Inspection on 09/06/06 for Ash Cottage

This inspection was carried out on 9th June 2006.

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

The inspector 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 01/11/05

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 Christine Mulcahy Key Unannounced Inspection 10:00 9 and 12th June 2006 th 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.V289960.R01.S.doc Version 5.1 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.V289960.R01.S.doc Version 5.1 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.V289960.R01.S.doc Version 5.1 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. 1st November 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. New service users will now receive a copy of the homes Statement of Purpose. Fees range from £360 - £370 per week and service users are billed separately for hairdressing, newspapers, magazines and chiropody. Ash Cottage DS0000009498.V289960.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first key unannounced inspection and took place over two days on 9th and 12th June 2006 Information was obtained from care plans, staff records, management systems, observations and policies and procedures. The inspector also spoke to 9 service users, 4 staff, 1 relative the registered manager and the registered provider. The Commission for Social Care Inspection have received no complaints about the service since the last inspection. What the service does well: What has improved since the last inspection? What they could do better: There has been some progress towards meeting some of the requirements made at the previous inspection. However new service users still require a copy of the homes Service User Guide this will provide them with a brief description of the accommodation and services provided. Ash Cottage DS0000009498.V289960.R01.S.doc Version 5.1 Page 6 All service users must be provided with plan of care within one week of moving into the home. This will enable staff to ensure that all aspects of the service user health, social and personal care needs are as fare as possible met. Limited variety of leisure and recreational activities meant that service users social interests and social needs were not being met fully. The registered manager said that she would look into improving the homes activity plan. All staff has received basic training in abuse awareness. However the number of staff to receive more in depth training must increase to prevent abusive practices being unrecognised and therefore unreported. 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.V289960.R01.S.doc Version 5.1 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.V289960.R01.S.doc Version 5.1 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): OP 1, 3 & 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users now have access to recent information about the home. Service users are admitted following a full assessment. There was no care plan for the most recent admission to the home. Intermediate care is not provided EVIDENCE: The homes Statement of Purpose has recently been reviewed and work is being done on the Service User Guide. The care plan of one service user was examined and showed that the registered manager had carried out a needs assessment before the service user moved into the home. The assessment documentation was available to staff which helped familiarise them with the new service user. However there was no service user plan of care and this should have been based on the initial assessment. Ash Cottage DS0000009498.V289960.R01.S.doc Version 5.1 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): OP 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Not all service user care needs were set out in plan of care this meant that their personal and health care needs could not be met properly. Service users were protected by the homes medicine policies and procedures. Care practiced observed showed Service users privacy and dignity was respected. EVIDENCE: Overall care plans viewed included sufficient details for staff to meet the needs that had been identified. However case tracking confirmed that one service user who moved into the home in April still had no plan of care. This meant that staff could not properly meet the personal and health care needs because they did not have all of the information to do this. Staff could not be fully aware of potential risks to the service user and there were no risk assessments to identify falls. A plan of care for the service user was completed at the end of the inspection and met the requirements of this standard. Ash Cottage DS0000009498.V289960.R01.S.doc Version 5.1 Page 10 Medication was stored and recorded properly. Only trained staff in the home administered medication and medicines handling was well managed. Access to other health professionals was given and evidence of district nurse, chiropody and ophthalmic services were seen. Screens were provided in all shared bedrooms Service users confirmed that clothing worn that day was their own and clothing seen in wardrobes were named accordingly. Health and personal care arrangements ensured service user privacy. Ash Cottage DS0000009498.V289960.R01.S.doc Version 5.1 Page 11 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): OP 12, 13, 14, & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Limited leisure and recreational activities meant that service users social interests and social needs were not being fully met. Visiting from relatives and friends is flexible. Service users autonomy and choice was maximised in relation to meals and snacks ensuring variety and nutrition. EVIDENCE: There was little evidence of activities at the home. When asked the registered manager confirmed these were limited and acknowledged that she needed to meet with service users to gather information about activities they would like to do. This meant that activities would be more varied to suit service users preferences and capabilities. Notices around the home advertising the summer fair activity to fundraise for service user trips out were seen. Visitors were seen at various times in the home. One service user said, “Visitors are always welcome here.” Ash Cottage DS0000009498.V289960.R01.S.doc Version 5.1 Page 12 Another service user said, We get up when we like except for those who need help, I usually go to my bedroom around 8.30pm watch my TV and fall asleep I visit church every Sunday, my daughter takes me to St. Joseph’s just down the road. The Catholic Priest visits every 4 weeks for Holy Communion. The Methodist Vicar does services at the home for those who cant go to Church.” Menus were changed regularly and service users were reminded of the day’s menu each morning. There is always a choice if people don’t like the main meal and 2 service users when asked confirmed they could have what they like. Hot and cold drinks were available throughout the day and these were given out during when service users required. Discussion with the senio0r carer confirmed that special theraputic diets were provided when necessary and it was evident throughout the menus and meals served records. The meal served on the day of the inspection was home made meat pie or gammon with seasonal vegetables and home made rice pudding. Ash Cottage DS0000009498.V289960.R01.S.doc Version 5.1 Page 13 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Complaints made by service users and relatives were acted on and recorded. The lack of staff training in protection of vulnerable adults may result in abusive practices being unrecognised and therefore unreported. EVIDENCE: The homes complaints procedure specifies how complaints may be made and who will deal with them. There is an assurance that complaints will be responded to within a maximum of 28 days. Although there have been no complaints to the CSCI since the last inspection the registered manager said that complaints made would include details of the investigation and any action taken. One service user said, “We can complain to the manager about anything, Ive never had to but we can talk to her.” There were procedures for staff to follow if they suspected an incident of abuse had taken place. According to the manager all staff had received half a day basic abuse awareness training that covered all areas of abuse. However there was no evidence to confirm this. This meant that the staff might not be aware of abusive practices and would not know to report them. Ash Cottage DS0000009498.V289960.R01.S.doc Version 5.1 Page 14 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): OP 19 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was decorated and furnished to a good standard making the environment very comfortable and homely. The bathroom environment was not safe and service users were at risk of harm. Some bedrooms were mal-odourous and required deep cleaning to eradicate the odour. EVIDENCE: A tour of the building showed there was a malodorous smell in 4 service user bedrooms and the registered manager said that this would be addressed as part of the homes cleaning plan. An upstairs bathroom was cluttered with furniture and unused clothing. The bathroom floor was uneven and a bath panel was missing. There was limited space to manoeuvre equipment like wheelchairs and service users were at risk of slipping, trips or fall. Ash Cottage DS0000009498.V289960.R01.S.doc Version 5.1 Page 15 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): OP 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Recruitment process ensured the protection of service users. There were appropriate numbers and skill mix of staff Staff were trained and competent to do their jobs EVIDENCE: The duty rota was examined and showed which staff were on duty and at what times. Care staff were on duty in sufficient numbers. The file of one new employee was examined and showed that the registered manager had followed the homes recruitment procedures. All pre employment checks had been carried out. However there were no documents to prove the employee identity. Discussion with the employee confirmed that she had received appropriate information about the home and had completed an induction on arrival at the home. She said that she had learned new things about the home like the emergency evacuation procedure and other important procedures. A record of training and development by all staff was not available for inspection. This meant that it could not be shown that staff had the skills, knowledge and competency to do their work. The registered manager said that training for abuse awareness, moving and handling and dementia care has been booked and they are awaiting details of course times and dates. 100 of the care staff was qualified to NVQ Level 2 and above Ash Cottage DS0000009498.V289960.R01.S.doc Version 5.1 Page 16 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): OP 31, 33, 35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is run in the best interest of the service users The health, safety and welfare of service users and staff were not fully promoted and protected. EVIDENCE: The manager of the home has many years experience of working in a care setting with older people. She is qualified and competent to run the home and meet it’s stated purpose. An internal audit is done annually to determine service user satisfaction. A copy of the homes quality assurance monitoring system with outcomes was forwarded to the CSCI. The system used helps to measure success in meeting the aims of the service. Ash Cottage DS0000009498.V289960.R01.S.doc Version 5.1 Page 17 Fridge and freezer temperature records were examined and were accurate. All food stored was labelled and in date. Some dried food stored required sealing to prevent contamination. There were details of fees charged and paid. A record of service user cash held at the home was kept. A record of water temperatures was kept along with other relevant health and safety records. A record of hot water temperatures was kept and was consistent with health and safety requirements. However water temperature taken at one outlet measured 47.6oC this meant that service users were at risk of scalding. One upstairs bedroom window needed restrictors to prevent risk of harm to service users. Records confirmed the last fire drill took place on 3.5.06 Ash Cottage DS0000009498.V289960.R01.S.doc Version 5.1 Page 18 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 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 2 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 3 X 3 X X 2 Ash Cottage DS0000009498.V289960.R01.S.doc Version 5.1 Page 19 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. Standard Regulation Requirement Timescale for action 1. OP1 5 The registered manager must 31/08/06 ensure that a Service User Guide must be produced in accordance with regulation 5 of the Care Home Regulations. Please forward a copy of the document to the Commission by the date shown Not complied with following the inspection of October 2002 3. OP7 15(1) The registered manager must 31/08/06 ensure that service users 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 3 OP12 16(2)(n) Service users are given more 31/08/06 opportunities for stimulation through leisure and recreational activities in and out of the home That suits their needs preferences and capacities. Please forward a copy of the Ash Cottage DS0000009498.V289960.R01.S.doc Version 5.1 Page 20 4 OP18 5 OP19 7. OP26 8. OP29 9 OP30 9. OP38 homes activities programme to the Commission by the date shown. 13(6) The registered manager must ensure that all staff receives training in Protection of Vulnerable Adults. Please indicate when this training will take place on the homes staff training plan and forward a copy to the CSCI by the date shown. 13(4) The registered manager must ensure that all parts of the home to which service users have access are free from hazards to their safety. Please ensure that the upstairs bathroom is made safe and cleared of clutter and furniture. 16(2)(k) The registered manager must ensure that the care home is free from offensive odours and include the carpets in the identified bedrooms are cleaned thoroughly as part of the homes cleaning programme. Schedule The registered person must 2 ensure that all employee ID Regulation information and documents are 7,9,19 kept in accordance with Schedule 2 of the Care Homes Act 2000 12(1) The registered person shall ensure that proper provision is made for the health and welfare of service users by ensuring there is a staff training and development programme that meets the changing needs of service users. Please forward a copy of the plan to the Commission by the date shown 13(3) (4) The registered person must (a b c) ensure the health and safety and welfare of service users and staff is promoted by ensuring that hot water temperatures in the home do not exceed the temperatures required by the Environmental DS0000009498.V289960.R01.S.doc 31/08/06 31/08/06 31/08/06 31/08/06 31/08/06 31/08/06 Ash Cottage Version 5.1 Page 21 Health Department. Also the identified bedroom window is fitted with window restrictors to protect service users. Also food stored in the large food storage area is labelled and sealed to prevent contamination. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Ash Cottage DS0000009498.V289960.R01.S.doc Version 5.1 Page 22 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.V289960.R01.S.doc Version 5.1 Page 23 - 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. 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