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Inspection on 03/10/07 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 3rd October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

People using the service are provided with a safe and comfortable environment to live in. People are enabled to personalise their bedrooms and to use all areas of the building as they wish. The routine in the home was flexible, and residents were observed using their bedrooms as they wish. Visitors are made welcome at anytime and encouraged to participate in the daily routine and activities if they wish. Residents are enabled to take part in activities that they enjoy and are interested in, although it was recognised that this could be developed further. Residents needs are assessed and planned for, and efforts made to involve residents and relatives in this process whenever possible. The care provided is also reviewed on a regular basis. Residents are cared for by a staff team that has been recruited correctly and received training appropriate to their role.

What has improved since the last inspection?

The Company has introduced well set out and detailed assessment and care planning documentation, which should direct staff towards providing person centred care.

What the care home could do better:

Qualified staff need to ensure that they always sign medication records to show that the residents have had their medication. Qualified staff also need to check hand written entries on mediation records, to make sure that the information is correct. The manager, with the support of the company, needs to continue to monitor the needs of residents and ensure that staffing levels are sufficient. In addition, people`s expectations and what the service can realistically provide needs to be discussed, either in resident/relative meetings or individually.

CARE HOMES FOR OLDER PEOPLE Aylesham Court Nursing & Residential Home 195 Hinckley Road Leicester Forest East Leicestershire LE3 3PH Lead Inspector Jo Wright Key Unannounced Inspection 3rd October 2007 09:30 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 Aylesham Court Nursing & Residential Home DS0000001886.V347587.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. Aylesham Court Nursing & Residential Home DS0000001886.V347587.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Aylesham Court Nursing & Residential Home Address 195 Hinckley Road Leicester Forest East Leicestershire LE3 3PH 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) 0116 2395599 0116 2395982 dudda@bupa.com www.bupa.com BUPA Care Homes (BNH) Limited *** Vacant *** Care Home 60 Category(ies) of Old age, not falling within any other category registration, with number (60), Physical disability (14), Physical disability of places over 65 years of age (60) Aylesham Court Nursing & Residential Home DS0000001886.V347587.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 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. 1st August 2006 3. Date of last inspection Brief Description of the Service: Aylesham Court is a 60-bedded a purpose built care home providing personal and nursing care for older persons. It is located on a main road on the outskirts of Enderby and Kirby Muxloe in Leicestershire and is easily accessed by public transport from the City of Leicester and the County. The home provides residential and 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 or Terminally Ill. The home is arranged over two floors with good access for residents with a physical disability. The first floor is accessed by, either the stairs or a passenger lift. There are bedrooms, lounges and a dining room on both floors. The two spacious lounge areas on the ground floor have an outlook onto the well-landscaped gardens, which are mainly laid to lawn with surrounding shrubbery and have a patio area where the residents can walk and sit. The home has two large dining rooms, which are well decorated, and have a private area where the residents can have a meal with relatives or friends if they wish. The home has fifty-six single bedrooms and two double bedrooms; all have ensuite facilities of a W.C. and wash-hand basin. Many of the ground floor bedrooms open directly onto the patio area. The latest copy of the Inspection report from the Commission for Social Care Inspection is available in the managers’ office. The current fee level ranges from £ 431.00 to £ 750.00 per week. There are additional costs for individual expenses such as personal toiletries, optician, hairdressing and some recreational activities. Aylesham Court Nursing & Residential Home DS0000001886.V347587.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit was part of the key inspection for this service. One inspector carried out the site visit. During this visit, time was spent speaking with residents, relatives and staff, and observing the daily routine within the home. The records for four residents were looked at in depth, as well as records relating to the general running of the home. Information held on file about the service as well as information received from the company prior to the inspection was used to inform areas to look at during the site visit. 5 resident surveys, 3 relative surveys and 5 staff surveys were completed and returned and the information within the surveys has been incorporated into the relevant sections of the report. What the service does well: What has improved since the last inspection? The Company has introduced well set out and detailed assessment and care planning documentation, which should direct staff towards providing person centred care. Aylesham Court Nursing & Residential Home DS0000001886.V347587.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Aylesham Court Nursing & Residential Home DS0000001886.V347587.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Aylesham Court Nursing & Residential Home DS0000001886.V347587.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 2 and 3 (Standard 6 is not applicable in this service) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient Needs Assessment information ensures that needs of the people using the service are identified and met. EVIDENCE: The residents files and comments from residents and management supported that people do not come to live at Aylesham Court unless their needs have been assessed, and the home is able to meet their health and social care needs. Additional information about the person’s needs was also obtained from other health and social care professionals. Comments made in the completed resident and relative surveys indicated that people had received enough information about the home to enable them to make decisions about moving in. Aylesham Court Nursing & Residential Home DS0000001886.V347587.R01.S.doc Version 5.2 Page 9 Since the last inspection, new documentation has been introduced called ‘Quest’. Information supplied by the provider prior to the inspection described this ‘person centred care documentation’. It was also reported that all qualified staff received training about the new documentation. The documentation had been completed for the four residents whose care was looked at in depth during this site visit. Information about the person’s needs had also been reviewed and updated after 6 months. There was sufficient information available to enable staff to identify individuals’ personal and health care needs. The written contract and terms and conditions of residence were on file. The fees at the time of admission were included. This means that residents have the information they need about the service they will receive and how much it will cost them. Aylesham Court Nursing & Residential Home DS0000001886.V347587.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Concise care planning and risk assessments ensure that residents’ needs are being met in the way that they choose. Medication procedures ensure that residents receive their mediation as prescribed so their health needs are met. EVIDENCE: Although residents and relatives spoken with were generally satisfied with care provided, they did raise issues about how long they had to wait for assistance from staff, especially when sat in the lounge areas, about not being able to get up at the time they were promised, and attention to detail with some aspects of personal hygiene. Information in the completed resident surveys indicated that two out five people felt that the care and support they required was not always available and commented that ‘too many promises made which have not been fulfilled’. Discussion with staff and comments in the completed staff surveys varied and indicated that whilst some staff had concerns, others did not, for example ‘service we provide is to the best of our ability’, ‘ think everyone’s’ needs are met’, as opposed to ‘more time with residents to meet Aylesham Court Nursing & Residential Home DS0000001886.V347587.R01.S.doc Version 5.2 Page 11 their specific needs’, and ‘ill residents and not enough time to take care of them as would like’. Staff were observed explaining to residents what they were doing before moving them in the hoist, and maintaining their dignity throughout the procedure. Staff were also observed sitting with residents to assist them with drinks. Relatives who completed the surveys indicated that they considered the home met the needs of person in home, and provided care and support as expected or agreed. The care of four residents was looked at in depth during this visit. The files were well organised, and care plans and risk assessments had been developed from the assessments for residents who lived a the home permanently. The care plans and risk assessments were detailed and provided staff with sufficient information to meet the individual needs of residents. There was evidence in the files to support that relatives had some involvement in planning and evaluating the care provided. Information supplied by the provider prior to this visit also indicated that this area had been recognised as an area for development during the next 12 months. One resident had been admitted for short term care, and although the assessment had been completed in detail, not all required care plans and risk assessments had been developed. This was discussed with the acting manager, who indicated that company policy is that care plans must be completed within 7 days of admission. The resident has been admitted 3 days prior to this visit. A member of staff was asked to complete the care plans. Although the care plans had not been written, there was sufficient information available for staff to deliver care. Information recorded in the files and discussions with residents, relatives and staff supported that residents have access to health care professionals as required. The completed resident surveys supported that medical support was available. Qualified staff were responsible for the management and administration of medication. Systems were in place for receipt of and destruction of medication, and identification of the medication record with the resident. A small number of ‘gaps’ were noted on the medication records, where staff had not signed to say they had administered the medication. These were checked against the monitored dosage system, and the medication has been given. A second member of staff had not checked hand written entries for accuracy, and labels were being used on the medication records. The acting manager reported that the community pharmacy had supplied the medication record with labels on. Controlled medication was stored and recorded correctly. Aylesham Court Nursing & Residential Home DS0000001886.V347587.R01.S.doc Version 5.2 Page 12 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): Standards 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ wellbeing was enhanced by the range and frequency of social and recreational activities provided. EVIDENCE: Information supplied by the provider prior to this visit indicated that a structured activity programme was in place. The company had also recognised that this area could be improved by offering a wider choice of activities tailored to meet individuals’ personal interests and hobbies. Activities were planned on a weekly basis, and the activity co-ordinator, who was relatively new in post, spent time working with groups of residents, as well as one to one time. Residents spoken with showed with pride the placements that they had made the previous day. Entertainment and events were also organised. A musician visited during the afternoon of this visit, and residents and relatives commented that they had enjoyed this. A number of residents regularly attend activities outside of the home or go out independently. Aylesham Court Nursing & Residential Home DS0000001886.V347587.R01.S.doc Version 5.2 Page 13 Relatives and friends were able to visit at any time, and many visitors were present throughout this visit. The completed surveys supported that relatives kept were kept informed about important changes, and that residents were supported to live the life they choose. Residents and families were encouraged to bring in personal possessions and bedrooms were very personalised. Residents were encouraged to remain as independent as possible although the manager recognised that the dependency of the residents being admitted to the home was increasing. Comments from residents and information within the surveys indicated that generally residents were satisfied with the meals provided. Comments in the surveys included ‘a good choice and they do their best to accommodate personal likes’. Information supplied by the provider prior to this visit indicated that a new night time menu called ‘Nite Bite’ has been introduced to improve residents access to food and snacks 24 hours a day. Staff were observed sitting to assist residents with meals. Information supplied by the provider prior to this visit indicated that over half of the residents accommodated a Aylesham Court required help, supervision or prompts with eating. Staff spoken with acknowledged that meal times are a challenge, but they assist residents on a one to one basis. A hostess position has been introduced to assist with mealtimes. Aylesham Court Nursing & Residential Home DS0000001886.V347587.R01.S.doc Version 5.2 Page 14 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): Standards 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Despite concise complaints procedures being in place people do not always feel that they are listened to and their concerns acted upon. People are protected from harm through staff training, polices and procedures. EVIDENCE: The complaints procedure was accessible to people living at the home and visitors. The majority of people who completed the surveys knew who to speak to and how to complain, although 1 person commented that they were not aware. Relatives who completed surveys indicated that they knew how to make a complaint and that any concerns raised had been responded to appropriately. Staff spoken with and all except one who completed the surveys knew what to do if a person has a concern about the home. Information provided prior this visit indicated that 7 complaints had been received by the management during the previous 12 months, and 5 of these complaints were upheld. Information relating to these complaints was on file. The Commission has received 2 complaints, that were forwarded to the company to investigate through their own complaints procedure. However, comments made by residents, relatives and in some staff surveys indicated that people do not always feel listened to or that their concerns are acted upon and resolved. Comments included ‘management never do Aylesham Court Nursing & Residential Home DS0000001886.V347587.R01.S.doc Version 5.2 Page 15 anything’ and ‘nothing seems to change’. Relatives spoken with commented that a relatives meeting had recently been held, and they had voiced their concerns to the regional support manager, and were waiting to see if any action was taken to address their concerns. Information supplied prior to this visit stated that robust procedures were in place for dealing with allegations of abuse or neglect, and procedures for reporting staff under Protection of Vulnerable Adults. Staff receive training on safeguarding procedures as part of their induction programme, and evidence to support this was seen. Staff spoken with were aware of safeguarding procedures and how to report internally and externally. However, the company has recognised that it could improve safeguarding and whistle blowing training, as well as training on the mental capacity act, and plans to make improvements over the next 12 months. Aylesham Court Nursing & Residential Home DS0000001886.V347587.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a comfortable and safe environment that meets their needs. EVIDENCE: Aylesham Court was well maintained, and there was evidence to support ongoing investment in the decoration of the ground floor corridors and upstairs lounge. Systems were in place for ongoing maintenance, and a full time maintenance person was employed. Information provided prior to this visit and discussion with management indicated that plans were in place to fit new carpets and curtains in the ground floor corridors and upstairs lounge and to replace one of the specialist baths. In addition, an addition ‘standaid’ was on order, due to one of the two in the home being out of use and not able to be repaired. Aylesham Court Nursing & Residential Home DS0000001886.V347587.R01.S.doc Version 5.2 Page 17 Residents had access to a large garden area. The gazebo in the garden was the designated smoking area for residents, and a portable staff call system had been provided, enabled residents to call for assistance when outside. Management reported that domestic and laundry were satisfactory, and the home was clean and tidy at the time of this visit. Everyone who completed the surveys were satisfied with the cleanliness of the home. Systems were in place for laundering of personal clothing. Information supplied prior to this visit indicated that policies and procedures were in place, and that staff had received training on the management and prevention of infection. Aylesham Court Nursing & Residential Home DS0000001886.V347587.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are supported by a staff team with the necessary skills, knowledge and experience to fully meet their needs. EVIDENCE: Information gathered through the surveys, comments from residents, relatives and staff, and complaints indicated that some people using the service considered that staffing levels were not always sufficient to meet their needs. Staff opinions varied, and some staff considered that staffing levels were sufficient, whilst others commented that staffing is sufficient is no one is off sick, or residents do not have to be accompanied to appointments. Comments were also made about being short staffed on nights, and roles and responsibilities between day and night staff. Discussion with the manager and staff indicated that staffing levels for the current occupancy were 2 qualified staff and 10 care staff on in the morning and 2 qualified staff and 8 care staff on in the afternoon pm. The company considers this level of staffing to be sufficient to meet the needs of the residents, but also recognised the need to continue to monitor the needs of residents and review staffing levels accordingly. Copies of the duty rota provided on the day of this visit supported that this level of staffing was Aylesham Court Nursing & Residential Home DS0000001886.V347587.R01.S.doc Version 5.2 Page 19 planned. However, management have recognised the needs to monitor staff practice, through clinical supervision, in order to assess that staff are using their time effectively and are deployed appropriately. Discussion with staff, comments in surveys and training records supported that staff were provided with a range of training opportunities. The majority of staff who completed surveys considered that the training was relevant to their role and helped them to understand and meet the needs of residents. Staff confirmed that they also completed induction training. Almost 50 of care staff have completed training towards National Vocational Qualifications and this training was offered on a ongoing basis to care staff. Information supplied prior to this visit indicated that comprehensive recruitment policies and procedures were in place, and that all of the required recruitment checks were obtained. Discussion with staff, completed surveys and the three staff files checked supported that these procedures were followed, as the required information was held on file. Aylesham Court Nursing & Residential Home DS0000001886.V347587.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems were in place for monitoring the quality of the service provided so that it meets the needs of the residents. EVIDENCE: The Registered Manager left her employment in May 2007. The deputy manager has taken on the responsibilities of the acting manager until a replacement manager has been recruited. The deputy manager was supported in her role by the Regional Support Manager. Comments made by residents, relatives and staff, both in discussion and in the surveys indicate that people using the service and some staff do not feel that Aylesham Court Nursing & Residential Home DS0000001886.V347587.R01.S.doc Version 5.2 Page 21 the service has been run with their best interests in mind. Residents, relatives and some staff did not appear to have confidence in the abilities of the management to take on board any issues they raise and deal with them appropriately. However, other staff spoken with felt that management were supportive. Comments in surveys included ‘fairly good home, could benefit from more care staff and better organisation’, ‘look after my relative well and are helpful’, ‘not be telling residents they can have the things that are sometimes impossible to do’ and ‘more time with resident to meet their specific needs’. The company has developed a Quality and Compliance team to monitor and improve quality of care and services provided at its services. The Regional Manager or a representative visits Aylesham Court at least once a month to carry out the Regulation 26 visits. The company also have an annual customer satisfaction survey. Information supplied prior to this visit indicates that the company has recognised that more relative and resident meetings need to be organised, to get the views of people using the service on a regular basis. Discussion with relatives indicated that they were unaware of the availability of the inspection report, and the acting manager acknowledged information about the availability of the report was not made displayed, even though the report was available. Satisfactory systems were in place for safe keeping of residents monies. Staff spoken with confirmed that they received regular supervision, and evidence to support this seen in the files. However, completed staff surveys indicated that one person never met with the manager for support and to discuss work practices, whilst three people said that this sometimes occurred and one person said this occurred often. Comments included ‘ you have to ask’, ‘don’t listen to what night staff have to say’ and ‘have time with staff individually so we can express ourselves and mention our problem’. Mandatory training is provided for all staff, and was supported by training g records and in discussion with staff. Information supplied prior to this visit indicated that all equipment had been serviced or tested as recommended by the manufacturer or other regulatory body. Aylesham Court Nursing & Residential Home DS0000001886.V347587.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 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 X 18 3 3 X X X 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 3 X 3 X 3 3 X 3 Aylesham Court Nursing & Residential Home DS0000001886.V347587.R01.S.doc Version 5.2 Page 23 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(2) Requirement Medication records must be signed followed administration of medication to residents. This will ensure that all staff are aware of what medication residents have received. Timescale for action 30/11/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP9 Good Practice Recommendations Printed pharmacy labels should not be used on medication records. Hand written entries on medication records should be checked for accuracy by a second member of staff. The staffing levels should be continually reviewed to ensure that they are sufficient to meet the changing needs of the residents. The manager should ensure that all staff are receiving supervision on a regular basis. 2 3 OP27 OP36 Aylesham Court Nursing & Residential Home DS0000001886.V347587.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Aylesham Court Nursing & Residential Home DS0000001886.V347587.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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