Inspection on 01/11/05 for Ash Cottage

This inspection was carried out on 1st November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Ash Cottage 16/07/07

Ash Cottage 09/06/06

Ash Cottage 03/05/05

Ash Cottage 19/10/04

Ash Cottage 11/05/04

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 Ash Cottage Crow Woods Edenfield Ramsbottom Lancashire BL0 0HY Lead Inspector Mrs Lynn Mitton Unannounced Inspection 1st November 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ash Cottage DS0000009498.V256242.R01.S.doc Version 5.0 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. Ash Cottage DS0000009498.V256242.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ash Cottage Address Crow Woods Edenfield Ramsbottom Lancashire BL0 0HY 01706 826926 01706 826926 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) Mrs Margaret Mary Holt Ms Ann Josephine Zieme Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Ash Cottage DS0000009498.V256242.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service should employ a suitably qualified and experienced person who is registered with the Commission for Social Care Inspection as manager of Ash Cottage only. 3rd May 2005 Date of last inspection Brief Description of the Service: Ash Cottage is a detached residence in its own grounds, located in a semi-rural area in the village of Edenfield, on the outskirts of Rawtenstall. The home has a large purpose built extension, and opened in 1989. There are views of open countryside on one side of the home. Public bus routes to Rawtenstall, Ramsbottom and Bury are nearby. In the nearby village are a number of small shops, and public house. Banks, larger stores and other amenities can be found in Rawtenstall approximately 2 miles away. Ash Cottage can accommodate up to 20 service users aged 65 or over. Service users are either privately or local authority funded. There are three separate lounge and dining areas giving service users a choice of where and who to sit with. Toilets and baths are conveniently located to communal rooms and bedrooms, and have various aids and adaptations to assist and promote mobility and selfhelp. Accommodation is offered in 12 single rooms, 5 having en-suite facilities, and four double bedrooms 1 with en-suite facilities. Ash Cottage DS0000009498.V256242.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced. It took place over one day and lasted about 5 hours. There were 20 residents accommodated at this time. Over the course of the inspection approximately 10 residents were spoken to. A tour of the communal areas of the home took place. Documents were read and care observed. What the service does well: What has improved since the last inspection? What they could do better: A completed copy of the service user guide and statement of purpose should be available to all prospective and present service users, and on display at the home. Written information must be in place for each resident regarding their care and health needs and how they are to be met. Any identified risks and how they are to be managed must be recorded. Ash Cottage DS0000009498.V256242.R01.S.doc Version 5.0 Page 6 Regular planned activities would ensure that residents were stimulated and had opportunities to try new things. All procedures for recruitment of staff, checks and appropriate training to safeguard residents must be in place. The health and safety of the residents and staff must be of highest priority and all safeguards possible put in place to ensure this. 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. Ash Cottage DS0000009498.V256242.R01.S.doc Version 5.0 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 Ash Cottage DS0000009498.V256242.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): OP1, OP3 OP6 The written information must provide a clear picture of the homes facilities and services. The admission procedure for new residents ensured that information about their care needs was obtained before they arrived. This enabled staff to have a clear understanding of what they needed to do for them. EVIDENCE: The statement of purpose and service user guide had not been updated since the last inspection. These documents did not contain all the information needed for a prospective resident to understand how the home was run and what facilities were offered. This issue has been outstanding since 2002. A recent admission to Ash Cottage told the inspector that she had been given a “brochure” when she first arrived. Assessments of need were completed prior to new residents being admitted. The inspector saw these on resident’s files. Intermediate care is not offered at this home. Ash Cottage DS0000009498.V256242.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): OP7, OP8, OP9 All resident’s care and health needs must be appropriately recorded. Regular reviews of care plans would ensure that any changes were documented. Risk assessments must be completed for all residents self-medicating. Residents were treat with dignity and respect. EVIDENCE: The inspector looked at two residents care plans. On them was some information identifying the resident’s care and health needs and how these should be met. The care plans had not been signed by the resident or their next of kin. Some information/records were out of date or incomplete. These were discussed at the time of the inspection with the registered manager. One resident self medicates, a risk assessment had still not been completed in this regard. Residents spoken to told the inspector that they were spoken to and treat with dignity and respect and gave examples of this. The inspector and registered manager discussed the location of the TV in the first lounge. Ash Cottage DS0000009498.V256242.R01.S.doc Version 5.0 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): OP12, OP13 & OP15 Residents had opportunities to maintain family links, and they valued this. The introduction of a regular programme of planned activities would ensure that residents had opportunities for their enjoyment, mental and physical stimulation. Meals were varied and provided a social occasion on a daily basis. EVIDENCE: One resident said; “ We get lots of visitors here”, another told the inspector, “Visitors can come anytime, they never turn anyone away”. The visitors book was not being completed. The inspector spoke with one visitor to the home, who was happy with the care her relative received. The inspector discussed with the residents what activities were currently on offer. One said “there’s not much going on, only the TV”. The inspector and registered manager discussed activities for residents. A record of activities undertaken with residents could not be located at the time of the inspection. Ash Cottage DS0000009498.V256242.R01.S.doc Version 5.0 Page 11 The inspector enjoyed lunch with the residents. Residents spoken to by the inspector were complimentary about the quality, quantity and variety of meals provided. Staff were ready to offer assistance with eating where necessary, whilst independent eating was encouraged for as long as possible. How this was done was discussed with the registered manager at the time of the inspection. Meals were seen to be well presented, and were unhurried. Those who needed it were using adapted cutlery/crockery. This promoted their independence. Ash Cottage DS0000009498.V256242.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: Both these standards were looked at during the last inspection. A minor amendment to the wording of the complaints policy had been implemented and was seen by the inspector. The commission had received no complaints since the last inspection. Financial abuse by family members of one resident was discussed. Ash Cottage DS0000009498.V256242.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: Both these standards were examined and met at the last inspection. The inspector was updated by the registered manager of ongoing maintenance and replacement of furnishings programme. Ash Cottage DS0000009498.V256242.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): OP27, OP29 & OP30 Staff numbers were adequate to meet the needs of the residents. The care staff team were experienced in meeting the needs of the residents. All procedures for recruitment of staff and checks to safeguard residents must be in place. Staff training should demonstrate that new care staff are able to competently care for the residents. EVIDENCE: One resident said “ The girls are wonderful, they’ll do anything for you”. The staffing rota was seen and it demonstrated that there were 2 care staff and one senior staff on duty during the day and evening, and then 2 waking night staff overnight. Many of the care staff team had considerable experience in caring for older people, and were well established at Ash Cottage. There were cooks, cleaners and a handy man also employed. Two staff recruitment files were case tracked and both were found to have shortfalls in the documentation required by legislation. The inspector was advised that out of the 15 care staff 13 have obtained the NVQ 2 qualification. The remaining 2 had recently begun this training. Induction for new staff consisted of working alongside experienced senior staff for one week. The registered manager was advised that this did not comply with TOPSS specification for induction and foundation training. Ash Cottage DS0000009498.V256242.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): OP31, OP33, & OP38 Some practices do not safeguard the health and safety of the residents and staff. Ash Cottage DS0000009498.V256242.R01.S.doc Version 5.0 Page 16 EVIDENCE: The registered manager had recently completed the NVQ 4 qualification in care and management. The registered person visits the home approximately two days per week. The inspector was satisfied that there were clear lines of accountability within the home. The inspector was satisfied that resident’s opinions were sought on a day to day basis regarding the running of the home, and informal meetings took place. However, the most recent service user survey had been conducted in September 2004. A further survey was overdue. Fire test records showed that monthly checks were not taking place, the last test being August 2005. The inspector advised the registered manager of the importance of conducting regular fire tests in order to ensure the safety of residents and staff. The inspector noted that one resident’s wheelchair had footplates missing. Ash Cottage DS0000009498.V256242.R01.S.doc Version 5.0 Page 17 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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X 2 X 2 Ash Cottage DS0000009498.V256242.R01.S.doc Version 5.0 Page 18 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 OP1 Regulation 4&16 Requirement A Statement of Purpose must be produced in accordance with schedule 1 of the Care Home regulations. A copy of this document must be supplied to the National Care standards Commission and available to every service user and any of their representatives. Not complied with following the inspection of October 2002 A Service Users Guide must be produced in accordance with regulation 5 of the Care Home Regulations. A copy of this document must be made available to the National Care Standards Commission and each service user. Not complied with following the inspection of October 2002 3 OP7OP8 Sch 3 15, 17(3a) Ensure care plans comply fully with Schedule 3 of Care Homes Act 2000. All service users must have fully DS0000009498.V256242.R01.S.doc Version 5.0 Page 19 Timescale for action 31/03/06 2 OP1 5 31/03/06 31/03/06 Ash Cottage completed care plans in place. The service users, and their family must be fully involved in the ongoing development of these care plans, and agreed and signed. Care plans must set out in detail the action which needs to be taken by the care staff to ensure how all aspects of health, personal and social care needs are met. Not complied with following the inspection of September 2003 Unnecessary risks to the health and safety of residents are identified and as far as is possible, eliminated. A record of all visitors to the home must be made. The registered person must operate a thorough recruitment process at all times. Not complied with following the inspection of October 2004 The registered person shall provide for consultation with residents and their representatives. The registered person must ensure the health and safety of service users and staff by ensuring fire drills take place at least each month. Not complied with following the inspection of September 2003 4 OP9 13 (4) 31/03/06 5 6 OP13 OP29 Schedule 4 (17) 19 31/03/06 31/03/06 7. OP33 24 31/03/06 8. OP38 13(3) (4) (a b c) 31/03/06 Ash Cottage DS0000009498.V256242.R01.S.doc Version 5.0 Page 20 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 3 Refer to Standard OP12 OP30 OP36 Good Practice Recommendations Residents are given opportunities for stimulation and leisure through recreational activities. Ensure that the induction and foundation training is in accordance with National Training Organisation specifications. Care staff should receive formal supervision at least 6 times each year. Ash Cottage DS0000009498.V256242.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ash Cottage DS0000009498.V256242.R01.S.doc Version 5.0 Page 22 - 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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