Inspection on 07/09/05 for Asmall Hall Nursing Home

This inspection was carried out on 7th September 2005.

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

Asmall Hall Nursing Home 17/09/07

Asmall Hall Nursing Home 08/08/06

Asmall Hall Nursing Home 08/03/06

Asmall Hall Nursing Home 20/09/04

Asmall Hall Nursing Home 27/04/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Asmall Hall Nursing Home Asmall Hall Asmall Lane Ormskirk, Lancashire L40 8JL Lead Inspector Vivienne Morris Unannounced 7 September 2005 9.30 th 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 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. Asmall Hall Nursing Home F57 F08 S25551 Asmall Hall V223194 070905 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Asmall Hall Nursing Home Address Asmall Hall Asmall Lane Ormskirk Lancashire L40 8JL 01695 579548 1695 579978 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) JenCare Homes Limited Mrs Jennifer Chapman Care Home 57 Category(ies) of Dementia (12), Old age, not falling within any registration, with number other category (45), Physical disability (3) of places Asmall Hall Nursing Home F57 F08 S25551 Asmall Hall V223194 070905 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1) Within the overall total of 57 a maximum of 45 service users requiring either nursing or personal care who fall into the category OP - Old age not falling within any other category. 2) Within the overall total of 57 a maximum of 3 service users requiring either nursing or personal care who fall into the category PD - Physical disability (age 40-65 years). 3) Within the overall total of 57 a maximum of 12 service users requiring nursing or personal care who fall into the category DE - Dementia. 4) The registered person must, at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 5) Staffing must be provided to meet the dependencey needs of the service users at all times and comply with any guidelines which may be issued through the Commission for Social Care Inspection rgarding staffing levels in care homes. Date of last inspection 20/09/2004 Brief Description of the Service: Asmall Hall has fifty-seven beds, the majority of which accommodate elderly service users who require personal or nursing care. Included within the total of fifty-seven, twelve beds are available, in a separate unit, for elderly service users with dementia care needs. Included in the registration are three beds that accommodate service users with a physical disability under the age of sixty-five years. A qualified nurse is on duty in the main part of the home and the specialist unit at all times. Mr and Mrs Chapman privately own Asmall Hall and Mrs Chapman is also the registered manager.The home is set in extensive well maintained grounds in a quiet residential area of Ormskirk. The grounds are accessible to wheelchair users and the less mobile and outdoor seating is provided to enable service users to enjoy the gardens. A number of aids are provided to assist service users with their activities of daily living and to promote and maintain their independence. Asmall Hall Nursing Home F57 F08 S25551 Asmall Hall V223194 070905 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted over one day during September 2005. The inspection process focused on the outcomes for people living at the home. During the course of the inspection service users, relatives and staff were spoken to, relevant records and documents were examined and a tour of the premises took place, when a random selection of private accommodation was viewed and all communal areas and service areas were seen. The Commission for Social Care Inspection had not received any complaints about this service since the last inspection. What the service does well: What has improved since the last inspection? The care planning process had improved since the last inspection and although the standard format was still being used additional information had been included which made the plans of care more individualised, which were seen to be well written documents, in general, providing staff with clear guidance as to how individual needs were to be met. The risk management framework had improved since the last inspection and a number of risk assessments had been conducted, particularly in relation to the risk of falling and the use of bed rails. Asmall Hall Nursing Home F57 F08 S25551 Asmall Hall V223194 070905 Stage 4.doc Version 1.30 Page 6 The system for the recording of complaints received by the home had improved since the last inspection. The investigative process was more clearly written, providing more detail to ensure that complaints were dealt with appropriately. What they could do better: The plans of care must demonstrate how all the assessed needs of each person living at the home are to be met, including psychological and social care needs. The plans of care must be drawn up with the involvement of the service user or their representative and should be reviewed at least on a monthly basis to reflect changing needs of those living at the home. The serving of meals should be better managed to promote health and safety for those working at the home. The soft diets should be presented in a more attractive manner in order to maintain appetite and nutrition. The policies of the home should be revised to ensure that those living there are adequately protected from abusive situations. A number of carpets within the home were in poor condition, which had been identified at the previous inspection as requiring replacement. Only one bedroom carpet had been replaced since the previous inspection. The remaining must be replaced to enhance the environment for those living at the home and to promote health and safety. The dining room furniture on the dementia care unit was poor condition and in need of restoration or replacement to promote health and safety for those living at the home and to provide a comfortable dining area. The ratio of care staff to service users should be calculated in accordance with the assessed needs of those living at the home to ensure that adequate staff are on duty to meet the needs of those living there. Asmall Hall Nursing Home F57 F08 S25551 Asmall Hall V223194 070905 Stage 4.doc Version 1.30 Page 7 The registered person must ensure adequate domestic and laundry staff input in order to maintain standards of cleanliness, hygiene and odour control, taking into consideration the size and layout of the home. A minimum ratio of 50 trained members of care staff (National Vocational Qualification level 2 or equivalent) should be achieved by the home to ensure that staff are appropriately trained to provide adequate care for those living at the home. The registered person must ensure the health and safety of those living at and those working at the home by making sure that all necessary checks have been conducted on systems and equipment to ensure their safety and any work identified as needing to be dome must be completed within acceptable time scales. 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. Asmall Hall Nursing Home F57 F08 S25551 Asmall Hall V223194 070905 Stage 4.doc Version 1.30 Page 8 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 Standards Statutory Requirements Identified During the Inspection Asmall Hall Nursing Home F57 F08 S25551 Asmall Hall V223194 070905 Stage 4.doc Version 1.30 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 The needs of those admitted to the home had been sufficiently assessed prior to admission to ensure that the home could provide adequate care for each individual. EVIDENCE: At the time of the inspection the files of four service users with differing health and personal care needs were case tracked. The assessment form used covered all of the elements of standard 3 and provided some detailed information in relation to the needs of those wishing to live at the home to ensure that prospective service users were assured that the home could meet their needs. Pre-admission assessments had also been conducted by a social worker, for those funded by the local authorities and copies of these had been retained at the home for staff reference so that they were aware of individual assessed needs. Each resident had a plan of care, which, in general, was based on the information obtained during the pre-admission process so that those working Asmall Hall Nursing Home F57 F08 S25551 Asmall Hall V223194 070905 Stage 4.doc Version 1.30 Page 10 at the home were aware of how assessed needs could be met. However, the assessed dementia care needs of one service user had not been identified within the plan of care to show how these specific needs could be met by the home. Asmall Hall Nursing Home F57 F08 S25551 Asmall Hall V223194 070905 Stage 4.doc Version 1.30 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 and 9 The service user’s psychological and social care needs were not always set out in their plans of care to ensure that staff were aware of how individual needs could be met. The health care needs of those living at the home were adequately met. EVIDENCE: The care planning process had improved since the last inspection and although the standard format was still being used at the home, additional information had been included, making the plans of care more individualised. Three out of the four care plans examined had been reviewed and updated to reflect changing needs of those living at the home. These were very detailed documents, providing clear guidance for staff as to how individual needs in relation to health, personal and social care were to be met. However, one plan of care did not include assessed dementia care or social care needs and had not been reviewed at monthly intervals, therefore it did not provide staff with guidance as to how all the assessed needs of this individual could be appropriately met. Asmall Hall Nursing Home F57 F08 S25551 Asmall Hall V223194 070905 Stage 4.doc Version 1.30 Page 12 The plan of care for one resident had been agreed with them, but there was no evidence to demonstrate that the other three care plans had been developed with the individual service users, therefore evidence was not available to demonstrate that all those living at the home had some input into the care they were receiving. Information detailed in the service users’ care plans chosen for case tracking purposes, in general outlined the management of service users’ needs and capacity to self-care to ensure that assessed needs were being met. However, the plan of care for one person with dementia care needs did not demonstrate that these needs were being adequately met or that psychological health needs were being regularly monitored Care records showed that professional advice had been sought regarding the assessment and management of service users who were incontinent and sufficient supplies of aids and equipment needed for the management of incontinence were available at the home to ensure that these needs were appropriately met. The home had conducted a variety of risk assessments and appropriate measures had been put in place to manage those identified as being at risk, including advice sought from a number of external professionals, to ensure that health care needs were adequately met. The pharmacy inspector assessed the management of medications at this inspection. A detailed report of the findings will be forwarded to the home under separate cover. Asmall Hall Nursing Home F57 F08 S25551 Asmall Hall V223194 070905 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13 and 15 The home encouraged those living there to maintain contact with family, friends and the outside community. EVIDENCE: A visiting policy was in place at the home and information relating to visiting was also included in the statement of purpose and service user guide to ensure that all interested parties were aware of the visiting arrangements of the home. The manager said that service users were able to choose which visitors they wished to see or not see and that their requests would be respected and recorded in individual care plans. Discussion with service users confirmed that they were able to receive visitors at any time and that they could see them in their own room or in one of the communal areas of the home, if they preferred. There was evidence available to suggest that links with the local churches and schools were encouraged so that those living at the home were able to maintain community contact. One service user stated “When the weather is nice the staff take me out in the grounds in my wheelchair, which I like” and another commented “I join in the Asmall Hall Nursing Home F57 F08 S25551 Asmall Hall V223194 070905 Stage 4.doc Version 1.30 Page 14 activities when I want, no-one makes me join in, I can please myself. I can sit in my room, or in the lounges if I want”. The catering facilities were seen to be clean and appeared to be well organised. Specialised implements were provided for those who had difficulty in feeding themselves in order to promote independence. A five weekly menu was in place at the home, which offered a choice of meals and showed a suitable variety of dietary provision. Soft diets should be presented in a more attractive manner in order to maintain appetite and nutrition. Relevant records were examined which demonstrated that food intake was monitored and that dietetic advice had been sought as required to ensure adequate nutritional intake. Some service users were seen to be sitting in wheelchairs at the dining tables, but those spoken to confirmed that this was by choice. One service user commented, ‘I am happy living here. I have no complaints. The food is very good’. Staff were seen to be assisting those who required some help with their meals, although independence was also encouraged, as much as possible. The inspector recommends that the management of serving meals is risk assessed and the possibility of alternative, safer methods of serving meals is considered. At the time of the inspection staff were seen queuing up outside the kitchen, in the corridor with trays to collect service users’ meals. It was necessary for staff to hold the kitchen door open whilst receiving meals on a tray, which could be a potential hazard for those working at the home. This was discussed with the manager at the time of the inspection. Asmall Hall Nursing Home F57 F08 S25551 Asmall Hall V223194 070905 Stage 4.doc Version 1.30 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 The policies of the home did not ensure that those living there were protected from abusive situations. EVIDENCE: The home had developed a policy in relation to the protection of vulnerable adults, which was accessible to all staff. The policy contained a lot of information about the subject of abuse and new policies had been introduced. The new polices clearly outlined the action to be taken following an incident or suspicion of abuse and the management of aggression and restraint. However, there was some conflicting information provided as both the old and the new policies were available. This needs to be addressed to ensure that those working at the home follow the correct procedure should an allegation of abuse be reported. The manager had obtained a copy of the ‘No secrets in Lancashire’ and the home had a separate policy that covered whistle blowing to ensure that staff were aware of their responsibilities should they have any concerns about the protection of those living at the home. Policies and procedures were in place at the home to ensure that staff understood physical and verbal aggression and that such episodes were dealt with appropriately. There were no written policies available in relation to the security and management of service users’ money and valuables to ensure that adequate protection was provided for service users who retained any money or valuables at the home. These policies should include the preclusion of staff from assisting with or benefiting from service users’ wills. Asmall Hall Nursing Home F57 F08 S25551 Asmall Hall V223194 070905 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 The home was not well maintained as some work was outstanding. Service users did not live in a completely safe environment. EVIDENCE: The inspector toured the premises during the course of the inspection. The external grounds of the home were well maintained, providing pleasant areas for service users to sit during the warmer weather. The external window frames were being treated and painted at the time of the inspection to protect the timber from decaying and to promote the external appearance of the home. An action plan had been implemented to demonstrate that consideration had been given to forward planning of the maintenance of the home. Although it was evident that a carpet had been replaced in one bedroom, the requirement from the previous inspection in relation to the replacement of a number of carpets within the home remained outstanding. This issue was Asmall Hall Nursing Home F57 F08 S25551 Asmall Hall V223194 070905 Stage 4.doc Version 1.30 Page 17 included on the home’s action plan for December 2005. As this requirement has been made at the previous two inspections, it is expected that such carpets be replaced by the end of December 2005. The inspector noted that a number of carpets were secured by tape as they were fraying and joints were drifting apart. The carpet on the corridor of the dementia care unit was not fully secured by the carpet tread and was therefore was creating a trip hazard. The registered person informed the inspector that repair work to the roof in the main part of the house had been completed, but that she had not been able to determine if the work had been successful, due to the recent fine weather. The registered person should monitor this situation to ensure that the leak has been appropriately repaired. It is recommended that the home take action to address the outstanding recommendation made by the environmental health officer to ensure that the health and safety of those living at and those working at the home is maintained. The fire door at the top of the stairs on the first floor was not closing completely into the doorframe and loose sheets of paper were noted behind a radiator on the ground floor, which were creating potential fire hazards. A comment received from one service user was “I am happy with my room, it is very comfortable”. Asmall Hall Nursing Home F57 F08 S25551 Asmall Hall V223194 070905 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 At the time of the inspection the staffing levels had not been calculated in accordance with the assessed needs of those living at the home to ensure that individual assessed needs were being adequately met. EVIDENCE: At the time of the inspection the staffing levels met the minimum requirements of the previous regulating authority. Although the home determined individual levels of dependency, these were not directly linked to the calculation of service user to care staff ratios in order to ensure that sufficient numbers of experienced staff were on duty to adequately meet the needs of those living at the home. The duty rota demonstrated that additional staff were on duty at busier periods of the day and that qualified nurses were on duty at all times to ensure that appropriate care was being provided. At the time of the inspection the cleanliness of the home was of a satisfactory standard, although there was an unpleasant odour in some areas, which did not enhance the environment. Comments from those spoken to included “the cleaners do a good job. They clean my room every day. It is spotless”. The inspector established that there was a deficit of ancillary hours, although active recruitment was taking place to ensure that adequate domestic and laundry staff were on duty to meet the needs of the service users and the home. Asmall Hall Nursing Home F57 F08 S25551 Asmall Hall V223194 070905 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 The health, safety and welfare of service users and staff was not adequately promoted and protected. EVIDENCE: The inspector examined relevant records and certificates to determine if service users and staff were adequately protected in relation to their health and safety. It was found that although some systems and equipment had been routinely serviced, others had not. There were some issues identified following the last service of the fire prevention systems in April 2005, which remained outstanding. There was no evidence available to demonstrate that a fire drill had been conducted recently to ensure that all staff had been kept up to date with fire precautions in the work place. These issues need to be addressed as a matter of urgency to ensure that adequate fire precautions are in place for the protection of those living at and those working at the home. Asmall Hall Nursing Home F57 F08 S25551 Asmall Hall V223194 070905 Stage 4.doc Version 1.30 Page 20 There was no evidence available to demonstrate that solutions had been implemented for the control of Legionella or that the boilers and central heating systems had been serviced. These issues must be addressed in order to ensure the health and safety of service users and staff. The electrical installation had been recently serviced and was found to be in an unsatisfactory condition. There were 18 requirements and recommendations on the electrical installation report, which remained outstanding. This work needs to be completed as a matter of urgency to ensure the health and safety of residents and staff. Accident books were used for the recording of accidents occurring within the home. However, there were two different books being utilised, which did not comply with the Data Protection Act. Asmall Hall Nursing Home F57 F08 S25551 Asmall Hall V223194 070905 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 2 COMPLAINTS AND PROTECTION 2 x x x x x x x STAFFING Standard No Score 27 2 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 2 x x x x x x x 2 Asmall Hall Nursing Home F57 F08 S25551 Asmall Hall V223194 070905 Stage 4.doc Version 1.30 Page 22 YES Are there any outstanding requirements from the last inspection? 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 3, 7. 8 Regulation 15(1) Timescale for action Unless it is impracticable to carry 15.10.05 out such consultation, the registered person shall, after consultation with the service user, or a representative of his, prepare a written plan as to how the service users needs in respect of his health and welfare are to be met, including dementia care and social care needs. The registered person shall 15.10.05 having regard to the size of the care home and the number and needs of service users provide, in adequate quantities, suitable, wholesome and nutritious food which is varied and properly prepared, including soft diets. The registered person must 31.12.05 repair or replace the carpets identified at the time of the previous inspection. (Timescale of 31st December 2004 not met) The registered person must 31.12.05 ensure adequate domestic and laundry staff input in order to maintain standards of cleanliness, hygiene and odour control, taking into consideration Version 1.30 Page 23 Requirement 2. 15 16(2)(i) 3. 19 16(2)(c) 4. 27 18(1)(a) Asmall Hall Nursing Home F57 F08 S25551 Asmall Hall V223194 070905 Stage 4.doc 5. 33 6. 38 7. 38 8. 38 9. 38 the size and layout of the home. (Timescale of 30.11.04 not met) 10(1) Action must be progressed within agreed timescales to implement requirements identified during CSCI inspections. (Timescale of 31.10.04 not met) 23(4)(b)(c All work identified in relation to ) the fire prevention systems must be carried out and on completion written confirmation sent to the Commission. 23(5) The registered person shall after consultation with the fire authority ensure, by means of fire drills and practices at suitable intervals, that the persons working at the care home and, so far as practicable, service users, are aware of the procedure to be followed in case of fire, including the procedure for saving life. 13(4) The registered person shall ensure that unnecessary risks to the health or safety of service users are identified and so far as possible eliminated, incuding solutions to be implemented for the control of Legionella and servicing of the boilers and central heating systems to be conducted. 13(4) The registered person shall ensure that unnecessary risks to the health or safety of service users are identified and so far as possible eliminated, by ensuring that appropreiate action is taken to address the outstanding issues identified on the electrical installation service certificate. 31.12.05 31.10.05 31.10.05 31.10.05 31.10.05 10. Asmall Hall Nursing Home F57 F08 S25551 Asmall Hall V223194 070905 Stage 4.doc Version 1.30 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard 7 15 18 Good Practice Recommendations The service users plan of care should be reviewed by care staff in the home at least once a month. The registered person should risk assess the arrangement for the serving of meals and should consider alternative, less hazardous methods of serving meals. The policies in relation to the protection of vulnerable adults should be revised so as not to provide conflicting information. Policies should be introduced in relation to the security and management of service users money and valuables retained within the home to ensure adequate protection. It is recommended that the home take action to address the outstanding recommendation made by the environmental health officer. It is recommended that the dining furniture in the specialist unit be renovated or replaced. The registered person should ensure that the ratio of care staff to service users reflect the dependency needs of those living at the home. A minimum ratio of 50 of care staff should have achieved a National Vocational Award at level two or equivalent, which should include agency staff working at the home. It is recommended that the registered manager complete a recognised management course by 2005. It is recommended that the registered manager develop strategies for enabling stakeholders to affect the way in which the service is delivered. The registered person should ensure that a copy of the certificate to confirm that the home has taken steps to control the risk of legionella is submitted to the Commission. The registered person should ensure that a copy of the certificate to confirm that the boilers and central heating system have been serviced is submitted to the Commission. It is recommended that the accident books used by the home comply with the Data Protection Act. F57 F08 S25551 Asmall Hall V223194 070905 Stage 4.doc Version 1.30 Page 25 4. 5. 6. 7. 19 20 27 28 8. 9. 10. 31 32, 33 38 11. 38 12. 38 Asmall Hall Nursing Home Commission for Social Care Inspection Levens House Ackhurst Business Park Foxhole Road Chorley PR7 1NW National Enquiry Line: 0845 015 0120 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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