Inspection on 01/06/07 for Aston Grange

This inspection was carried out on 1st June 2007.

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

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

Other inspections for this house

Aston Grange 17/12/07

Aston Grange 24/01/07

Aston Grange 08/05/06

Aston Grange 29/09/05

Aston Grange 15/04/05

Aston Grange 04/08/04

Aston Grange 21/05/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Aston Grange 484-512 Forest Road Walthamstow London E17 4PZ Lead Inspector Zita McCarry Unannounced Inspection 06:50 1st June 2007 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 Aston Grange DS0000007241.V337796.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. Aston Grange DS0000007241.V337796.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Aston Grange Address 484-512 Forest Road Walthamstow London E17 4PZ Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8509 1509 020 8509 1609 manager@astongrange.fsnet.co.uk Aston Grange Limited Deepak Luckhun Care Home 45 Category(ies) of Dementia - over 65 years of age (29), Old age, registration, with number not falling within any other category (16) of places Aston Grange DS0000007241.V337796.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th January 2007 Brief Description of the Service: Aston Grange is registered to provide care to 45 elderly people, 29 of whom have a diagnosis of dementia. The home is operated by ‘Aston Grange Ltd’, linked to ‘Carebase Ltd’, who own other care homes. Short-term respite stays are offered where there are vacancies between long-stay placements. Each of the three floors is designed as a separate unit, the upper two accommodating residents with dementia. All residents have a single bedroom, with an en-suite lavatory and washbasin. There is one bathroom with a bath suitable for assisting people with limited mobility, a shower room, and a sluicing facility in each unit. A large lift links all levels. One of the seating areas on the middle floor can be used by residents to meet visitors in private. Meals are prepared in the kitchen on the second floor and served in the dining area on each unit. The ground floor sitting/ dining room also has a kitchenette area where residents or staff can prepare drinks and snacks. The building is on a main road in Walthamstow, near shops and transport links. There is limited garden area, but it has seating areas and space to walk. Overall space standards for residents are adequate, but office and storage space is limited. A bonus for visitors is a good-sized parking forecourt as the neighbourhood has restricted parking. Aston Grange DS0000007241.V337796.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the report of a 10 hour unannounced inspection undertaken in early June 2007. The inspector met with service users and staff and was assisted in the process by the registered manager. The services’ business manager was available throughout the day. The inspection involved seeking feedback from the people who live and work in Aston Grange, observing how staff undertake their work, reading records which relate to the care of service users, and the management of the service. The inspector would like to thank everyone involved for their co-operation in the inspection process. A major part of the inspection involved monitoring the service’s compliance with the 28 statutory requirements from the previous inspection. It was positively noted that 18 requirements were found to have been met. It is evident that the service has been working toward improving the outcomes for the service users who live in Aston Grange. However these efforts have been considerably undermined by the service’s failure to adhere to processes that would secure the safety of service users. The Commission remains concerned about the admission of service users to Aston Grange where there is a failure to demonstrate that identified risks are not adequately considered. The Commission is further concerned about the unsafe recruitment of staff where the service has failed in its responsibility to safeguard service users by adhering to a robust recruitment process. An immediate requirement notice was service to ensure service users were not placed at risk of harm as a result of the service poor recruitment practices. What the service does well: What has improved since the last inspection? The home has continued to develop its care planning, whilst the inspection identified issues of concern the improvement of the system was noted. Aston Grange DS0000007241.V337796.R01.S.doc Version 5.2 Page 6 The home has improved its documenting of complaints and prompt responses to concerns raised were evident. The service has improved its accident recording and management response to accidents is now documented. Although work is still required in this area. The home is now providing support to staff through supervision. The service has improved staffing levels and there was evidence of the service being responsive by putting in place additional resources to meet identified needs. What they could do better: As noted above the service has continued to admit service users without adequate consideration to identified risks. Following the previous inspection the Commission served an enforcement notice to ensure compliance in with statutory requirements. In light of the findings at this inspection the Commission will hold a management review to consider its response. The service had been previously required to ensure it was in receipt of satisfactory pre employment checks before allowing someone to work in the home. As noted above this inspection identified the unsafe recruitment of staff where service users were put at risk because of the service failure to adhere to a robust recruitment process. The Commission is concerned about the inadequate protection of service users and the homes repeated failure to appropriately address identified risks or respond appropriately when abuse takes place. The Commission previously required the service to ensure that it responded appropriately to information that would indicate the need for additional safeguarding measures. It has failed to comply with this requirement. The Commission will therefore take enforcement action to ensure compliance and the safety and wellbeing of service users living in Aston Grange. The service must adequately detail the criteria it uses in the admission processes of the home. The service must demonstrate safe practices in the administration of medication and ensure service users have their medication as prescribed. Please contact the provider for advice of actions taken in response to this Aston Grange DS0000007241.V337796.R01.S.doc Version 5.2 Page 7 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. Aston Grange DS0000007241.V337796.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 Aston Grange DS0000007241.V337796.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4 Quality in this outcome area is poor. Neither prospective service users nor those already living in Aston Grange can be satisfied that admissions to he home are properly considered and safe. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service’s Statement of Purpose was reviewed this document had last been updated several weeks earlier. The Statement fails to provide adequate details of the arrangements it made for admitting people into the home, in particular the range of needs it can meet and the criteria it uses to decide whether it can meet someone’s presenting needs. The service admits service users into the home for “respite care” however on discussion with the manager in relation to one admission it appeared to be an arrangement to facilitate hospital discharge. The service needs to make clear in its Statement of Purpose exactly the services offered and how temporary placements are accommodated without negatively impacting on the quality of life experienced by the existing Aston Grange DS0000007241.V337796.R01.S.doc Version 5.2 Page 10 service user group. The service has previously been required to clarify its Statement of Purpose and despite amendments made the purpose and functioning arrangements of the service are unclear and not in line with the details required in Schedule 1 of the Care Homes Regulations 2001. The inspector reviewed the files of two service users to test the admission process into the home. The first file indicated a history of both verbal and physical aggression. The social workers assessment made very clear that there had been a history of aggression, which culminated in the service user being detained in hospital. The Social worker advised the home that again whilst in hospital a further incident of physical aggression too place. Despite this information the home failed to adequately assess the degree of risk to others in Aston Grange before admitting this service user into the home. The admission of a second service user was reviewed both a social worker assessment along with the homes own assessment of need were in place. The service users assessment indicated a different range of needs from the other service users. The service user’s needs assessment identified primary care needs that were not those of that the service were registered to meet. The service user was therefore admitted outside the category of registration of Aston Grange. Aston Grange DS0000007241.V337796.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is adequate. However service users cannot be sure that the service will consistently have up to date details on how their needs are to be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: From reviewing three service users care plans it was evident the service had made substantial improvement in developing service users care plans to reflect their individual needs and provide adequate direction to staff in how to meet those needs. On one service users care plan where there was a concern regarding behaviour that challenged, staff were given clear guidance in how to manage it. Care plans clearly reflected the involvement of service user or their families advocating on their behalf. It was very positively noted that the service has now begun inviting families formally to become more involved in the planning arrangements for the care to be delivered within the service. Aston Grange DS0000007241.V337796.R01.S.doc Version 5.2 Page 12 However on a care plan seen it was noted that the service users needs were not as described in the care plan. The service user was unwell, bedfast and non-weight bearing requiring the use of a hoist to transfer however the plan of care did not reflect the arrangements that needed to be in place to meet these needs. A second care plan failed to put strategies in place to address identified issues and the safety of other service users. The risk assessment of this service user failed to address known risks and the potential for causing harm. The inspector visited a service user very early in the morning and noted that the electric profiling bed was at its highest possible height, the bed had sides to reduce the likelihood of the service user rolling out of the bed none the less had the service user fallen from this height it would have most likely resulted in extremely serious injuries. The night care worker was unable to explain why the bed was at such a height. One service user in the home had a grade 5 pressure sore and on the day of the inspection was visited by the tissue viability nurse. The service users care plan referred staff to the “pressure sore care plan” however the inspector was unable to locate this document and the manager confirmed there was none in place. There has been a notable improvement in the recording of accidents in the service. There were 15 recorded accidents/incidents within the service since the last inspection. The quality of the recording had improved and the manager and inspector discussed how to include outcomes of treatment given. It was positively noted that a process of reviewing accidents within the home has begun. However 3 out of the 15 recorded injuries to service users occurred during staff handling of service users. The service needs to ensure all staff are competent in the safe moving and handling of service users and can demonstrate management response in relation to such occurrences. It was noted that whilst there was an improvement in this area the service did not consistently record accidents appropriately. The inspector noted in the daily records that the doctor was called after a service user had an accident but there was no details of the accident recorded in the accident record book presented for inspection and no details of how or when the accident occurred. The inspector checked the management of service users medications within the service. Medication is held securely within the home and only administered by the senior staff on duty. The inspector checked a random sample of medications on two floors. On both floors it was noted that there were a box of pots with service users names written on them. None of the senior staff on duty were able to present a explanation for these and in one instance the inspector was presented with mis-information about the containers. The inspector checked all and noted that the 13 pots corresponded to the 13 Aston Grange DS0000007241.V337796.R01.S.doc Version 5.2 Page 13 service users receiving night medication. There were no labelled pots for service users who did not receive night medication. This may indicate that medication is not administered to service users in a safe manner. The inspector noted that once brought to the attention of senior management within the organisation immediate robust action was taken to investigate the matter. The Commission awaits the outcome of the investigation. All staff have received extensive training in the administration of medication. The inspector audited 4 service users medication and found them all to be in order. However one service user had Ferrous Sulphate 200mg one twice a day discontinued. No record could be presented as to who had stopped the medication or indeed why. There were also tablets missing from the blister pack for 2 doses after the medication had been stopped. Whilst this is not evidence that medication was administered after it was discontinued it is of concern that medication managed by the home is not accounted for. The service has therefore been unable to demonstrate medications have been administered as prescribed. Service users described staff as “kind“ and “patient”, the inspector noted that staff were respectful in there interaction with service users. Aston Grange DS0000007241.V337796.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. However service users cannot be assured of consistency in the provision if social activities. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service is now documenting service users life history and enlisting the assistance of families to obtain this information. The inspector noted that staff were supporting a service user to cut out shapes from newspapers. In discussion staff were able to link this activity to the service users previous employment. Whilst the activity was inadequately resourced it was evidence that staff had an understanding of the service users individuality and her life before residential care. However on another unit when asked if the scheduled activity took place for the service users as advertised the staff confirmed it had not. There was no reasonable explanation presented as to why this was not provided. The inspector read a review that was undertaken to assess the first six weeks of a service users stay at the home and decide on whether the placement was Aston Grange DS0000007241.V337796.R01.S.doc Version 5.2 Page 15 to continue. It was noted the service user was not included in the actual review or any of the decision making processes. Whilst the social worker had sought feedback from the service user there was no evidence that it was explored at the review. Notes from the review failed to demonstrate how the service enabled the service user exercise any control over his life, to the extent that visits were being determined by the manager and social worker. In general the service users gave positive feedback on the quality and choice of food provided. One service user told the inspector that she was provided with a diet that suited her cultural needs. Aston Grange DS0000007241.V337796.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is poor. The service fails to adequately protect service users even when risks are identified. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints process was reviewed as part of the inspection. It was positively noted that the manager has put in place a comprehensive logging system that records complaints received into the service. There were three concerns recorded, which were all dealt with promptly, and well within timescale. There was evidence in the complaints log that staff were advocating on behalf of service users on an external service they had received. There are two current safeguarding adults enquiries taking place in the home in relation to service users being physically aggressive to each other. In one instance the alleged perpetrator of the abuse was admitted to the service without adequate consideration of the identified risks. It had been noted that on the day of the assault staff had identified triggers to an incident and despite identifying a need for close supervision and monitoring none was put in place. The incident became an Adult Protection issue after the London Ambulance Service reported the assault and the service user’s fear to the local authority. The assault was not reported to either the placing authority or the adult protection team, although the Commission was notified. Aston Grange DS0000007241.V337796.R01.S.doc Version 5.2 Page 17 The service has not been able to demonstrate a timely sharing of information with placing authorities. Again a service user was admitted without the home demonstrating adequate consideration to a history of physical aggression. The inspector noted three incidents in the home that should have triggered a management response. Such as the service user trying to pull another service user out of the chair, verbal aggression wanting to hit staff, and grabbing females by the arm with a “tight grip”. Despite these three occurrences the manager reviewed the risk assessment and noted that there had “not been any physical behavioural issues at all”. Similarly, information presented to the social worker for review noted “no challenging behaviour”. The Commission is concerned that there is no evidence to demonstrate the placing authority were advised of the recorded incidents. Failure to recognise or address such incidents undermines the safety of service users in the home. The Commission previously required the service to ensure that it responded appropriately to information that would indicate the need for additional safeguarding measures. It has failed to comply with this requirement. The Commission will therefore take enforcement action to ensure compliance and the safety and wellbeing of service users living in Aston Grange. Aston Grange DS0000007241.V337796.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Service users live in a clean well maintained environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: It was evident throughout the building that the service is well maintained with the fabric and decoration in good order. The building complies with fire and local environmental health regulations. There was evidence that appropriate equipment was in place to meet service users needs such as a profiling beds and moving and handling equipment. The service has provided service users with new mattress protectors and pillows, which will enhance their comfort. The building has appropriate signage, is bright and clean. Aston Grange DS0000007241.V337796.R01.S.doc Version 5.2 Page 19 Aston Grange DS0000007241.V337796.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is poor. Service users are put at risk of abuse because the service has failed to undertake a safe recruitment of staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The units in the home did not have a full compliment of service users in residence, the inspector was satisfied that the home had adequate staffing levels to meet the assessed needs of service users. There was also evidence that as a result of an incident the service had put in place additional staff resources to provide a high level of supervision. The service has now appointed a deputy manager to support the running of the home. There was evidence from an adult protection meeting that prior to an incident when staff identified the need for close supervision and monitoring of challenging behaviour none was provided. In the absence of the identified supervision a service user was assaulted. It is of concern that having identified the presenting agitation may lead to an incident and the need for close monitoring that the senior staff failed to ensure it was in place. As with the medication the Commission has noted a robust response from the organisation in its attempt to address issues of apparent poor staff performance. Aston Grange DS0000007241.V337796.R01.S.doc Version 5.2 Page 21 The home has over 50 of its staff team holding NVQ 2 in care. There was evidence that the service has invested in training its staff team. Since the last inspection staff have had training in safeguarding adults, safe administration of medication, care planning and first aid and infection control. The inspector checked the staff files to review the service’s recruitment processes. Of the four files inspected serious concerns were identified. Staff A Has been working in Aston Grange without the service being in receipt of a satisfactory Criminal Records Bureau disclosure. The service had failed to demonstrate it reviewed gaps in employment or verified references. The inspector and manager met with the member of staff and from discussion neither were satisfied with the authencity of a reference. Staff B Gaps in employment were evident on the application form but there was no evidence that these were explored at interview. Again references were not verified. The member of staff was employed before receipt of a PoVA first or CRB disclosure. A satisfactory CRB disclosure dated three weeks after the employee commenced work in the home was in [place. Staff C Again gaps in employment were evident which were not explored at interview. There was no evidence that the service had attempted to verify references particularly when the employer’s stamp of authencity was of concern. Again the employee was working in the service for over a month before the service was in receipt of a PoVA first check or CRB disclosure. Staff D This member of staff had received her induction into the service and was employed for over 2 months before the service was in receipt of a PoVA first check or CRB disclosure. Again gaps in employment were not explored nor references verified. The Commission is very concerned about the service’s failure to adhere to a robust recruitment process that would offer protection to service users. The service has previously been required to undertake a safe recruitment in line with regulations. An immediate requirement notice was service to ensure the service took action to secure the safety and wellbeing of service users. Aston Grange DS0000007241.V337796.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is poor. Service users cannot be assured that the day to day management of the service consistently takes appropriate measures to ensure their protection. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service has recently appointed a registered manager to run Aston Grange. The Commission has been concerned about aspects of the care provided in this service over a period of time and this report identifies improvements and evidence of the complying with statutory requirements. However the report also identifies concerns about the current management’s failure to demonstrate compliance with practices that have the purpose of safeguarding the service users that live in the home. Aston Grange DS0000007241.V337796.R01.S.doc Version 5.2 Page 23 There was evidence of service users meetings taking place. The homes line manager seeks feedback as part of the provider monitoring visits. The service has introduced a system whereby feedback is actively sought as part of the review process from both service users and families; it is good evidence of the service attempting to reflect the views of stakeholders in the development of the home. However this area will need to be further developed particularly how views are ascertained of people with dementia and how their feedback and comments are reflected in the running of the service. The service does not hold or manage any service users monies. The manager does not act and an agent or appointee for any service user. There was evidence that has a supervision program is now in place and on files checked staff were receiving supervision every 2 months. On the morning of the inspection the fire alarm was sounded for a brief period. On investigating the fire alarm the inspector noted staff failed to respond appropriately to the alarm being sounded. Staff failed to respond to the alarm commenting that it was most likely to be caused by toast being burnt in the unit above, no attempt was made to confirm this assertion. The manager later advised the inspector that the alarm being set off was actually a weekly fire alarm panel test. On tracking staff files it was noted neither staff concerned had attended fire drills although there was evidence that they had received fire safety training as part of their induction. This will need to be reviewed. Following problems identified at the last inspection the service has undertaken an assessment of the nurse call system and identified that there are several points within the home at which the system can be cancelled and not just the point of origin. The registered manger confirmed that this has not yet been rectified but the service has commissioned the system to be reprogrammed. The service has undertaken a full fire risk assessment and undertakes weekly checks of the emergency lighting system. The inspector checked the chilled food storage and noted that records were maintained to evidence safe storage. Aston Grange DS0000007241.V337796.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 2 X 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 3 X X X X X X 3 STAFFING Standard No Score 27 1 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 3 X X 1 Aston Grange DS0000007241.V337796.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP8 Regulation 13 Requirement The registered person must ensure all accidents are properly recorded and in sufficient detail and a record held for inspection. Unmet for previous inspection. The registered manager must ensure service users receive their medication as prescribed. Unmet for previous inspection. The registered person must ensure that care plans are underpinned by a comprehensive up-to-date risk assessment. Unmet for previous inspection. The registered person must ensure the service develops a Statement of Purpose that details how the service is to function and meets the criteria as detailed in Schedule 1 of the CHR 2001. Unmet for previous inspection. The registered person must ensure all information identified in the assessment process is DS0000007241.V337796.R01.S.doc Timescale for action 20/08/07 2. OP9 13 20/08/07 3 OP7 14 & 15 20/08/07 4 OP1 4 20/08/07 5. OP7 14 & 15 20/08/07 Aston Grange Version 5.2 Page 26 6 OP8 7. OP8 appropriately recorded in the service users care plan. Unmet for previous inspection. 18, 13, 17 The registered manager must evidence a management response when service users are injured as a result of staff handling. 13 The registered person must ensure that current moving and handling strategies are recorded in the service users care plan and staff follow to them. 23 Unmet for previous inspection. The registered person must ensure all assistance calls can only be cancelled or silenced at the point of origin. Unmet for previous inspection. The registered manager must ensure that the service undertakes an adequate assessment of need prior to admitting a prospective service user. All identified risks must be adequately considered prior to admission. 20/08/07 20/08/07 8. OP38 20/07/07 9 OP3 14 20/08/07 10 OP8 15 12 11 OP12 12 12 OP14 16, 12 Unmet for previous inspection. The registered manager must 20/08/07 ensure that care plans incorporate directions from other professionals in the management of care of service users with pressure sores. The registered manger must 20/08/07 ensure service users scheduled activities take place as planned and activities are adequately resourced. The registered manager must 20/08/07 ensure service users are supported to exercise choice and control over their daily lives and where ever possible are involved in the decision making DS0000007241.V337796.R01.S.doc Version 5.2 Page 27 Aston Grange 13 OP29 19 14 OP29 19 15 OP31 9 16 OP38 18 processes. The registered person with immediate effect (4/6/07) must ensure that no staff are employed unless satisfactory details as required in schedule 2 of the CHR 2001 are satisfactorily met. The registered person must undertake an audit of all staff files and ensure the documentation of those appointed are checked and verified and meet the criteria of schedule 2 of the CHR 2001. The registered provider must review the skills and experience gaps within the management team at Aston Grange and provide the Commission with details of the measures that will be put in place to address these. The registered manager must review staff’s understanding of fire procedures within the home and assure itself of staff competence. 04/06/07 08/06/07 20/07/07 20/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Aston Grange DS0000007241.V337796.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Aston Grange DS0000007241.V337796.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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