Inspection on 05/06/07 for Aynsley Nursing Home

This inspection was carried out on 5th June 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.

Other inspections for this house

Aynsley Nursing Home 13/08/08

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Aynsley Nursing Home 60-62 Marlowe Road Wallasey Liverpool CH44 3DQ Lead Inspector Mrs Julie Garrity Key Unannounced Inspection 5th June 2007 10:25 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 Aynsley Nursing Home DS0000069375.V343859.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. Aynsley Nursing Home DS0000069375.V343859.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Aynsley Nursing Home Address 60-62 Marlowe Road Wallasey Liverpool CH44 3DQ 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) 01516384391 01516384402 S.J. Care Homes (Wallasey) Limited Julie Catherine Rossiter Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28) of places Aynsley Nursing Home DS0000069375.V343859.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only. Care home only - code PC, to service users of the following gender:Either. Whose primary care needs on admission to the home are within the following categories: Old age not falling within any other category - Code OP. The maximum number of service users who can be accommodated is: 28 Date of last inspection None Brief Description of the Service: Aynsley Care Home with Nursing is a two storey converted house situated in the residential area of Wallasey. It is registered to provide care and support for up to 28 older people. There are three main lounges and a conservatory attached to the dining room. Bedroom accommodation is provided in both single and shared rooms, some of the bedrooms have en-suite facilities. There is a passenger lift that services all the floors and assisted bathing facilities and shower facilities available. The front garden area is paved with shrub borders and there is a secluded garden to the rear of the home. Parking is available at the front of the building. The home is close to the town centre, which has shops and other community amenities. Public transportation links such as the bus service are close to the home, rail links are a 10-minute drive away. The home is not far from the Wallasey tunnel and is easily accessed from Liverpool. Main motorway links to the rest of the Wirral area are a 5-minute drive away. The manager has been in post for several years and the ownership of the home has recently changed. Fees for the home are £475 to £495. Fees cover all spending of residents in the home including hairdressing and newspapers as examples. Aynsley Nursing Home DS0000069375.V343859.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out over a period of one day. The inspector arrived at the home at 10:25 and left at 18.05. The inspector spoke with 7 residents, 2 relatives, 7 staff the deputy manager, the manager and the homeowner. The manager was escorting residents to a trip out and the site visit was done with a bank nurse, administrator and homeowner. Feedback was given to the administrator, bank nurse and homeowner through out the visit. On her return feedback was given to the manager and the deputy manager The inspector completed the inspection by a site visit to Aynsley Nursing Home, a review of records available in Aynsley and CSCI offices. Records viewed included maintenance records, fire testing, gas and electrical certificates, moving and handling equipment checks. Care plans for four residents were reviewed, medication records, daily records, risk assessments, wound care records and external professionals visits. Other records included, staff training, staff files, policies and procedures, supervision of staff, staff recruitment and recruitment checks. The inspector followed an inspection plan written before the start of the inspection to ensure that all areas identified in need of review were covered. All of the Key standards were covered in this inspection, these are detailed in the report. The arrangements for equality and diversity were reviewed throughout the visit and are detailed in this report. Particular emphasis was placed on the methods that the home used to determine individual needs and the practices that they put into place to meeting those needs. What the service does well: There is a variety of communal areas such as a dining room and alternative sitting rooms. Residents are supported to spend their time wherever they like and to participate in the activities available, as they would wish. The decoration in the home is domestic in nature and makes it feel welcoming and homely. Residents are encouraged to bring in their favourite ornaments, furniture and photographs to decorate their bedrooms. All of the residents spoken with are “happy” living in the home, their comments were positive in nature and praised the care staff for their kindness. Visitors and relatives supported to visit the home and are encouraged to join in trips out. Staff communicate very well with the residents with a resident describing the staff as “good for a laugh”. Staff displayed a genuinely kind and caring attitude that has the residents best interests in mind at all times. Aynsley Nursing Home DS0000069375.V343859.R01.S.doc Version 5.2 Page 6 The manager has been in post for several years and is able to support a stable and caring staff. The residents, relatives and staff have confidence in her ability to address any issues they may have and support all the individuals in an appropriate manner. What has improved since the last inspection? What they could do better: Some of the records in the home need to be reviewed to make sure that they meet the residents needs, this includes, assessments of residents needs, care plans that do not always detail the needs of the residents, staff training that is unclear, checks not completed for one staff member and some medications records. Information for the residents is not always available such as menus, activities programme and information about the home that would help them make a choice before they move in. Although the home does have a copy of social services protection of vulnerable adults procedure staff are unaware of the contents or of how to deal with any allegation of this nature. This would place residents at risk, as issues may not be dealt with appropriately There were a number of maintenance issues that had not been addressed however the owner of the home is aware of this and had addressed several areas within two weeks of this site visit. There is no structured manner that the home uses to determine what it does well and what areas it needs to improve on. This process will help the home increase the quality of the service it process. Aynsley Nursing Home DS0000069375.V343859.R01.S.doc Version 5.2 Page 7 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. Aynsley Nursing Home DS0000069375.V343859.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 Aynsley Nursing Home DS0000069375.V343859.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): Standards 3 and 4 were reviewed at this inspection. Standard 6 is not applicable. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. All residents have an assessment before they move in. This helps the resident decide if the home meets their needs. Not all residents get the information they need to decide if the home is for them, this prevents them from making an informed choice. The assessments help the manager and staff to decide if they can meet the physical individuals needs of potential residents and plan the care needed. However the assessments need to be developed to make sure that the staff have the training to support residents who are admitted. EVIDENCE: The manager makes sure that potential residents are assessed before they move in. This gives the staff an opportunity to make sure that the home is suitable to meet the resident’s needs. Aynsley Nursing Home DS0000069375.V343859.R01.S.doc Version 5.2 Page 10 A number of residents have been admitted with dementia care needs, the assessment in place does not determine these needs and staff have not received training in this area. The manager makes sure that the home gets information from all who are involved in the support or care of the resident including social services. A copy of all assessments prior to admission was available for review. The homes policy is available for assessments but is out of date and does not reflect the current practice. Questionnaires were sent to the home before this inspection from the inspector three of the seven returned said that they had not received enough information before they moved in. One relative did say, “I was given all the information required and I was shown around the home”. One resident said “the manager came to see me in hospital before I came in, she spoke about what I needed. I didn’t get any written information.” The home does not have information about who they will deliver the services they provide to give to potential residents, this would provide general information about the home such as special needs catered for, complaints process, and resident’s views of the home as examples. The home does have a copy of other information know as a statement of purpose, which details what the services of the home are. This is out of date, as new owners have bought the home recently. This document did not fully meet the equality and diversity needs of all the residents, as it was not available in different formats. The home has contracts for each individual resident the contracts were clear about the fees charged from the home. Resident’s fees cover all items and there is no extra charge for hairdressing, newspapers or toiletries. Aynsley Nursing Home DS0000069375.V343859.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): Standards 7, 8, 9 and 10 were reviewed at this inspection. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of medications has improved, however the records are not always completed properly and this can place residents at risk of not receiving their medications correctly at all times. Staff do not have the information that they need to make sure they understand how to meet the residents needs at all times. Without the correct training and information staff will not be able to support the residents in a manner that suits their individual needs. EVIDENCE: Medications were significantly improved, in all but the current month medication had been recorded on arrival. The manager was doing counts of medications to make sure that they were correct. Aynsley Nursing Home DS0000069375.V343859.R01.S.doc Version 5.2 Page 12 But as yet has not been doing full audits that look at the entire management and handling of medications. The application of creams is done by the care staff but there are no instructions that tell where, when, how, the amount or any side effects. An error in the recording of a controlled drug was noted. The homeowner sent information following this site visit detailing that this would be looked into Resident’s questionnaires showed that all residents who replied thought that they received appropriate care and support from the staff. Staff observed during the day were respectful to the residents. The residents spoken with were very positive about the staff and the care that they received. One resident said “I wouldn’t want to live anywhere else” and another said, “they are so caring here, its my home”. Each resident has a care plan, of the four care plans viewed none of these were individual, specific or up to date. The care plan as to how to meet the needs for hygiene was identical for three of the residents and did not detail how to meet their specific needs. One care plan discussed the care of a catheter for a resident that was removed some months previously and did not contain any information about a pressure ulcer that was being treated. The majority of care plans have been agreed with either by the resident or their relatives. Risk assessments that support the resident’s choices were available and kept up to date. Jargon and abbreviations were frequently used in the care plans and staff spoken with rarely read the care plans. Care plans that are not easily readable, accurate and not kept up to date means that vital information will be missed and staff will not be able to always deliver a service that meets the resident’s individual needs. Wound Care records, did not have photographs, wound mapping, grade or depth and did not assist the staff to monitor that wound care treatment is effective. Staff would be unable to know what was the correct treatment to be used. Residents are supported to access healthcare services such as GP, dentistry and chiropody. Information regarding other professional’s decisions are recorded. This practice makes sure that instructions about the resident’s medical needs are easier to follow, however this is not always kept and the changes in the medication of one resident on the instructions of the GP had not been written down. Induction training covers privacy and dignity and the homes brief statement of purpose also includes reference to maintaining privacy and dignity. All of the residents spoken to were clear that the staff treated them well at all times. Aynsley Nursing Home DS0000069375.V343859.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 were reviewed at this inspection. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There has been an improvement in the activities provided in the home. This has impacted positively on the residents. Residents personal preferences and choices have not been fully explored as staff are making choices for the residents based on what they think they know about them. EVIDENCE: The home provides activities each week. A new activities co-ordinator has been recruited. On the day of the site visit several of the residents went out for the day to Chester Zoo. Staff and residents said that the activities had been of value two of the residents said that they particularly enjoyed the “reminiscence therapy”. The home operates an open visiting policy, families and friends are encouraged to visit as often as they wish. Residents spoken with said, “I am always out and about with my family”. One relative said, “Staff are very friendly, the home has a lovely atmosphere I enjoy visiting”. Aynsley Nursing Home DS0000069375.V343859.R01.S.doc Version 5.2 Page 14 The deputy manager said that regular meetings are held to discuss residents and relative’s ideas. Questionnaires from the residents said that of the seven returned six residents believed that their views were listened to. One resident said, “The staff are very friendly and we have a lot of laughter”. There were no records within the home that detailed what residents preferred choices and how to make sure that staff meet these choices. Residents spoken with said that in general the routines in the home were of their choosing. Menus were seen, however these did not show consideration of any special diets, such as high protein. All the residents, spoken with said that if they did not want what was on the menu an alternative would be made for them. Discussions with the cook detailed that they the kitchen staff had not received any specific training in special diets such as diabetic diet. Kitchen staff said that they would really enjoy having training in specialised diets and think it would benefit the residents. One resident has a special diet that is of their choosing however this is not always available for them. Aynsley Nursing Home DS0000069375.V343859.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 were reviewed at this inspection. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents said that their concerns are dealt with. Staff have received training in safeguarding vulnerable adults and they aware of how to report concerns regarding the protection of vulnerable adults. EVIDENCE: There have been no complaints sent to the Commission since the last inspection. Five residents did know how to bring a concern to the attention of the staff however two did not. Residents spoken to said, there is a number of staff I could talk to if not happy and I would talk to the matron. The home does not keep records of any concerns raised and the lack of a policy that informs residents of their rights does not promote residents ability to raise concerns. The deputy manager stated that they have not recently received any complaints. However staff have raised concerns regarding the shower facility that has not been addressed. Staff have now had training in protection of vulnerable adults. This has given them the understanding to recognise and report any potential abuse of residents. Aynsley Nursing Home DS0000069375.V343859.R01.S.doc Version 5.2 Page 16 However, although the home does have a copy of the social services protection of vulnerable adults policies and procedures, discussion with the staff detail that they were not aware of how concerns are dealt with, investigated and resolved. Without this information staff may not be able to make sure that residents rights are fully protected. Aynsley Nursing Home DS0000069375.V343859.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 22, 23, 24 and 26 were reviewed at this inspection. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was clean and tidy, with a good variety of facilities available for the residents. Some of the areas of the home are in need of repair and redecoration. Resident’s bedrooms have their own items brought in to the home, making them appear comfortable and welcoming. One of the facilities in the home is not suitable to meet all the residents’ needs. EVIDENCE: Aynsley Nursing Home, is nicely presented, however over recent months areas of the home such as furnishings and carpets have started to show signs of wear and tear. The carpet in the main lounge was recently replaced but is already damaged. A number of maintenance areas have not been addressed or planned for as the homeowner has only recently bought the home. Aynsley Nursing Home DS0000069375.V343859.R01.S.doc Version 5.2 Page 18 He is aware that areas need to be attended to and intends to put into place a full maintenance plan that would redecorate and refurbish many areas of the home examples of this includes painting and re-carpeting the main corridors, reviewing the lighting which is dark in some areas and replacing the floor tiles in the kitchen. This will take time, as it will mean spending a lot of money to make the home. Residents spoken with the made the following comments, very nice I like the home” and my room is just as I would like it . A relative said “it’s a very nice home Nan’s got all her stuff around her, makes it look very comfortable”. All of the areas of the home were clean and tidy. Residents bedrooms were viewed and all were clean and tidy. Residents are encouraged to bring in their own items and this makes the bedrooms appear very homely and comfortable. All the bedrooms are decorated differently and vary in size, some of the rooms are very bright and airy. The design of the home has taken into account some of the residents diverse needs. There are handrails and ramps as appropriate and equipment designed to assist in the moving and handling of residents as appropriate. The shower unit has a step on it that some residents cannot step over. Staff say they have to lift the shower chair over this step for some residents and this can be difficult. The shower facilities available are not suitable for all the residents. Kitchen and laundry were examined, both of these were well organised, tidy and clean. Some items of food were undated as to when they would expire. The cook explained that it arrives this way from the butchers. Staff will not know if items can still be used if not dated. The cleaning schedule was available for all areas of the home and is completed on a regular basis. Aynsley Nursing Home DS0000069375.V343859.R01.S.doc Version 5.2 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 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 were reviewed at this inspection. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff are kind and caring towards residents. Most of the residents said there is enough staff to meet their needs and staff support this point of view. The training and recruitment records of staff are in need of development in order to make sure that staff can fully meet the needs of residents at all times. EVIDENCE: Residents living within the home said that there was always enough staff around to meet their needs. The staffing rota detailed that normally the home had a RGN on-duty as well as the manager. On the day of the visit the manager and the deputy manager were with the residents visiting Chester Zoo and there was a bank RGN on-duty. Although the home does assess the dependency needs of the residents this is not used to decide on staffing levels. Staff spoken with, were confident that there was enough staff on a daily basis and the residents were very rarely asked to wait. Residents spoken with agreed that in general there are enough staff. Seven residents completed a questionnaire three said that there was always enough staff available. Aynsley Nursing Home DS0000069375.V343859.R01.S.doc Version 5.2 Page 20 An examination of some of the staffing records, showed all staff but one had the correct records in place. A file for a nurse did not have two references and did not have proof that she was qualified to do the job. The homeowner sent information following the site visit stating that they would check that all the staffing files were correct. All other staff files seen had records which detailed that staff had two references, fitness to work with vulnerable adults check, police check and an application form on file. Staff training records were unclear, it was difficult to see what staff had been trained in recently. Resident’s needs included specific medical and mental health needs. Staff had received no training in these areas. Induction records were also unclear and did not detail what training staff received within their first three months. Staff spoken with detailed that they had received training in health and safety, first aid and the prevention of abuse. They had not had training in dementia care but would like to have that training, the kitchen staff would like training in special diets. Residents spoken with said, the staff are very good at what they do and they know how to be caring. Aynsley Nursing Home DS0000069375.V343859.R01.S.doc Version 5.2 Page 21 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 and 38 were reviewed at this inspection. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Health and Safety arrangements have improved however this needs to be developed in order to fully maintain residents safety at all times. The manager is auditing some areas of the home in order to make sure that any areas of practice that need to be developed can be identified and addressed. EVIDENCE: The manager is registered with the Commission for Social Care Inspection. She has many years of nursing experience. Both residents’ and staff spoken with stated the manager was “lovely”, “fair” and “always happy to help”. Aynsley Nursing Home DS0000069375.V343859.R01.S.doc Version 5.2 Page 22 The home operates its own internal audit system through the use of questionnaires sent to residents’ and their families on an annual basis. These had been returned to the home but as yet not looked at. These provide good information but as yet they are not used to assist in forming a plan that would identify the strengths of the service and the areas to be improved. The home does not have legal responsibility for money belonging to the residents, they hold small amounts left by relatives for the residents. Records regarding these funds are held by the home on behalf of the residents and were clear and residents were signing to say that they had received the money. Certificates relating to Health and Safety were examined there were significant issues that needed to be addressed on the gas and electrical certificate. The homeowner sent information following this site visit detailing how these would be addressed. Additionally there had not been a handyman for some time and as such checks for fire equipment, call systems and emergency lighting had not been done. Again following this site visit the homeowner forwarded information detailing that these were now being addressed. Staff fire training could not be determined as there were no records in this area. Aynsley Nursing Home DS0000069375.V343859.R01.S.doc Version 5.2 Page 23 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 X 3 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 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 2 2 X X 2 3 3 X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Aynsley Nursing Home DS0000069375.V343859.R01.S.doc Version 5.2 Page 24 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 OP1 Regulation 5 (1) (a) (b) (c) (d) (e) (f) (2), (3) 15 (1) (2) (a) (b) (c) (d) Requirement A service users guide and statement of purpose need to be developed that includes all the areas as detailed in the Care homes regulations 2001. Resident’s individual Care plans need to be kept up to date and accurate. The care plans need to detail what the residents needs are and give clear instructions to staff how to meet those individual and specific needs. All medications received by the home need to be fully accounted for. Medications must be clearly documented and given as the doctor prescribed. The inaccurate records regarding a controlled drug need to be reviewed and staff reminded of their role and responsibilities. The areas in the home that require refurbishment, redecoration or maintenance need to be determined and a plan put into place to attend to these areas. Staff training needs to be given to meet the specific and DS0000069375.V343859.R01.S.doc Timescale for action 05/10/07 2. OP7 05/08/07 3. OP9 13 (2) 05/07/07 4. OP19 23 (1) (a) (2) (b) (c) (d) (e) 05/08/07 5. OP30 18 (1) (c) (i) (ii) 05/08/07 Aynsley Nursing Home Version 5.2 Page 25 individual assessed needs of the residents. A programme of training that clearly identifies the needs of the residents, what skills the staff have and how they will be trained to develop the skills that they require to meet the needs of the residents is essential. 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 OP1 Good Practice Recommendations Information in the home such as complaints, care plans, activities and menus should be written in formats that are easily accessible by the residents and relevant stakeholders. Assessments for prospective clients need to be holistic and not just based on finding out the physical needs of the residents. Records regarding wounds, need to include best practice, such as depth and grade of wound, The opportunity to full explore residents preferences, capabilities and diversity needs should be explored, recorded and detailed to all staff to make sure that they are aware of these preferences. The menu should reflect the choices available in order to act as a prompt to remind residents what is available. The shower that has a step to get in and out should be assessed to make sure that those residents who like to use the shower are not lifted in and out. Policies and procedures within the home should be reviewed, up dated and brought in line with the practices in the home and best practice guidance available. The manager should put into place a development plan that details how the quality of the service will be reviewed, what the service will do to increase quality and how this will be done. Supervision practices should be reviewed to make sure that staff are included in the process which covers all DS0000069375.V343859.R01.S.doc Version 5.2 Page 26 2. 3. 4. OP3 OP8 OP14 5. 6. 7. 8. OP15 OP22 OP33 OP33 9. OP36 Aynsley Nursing Home areas of practice and staff support and not just clinical practices Aynsley Nursing Home DS0000069375.V343859.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG 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 Aynsley Nursing Home DS0000069375.V343859.R01.S.doc Version 5.2 Page 28 - 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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