Care Home: Ashgrove Care Home

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What the care home does well Prospective residents are fully assessed prior to admission and the processes in place ensure the home is able to fully meet their needs. Service user plan documentation is well formulated, personalised and up to date, providing a clear picture of each residents needs. The privacy and dignity of the residents is prioritised and there is a happy atmosphere throughout. Information regarding residents` end of life care wishes has been sought and recorded. The activities provision is good and residents are encouraged to participate in a range of individual and group activities. The home has an open visiting policy and visiting is encouraged. Information regarding advocacy services is available. The food provision is good, offering variety and choice. The complaints procedure is on display throughout the home and complaints are dealt with appropriately. Safeguarding Adults procedures are in place and are followed. Procedures for infection control are in place and are followed, thus minimising risks. The home is appropriately staffed to meet the needs of the residents. There is an on going programme of training with several of the care staff having qualified to NVQ in care level 2 or above. The majority of staff working in the home have received dementia care training. The induction programmes for all new staff are available. The home is being effectively managed and staff work well together as a team. There are clear systems in place for quality assurance with shortfalls being promptly identified and addressed. Personal monies held on behalf of residents are being well managed and securely stored. Overall health and safety is being well managed. Some shortfalls identified in this area should be easy to address.The comments received via the CSCI comment cards were positive. Examples of these are: `I am proud to be an employee of Ashgrove Care Home`. `Staff provide excellent care.` `I am completely satisfied with the standard of services provided by this home. `The staff are excellent`. `All the staff are very caring and polite.` `Very good professional and caring staff`. What has improved since the last inspection? A copy of the assessment completed by Social Services is obtained as part of the pre-admission assessment. All assessment documentation viewed had been signed and dated. Liquid medications have the date of opening recorded. What the care home could do better: Overall medications are being well managed. Shortfalls identified at this inspection in relation to room and fridge temperatures and lancing devices for blood glucose monitoring should be easy to address. The redecoration and refurbishment plan must be kept up to date and evidence that timescales are being met. The suitability of flooring in some areas of the home must be reviewed to aid the management of malodours. Where profiling beds are not working these must be repaired. Cleaning records in the kitchen must be kept up to date. Risk assessments on safe working practices and equipment must be up to date and available in the home. CARE HOMES FOR OLDER PEOPLE Ashgrove Care Home Firtree Road, Off Martindale Road Hounslow Middlesex TW4 7HH Lead Inspector Mrs Rekha Bhardwa Key Unannounced Inspection 15th September 2008 10:20 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 Ashgrove Care Home DS0000010939.V366586.R02.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. Ashgrove Care Home DS0000010939.V366586.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashgrove Care Home Address Firtree Road, Off Martindale Road Hounslow Middlesex TW4 7HH Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8577 6226 020 8577 9229 ashgrove@schealthcare.co.uk www.schealthcare.co.uk Southern Cross Healthcare Services Ltd Mrs Remedios Chico Care Home 50 Category(ies) of Dementia (0), Learning disability (0), Learning registration, with number disability over 65 years of age (0) of places Ashgrove Care Home DS0000010939.V366586.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. A maximum of 10 beds for adult/elderly patients of either sex with `Challenging Behaviour` A maximum of 40 beds for the elderly mentally infirm of either sex over the age of 60 years 20th April 2006 Date of last inspection Brief Description of the Service: Ashgrove Care Home is a purpose built home, which provides care for fifty older people with mental health care needs. The home is situated in a residential area of Hounslow and is close to local transport links. There are some local shops close by and the home is a short distance from Hounslow town centre. There are three floors in the home and a passenger lift providing access to all floors. The bedrooms are situated on the ground and first floors. All bedrooms are single and have en suite facilities. There are two communal lounge/dining rooms on each floor. The people living at the home also have access to a well maintained garden to the rear of the home. The fees range from £600 to £850 per week. Ashgrove Care Home DS0000010939.V366586.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This was an unannounced inspection carried out as part of the regulatory process. A total of 16 hours was spent on the inspection process. We carried out a tour of the home, and service user plans, medication management & records, staff rosters, staff records, financial & administration records and maintenance & servicing records were viewed. 2 residents and 11 staff were spoken with, plus several residents were observed as part of the inspection process. The Annual Quality Assurance Assessment (AQAA) document completed by the home, plus comment cards from residents and staff have also been used to inform this report. There were no equality and diversity issues identified at this inspection. It must be noted that it is not always easy to ascertain the views of people with mental health and/or dementia care needs. What the service does well: Prospective residents are fully assessed prior to admission and the processes in place ensure the home is able to fully meet their needs. Service user plan documentation is well formulated, personalised and up to date, providing a clear picture of each residents needs. The privacy and dignity of the residents is prioritised and there is a happy atmosphere throughout. Information regarding residents’ end of life care wishes has been sought and recorded. The activities provision is good and residents are encouraged to participate in a range of individual and group activities. The home has an open visiting policy and visiting is encouraged. Information regarding advocacy services is available. The food provision is good, offering variety and choice. The complaints procedure is on display throughout the home and complaints are dealt with appropriately. Safeguarding Adults procedures are in place and are followed. Procedures for infection control are in place and are followed, thus minimising risks. The home is appropriately staffed to meet the needs of the residents. There is an on going programme of training with several of the care staff having qualified to NVQ in care level 2 or above. The majority of staff working in the home have received dementia care training. The induction programmes for all new staff are available. The home is being effectively managed and staff work well together as a team. There are clear systems in place for quality assurance with shortfalls being promptly identified and addressed. Personal monies held on behalf of residents are being well managed and securely stored. Overall health and safety is being well managed. Some shortfalls identified in this area should be easy to address. Ashgrove Care Home DS0000010939.V366586.R02.S.doc Version 5.2 Page 6 The comments received via the CSCI comment cards were positive. Examples of these are: ‘I am proud to be an employee of Ashgrove Care Home’. ‘Staff provide excellent care.’ ‘I am completely satisfied with the standard of services provided by this home. ‘The staff are excellent’. ‘All the staff are very caring and polite.’ ‘Very good professional and caring staff’. What has improved since the last inspection? 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. Ashgrove Care Home DS0000010939.V366586.R02.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 Ashgrove Care Home DS0000010939.V366586.R02.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): 3. The home does not provide intermediate care. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are fully assessed prior to admission, thus the home ensures they are able to meet each persons needs. EVIDENCE: The home has a comprehensive pre-admission assessment document that provides a good picture of the resident and their needs. This is completed for all prospective residents in order to ascertain if the home is able to fully meet their needs. Completed assessments were viewed on each floor and had been well completed. The home also obtains a copy of the assessment undertaken by social services. Ashgrove Care Home DS0000010939.V366586.R02.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 & 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service user plan documentation is well completed to provide staff with the information to meet each resident’s needs. Medications are being well managed at the home, thus safeguarding residents. Staff care for residents in a gentle and professional manner, respecting their privacy and dignity. The home provides good end of life care, and ensures that residents and their families have their wishes and needs discussed, recorded and met. EVIDENCE: 5 service user plans were viewed as part of the inspection process. The documentation is comprehensive and had been well completed to identify residents needs and how these are to be met. New care plans had been formulated for any newly identified needs. Where residents were exhibiting challenging behaviour there were clear management plans in place, plus a behavioural record is maintained. The service user plans had been reviewed monthly and when there had been any relevant changes in a residents’ Ashgrove Care Home DS0000010939.V366586.R02.S.doc Version 5.2 Page 10 condition. There was evidence of service user plan reviews being carried out with the resident’s representative. Risk assessments for falls and other identified areas of risk had been completed and updated following any relevant incidents. Risk assessments for the use of bedrails had been completed and written consents for their use obtained. Daily records were clear and detailed the care being provided. There was evidence that the service user plans are audited and action plans are in place to address any shortfalls identified. Overall the documentation is comprehensive and completed to a good standard. The home did not have any residents with pressure sores. Where there was a wound or poor skin integrity, documentation to include body mapping, photographs with consent and care plans to identify the treatment regime had been completed and updated. Information regarding dressing changes was available, and we recommended that this information be contained in one set of documentation, so that the frequency of dressings could be easily identified. Pressure sore risk assessments were in place for each resident and the pressure relieving equipment in use had been identified. Moving & handling assessments were in place and the specific equipment to be used for each manoeuvre had been documented in the moving and handling care plan. Nutritional assessments had been carried out and there was evidence of weights being monitored monthly. Continence assessments were in place with continence regimes recorded in the care plan. There was evidence of input from healthcare professionals to include GP, community psychiatric nurse, tissue viability nurse, dietician, chiropodist, optician and dentist. The GPs do not have a regular day for carrying out visits to the home and this results in many telephone conversations to ensure medical needs are discussed and addressed. Where they are able to do so, residents attend appointments at the GP practices. We viewed medication management on each unit. The home uses a Monitored Dosage System (MDS). Lists of staff signatures and initials had been completed. Fridge minimum/maximum temperatures had been recorded daily and were not always within safe range. The clinical room temperatures were also regularly above the 25° centigrade safe maximum temperature. These issues need to be addressed so that medications are stored at recognised safe temperatures. Receipts, brought forward balances, administration and disposal of medications had been recorded. For good practice the home keeps a copy of the prescription with the Medication Administration Record (MAR). For residents on warfarin therapy the result of the blood tests and the resulting warfarin dosage is kept with the MAR. The actual prescribing information for the warfarin on the MAR did not contain full administration instructions, and this is to be addressed so that the actual dosage to be given is clearly identified. It is noted that the actual dosage given each day had been recorded on the back of the MAR. Medication reviews take place with the GPs. The lancing system in use for blood glucose monitoring was not one approved for multi-patient use. The home needs to ensure that to prevent the risk of Ashgrove Care Home DS0000010939.V366586.R02.S.doc Version 5.2 Page 11 infection from blood borne diseases that they follow national guidance and use a lancing system approved for professional use. The Controlled Drugs register was viewed and had been appropriately completed. Liquid medications and eye drops had the date of opening recorded. For residents who have medication administered covertly, this had been agreed in writing with the GP and the residents’ representatives. The inclusion of this information in the care plans was discussed. Staff were seen caring for residents in a gentle, caring and professional manner and staff exhibited much patience in caring for the residents. Bedrooms had been personalised and there was a homely feel throughout. Personal clothing is labelled and residents were well groomed and dressed to reflect individuality. The hairdresser visits weekly, and residents are encouraged to have their hair done, however their right to refuse is respected. Some residents were able to express their satisfaction with the care they receive at the home, and several positive comments were received on CSCI comment cards. Information regarding the wishes of residents and relatives regarding end of life care discussed and recorded. Where the resident and/or their families do not wish to discuss such matters this is also recorded. Care plans viewed for end of life care were personalised and reflected the wishes of residents and their families, so that these can be respected. Ashgrove Care Home DS0000010939.V366586.R02.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): 12, 13, 14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The activity provision for the home is good, providing a variety of activities, outings and entertainments to meet residents’ individual needs. The home has an open visiting policy, thus encouraging residents to maintain contact with family and friends. Information regarding advocacy services is available, thus ensuring the residents’ right to independent representation is respected. The food provision in the home is good, offering variety and choice, to meet residents individual dietary needs. EVIDENCE: The home employs a full-time activity person. The activities programme for the week was displayed throughout the home. Residents were seen partaking in individual and group activities. The activity records for each resident were up to date and identified the activities that the resident had taken part in. There is also a personal preference plan for each resident in the service user plan and the majority of these viewed had been completed and gave a good picture of their lives and interests. There are regular outside entertainers arranged and also outings from the home. Representatives from religious denominations visit the home regularly and prayer and hymn sessions take place. Due to cognitive impairment many of the residents are not able to join in activities for a Ashgrove Care Home DS0000010939.V366586.R02.S.doc Version 5.2 Page 13 prolonged period of time, and the activities co-ordinator plans activities taking this into account. The mobile library visits the home regularly. The home has an open visiting policy and visiting is encouraged. Residents can choose to receive visitors in one of the communal rooms or in their bedrooms, as they so wish. Leaflets regarding advocacy services in relation to financial issues were available. The Registered Manager said that if a resident does not have a representative then their Care Manager acts on their behalf. The Registered Manager is aware that advocates can be requested from Age Concern and Alzheimer’s Concern. We viewed the kitchen and it was clean and tidy. Good food stocks were available to include fresh fruit and vegetables. The cook explained that where possible she follows the new ‘NUTMEG’ menu, which has been calculated to meet nutritional requirements. However, the menu does not include sandwiches for the suppertime meal and many residents enjoy these for their supper. There was evidence that sandwiches, soup plus a hot meal option are offered for supper. Records of meal choices were available and staff are very aware of each residents likes and dislikes. We viewed the lunch mealtime and meals to include liquidised meals were well presented and looked appetising. Staff were available to assist residents with their meals and did so in a discreet and professional manner. Drinks and snacks are available throughout the 24hour period. Ashgrove Care Home DS0000010939.V366586.R02.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): 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has clear complaints procedures in place to address any concerns raised by residents and their visitors. There is a robust system in place for the safeguarding of residents from abuse. EVIDENCE: The home has a clear complaints procedure and this is on display in the main entrance and in other areas throughout the home. The home has not had any complaints in the last 12 months. The Registered Manager does ensure she sees residents and relatives regularly and staff are also available to speak with, thus any issues can be listened to and addressed promptly, before it escalates to a complaint. The home has safeguarding adult policies and procedures in place that dovetail with the Hounslow Safeguarding Adults documentation. Posters and information were displayed throughout the home in relation to safeguarding adults. Staff spoken with said that they had received safeguarding adults training to include whistle blowing and were clear to report any concerns. Ashgrove Care Home DS0000010939.V366586.R02.S.doc Version 5.2 Page 15 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): 19 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is being maintained, however work needs to be progressed to improve areas of the environment for residents to live in. Procedures are in place for infection control and these are practiced, thus minimising the risk of infection. EVIDENCE: The home has a redecoration programme and timescales for completion are recorded, however it was not easy to ascertain if the timescales had been adhered to in all instances. The programme states it is also for refurbishment, however no refurbishment information was contained therein. A full programme of redecoration and refurbishment, to accurately identify when work is actually completed, must be in place. The corridors on the first floor were marked and in need of redecoration. The Registered Manager advised that the corridor carpet on the first floor is to be replaced and we suggested that the decoration be dovetailed with the carpet replacement. Several Ashgrove Care Home DS0000010939.V366586.R02.S.doc Version 5.2 Page 16 bedrooms have been redecorated and some refurbishment has also taken place. The beds are steadily being replaced with profiling beds, to meet the moving & handling needs of the residents. Some areas were malodorous and it was clear that this was due to continence issues. Consideration must be given to providing appropriate, easy to clean bedroom flooring to assist with odour control. The garden is well maintained with splashes of colour and the entrance is welcoming. Some of the residents enjoy participating in gardening, and this is encouraged. The windows throughout the home are in the process of being replaced with specialist windows, to aid with the exclusion of noise caused by being directly under the flight path. We noted that there were some items of old furniture in the garden and the Registered Manager informed us that once the window replacement had been completed all old furniture and other items would be disposed of. We viewed the laundry and this was clean and tidy. Good practice notices and laundering guidelines were on display. The washing machines have sluice programmes for infection control and there are 2 washing and 2 drying machines, all industrial standard. Protective clothing to include gloves and aprons was available throughout the home. Infection control procedures are in place and were being followed. The staff work hard to maintain a good standard of cleanliness throughout the home, however some areas are malodorous and a review of some of the bedroom flooring should address this issue (see Standard 19). Ashgrove Care Home DS0000010939.V366586.R02.S.doc Version 5.2 Page 17 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): 27,28, 29 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is appropriately staffed to ensure that the needs of the residents are met. Systems for vetting and recruitment practices are in place and are followed, thus protecting residents. There is an ongoing training programme, providing staff with the knowledge and skills to meet the needs of residents. EVIDENCE: At the time of inspection the home was being staffed appropriately to meet the needs of the residents. Staff spoken with felt that the home was being appropriately staffed to meet residents needs. The home is being maintained and the numbers of kitchen, domestic, administration and maintenance staff are appropriate to meet the needs of the home. It is acknowledged that the home has good staff retention and many staff have worked at the home for several years. There are 9 care staff qualified to NVQ 2 in care, and 11 of the care staff are currently undertaking NVQ level 2 and 6 NVQ level 3 in care. There is also evidence that the kitchen and domestic staff have undertaken NVQ level 2 kitchen and domestic duties. We viewed 3 sets of staff employment records and these contained all the information required under the Care Homes Regulations 2001. Criminal Records Bureau check information is stored on the computer and the Regional Ashgrove Care Home DS0000010939.V366586.R02.S.doc Version 5.2 Page 18 Administrator was able to confirm that for the records viewed the checks had been carried out. Southern Cross Healthcare has an induction programme based on the Skills for Care common induction standards. The Registered Manager said that she was currently awaiting more copies of the booklet but that all new staff had already received copies. They also have a general induction programme to be completed within the first 14 days of commencing work at the home and several completed documents were seen in the staff files. The training programme was displayed in the lift and identified the training due for each month. Several staff had completed the ‘Yesterday, Today and Tomorrow’ dementia care training, and commented on how beneficial this training had been in the understanding and care of the residents. This training is to be completed by all staff at the home. Ashgrove Care Home DS0000010939.V366586.R02.S.doc Version 5.2 Page 19 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): 31, 33, 35 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Manager has the skills and experience to manage the home effectively and promotes an atmosphere of openness and respect, thus making residents, visitors and staff feel valued. Systems for quality assurance are in place, thus providing an ongoing process of review and feedback. Resident’s monies are well managed and securely stored. Overall systems for the management of health and safety throughout the home are good, thus safeguarding residents, staff and visitors. Shortfalls should be easy to address. EVIDENCE: The Registered Manager is a first level registered nurse with several years experience in managing the home. She has post-graduate qualifications in caring for people with dementia and in teaching and assessing. She has Ashgrove Care Home DS0000010939.V366586.R02.S.doc Version 5.2 Page 20 undertaken the ‘Yesterday, Today and Tomorrow’ dementia care training and is in the process of doing the Registered Managers Award, which she should complete early in 2009. The CSCI must be informed that this has been completed. Southern Cross Healthcare has an annual development programme for quality assurance. Monthly audits had been carried out for medications and these were very comprehensive and included an audit of each medication being administered. Service user plan auditing is also carried out monthly. Monthly Managers audits are carried out and these are comprehensive, to cover all areas of the home. It was clear that where a shortfall is identified, action is promptly taken to address this finding. Regular meetings are held for staff and for heads of department, and minutes are recorded and distributed to each area. Relatives meetings are also held, however attendance is sometimes low, but the Registered Manager said that representatives had informed her that because they can discuss any issues with the staff they do not have much else to discuss in a meeting forum. The Registered Manager holds a weekly ‘surgery’ for representatives who wish to meet to discuss any issues. Regulation 26 visits on behalf of the Registered Provider are carried out and reports are available. Annual surveys of representatives are carried out. Clear computerised records are maintained for all monies being held on behalf of residents. 4 residents records were viewed and these were up to date and recorded all income and expenditure. Receipts for all income and expenditure are kept. Interest is allocated to each residents account on a monthly basis. Monies are securely stored. The home had up to date insurance cover. Maintenance and servicing records were sampled. Servicing was up to date and there was evidence of repairs being carried out to ensure all equipment is maintained in good working order. The in-house maintenance checks were up to date, however it was noted that 6 of the profiling beds had problems identified over a period of several weeks, and the Registered Manager had not been aware of this. The importance of ensuring any issues are reported and action taken to address them was discussed with the Registered Manager. Monthly checks of the wheelchairs are carried out and when a fault is identified the chair is taken out of service until it has been repaired. Checks for fire safety aspects and water testing were complete and up to date. The Fire risk assessment was last completed in August 2008 and the Registered Manager said that the action plan points had all been addressed. Fire drills are carried out on a regular basis for both day and night staff. Risk assessments for equipment and safe working practices were available, however the majority of the documentation was several years old. Southern Cross Healthcare has up to date generic risk assessments available and the Registered Manager must ensure that up to date risk assessments for equipment and safe working practices are available in the home, and copies of the relevant ones are placed in areas such as the kitchen and laundry. Daily cleaning schedules had been completed, however the weekly and monthly schedules for the kitchen had not Ashgrove Care Home DS0000010939.V366586.R02.S.doc Version 5.2 Page 21 been completed, although it was apparent the work is being done. The training records show that staff receive training and updates in health & safety topics to include moving & handling, fire safety, food hygiene, infection control, safeguarding adults and First Aid. The home has a Health & Safety committee who meet regularly and minutes of the meetings are recorded. Ashgrove Care Home DS0000010939.V366586.R02.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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 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 2 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 X X 2 Ashgrove Care Home DS0000010939.V366586.R02.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) Timescale for action Action must be taken to maintain 01/10/08 the temperature in the medications rooms below 25° centigrade and for the fridge temperature to be maintained within safe range so that medications are stored at safe temperatures. The MHRA advice with regard to 01/10/08 blood glucose testing must be followed in order to safeguard the residents. The redecoration and 01/10/08 refurbishment plan must identify all areas of redecoration and refurbishment and evidence that timescales are being adhered to, in order to provide a good environmental standard. The suitability of the flooring 01/11/08 must be reviewed in areas of the home where malodours are present, in order to address this issue and provide a pleasant environment for residents to live in. Action must be taken to repair 01/10/08 the profiling beds in order to meet the moving & handling DS0000010939.V366586.R02.S.doc Version 5.2 Page 24 Requirement 2. OP9 13(2) 3. OP19 23(2)(b)& (d) 4. OP19 16(2)( c) & (k) 5. OP38 23(2)(c) Ashgrove Care Home 6. OP38 16(2)(j) 7. OP38 13(4) (c ) 12 needs of the residents. Cleaning records must be up to date to evidence that all areas of the home are being maintained in a clean condition. The Registered Manager must ensure that risk assessments for safe working practices and equipment are up to date in accordance with current legislation in order to protect the residents. 01/10/08 01/10/08 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 Information for covert administration of medications should be included in the residents service user plan. Ashgrove Care Home DS0000010939.V366586.R02.S.doc Version 5.2 Page 25 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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. 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