Inspection on 08/07/09 for Aspen Grange Care Home

This inspection was carried out on 8th July 2009.

CQC found this care home to be providing an Adequate service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Aspen Grange Care Home 08/01/09

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Poldhu

Queensmount

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Extracts from inspection reports are licensed from CQC, this page was updated on 15/11/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Aspen Grange Care Home 18 Wharncliffe Road Boscombe Bournemouth Dorset BH5 1AH Lead Inspector Jo Johnson Key Unannounced Inspection 8th July 2009 09:00 DS0000072288.V376740.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Aspen Grange Care Home DS0000072288.V376740.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Aspen Grange Care Home DS0000072288.V376740.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Aspen Grange Care Home Address 18 Wharncliffe Road Boscombe Bournemouth Dorset BH5 1AH 01202 395435 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) Mr Kevin Gunputh Mr David Leedham Mrs Louise Tabitha Pidgeon Mrs Deborah Mary Usher Care Home 43 Category(ies) of Old age, not falling within any other category registration, with number (43) of places Aspen Grange Care Home DS0000072288.V376740.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: 2. Old Age, not falling within any other category (Code OP) The maximum number of service users who can be accommodated is 43. 8th January 2009 Date of last inspection Brief Description of the Service: Aspen Grange is a large, detached house, situated in the Boscombe area of Bournemouth. It is registered to accommodate up to 43 older people who are in need of personal care. The property has limited on-site parking for visitors. Street parking is also available in the vicinity of the home. The home has a small, sheltered garden with lawn area and a courtyard garden with summerhouse. Aspen Grange is situated within level walking distance of the amenities of Boscombe, including shops, restaurants, cafes, places of worship, library etc. The sea front and Boscombe Gardens are also within walking distance (sloping in part). There is a bus service to the centre of Bournemouth and other areas of the town from the nearby Christchurch Road. Aids and equipment are available for people with disabilities, including ramps to aid access to and from the home, (portable ramp used for two doors) and assisted bathing facilities. Accommodation is provided over two floors in 39 single and 2 double rooms. The home is centrally heated throughout and 28 bedrooms have en-suite facilities. Access between floors is by means of two passenger lifts or stairs. The home has lounges and two dining rooms. Aspen Grange Care Home DS0000072288.V376740.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is one star. This means the people who use this service experience adequate quality outcomes. The focus of inspections undertaken by us is upon outcomes for people who live at the home and their views of the service provided. This process considers the homes capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provisions that need further development. This report uses information and evidence gathered during the key inspection process, which involves a visit to the home and looking at a range of information. This includes the service history for the home and inspection activity, notifications made by the home, information shared from other agencies and the general public and a number of case files. The manager supplied the commission with an AQAA (Annual Quality Assurance Assessment). Information from this has been used to make judgements about the service, and have been included in this report. This inspection visit was unannounced (We did not let the home know that we were coming) and took place on 8th July. The duration of the inspection, being the combined total hours spent in the home by two inspectors was 10 hours. The acting manager was present throughout the inspection and one of the registered providers was present for part of the inspection. The inspection was conducted by two inspectors and involved observations of and talking with people who live or were staying at the home, the staff on duty and the manager. Four people were identified for close examination by reading their care plan, risk assessments, daily records and other relevant information. This is part of a process known as case tracking, where evidence is matched to outcomes for people. A tour of the environment was undertaken, and home records were sampled, including staff training and recruitment, health and safety, and staff rotas. What the service does well: Aspen Grange Care Home DS0000072288.V376740.R01.S.doc Version 5.2 Page 6 The home has warm and friendly atmosphere. People spoke positively about the home and the staff. There are good quality and easy to follow care plans in place. The people living at the home have good relationships with staff and they are relaxed with them. People have good access to local District Nurses, General Practitioners and specialist health care when required. People enjoy the food provided by the home and specialist diets are catered for. The home is homely and is clean and comfortable and generally well maintained. People and their families know how to complain or raise their concerns about the home. Visitors are made welcome and people are encouraged to maintain contact with family and friends. Staff employed by the home undergo an induction and ongoing training program. What has improved since the last inspection? All of the requirements issued at the last key inspection have been met so there have been improved outcomes for people living at the home. Accurate full assessments are now completed for people and the ongoing assessment process for people now identifies when the home is not able to continue to safely meet their needs. Accurate care records are now maintained for people. Peoples care plans are now reviewed, kept up to date, and include all the individuals needs identified in their assessments. Any areas of risk identified for an individual are now assessed and these assessments include nutrition, pressure areas, behaviour and falls. People are now provided with suitable stimulation and have the opportunity to be occupied. Aspen Grange Care Home DS0000072288.V376740.R01.S.doc Version 5.2 Page 7 All allegations of abuse are now referred to the local authority and the commission. Windows are now risk assessed, made safe and risks minimised where any risks were identified. Staffing levels provided at the home are now based upon the individual needs of the people who live there, and not based upon the number of people in residence. The overall management of the home has improved, effective ways of assessing and monitoring the quality of the service have been put in place. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Aspen Grange Care Home DS0000072288.V376740.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Aspen Grange Care Home DS0000072288.V376740.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who are considering moving into the home will benefit from having their care needs assessed so that they can be sure the home can meet their needs. EVIDENCE: There have been no new admissions in to the home since the Key inspection. We are unable to fully assess assessment and admissions process as there have been no admissions into the home. However, the acting manager has rewritten the admissions policy and has demonstrated at the random inspection their understanding of the level of need that the home is able to meet. Aspen Grange Care Home DS0000072288.V376740.R01.S.doc Version 5.2 Page 10 The acting manager or deputy manager will undertake a pre admission assessment before determining whether they can meet someones needs. A fuller assessment, risk assessments will be completed with people as soon as they move in. From this a care plan will be developed. At the random inspection we looked at two people’s care records that have had their needs reassessed since the last inspection. The assessments seen reflected the individual’s current needs and the information had been transferred into a care plan. People spoken with and records seen told us that they had enough information about the home and have a contract. Aspen Grange Care Home DS0000072288.V376740.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: We looked at four peoples care records. The care plans seen were of a good quality and detailed how staff were to meet peoples needs. They included good clear descriptions of how staff are to care and support people and specifically how to interact and talk with people who have dementia. They included assessments for any areas of risk and the action staff need to take to minimise these and the how often to monitor for any changes. Risk assessments were completed for falls, tissue viability, mobility, and nutrition. Aspen Grange Care Home DS0000072288.V376740.R01.S.doc Version 5.2 Page 12 The daily records are now completed throughout the day whenever staff interact with people. The daily records now give a full and complete picture of the care and support provided to people and how they are spending their time. The acting manager told us that all of the care plans have now been reviewed since the last key inspection. There was good personal history information available in the four people’s care plans. Individuals or their relatives have signed their care plans and they are kept in people’s bedrooms. One person told us that they had been involved in reviewing and saying what was important to them in their new care plan. Since the last key inspection, the standard of care planning and record keeping about people has improved. One person’s care records included a DNR (Do Not Resuscitate) decision made by a GP in 2006. Any historical DNR decisions must be reassessed under the Mental Capacity Act. Staff observed had good relationships with the people living at the home and were patient and encouraging. Staff respected peoples privacy and dignity, by knocking on their doors and offering personal care discreetly and in private. Staff spoken with had a good understanding of recognising people as individuals, respecting their privacy and dignity and they were knowledgeable about them as a person. Discussion with the manager, staff, a district nurse and observation of care plans and daily records tell us that people living in the home have access to health professionals such as GP, dietician, dentist and specialist consultants and chiropodist. We spoke with a district nurse who told us that there were now good relationships between them and the home and that they are contacted appropriately. The medication systems and administration at the home are well managed. Medication policies and procedures are safe, with medication being stored safely, labeled correctly and administered safely. All of the medication records seen were correct. The lockable medication fridge is stored in the main dining room. Another area to keep the medications fridge should be looked at. This is because it is very visible and is at times noisy whilst be people are eating their meals. Aspen Grange Care Home DS0000072288.V376740.R01.S.doc Version 5.2 Page 13 A number of people have as needed medication prescribed. There must be PRN (as needed) medication plans in place. These plans need to describe under what circumstances it is to be given, how long between doses, what is the maximum dose in 24 hours and whether it can be taken with other medications. These should be agreed with the prescribing practitioners where possible. It is recommended that these plans be kept with the administration records so that staff can easily refer to them. Some people who have as needed medication prescribed are taking it on a daily basis. It is recommended that the home request that the GP review these individuals medication if they need it daily. Aspen Grange Care Home DS0000072288.V376740.R01.S.doc Version 5.2 Page 14 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in the home are supported to maintain their independence, contact with important others and lifestyle, which enhances their quality of life. EVIDENCE: People living in the home are supported to maintain their independence, contact with important others and lifestyle, which enhances their quality of life. One person takes Holy Communion each week and we spoke to the individual and the visiting clergy who said that people are supported to worship how they choose. There is now an activities co-ordinator at the home and there is a regular programme of social activities. Since the last key inspection, a part time activities co-ordinator has been employed and the activities and levels of Aspen Grange Care Home DS0000072288.V376740.R01.S.doc Version 5.2 Page 15 stimulation for people have increased. There is now a weekly programme of activities including a weekly trip out of the home. The week of the inspection there was a trip out, music, pet therapy, board games, ‘pamper day’ and Bingo. From discussion with the acting manager and information provided in the AQAA there are plans to increase the activities co-ordinator to full time when the occupancy of the home increases and there will be more opportunity to provide one to one with people who do not wish to join in group activities. People spoken with and observed got up and spent their time how and where they chose. There is now a large wipe board in the main dining room. The day’s menu choices and activities were clearly displayed. We observed people during lunch, the atmosphere was relaxed and there were enough staff to serve the meal at a suitable pace. All meals were served hot and any support needed from staff was given discretely and sensitively Aspen Grange Care Home DS0000072288.V376740.R01.S.doc Version 5.2 Page 16 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Complaints procedures make sure that peoples, relatives and representatives concerns and complaints are listened to and acted upon. A staff team who have a fair knowledge of how to respond to any suspicion of abuse and to keep people safe from harm support the people living at the home. EVIDENCE: The home has a formal complaints policy which is accessible to people and their families. People are encouraged to raise their concerns with the manager. People who live at the home told us that they know who to speak to if they are unhappy and how to complain. We have received one written complaint since the last key inspection. We referred the complainant to raise their complaint with the acting manager or owners. From discussion with the manager the complainant has been in contact but has raised different concerns to those raised with us. The complainant stated that they were not making a formal complaint. The acting Aspen Grange Care Home DS0000072288.V376740.R01.S.doc Version 5.2 Page 17 manager has followed this concern up but has not kept a written record. It is good practice to keep a written record of informal complaints and concerns. We looked at the complaint records kept at the home. The home has received one complaint since the last key inspection. There was a record of the complaint, investigation and outcome to the complainant. Following the last key inspection there was an increase in adult protection safeguarding referrals. This was following an increase in understanding of what constitutes adult protection and a change in management and staff culture. The acting manager and staff have co-operated fully with the investigations and improved practices to prevent recurrence of any incidents. Staff have been provided with basic adult protection training during induction. Following discussion with staff and the acting manager, it is recommended that adult protection safeguarding training be prioritised. Aspen Grange Care Home DS0000072288.V376740.R01.S.doc Version 5.2 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is maintained and furnished so that people live or stay in a homely, clean, comfortable environment. EVIDENCE: The home has a warm and relaxed atmosphere. The home is well decorated and generally well maintained throughout. The three lounges and two dining areas are comfortably furnished. Ramped access is provided from these rooms to the courtyard garden with seating and a summerhouse for residents to enjoy. There is a garden area, laid mainly to lawn. There are five communal bathrooms at Aspen Grange, one being a wet room. Aspen Grange Care Home DS0000072288.V376740.R01.S.doc Version 5.2 Page 19 Assisted baths are available. There are sufficient communal WCs, including some situated close to the lounges and dining areas. A number of bedrooms also have their own en-suite facilities. Twenty-eight of the 41 bedrooms have en-suite facilities, including both of the shared rooms. Since the last key inspection the laundry has been relocated and the main office has been moved to a more central part of the home. The windows on the first floor are not all restricted. Risk assessments have been completed based on the people staying in the bedrooms or restrictors have been fitted. We looked at some of the bedrooms of the people involved in case tracking. They were clean and well furnished. The rooms were personalised with their own belongings. There are some radiators and exposed heating pipes that may pose a risk to people. One person’s bed is against the radiator in their bedroom. This may pose a risk when the heating is on. This radiator should be covered or the bed repositioned. The floor on the staff toilet should be sealed to aid cleaning. There was a disposable razor above a bath. This should either be disposed of or kept in the individual’s bedroom. Systems are in place to reduce the risk of infection. Disposable gloves, aprons and hand scrub were available and were used by staff when handling soiled linen and when supporting people with personal care. However, there are not foot operated bins in all of the bathrooms and toilets. There is one sink in the laundry that had linen soaking in it. There should be a separate sink for staff to wash their hands. Aspen Grange Care Home DS0000072288.V376740.R01.S.doc Version 5.2 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people living in the home are and supported by a competent and managed staff team. Shortfalls in the safe recruitment of staff places potentially people at risk of harm. EVIDENCE: On the day of the inspection there were 26 people living at the home. During the inspection there were sufficient staff on duty to meet the current needs of the 26 people living at the home. The acting manager is now aware of the numbers of staff needed to meet the current needs of the people at the home. She is also very clear about the need to balance the dependency of the people with the number of staff available. Four staff files were seen including the most recently recruited staff. All files included evidence of CRB (Criminal Records Bureau) checks and PoVA (Protection of Vulnerable Adults) checks. Three of the four files included two Aspen Grange Care Home DS0000072288.V376740.R01.S.doc Version 5.2 Page 21 suitable references. However, one staff member has a recent criminal conviction relating to vulnerable people. This had been declared on the application and discussed at interview. The subsequent offer letter from the registered provider included a statement of the individual’s version of events that led to the conviction and a request that this employee sign to confirm. However, there were not any written references on file or any risk assessment in relation to the recent conviction, the duties of the post and contact with vulnerable people at the home. These shortfalls in the safe recruitment of this individual were identified by Bournemouth Borough Council during a monitoring visit on 11th June 2009 and still were not in place at the time of the inspection. The registered provider immediately contacted the previous employer for references. At the time of writing the report one character reference and one employer reference has been received and a risk assessment completed. However, the circumstances relating to criminal conviction have not yet been established from the employer and compared with the employee’s version. The registered provider has been pursuing this on a regular basis and informed us that he is redoing the CRB and PoVA checks following the receipt of the employee reference. The AQAA, discussion with staff, and the staff training records demonstrate that staff complete an induction program. The training matrix shows that staff attend a range of training programs to be able to meet the needs of the people living at the home. Aspen Grange Care Home DS0000072288.V376740.R01.S.doc Version 5.2 Page 22 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Overall people benefit from living in an improving and well managed home. Shortfalls in the safe recruitment of staff potentially place people at risk. People and others are able to express their views and these are listened to and acted upon. EVIDENCE: Since the last key inspection there has been a change in the managers at the home. A new acting manager and a new deputy manager have been appointed. The acting manager is not yet registered with us. Aspen Grange Care Home DS0000072288.V376740.R01.S.doc Version 5.2 Page 23 During the visit staff appeared confident in their roles, the home was relaxed and people appeared at ease and comfortable. Staff spoken with commented positively about the style of management and leadership from the manager, their job role and the people living at the home. The acting manager and registered provider have taken action to ensure that the outcomes for people living at the home have improved since the last key inspection. The acting manager and registered provider produced an improvement plan on how the shortfalls were to be met. All of the requirements and a majority of the recommendations issued at the last key inspection have now been. The shortfalls in the safe recruitment of staff identified in the staffing section are of concern and reflect on the overall management of the home. Particularly as it had been identified over three weeks prior to the inspection and the individual had been working at the home since May 2009. There is a quality assurance system in place that includes new monthly audits, monthly monitoring of accidents, incidents and falls analysis. Surveys and regulation 26 visits are also undertaken. The regulation 26 visits are undertaken by an independent consultant. The AQAA completed by the manager tells us that the findings of this information inform the plans for the home. Information provided before the inspection, by the acting manager in the AQAA (Annual Quality Assurance Assessment) shows that relevant Health and Safety checks and maintenance are being carried out at the home. A number of Health and Safety records were checked, including the fire safety log. These records showed that health and safety matters are well managed. Staff training in mandatory areas, including fire safety, health and safety, moving and handling, emergency aid, and basic food hygiene, is ongoing. Aspen Grange Care Home DS0000072288.V376740.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x 3 X 3 3 Aspen Grange Care Home DS0000072288.V376740.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13 Requirement There must be PRN (as needed) medication plans in place. These plans need to describe under what circumstances it is to be given, how long between doses, what the maximum dose is in 24 hours and whether it can be taken with other medications. This is to make sure that staff know in what circumstances to administer as needed medications and the maximum dosage people can safely be given at any time. Two written references must be obtained before staff start work at the home and where applicable a reference relating to the staff’s last employment with vulnerable adults. Timescale for action 01/10/09 2 OP29 19 01/09/09 4 OP29 13 This is to ensure the suitability of staff to work with vulnerable people. 01/09/09 Risk assessments specific to an individual’s roles and responsibilities must be completed for any staff that have DS0000072288.V376740.R01.S.doc Version 5.2 Page 26 Aspen Grange Care Home criminal convictions. This is to make sure that any risks have been assessed and that staff are suitable and safe to work with vulnerable people living at the home. 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 OP7 Good Practice Recommendations Personal profiles in care plans and or Life History books should be developed that include details and photographs of their history such as family, friends, where they have lived, pets, work etc. These profiles or life history books will assist staff to have a greater understanding of them as an individual. PRN plans should be agreed with the prescribing practitioners where possible. It is recommended that these plans be kept with the administration records so that staff can easily refer to them. Another area to keep the medications fridge should be looked at. This is because it is very visible and is at times noisy whilst be people are eating their meals. Adult protection training should be prioritised. This is so that staff have the skills and knowledge to identify and report any allegations of abuse. Radiators and exposed heating pipes should either be risk assessed or covered to reduce to risks to individuals. This is to make sure people are protected from being scalded or burnt. The floor on the staff toilet should be sealed to aid cleaning. DS0000072288.V376740.R01.S.doc Version 5.2 Page 27 2 OP9 3 OP9 4 5 OP18 OP19 6 OP26 Aspen Grange Care Home 7 8 9 OP26 OP26 OP26 Disposable razors should either be kept in individual’s bedrooms or disposed of. They should not be kept in communal bathrooms. Foot operated bins should be in all toilets and bathrooms. There should be a separate sink in the laundry for washing hands. Aspen Grange Care Home DS0000072288.V376740.R01.S.doc Version 5.2 Page 28 Care Quality Commission South West Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.southwest@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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