) 17(3) 12 and 13 OP37 OP38 accurately recorded in the controlled drugs register and discrepancies investigated. Arrangements must be made to dispose of unwanted medicines through a licensed waste disposal company and to retain records of the transactions. A supply of medicines, currently prescribed for residents, must be available including those to be taken when required. There must be arrangements for accurate recording of medicine administration and supply of medicines for temporary absence of a resident from the home. Lancing devices intended for single person use must not be used for more than one resident. Specific staff references must be received and recorded. Care staff must not commence employment until relevant checks have been received. A current photograph of each resident must be kept, for identification purposes. All records relating to residents must be complete and up to date. All potential risks to residents must be assessed and recorded. 22/03/07 22/03/07 22/03/07 08/03/07 30/04/07 19/03/07 31/05/07 31/05/07 31/05/07 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. Refer to Standard OP33 Good Practice Recommendations That a spreadsheet be developed to support and record the quality assurance systems in place throughout the year. Not inspected DS0000013957.V331381.R01.S.doc Version 5.2 Page 25 Ashwood Nursing Home 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. OP36 OP38 OP38 OP3 OP8 OP8 OP8 OP11 OP12 OP15 OP18 OP18 OP27 OP28 OP30 OP33 OP35 That a record of supervision be kept. Not inspected That accident records be reviewed for trends and patterns and show when risk assessment are updated. Not inspected That staff working in the kitchen are qualified in basic food hygiene. Not inspected Admission assessments must be complete of all fields and prompts. It is strongly recommended that medical equipment be maintained according to the manufacturer’s directions. It is recommended that pain management tools be included in care plans, when appropriate. Risk assessments including nutrition, skin integrity and moving and handling, must be completed in full and regularly reviewed. Details of residents’ spiritual and cultural wishes and preferences in respect of death and dying should be obtained in the care records. It is strongly recommended that the current provision of occupation and activities be reviewed in consultation with all residents and their advocates. Residents meals should not be left uncovered and unheated. All care staff must receive adult protection training to reflect the County’s current procedures. A copy of the County’s current Adult Protection procedures must be obtained and is readily available to all staff. Dependency assessments should be introduced to ensure sufficient care staff are on duty at all times to meet the assessed needs of the current residents. 50 of unregistered care staff should be trained to NVQ level II care. All care staff must be appropriately trained to reflect the assessed care needs of the current residents. Policies and procedures must be reviewed annually and revised accordingly. It is strongly recommended that alternative arrangements be explored for maintaining and managing monies on behalf of the resident. Ashwood Nursing Home DS0000013957.V331381.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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