Inspection on 01/03/06 for Ashcroft

This inspection was carried out on 1st March 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

Ashcroft 28/06/07

Ashcroft 09/06/06

Ashcroft 26/05/05

Ashcroft 06/01/05

Ashcroft 23/06/04

Ashcroft 10/02/04

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Ash Croft Halstead Road Eight Ash Green Colchester Essex CO6 3QH Lead Inspector Neal Wolton-Harragan Unannounced Inspection 1st March 2006 10:45 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 Croft DS0000017750.V280204.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 Croft DS0000017750.V280204.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Ash Croft Address Halstead Road Eight Ash Green Colchester Essex CO6 3QH 01206 767367 01206 573970 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 Noeline Barbara Crowley Mrs Noeline Barbara Crowley Care Home 24 Category(ies) of Dementia - over 65 years of age (24) registration, with number of places Ash Croft DS0000017750.V280204.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th May 2005 Brief Description of the Service: Ash Croft is a family run home providing personal care for 24 older people with dementia. Owned and run by Mrs Crowley, and her family, the home has been open since 1986. A detached property, located in the village of Eight Ash Green, on the outskirts of Colchester, residential accommodation is all at ground floor level. There is a large communal lounge/dining area, 18 single rooms and 3 shared rooms. The home has a large secure garden to the rear of the property and ample parking to the front. Ash Croft DS0000017750.V280204.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report follows an unannounced inspection at Ash Croft on March 1, 2006, the second inspection at the home for the year 2005/2006. Mrs Noeline Barbara Crowley, the registered proprietor/manager was at the home on the day of the inspection, as was her daughter, Andrea Crowley, the homes assistant manager. Both contributed fully to the inspection process. During this inspection, a total of 21 standards were assessed; 17 were met, three were partially met and one standard was not applicable. This inspection included discussions with service users, staff, the registered manager and assistant manager, as well as the opportunity to look at records relating to how people were cared for. During the day three members of staff, four service users and two visiting relatives were spoken with and were positive about the home and how it was being managed. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ash Croft DS0000017750.V280204.R01.S.doc Version 5.1 Page 6 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 Croft DS0000017750.V280204.R01.S.doc Version 5.1 Page 7 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): 1, 2, 3, 5 & 6 Prospective service users had the information they needed to make an informed choice about where to live. The needs of service users were assessed prior to moving into the home and prospective service users, and their relatives or friends, had opportunity to visit the home prior to choosing to live there. Recently admitted service users had written contracts/statements of terms and conditions with the home. The home did not offer intermediate care. EVIDENCE: The home had an adequate Statement of Purpose and Service User Guide and these documents were made available to all prospective service users and/or their families. Service user records sampled gave evidence that detailed needs assessments were undertaken prior to service users entering Ash Croft and that there were opportunities for prospective service users and/or their families or representatives to visit the home prior to making a decision to move into the home. The records for service users recently admitted to the home showed Ash Croft DS0000017750.V280204.R01.S.doc Version 5.1 Page 8 that Ash Croft now issued a written contract or statements of terms and conditions of residence and the assistant manager reported that the home was in the process of issuing these to people who have been at the home for a longer period of time. The registered person must ensure that contracts or terms and conditions of residence are issued to all those living at the home. Ash Croft DS0000017750.V280204.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): 7, 8 & 9 Each service user’s health, personal and social needs were set out in an individual plan of care and these needs were met. No service users were responsible for their own medication at the time of this inspection. Service users were protected by the homes policies and procedures for dealing with medicines. EVIDENCE: Examination of service user records gave evidence that health, personal and social care needs were clearly identified and regularly reviewed. Entries in daily records showed that the health care needs of service users were met and the services of health care professionals were accessed as required. Discussions with visiting service user relatives indicated that they and the service users were involved in determining care needs and there was general satisfaction with the care provided at Ash Croft. No one living at Ash Croft retained, administered or controlled their own medication at the time of this inspection. The examination of records at Ash Croft showed that appropriate policies and procedures were in place for dealing with medications and observation of the administration of medications showed that these procedures were adhered to in a caring manner. Ash Croft DS0000017750.V280204.R01.S.doc Version 5.1 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): 12, 13, 14 & 15 Service users were able to maintain contact with family, friends and the local community as they wished and there were activities offered within the home. Service users received a wholesome, appealing balanced diet. Service users were supported to exercise control over their lives where possible. EVIDENCE: The examination of service user records, discussions with service users and discussions with staff gave evidence that service users were able to maintain contact with family and friends and a number of service users received visitors on the day of inspection. Discussions with visitors indicated that service users were supported to exercise control over their own lives wherever possible, although due to the nature of the conditions of those living at Ash Croft this was not always possible. Where service users could not express choice, relatives were consulted on their behalves. As at the last inspection, discussions with the homes cook, along with the examination of records and the observation of lunchtime at the home, gave evidence that service users received a wholesome, appealing, balanced diet and the food was served in appropriately sized portions. Where service users required softer diets, each of the constituent parts of the meal were individually liquidised, and served, to maintain a variety and contrast of Ash Croft DS0000017750.V280204.R01.S.doc Version 5.1 Page 11 colours, flavours and textures. Service users were encouraged to eat their meal in the dining room although some chose to eat in the lounge or in their own rooms. Those that required assistance with eating were supported in a dignified manner to ensure adequate nutritional intake was maintained. Ash Croft DS0000017750.V280204.R01.S.doc Version 5.1 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): 16 & 18 Service users and their relatives were confident that their complaints would be listened to and acted upon. Arrangements were in place to help protect service users from abuse. EVIDENCE: Examination of records, policies and procedures showed that steps were taken to protect service users from abuse and there was a robust complaints procedure in place. Ash Croft had introduced a complaints log that detailed the nature of all complaints, actions taken and outcomes achieved. Discussions with visiting relatives of service users indicated that there was a feeling that complaints would be listened to, taken seriously and acted upon. Relatives were able to cite examples of when they had raised issues and these had been resolved without the need to make formal complaints. Ash Croft DS0000017750.V280204.R01.S.doc Version 5.1 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): 19 & 26 Service users lived in a safe, well-maintained environment and the home was clean, pleasant and hygienic. EVIDENCE: Although a full environmental inspection was not conducted during this visit, those areas seen were found to be clean, pleasant and hygienic. Some areas had been decorated since the last inspection, including a number of bedrooms as well as communal areas and corridors. All areas within the home appeared well maintained. Ash Croft DS0000017750.V280204.R01.S.doc Version 5.1 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): 27, 29 & 30. The number and skill mix of staff was adequate to meet the assessed needs of the service users and staff were trained and competent to do their jobs. The home’s recruitment policies and practices were not always adequately applied to protect service users. EVIDENCE: Examination of duty rotas and discussions with staff gave evidence that staffing numbers provided adequate support to meet the assessed needs of the service users. Staffing levels were based on calculations using the Residential Forum. There were records of regular staff training and direct observation of staff gave indication that this was translated into practice. However, the examination of staff files showed that some carers had been appointed prior to receiving adequate references and for one person there was no record of an application form being completed. The registered person must ensure that all checks and references are obtained before new carers start at Ash Croft and that selection and recruitment procedures are followed to ensure the protection of those living at the home. Ash Croft DS0000017750.V280204.R01.S.doc Version 5.1 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): 35, 36 & 37 Service users’ financial interests were safeguarded and staff were appropriately supervised. The home’s record keeping did not always safeguard the service users’ rights and best interests. EVIDENCE: Records relating to money held on behalf of service users were appropriately maintained and showed that the financial interests of those living at the home were safeguarded. In most cases relatives of service users were billed for additional items, such as toiletries for hairdressing, although small amounts of money were kept on behalf of some people to cover these expenses. Staff records, and discussions with the assistant manager and carers, showed that regular supervision was now provided for staff working at the home. However, there were deficits within the record keeping at the home relating to the employment process and the issuing of contracts to service users. The Ash Croft DS0000017750.V280204.R01.S.doc Version 5.1 Page 16 registered person must ensure that all records required under Regulation 17, Schedules 3 and 4, and Regulation 19, Schedule 2, of the Care Homes Regulations 2001, are maintained to ensure service users’ rights and best interests are not compromised. Ash Croft DS0000017750.V280204.R01.S.doc Version 5.1 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 3 2 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 3 2 X Ash Croft DS0000017750.V280204.R01.S.doc Version 5.1 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 OP2 Regulation 17(2) Sch 4 Timescale for action The home must provide each 30/06/06 service user with an individually costed contract/statement of terms and conditions of residence. Although there has been progress in this area, the previous timescale of 30/09/05 was not fully met. The registered person must 30/06/06 ensure that two written references are received before appointing a member of staff. Although there has been progress in this area, the previous timescale of 30/09/05 was not fully met. The registered person must 30/06/06 ensure that records required in respect of Regulation 17, Schedule 4 and Regulation 19, Schedule 2, of the Care Homes Regulations 2001 are maintained. This refers specifically to the issues raised in the main body of the report. The previous timescale of 30/09/05 was not met. Requirement 2. OP29 19(4)(c) 3. OP37 17(1a)&2 19(4) Ash Croft DS0000017750.V280204.R01.S.doc Version 5.1 Page 19 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 Croft DS0000017750.V280204.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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. 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