Care Home: Ashgrove Nursing Home

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What the care home does well The home is very well presented to prospective clients both in general appearance and in the excellent sources of information provided. The home provides very person centred personal care in a friendly, homely atmosphere and a very pleasantly maintained environment. The home has an experienced Home Manager who has been pivotal ensuring that the home develops and that service users receive required care. Staff ensure service users needs and interests are identified to enable their needs to be met. The home has an appropriate skill mix of well trained staff and allocated numbers. The home undertakes regular quality assurance monitoring which informs and promotes further developments. Service users are in particular pleased with the high standard of the meals and also find the gardens a good source of pleasure. Visitors to the home say that they are always made welcome. The home is clean and pleasantly decorated, health and safety is proactively managed. Recruitment and selection procedures are robust and safeguard the service users. The homes policies demonstrate an open ethos and a positive stance to complaints and the protection of vulnerable people. What has improved since the last inspection? Staff involved in administration of medicines have had competency assessments and the medication policy reissued. Medication records are of a good standard and monitoring of the medication fridge temperature introduced. Increased auditing of medications has been implemented. The induction training programme for new staff has been updated to skills for care specifications. Staff supervisions are now undertaken on a programmed basis to ensure the standard required is met consistently. The procedure for documenting complaints has been amended to ensure the outcome of investigation is clearly shown. A programme of redecoration and refurbishment of bedrooms including change of carpets has began and will continue over the summer. What the care home could do better: The Statement of Purpose and Service Users Guide are excellent documents but would benefit from review dates and an expanded list of alternative formats in which they can be provided. The home is very good at assessing and care planning to meet service users needs, the inspector has some reservations about the respite service users care plans lacking the holistic standard afforded permanent service users although no shortcomings were identified during the inspection. Good progress has also been achieved in ensuring medication is delivered safely but it was seen that a respite service user receiving `as required` medicines had no care plan to guide staff of the circumstances when it may be required. Monitoring of the medicine room temperature is undertaken but the timing would not include peak temperature times. Managers and staff have been proactively addressing a specific malodour problem but have not yet succeeded otherwise the home is clean and hygienic to a high standard. The carpets in many bedrooms are outstanding to be replaced as required at the last key inspection in August 2006. The manager identifies that replacement has been budgeted for this year and a programme of redecoration is underway following which the carpets replaced and furniture and soft furnishings replaced from July onwards. In checking the monitoring records for hot water mixing valves at service user outlets the standard is achieved consistently but no testing is undertaken that force tests the valve to ensure it has not seized (anti-scald test). Staff hand wash outlets in sluices, medicine room kitchen and laundry are not controlled or supplied through mixer taps and should be addressed to promote good hand washing practice by staff. CARE HOMES FOR OLDER PEOPLE Ashgrove Nursing Home Dudley Wood Road Netherton Dudley West Midlands DY2 0DA Lead Inspector Mr Richard Eaves Key Unannounced Inspection 14th May 2007 10:00 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 Nursing Home DS0000004895.V339463.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. Ashgrove Nursing Home DS0000004895.V339463.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashgrove Nursing Home Address Dudley Wood Road Netherton Dudley West Midlands DY2 0DA 01384 413913 01384 413665 ashgrove@highfield.care.com 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) Southern Cross Care Centres Limited Jayne Griparis Care Home 57 Category(ies) of Dementia - over 65 years of age (18), Old age, registration, with number not falling within any other category (39), of places Physical disability (12), Physical disability over 65 years of age (2) Ashgrove Nursing Home DS0000004895.V339463.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Two service users identified in the variation approved on the 8.11.04 may be accommodated in the category of sensory impairment (SI). This will remain until such time that the service user placements are terminated and whilst the home is able to meet their needs. One service user (female) identified in the variation report dated 4.4.2005 may be accommodated at the home in the category MD. This will remain until such time that the service users placement is terminated. The 18 dementia beds accommodate only service users requiring personal care only. 28th February 2007 2. 3. Date of last inspection Brief Description of the Service: Ashgrove was previously a residential home which has been further adapted and extended to accommodate elderly service users with nursing needs. Coppice unit is a self contained new extension for service users with dementia requiring personal care. Ashgrove can accommodate up to 54 residents requiring either nursing or personal care within 51 single and 3 double bedrooms on two floors. The first floor can be accessed via a passenger lift. There are two lounge/dining rooms on the ground floor and a small lounge on the first floor. A hairdressing salon is on the ground floor of the main home. Laundry and catering facilities are available within the home. There is also a large lounge dining room within Coppice and a small reminiscence lounge. The home has parking facilities both at the front and rear of the property. There is a large well-maintained garden and sensory garden with garden furniture and garden lighting available enabling service users to sit out and enjoy the beautiful garden. Fees vary between £343 and £533 and are dependant on the needs of the service user and the type of room that will be occupied. Ashgrove Nursing Home DS0000004895.V339463.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection visit was undertaken by an Inspector from the Commission for Social Care Inspection using the following information the pre-inspection questionnaire, comment card responses from service users and relatives, records held at the home, including care records reviewed as part of the ‘case tracking’ of five service users and reports from the organisation relating to the conduct of the home. The inspection involved a full tour of the property including, a number of bedrooms, the communal rooms and service areas and provided an opportunity to speak with many of the service users as they were able. Good progress has been achieved in addressing previous requirements. What the service does well: What has improved since the last inspection? Staff involved in administration of medicines have had competency assessments and the medication policy reissued. Medication records are of a good standard and monitoring of the medication fridge temperature introduced. Increased auditing of medications has been implemented. Ashgrove Nursing Home DS0000004895.V339463.R01.S.doc Version 5.2 Page 6 The induction training programme for new staff has been updated to skills for care specifications. Staff supervisions are now undertaken on a programmed basis to ensure the standard required is met consistently. The procedure for documenting complaints has been amended to ensure the outcome of investigation is clearly shown. A programme of redecoration and refurbishment of bedrooms including change of carpets has began and will continue over the summer. 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 Nursing Home DS0000004895.V339463.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 Ashgrove Nursing Home DS0000004895.V339463.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 1 – 5 Quality in this outcome area is excellent. The homes statement of purpose and service user guide are good sources of information providing details of the service enabling service users and families to make informed decisions about admission to the home. Pre-admission assessments are undertaken by the most experienced staff and confirmation is given to the service users that their needs can be met by the home and further confirmed by contract at the time of admission. Service users are invited to visit and trial the home before committing themselves to staying at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The homes statement of purpose and service user guide are a good sources of information providing details of the service enabling service users and families to make informed decisions about admission to the home. This is due further review to show changes within the company. The date of last review should be shown and the range of alternative formats expanded to include large print and easy read pictorial. Ashgrove Nursing Home DS0000004895.V339463.R01.S.doc Version 5.2 Page 9 Pre-admission assessments are undertaken by the most experienced staff records show that staff liaise with medical staff and relatives to ensure the assessment of need is comprehensive. A sample of five case files were inspected including three nursing and two from Coppice unit, a number of other files were inspected to identify specifics relevant to individuals. Confirmation is given to the service users that their needs can be met by the home and further confirmed by terms and conditions at the time of admission. Relatives and the questionnaire responses confirmed that they had been consulted by staff on their relatives needs and had had an opportunity to visit the home prior to their relative coming to live at Ashgrove. Ashgrove Nursing Home DS0000004895.V339463.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 – 10 Quality in this outcome area is good. Care plans are derived from a comprehensive range of assessments and provide the basis for the delivery of care and detail the actions required of staff to meet the identified needs. Health care needs of service users are fully met. Medications are well managed all facilitating the promotion of service users health. Service users are treated with respect and their privacy upheld. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A sample of case files were selected at random to be inspected and case tracked. The care plans were drawn from the assessed needs process and were relevant and maintained to a good standard. The care plans reflect actual care requirements detail the actions required of staff. Plans are subject to monthly review and a daily record maintained by each shift. Care plans for respite service users are restricted to minimal care requirements and potentially do not give detailed guidance to staff for the reasons when, for example as required medication should be given. Ashgrove Nursing Home DS0000004895.V339463.R01.S.doc Version 5.2 Page 11 All service users are registered with a GP of their choice although most elect to use the services of one practice who visit at least weekly. Allied medical services such as dentist, ophthalmic and chiropody are provided on a regular and as required basis. A monitored dosage system is used for the administration of medicines provided by Boots chemist who also audits the service on a quarterly basis. An inspection of the administration of medication procedure identified that it is administered to a satisfactory level. Medications are stored in locked cupboards records are maintained of medicines received and a contract is in place for disposal of unused medications. Monitoring of room and refrigerator temperatures are undertaken but the time for the room monitoring should be changed to include the highest risk period of the day when the recommended maximum temperature of 25°c might be exceeded. Qualified Nursing Staff undertake the administration of medicines on the nursing unit and Senior Carers who have received accredited training on Coppice Unit. Previous requirements have been met, arising from this inspection it was noted that insulin and eye drops in use continue to be refrigerated unnecessarily. Used hypodermic needles seen in the sharps boxes have been resheathed. The induction programme includes a section on treating service users with respect and their privacy is upheld, locks are fitted to all bedroom doors, staff were observed to knock before entering bedrooms and interact in a friendly and open way using the service users choice of name. Ashgrove Nursing Home DS0000004895.V339463.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 – 15 Quality in this outcome area is excellent. The home provides varied social and recreational activities that provide interest and pleasure for the residents, suiting their preferences and capabilities. Visitors are welcome and help to keep service users informed about the wider community Many aspects of care evidences that service users exercise choice and control over their lives. Food served is nutritious and well balanced and offers a healthy and varied diet for residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has an Activity Coordinator who identifies service users interests and has been developing activities and arranging outing for service users to meet their interests, two external activity leaders visit weekly to provide art and craft sessions and exercises to music. Activities within the home include dominoes, bingo, crafts such as card making and painting activities are provided to both units. Some service users enjoy the garden and assist in planting bedding plants. The home has access tothe company mini bus every Thursday enabling groups of residents to go out shopping and trips further Ashgrove Nursing Home DS0000004895.V339463.R01.S.doc Version 5.2 Page 13 afield. Residents also enjoy pub lunches and shopping trips most weeks. Residents spoken said that they thoroughly enjoy the trips out. A programme of major events have been planned for over the summer and these are displayed on a notice board on Ashgrove. Events include A summer fete, garden party ‘A Greek Night’ and a pub night. Monthly coffee mornings are arranged when speakers visit. A recent entertainment from a Male Voice choir was particularly well received. The Home has three pets. Visitors are welcome at any time and those met said that they felt welcome, the local church also visit and provide regular services. Care plans identify residents individual likes and dislikes and choices about their individual routines such as whether they prefer a bath or a shower, getting up and going to bed, the light on when they are in bed and their preferred name these are carried out flexibly to provide for choice. Staff spoken with said they made efforts to encourage the service users to make their own choices in particular to choose their clothing daily and choose meals and where required take note of facial expression and known likes and dislikes. The home has a four-week menu providing a balanced and nutritious food with a choice of meal always provided, supper is included on the daily menu. Special diets such as pureed, soft and diabetic diets are catered for. Fresh fruit is provided each day and smoothies are made available to those who like them. During the inspection lunch was observed to be served and the three choices menu’d were served, service users spoken with said that they enjoy their meals and the choice available. Staff give residents discreet assistance to feed themselves whenever it is required. Ashgrove Nursing Home DS0000004895.V339463.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 & 18 Quality in this outcome area is excellent. The home complaints and protection policies are robust providing a safe environment in which service users feel they can voice concerns and that these will be listened and responded to. Staff demonstrate excellent knowledge and understanding of adult protection issues which contributes to an environment that is safe from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A clear and concise Complaints Procedure is displayed in the reception, which includes reference to the Commission for Social Care Inspection as the regulatory body, together with contact details, a number of complaints have been received over the year and these can be seen to have been taken seriously with learning resulting. Visitors spoken with were confident that they would be able to complain if the need arose and would get a positive reception. Policies relating to the protection of Residents from abuse were observed to be in place and readily accessible, these included, ‘Whistle Blowing’, ‘Abuse Awareness’ and ‘Adult Protection’. A flow chart was available to staff in the nursing office. Staff training files indicated that Staff receive training in respect of these Policies. Two adult protection issues have arisen over the past year and satisfactory outcomes were achieved that resolved concerns. Ashgrove Nursing Home DS0000004895.V339463.R01.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): Standards 19 & 26 Quality in this outcome area is good. The Home provides a comfortable, attractive, safe and ‘homely’ place to live. Specialist equipment, consistent with the needs of the Residents and the demands of tasks carried out by care staff, is available to facilitate the provision of care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is set in its own grounds with ample parking that is separated from the garden areas which are maintained in good order with spring planting ongoing. The exterior decoration is in good order. Internally the communal areas are well presented having been refurbished and decorated last year. The next phase is underway and currently bedrooms are being redecorated, new carpets and furniture are planned to provided from July onwards. Ashgrove Nursing Home DS0000004895.V339463.R01.S.doc Version 5.2 Page 16 Coppice unit decoration and furnishings remain in very good condition being relatively new. Some malodour was apparent in one area which the managers were previously aware and are trying methods to eradicate the problem arising from the behaviour of an individual. The kitchens are recently refurbished and are maintained and cleaned to very hygienic standards. All areas of the home were also noted to be clean and hygienic taking into account the previously mentioned problem odour. The laundry is well fitted and has dirty and clean areas the washers have sluice and disinfection programmes. The home has 3 sluice disinfectors one in Coppice and one on each floor of Ashlodge. A tour of the building show that there are adequate bathing and toilet facilities. Bedrooms are personalised and are currently being refurbished, each is furnished appropriately and service users requiring nursing in bed or require bedrails for their safety have electric profiling beds with integral bedrails that maximises their safety. Rooms were seen to have the requisite fittings such as lights electrical points, Safe radiators. Window ventilation is by high hopper openings. Some carpets are badly stained and due replacement. None of the rooms on Ashgrove are currently en-suite, all on Coppice are. All survey respondents were happy with the appearance and that the home was always fresh and clean. Staff handwash outlets in the treatment room, sluices, laundry and kitchen have very hot water. It is recommended that a method of control is introduced to promote good hand washing by staff. Also recommended is that all mixing valves are subjected to anti-scald testing annually and servicing if the valves are of a type that can be. Ashgrove Nursing Home DS0000004895.V339463.R01.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): Standards 27 – 30 Quality in this outcome area is excellent. Staff are clear as to their individual roles and responsibilities and are enthusiastic, sufficient in numbers, well trained, supportive and committed to maximising the service users quality of life. The recruitment practices, staff training and supervision all contribute to ensuring service users benefit from the skills and knowledge of the staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The current staffing rota, and those from the immediately preceding weeks, were examined. Staffing numbers and skill-mix is of a high standard and enables a high quality service provision meeting the care needs of the Service Users. The Home Manager is in addition to care staff numbers, as is the Activity Organiser, a full complement of domestic, catering, maintenance and laundry staff are also available through out the day. The number of care staff with a National Vocational Qualification (NVQ) level two or equivalent is now at 66 . A sample of five staff files were viewed and show that recruitment procedures are completed to a good standard with appropriate checks of Personal Identification Number and Criminal Record Bureau in place. Job descriptions appeared satisfactory for roles and support the underlying values of the home. Staff are subject to a thorough, and relevant, orientation/induction Ashgrove Nursing Home DS0000004895.V339463.R01.S.doc Version 5.2 Page 18 programme, which is followed by comprehensive ‘foundation’ training, e.g. ‘manual handling and lifting’, ‘fire safety’, ‘infection control’. In addition, the Home enjoys an excellent record for the continuing development of staff, and supporting staff in undertaking appropriate training based on a well-structured plan for determining individual training needs. Ashgrove Nursing Home DS0000004895.V339463.R01.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): Standards 31 - 33, 35 – 38 Quality in this outcome area is excellent. Leadership of this home is good and staff demonstrate an awareness of their roles and responsibilities. The managers approach is open and positive and develops positive relationships amongst service users and with staff. The home regularly reviews its performance which includes seeking the views of service users families. Service users financial interests are safeguarded and good record keeping protects the interests of service users. The health safety and welfare of residents and staff is promoted and protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager is a well qualified and experienced registered nurse, well regarded and liked by the service users and staff alike and this is apparent from the comment cards and in speaking with service users, families and staff as well as observing the interactions over the day. Ashgrove Nursing Home DS0000004895.V339463.R01.S.doc Version 5.2 Page 20 Quality audits are undertaken six monthly with corrective actions identified, with a copy of the audit sent to both the Regional Manager and Regional Director. The manager undertakes regular surveys of service users views and uses the findings to influence and improve the delivery of care. Secure facilities are available for the safe keeping of service users personal money and valuables. Written records are available for all transactions which detail the reason for the withdrawal and two signatures, receipts are available as proof of purchases. Regular external audits of service users personal money are undertaken. Supervision is fully implemented and the content relevant to the continued development of the service. A sample of records required by regulation were viewed and found to be up to date and well maintained. Documentation was seen of a full range of servicing, maintenance and regular monitoring of services and equipment undertaken, staff receive training in health and safety and first aid. Monitoring of hot water is good and records show that the standard of 43°c is achieved consistently. Fire safety including tests, staff training and equipment maintenance were seen to be up to date. Records of all accidents are recorded, using data protection compliant documentation and reported as necessary. Induction and foundation training is provided to Skills for Care standards. Overall the premises were observed to be well managed to meet safety requirements. Ashgrove Nursing Home DS0000004895.V339463.R01.S.doc Version 5.2 Page 21 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 4 3 4 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X 2 2 3 STAFFING Standard No Score 27 3 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 3 4 X 3 3 3 3 Ashgrove Nursing Home DS0000004895.V339463.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13(2) Requirement A care plan must be available that details the use and evaluation of as required medication. Previous timescale 31/08/06 not met. The home must be maintained odour free. Previous timescale 31/08/06 not met. The carpets in rooms : 4,6,7,10,20,22 and 26 and the upstairs corridor must be effectively cleaned or replaced. Room 3 is redecorated. Previous timescale 31/09/06 part met in that programme has commenced. The registered person must make sure that arrangements for the safekeeping of medicines ensures that the temperature of the medication room does not exceed 25°c. The manager must ensure that hypodermic needles are disposed of safely following administration of medication. Staff must not re-sheath used needles. Annual ante-scald testing of hot water mixing valves should be DS0000004895.V339463.R01.S.doc Timescale for action 30/06/07 2. 3. OP19 OP19 16(2)(k) 16(2)(k), 23(2) 30/06/07 30/08/07 4. OP9 13(2) 30/06/07 5. OP25 13(4)(a) 31/08/07 Ashgrove Nursing Home Version 5.2 Page 23 included in the monitoring of the safe delivery of hot water at service user outlets. Hot water at staff hand wash outlets should be delivered at a safe temperature. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP1 OP9 Good Practice Recommendations The statement of purpose and service users guide should show the date of last review and the alternative formats available documented more fully. The manager should ensure that medications such as insulin and eye drops are stored when in use according to the manufacturers guidance. Ashgrove Nursing Home DS0000004895.V339463.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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 Ashgrove Nursing Home DS0000004895.V339463.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. Re-publishing this information is in breach of the terms of use of that website. 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