Inspection on 03/05/05 for Ash Cottage

This inspection was carried out on 3rd May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 01/11/05

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 Lynn Mitton Unannounced 03 May 2005 10:00 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 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 F57 F07 S9498 Ash Cottage V221096 May 3rd 2005 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Ash Cottage Address Crow Wood Edenfield Ramsbottom Lancashire BL0 0HY 01706 826926 01706 826926 Telephone number Fax number Email 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 Only Personal Care (PC) 20 Category(ies) of Old age, not falling within any other category registration, with number (OP) 20 of places Ash Cottage F57 F07 S9498 Ash Cottage V221096 May 3rd 2005 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: 1 The service ahould employ a suitably qualified and experienced person who is registered with the Commission for Social Care Inspection as manager of Ash Cottage only. Date of last inspection 19 October 2004 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. A public bus route to Rawtenstall, Ramsbottom and Bury is within walking distance of the home. In the nearby locality of the 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 residents who are aged 65 or over. Residents are either privately or local authority funded. There are three separate lounge and dining areas. Toilets and baths are conveniently located to communal rooms and bedrooms, and have various aids and adaptations to assist and promote mobility and self-help. Accommodation is offered in 12 single room accommodation, 5 having en-suite facilities, and four double bedrooms 1 with en-suite facilities. The home is decorated and maintained to a high standard throughout. The aim is to provide a homely residential environment caring for older people. Ash Cottage F57 F07 S9498 Ash Cottage V221096 May 3rd 2005 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced. It took place over one day. There were 19 residents accommodated at this time, plus one person receiving day care. Over the course of the inspection approximately 14 residents were spoken to, including someone who had been admitted to the home that day. 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? Residents were now being given terms and conditions of their stay at Ash Cottage. Some policies and procedures had been written and implemented since the last inspection. The manager of the home is now registered with the Commission. Ash Cottage F57 F07 S9498 Ash Cottage V221096 May 3rd 2005 Stage 4.doc Version 1.20 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ash Cottage F57 F07 S9498 Ash Cottage V221096 May 3rd 2005 Stage 4.doc Version 1.20 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 Standards Statutory Requirements Identified During the Inspection Ash Cottage F57 F07 S9498 Ash Cottage V221096 May 3rd 2005 Stage 4.doc Version 1.20 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 standard(s) 1,2,3 &4 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 been updated since the last inspection. However, these documents still did not contain all the information needed for a prospective resident to understand how the home was run and what facilities were offered. The terms and conditions of living at Ash Cottage were seen for two residents, these documents had been fully competed. Assessments of need were completed prior to new residents being admitted. The inspector saw two of these. Letters had been sent to residents advising them that Ash Cottage was able to meet their needs. The inspector saw two of these on resident’s files. Ash Cottage F57 F07 S9498 Ash Cottage V221096 May 3rd 2005 Stage 4.doc Version 1.20 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 standard(s) 7, 8 & 9 All resident’s care and health needs must be appropriately recorded. Regular reviews of care plans ensured that any changes were documented. Secondary dispensation and appropriate disposal of medication issues must be reviewed and good practice ensured. Risk assessments must be completed for all residents self-medicating. EVIDENCE: The inspector looked at two residents care plans. On them was information identifying the resident’s care and health needs and how these should be met. One of these had not been fully completed, however information details required to be on the care plans were in place. One resident said “I felt better as soon as I walked through the door”. From observations, speaking to residents and visitors the inspector felt that staff knew resident’s needs. The inspector noted that medication for one resident had been dispensed into a pot and had been left out for them the night before. One resident self medicates, a risk assessment had not been completed in this regard. Ash Cottage F57 F07 S9498 Ash Cottage V221096 May 3rd 2005 Stage 4.doc Version 1.20 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 standard(s) 12 & 14 The home was run to make sure the service users enjoyed their life and had opportunities to fulfil their potential. Community links were maintained at Ash Cottage. Residents had opportunities to maintain family links. Residents were respected and valued as individuals. EVIDENCE: Residents talked to the inspector and observations were made demonstrating a number of ways in which they made daily decisions about their lives, for example, residents were seen to be getting up at various times throughout the morning, and there was a choice of three lounges so that residents could choose where and with whom to sit. Care staff were seen to knock on residents bedroom doors before entering. The inspector observed that residents were encouraged to maintain their personal care skills and independence to the best of their ability. A representative of the clergy visited during the inspection. Two visitors to the home were very positive about the care their relative received at Ash Cottage. The inspector was told “the food is always great here”. Since the last inspection the activities co-ordinator had left. The inspector discussed with two care staff what activities were currently on offer. A small number of residents who do not get visitors were also discussed. Ash Cottage F57 F07 S9498 Ash Cottage V221096 May 3rd 2005 Stage 4.doc Version 1.20 Page 11 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 standard(s) 16 & 18 Staff spoken to knew how to protect the residents in their care. The written procedures for responding to an allegation of abuse and complaints were in place, and staff were aware of the procedures to follow. EVIDENCE: Three care staff spoken to by the inspector could explain the complaints procedure, and knew what to do if they had any concerns about residents wellbeing, and had an awareness of the whistle blowing policy. The inspector advised those staff that they could come to the Commission at any time if they had concerns. A copy of the complaint procedure was in each resident’s room. A copy should also be placed in a communal area for visitors to the home. This document should also refer to the Commission being contacted “at any time”, not “if still not satisfied”. No complaints had been received by the commission since the last inspection. Documentation was in place for dealing with complaints and protecting residents from abuse of any kind. Ash Cottage F57 F07 S9498 Ash Cottage V221096 May 3rd 2005 Stage 4.doc Version 1.20 Page 12 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 standard(s) 19 & 26 The layout and décor of the home was suitable for the residents accommodated and provided comfortable surroundings. The home was clean, tidy, warm and mostly free from offensive odours. EVIDENCE: There was ramped access to the front of the home. The décor was clean. The garden to the front of the home was very well tended. The home was well maintained throughout. The registered manager advised that it was intended that some double glazing windows in the “top” lounge were due to be replaced in June. On the ground floor there were two communal toilets. All residents were encouraged to furbish their own room and this was witnessed as one resident moved in on the day of the inspection. There was one localised area of odour detected in the home. The registered manager assured the inspector this would be remedied as a matter of urgency. Ash Cottage F57 F07 S9498 Ash Cottage V221096 May 3rd 2005 Stage 4.doc Version 1.20 Page 13 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 Staff numbers were adequate to meet the needs of the residents. EVIDENCE: The staffing rota was examined and this demonstrated that there were 3 care staff on duty from 8am until 10pm and then 2 waking night staff overnight. A recent recruit to the staff team said that her induction had consisted of shadowing a colleague for one week. 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. The registered manager advised of her intention to work alongside all the staff team, at different times of the day and night. Since the last inspection the Commission had registered the homes manager. Recruitment records were unavailable due to the registered manager not being on duty, so the inspector was unable to evidence staff recruitment records or induction records. The NVQ assessor visited during the inspection, showing that staff continued to undertake NVQ 2 training. Ash Cottage F57 F07 S9498 Ash Cottage V221096 May 3rd 2005 Stage 4.doc Version 1.20 Page 14 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 Some practices do not safeguard the health and safety of the residents and staff. EVIDENCE: The inspector noted that one resident’s wheelchair footplates were missing, and that a risk assessment had not been completed. Fire doors were being wedged open. The visitor’s book was not being completed. Care staff spoken to were aware of the fire evacuation procedure. Fire test records showed that monthly checks were not taking place, the last test being March 2005. There were also gaps in 2004. Records showed that all staff had read the fire procedure/record book. Ash Cottage F57 F07 S9498 Ash Cottage V221096 May 3rd 2005 Stage 4.doc Version 1.20 Page 15 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 3 x x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 2 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x x x x x x x x x 1 Ash Cottage F57 F07 S9498 Ash Cottage V221096 May 3rd 2005 Stage 4.doc Version 1.20 Page 16 Yes Are there any outstanding requirements from the last inspection? 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, 5 & 16 Requirement A Statement of Purpose must be produced in accordance with schedule 1 of the Care Home regulations. A Service Users Guide must be produced in accordance with regulation 5 of the Care Home Regulations. A copy of both these documents must be made available to the CSCI, each service user, and any of their representatives. Not complied with following the inspection of October 2002 All service users must have fully 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. Promote and make proper provision for the health & welfare of service users as outlined in this standard. Timescale for action 31st August 2005 2. OP7 15, 17(3a) 31st August 2005 3. OP8 12(1a), 13(4b) 31st August 2005 Page 17 Ash Cottage F57 F07 S9498 Ash Cottage V221096 May 3rd 2005 Stage 4.doc Version 1.20 4. 5. 6. 7. 8. 9. 10. OP7 OP9 OP9 OP16 OP27 OP29 OP38 13(4c) 13(2) 22(2) 18(1b) Schedule2 13(4) Uneccesseray risks to the health and safety are identified and as far as is possible, eliminated. The safe keeping, safe administration, and disposal of medication must be made. The complaints procedure shall be appropriate to the needs of the service users. Ensure that all staff have received training appropriate to the work they are to perform. Ensure that all staff records are compliant with Schedule 2 of the Care Home Regulations. All parts of the home must be free from hazard. 30th June 2005 30th June 2005 31st August 2005 31st August 2005 30th June 2005 3rd May 2005 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. 4. Refer to Standard OP8 OP9 OP16 OP36 Good Practice Recommendations Nutritional assessments should be carried out and recorded on each service users care plan. All service users should have an annual medication check. A copy of the homes complaints policy/procedure should be on display in communal areas of the home. Care staff should receive formal supervision at least 6 times each year Ash Cottage F57 F07 S9498 Ash Cottage V221096 May 3rd 2005 Stage 4.doc Version 1.20 Page 18 Commission for Social Care Inspection 1st Floor, Unit 4, Petre Road, Clayton-Le-Moors Accrington Lancashire. 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 F57 F07 S9498 Ash Cottage V221096 May 3rd 2005 Stage 4.doc Version 1.20 Page 19 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!