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Inspection on 16/05/05 for Aylesham Court Nursing & Residential Home

Also see our care home review for Aylesham Court Nursing & Residential Home for more information

This inspection was carried out on 16th May 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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

What the care home does well

The home provides a well maintained, comfortable calm environment, which is conducive to this type of resident. The home employs an activities organisers who provide a good range of activities (including external trips ). The service has an excellent quality assurance system in place, which includes internal audits, regular meetings with management and the "Personal Best Programme" which BUPA have recently introduced. The programme is a behavioural programme for staff. A significant investment has been made in the programme by BUPA to ensure that all staff are working in the same manner which supports best practise. Staff observed during this inspection were noted to be friendly and caring towards residents. The trained staff complete an admission pathway to ensure that all aspects of assessment and admission are completed and documented.

What has improved since the last inspection?

Staff morale appears to have improved since the last inspection and working relationships internally and with other professionals appear to have improved. Staff have received additional care plan training and when case tracking care plans this was evident. The quality team is auditing care plans more frequently. Supervision of staff has improved and records evidenced this. Complaints about the service have reduced significantly since the last inspection. The manager has allocated staff an hour to update themselves on care plans and events for all staff returning from an extended period of leave or sickness to ensure they are fully aware of changes to service users care needs.

What the care home could do better:

The manager could improve the input of senior care staff into care plan evaluation and risk assessment. The manager could improve the method of giving feedback to residents when issues have been raised at meetings. The manager could improve the outcomes for service users by increasing the size of the font used on minutes and other documents in order that those with visual impairment are able to read essential information. The activities organiser could improve the method of informing residents of the dates and times of meetings in order that they can plan their schedules accordingly. The activities organiser and manager could improve the outcomes for residents by inclusion of the service user representative at discussion meetings between residents meetings. The activities organiser and manager could improve the outcomes for residents who are permanently nursed in bed by ensuring that planned and implemented one to one sessions are included in the activities programme.The outcomes for service users and staff could be improved by the monitoring of the temperature on the top floor rooms. Where inadequate ventilation is found appropriate action taken. The manager could improve the outcomes for residents by discussion with them regarding their concerns that they are missing out on afternoon drinks due to being in their rooms rather than in communal areas.

CARE HOMES FOR OLDER PEOPLE Aylesham Court Nursing & Residential Home 195 Hinckley Road Leicester Forest East Leicestershire LE3 3PH Lead Inspector Gillian Adkin Unannounced 16.May 2005 09:30 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. Aylesham Court Nursing & Residential Home C51 S1886 Aylesham Court V221452 270405.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Aylesham Court Nursing & Residential Home Address 195 Hinckley Road Leicester Forest East Leicestershire LE3 3PH 0116 2395599 0116 2395982 dudda@bupa.com BUPA Care Homes Limited 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) Amanda Dudd Care home with nursing 60 Category(ies) of OP Old age (60) registration, with number PD Physical disability (14) of places PD(E) Physical dis - over 65 (60) TI(E) Terminally ill (60) Aylesham Court Nursing & Residential Home C51 S1886 Aylesham Court V221452 270405.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Old age, not falling within any other category (60), Physical disability (14), Physical disability over 65 years of age (60), Terminally ill over 65 years of age (60) No person under 55 years falling within category PD may be admitted to the home. To be able to continue to accommodate the named person in category PD who is under 55 years of age, subject of variation application V10139, who is currently residing in the home as agreed with the previous registration authority. No person who falls within category PD may be admitted to the home when 14 persons of category PD are already accommodated within the home. Date of last inspection 30.09.04 Brief Description of the Service: Aylesham Court is a 60-bedded care home providing personal and nursing care for older persons. The home is purpose built; It is located on a main road on the outskirts of Enderby and Kirby Muxloe Leicestershire and is easily accessed by public transport from the City of Leicester and the County. The home provides nursing care for sixty service users whose care needs fall within the categories of Older Persons and or Physical Disability over 65 years of age, Terminally Ill.The home is purpose built and is accessible to service users with disabilities.Accommodation is located on two floors with a passenger lift between them. The ground floor has two spacious lounge areas, which look out onto landscaped gardens, which are mainly laid to lawn with surrounding shrubbery. The home has two large dining rooms, which are tastefully decorated, and has a private area where service users can have a meal with relatives or friends if they wish. The home has fifty-six single bedrooms and two double bedrooms; all are ensuite, many open directly onto the garden. The home is currently managed by a registered nurse and employs general nurses and care staff. Aylesham Court Nursing & Residential Home C51 S1886 Aylesham Court V221452 270405.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home was inspected for the ninth time against the Regulations as in the Care Standards Act 2000. This was an unannounced inspection, which took place over one day and commenced at 9.30 am on 15/05/05.The registered manager facilitated the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for Service Users and their views of the service provided. This process considers the home’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provisions that need further development. The primary method of inspection used was ‘case tracking’ which involved selecting four residents and tracking the care they received through review of their records, discussion with them, and their relatives, care staff and observation of care practices. This inspection report additionally addresses specific areas where requirements and/or recommendations were identified at the previous inspection. During this inspection a tour of the home took place and the inspector viewed internal records, and care plans. She also spoke to nurses, care and ancillary staff, residents and relatives. Discussions with the registered manager regarding requirements made at the last inspection indicated that all of the requirements and all recommendations had been met. Comment cards were received from a number of residents of whom two were selected for case tracking due to comments made. Remaining comments about the service were mainly positive. No comment cards were returned from external professionals. What the service does well: The home provides a well maintained, comfortable calm environment, which is conducive to this type of resident. The home employs an activities organisers who provide a good range of activities (including external trips ). The service has an excellent quality assurance system in place, which includes internal audits, regular meetings with management and the “Personal Best Programme” which BUPA have recently introduced. The programme is a Aylesham Court Nursing & Residential Home C51 S1886 Aylesham Court V221452 270405.doc Version 1.30 Page 6 behavioural programme for staff. A significant investment has been made in the programme by BUPA to ensure that all staff are working in the same manner which supports best practise. Staff observed during this inspection were noted to be friendly and caring towards residents. The trained staff complete an admission pathway to ensure that all aspects of assessment and admission are completed and documented. What has improved since the last inspection? What they could do better: The manager could improve the input of senior care staff into care plan evaluation and risk assessment. The manager could improve the method of giving feedback to residents when issues have been raised at meetings. The manager could improve the outcomes for service users by increasing the size of the font used on minutes and other documents in order that those with visual impairment are able to read essential information. The activities organiser could improve the method of informing residents of the dates and times of meetings in order that they can plan their schedules accordingly. The activities organiser and manager could improve the outcomes for residents by inclusion of the service user representative at discussion meetings between residents meetings. The activities organiser and manager could improve the outcomes for residents who are permanently nursed in bed by ensuring that planned and implemented one to one sessions are included in the activities programme. Aylesham Court Nursing & Residential Home C51 S1886 Aylesham Court V221452 270405.doc Version 1.30 Page 7 The outcomes for service users and staff could be improved by the monitoring of the temperature on the top floor rooms. Where inadequate ventilation is found appropriate action taken. The manager could improve the outcomes for residents by discussion with them regarding their concerns that they are missing out on afternoon drinks due to being in their rooms rather than in communal areas. 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. Aylesham Court Nursing & Residential Home C51 S1886 Aylesham Court V221452 270405.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 Aylesham Court Nursing & Residential Home C51 S1886 Aylesham Court V221452 270405.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) 3.4. Comprehensive assessments of residents prior to admission along with external professional assessments and internal risk assessments ensures that residents and their relatives are confident that their needs will be met by the home. EVIDENCE: All of the four care plans tracked contained a BUPA assessment, which was undertaken by the manager, and three of the four care plans contained a Community care assessment completed prior to admission by the social worker. Other assessments including risk assessments were in place and were in relation to individual risks identified on assessment. These included manual handling, nutrition, and dependency, pressure sore and falls assessments. Care plans tracked included the BUPA assessment and admission pathway, which ensures that essential information, is obtained to allow staff to appropriately care plan. This is considered as good practise and is commended. Other assessments undertaken by external professionals were also in place in care plans tracked. Aylesham Court Nursing & Residential Home C51 S1886 Aylesham Court V221452 270405.doc Version 1.30 Page 10 One care plan tracked however did not include a suitable continence assessment and the corresponding care plan did not appear to meet the needs of the individual resident. It was not possible to explore with the resident this subject but evidence would suggest that the outcomes for the resident could have been improved with an appropriate assessment and care plan in place. Three of the four residents tracked were unable to confirm if they had been involved in their initial assessment prior to admission to the home. The outcomes for residents were that care needs were mostly addressed and in the main met. Aylesham Court Nursing & Residential Home C51 S1886 Aylesham Court V221452 270405.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) 7.8.9. Ongoing assessment and audit of care records and inclusion of external professionals and relatives into care planning and evaluation will ensure that all care needs including medical social and psychological are appropriately met. EVIDENCE: Four care plans were case tracked and overall significant improvements have been made to them since the last inspection. Initial assessments in the main were reflected in corresponding care plans however evaluation of one care plan was significantly out of date in relation to nutritional risk and dependency. The outcomes of which could result in the resident being placed at risk nutritionally and at risk of tissue viability issues as she was bedridden and identified as at risk of pressure sore development. A further care plan tracked did not accurately identify continence issues and their management (risk of urine infections) or reflect the outcomes of current continence management (use of pads). Daily records seen indicated that a relative of one resident tracked was unhappy with the management of her relatives urinary tract infection no evidence was found to support that the General Practitioner had been notified or any treatment prescribed. Aylesham Court Nursing & Residential Home C51 S1886 Aylesham Court V221452 270405.doc Version 1.30 Page 12 A relative spoken with and observed during this inspection informed the inspector that she was involved in the feeding of her husband. This resident was identified as having a choke risk. No evidence was found in records to indicate that this risk had been assessed with regard to the relative assisting in this task. Adequate evidence was found to support that resident’s healthcare needs were addressed and included the input of other professionals. All residents tracked have a named nurse who has responsibility for the evaluation of their care plans. All residents spoken with stated (where possible) that they were able to see the General Practitioner when required. One resident tracked was attending a hospital out patient appointment during the inspection and was unable to give his view on input into his care plan. Other residents spoken with stated they were involved in reviews of their plans. Medication systems and management were inspected and all areas inspected were well managed and records examined were accurate and up to date. A new nurse recently appointed informed the inspector that she was undergoing induction, which included observation of drug rounds by the clinical nurse supervisor. No residents tracked self-medicated. Aylesham Court Nursing & Residential Home C51 S1886 Aylesham Court V221452 270405.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) 12.15. Giving residents’ choices over their daily lives and ensuring that they experience a homely life, which includes flexible routines, good quality meals and appropriate activities ensures that the experience of living in the care home matches their expectations and individual requirements. EVIDENCE: During this inspection a residents meeting was being held. One resident informed the inspector that he was the residents representative however he had not attended the meeting as he was angry that he had been given inadequate notice of the meeting and had taken the time to obtain the views of other residents in preparation for the meeting. This was discussed with the registered manager who agreed to investigate further. Opinions and views of residents were sought during the meeting and one resident raised a concern that she was constantly missed out on the afternoon drinks round as she was in her room which she described as “being at the end of the corridor” It was unclear if residents were aware that they could make their own drinks (according to risk assessment) the manager was informed of this matter. Residents spoken with stated that there was some flexibility in the routines but much was dictated by staff availability. One resident stated at the end of the residents meeting “ We want it minuteing that the staff are very good and we want to say thank you” Aylesham Court Nursing & Residential Home C51 S1886 Aylesham Court V221452 270405.doc Version 1.30 Page 14 Observation of routines indicated that much of the work was allocated within given time bands however staff responses to requests by residents were managed appropriately and in a timely manner. No complaints were received by the inspector regarding inflexibility. A good programme of entertainment and activities is provided and discussion with the activities organiser highlighted that although she attempts to meet the needs of the majority of residents some including those nursed permanently in bed do not get an equal share of her time. Meals and menus inspected appeared to be wholesome well cooked and presented and offered ample choice. Residents tracked indicated that they were very satisfied with food provided. The cook and staff associated with residents tracked were fully aware when questioned of their nutritional needs and risks. Aylesham Court Nursing & Residential Home C51 S1886 Aylesham Court V221452 270405.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) 16.17.18. Complaints are managed efficiently and responded to within given time scales. There is an adult protection procedure in place to respond to suspicion or allegation of abuse this ensures the protection of residents in the home. EVIDENCE: Examination of the written complaint procedure indicated that clear guidance is given to residents and their relatives on how to make a complaint on admission to the home. A copy of the complaint process is posted on the wall in the reception area of the home. No complaints were under investigation at the time of inspection. Only one of the four residents tracked indicated that they knew how to make a complaint (due to their medical condition). Other residents spoken with were fully aware of the process. One resident stated that he had made a complaint, which the manager had dealt with appropriately. Relatives spoken with identified either the manager or a senior member of staff whom they would direct a complaint towards. Examination of the written adult protection process indicated that procedures are in place to respond to allegations of abuse. Several staff members spoken to were able to demonstrate their knowledge of the home’s adult protection process and had received training during induction and in the NVQ programme. The registered manager has experience of referral and management of vulnerable adult situations. Several residents spoken to indicated that they felt safe in the home. Other residents spoken with were unable to answer questions. Aylesham Court Nursing & Residential Home C51 S1886 Aylesham Court V221452 270405.doc Version 1.30 Page 16 Aylesham Court Nursing & Residential Home C51 S1886 Aylesham Court V221452 270405.doc Version 1.30 Page 17 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) 19.20.21.22.26 Clean, safe and well maintained living areas and rooms, and provision of appropriate equipment and facilities ensure that residents live in surroundings, which maximise independence and are comfortable and homely. EVIDENCE: During this inspection all areas of the home including the rooms of those case tracked were clean, odour free, well decorated and appeared to be well maintained. An ongoing maintenance and decoration programme is in place. The home employs a full time maintenance person who is responsible for dayto-day repairs and general maintenance and associated records. No changes have been made to the fabric of the building since the last inspection. There are ample communal areas, which provide residents with a choice of rooms to sit. Activities are conducted in the lounges and externally the grounds are safe, well maintained and accessible. One resident freely accesses grounds in their electric wheelchair. All rooms are single and en-suite providing rooms, which suit individual needs. A resident raised the issue of a “broken bath” with the inspector and stated that this had been “out of action” for some time. He was being showered Aylesham Court Nursing & Residential Home C51 S1886 Aylesham Court V221452 270405.doc Version 1.30 Page 18 during this time although preferred a bath. The manager was informed of this matter and the maintenance person was contacted. The matter was put right immediately. The maintenance person described a lack of communication as the problem. It was recommended that the maintenance person is invited to staff meetings to ensure that he is made aware of current issues and in order to ensure that residents individual needs are wherever practicable met. All equipment as identified in assessments as required for resident’s case tracked was provided and seen in use during this inspection. This included nursing beds, specialist chairs, electric wheelchairs, hoists, and alarmed mats etc. the outcome is that resident’s specialist needs are fully met and independence is promoted where possible. Laundry facilities were inspected on this occasion and staff indicated that they were aware of the implications of residents with MRSA or other infectious conditions. Appropriate hand washing facilities and equipment are evident throughout the home and the laundry facilities include high wash temperatures and sluicing programmes the outcome being that infection control is effectively managed in the home.. The home has disinfectors in place for sterilising of commode pans and urinals. Staff spoken with indicated that they had received training in infection control and COSSH in the last twelve months. Policies and procedures are in place regarding infection control of which staff were aware. Aylesham Court Nursing & Residential Home C51 S1886 Aylesham Court V221452 270405.doc Version 1.30 Page 19 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) 27.28.29. The needs of residents are safely met by thorough recruitment and selection processes and adequate numbers of suitably skilled and trained staff. EVIDENCE: Inspection and calculation of staff rosters demonstrate that staffing levels and hours provided meet with the recommended guidelines of the previous registration authority. Three of the four residents tracked were assessed with high dependency needs and one with medium dependency needs. All information from care plans and received from residents on comment cards indicated that staffing levels were adequate to meet their needs. Staff spoken with and observed appeared to be very busy and constantly responding to resident’s requests for assistance. No concerns were raised with the inspector regarding number or quality of staff. The skill mix of staff identified on duty rosters appears to be appropriate to meet the needs of residents in occupancy at this inspection. Staff files were inspected on this occasion and all essential documentation was in place. The registered manager stated that she had checked staff files within the proceeding two weeks and found all to be in order. BUPA Quality Assurance team intend to undertake random audits of staff files one of which was due on the 19th May 2005.This process ensure that the quality of staff employed is conducive with the categories and needs of resident accommodated. Aylesham Court Nursing & Residential Home C51 S1886 Aylesham Court V221452 270405.doc Version 1.30 Page 20 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) 33.34.35.36.38 Staff’s failure to comply with manual handling risk assessments and associated care plans could result in residents being placed at serious risk of injury or harm. EVIDENCE: Continuous monitoring and internal audits of the home are undertaken. Policies and procedures are in place, which ensure that the home is run with the best interests of residents in mind. It was however apparent after discussion with a resident that an issue had been raised at the last residents meeting in January which had not been satisfactorily dealt with and which was raised again at this meeting. Residents indicated that they were frustrated that action had not been taken and that they had not been kept informed. A requirement has been made to address this matter. Seven residents currently manage their own financial affairs, however none of the residents tracked were able to discuss with the inspector their own situation. Six residents are under Power Of attorney processes. Aylesham Court Nursing & Residential Home C51 S1886 Aylesham Court V221452 270405.doc Version 1.30 Page 21 A number of thefts have been reported to the CSCI since the last inspection they have however been appropriately managed by the home and satisfactorily concluded. Observation of internal records and discussion with staff demonstrated that senior staff regularly supervise junior staff. Records seen were up to date. A new staff nurse informed the inspector that she was being supervised by the RGN whom she was working with on that shift. All records relating to the management of health and safety including fire records, COSHH assessments, accident records and Induction of new staff indicated that staff were trained and made aware of generic and individual risks. Manual handling risks were identified within the initial assessment and care plans of two residents tracked. On two separate occasions however the inspector observed care staff hoisting residents with the same sling. Examination of associated care plans indicated that they were using the wrong type and size of sling for both individuals despite informing the inspector that they checked the care plans for information. Failure to comply with the requirements of risk assessments and care plans could result in individuals concerned and others persons being placed at risk of serious injury or harm. Aylesham Court Nursing & Residential Home C51 S1886 Aylesham Court V221452 270405.doc Version 1.30 Page 22 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 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 x x x 2 3 2 3 x 1 Aylesham Court Nursing & Residential Home C51 S1886 Aylesham Court V221452 270405.doc Version 1.30 Page 23 NO 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 Regulation 14 Requirement Care plans must contain all assessments undertaken prior to admission to the home including the community care assessment. Care plans must fully address all medical,social,cultural and psychological needs. Wound care plans must be kept under constant review and must reflect the outcomes of treatmet given. Appropriate risk assessments must be put in place in care plans where identified such as ris of choking. Timescale for action By 20.07.05 By 20.07.05 By 20.07.05 By 20.07.05 By 20.07.05. Immediate 2. 3. 7 8 15 15 4. 8 13 5. 6. 8 38 12.13 13 Appropriate action must be taken to address the use of slings where identified at inspection. Risk assessments must be evaluated at least monthly and staff informed of any changes to risk or equipment to be used. Activities provided to service users must also include service users who are permanently nursed in bed. The registered manager must ensure that where issues arise 7. 12 12.16 By 20.07.05 By 20.07.05 Page 24 8. 33 12 Aylesham Court Nursing & Residential Home C51 S1886 Aylesham Court V221452 270405.doc Version 1.30 which are minuted in residents meetings that appropriate action is taken to rectify and that feedback is given to service users as soon as possible. 9. 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. Refer to Standard 33 38 Good Practice Recommendations It is recommended that the maintenance person is invited to attend staff meetings where practicable. It is recommended that unobtrusive observation of staff during hoisting procedures is commenced to ensure compliance with manual handling requirements. Aylesham Court Nursing & Residential Home C51 S1886 Aylesham Court V221452 270405.doc Version 1.30 Page 25 Commission for Social Care Inspection The Pavilions, 5 Smith Way Grove Park, Enderby Leicester LE19 1SX 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. Extracts may not be used or reproduced without the express permission of CSCI Aylesham Court Nursing & Residential Home C51 S1886 Aylesham Court V221452 270405.doc Version 1.30 Page 26 - 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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