Inspection on 26/05/05 for Ashcroft

This inspection was carried out on 26th May 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Ashcroft 28/06/07

Ashcroft 09/06/06

Ashcroft 01/03/06

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 26th May 2005 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 Croft I56_IO5_s17750_Ash_Croft_v219098_ui260505_Stage4.doc Version 1.30 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 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 I56_IO5_s17750_Ash_Croft_v219098_ui260505_Stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, over the age of 65 years, who require care by reason of dementia. 2. The total number of service users accommodated in the home must not exceed 24. Date of last inspection January 6th 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 I56_IO5_s17750_Ash_Croft_v219098_ui260505_Stage4.doc Version 1.30 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 May 26th 2005, the first 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 inspection, as was the assistant manager, Ms Andrea Crowley, who assisted with the inspection. During this inspection, 27 of the 38 standards were assessed; 19 were met, seven were partially met and one standard was not applicable. During the day of inspection, four staff were spoken with as were five service users. Staff and service users spoke well of the home and of the owner. Service users appeared at ease with the care staff and were happy to talk to the Inspector. Contact between staff and service users seen during this inspection was positive. This inspection included a tour of the home, discussions with service users, staff, the home manager and the assistant manager, as well as the opportunity to look at records of how people living at Ash Croft are cared for and how the staff are recruited and trained. What the service does well: What has improved since the last inspection? Since the last inspection, training for staff had improved and staff were receiving training in relation to their work. Supervision had been introduced for some carers, although this still needed to be developed for the whole of the staff team. The home had introduced a system of quality monitoring since the last inspection. Ash Croft I56_IO5_s17750_Ash_Croft_v219098_ui260505_Stage4.doc Version 1.30 Page 6 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 I56_IO5_s17750_Ash_Croft_v219098_ui260505_Stage4.doc Version 1.30 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 Croft I56_IO5_s17750_Ash_Croft_v219098_ui260505_Stage4.doc Version 1.30 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, 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. Not every service user had a written contract/statement 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. Records for three service users were examined and gave evidence that appropriate needs assessments were undertaken prior to service users entering Ash Croft and that there were opportunities for prospective service users and/or their families/representatives to visit the home prior to making a decision to move into the home. None of the records examined gave evidence of service users being issued with written contracts or statements of terms and conditions of residence at the home. Ash Croft I56_IO5_s17750_Ash_Croft_v219098_ui260505_Stage4.doc Version 1.30 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 & 10. Each Service users’ health, personal and social needs were set out in an individual plan of care and these needs were met. Service users felt they were treated with respect and their right to privacy was upheld. 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 service users, both individually and in groups, gave evidence that people did feel they were treated with respect and their privacy was upheld. This was supported by direct observation of care staff going about their duties and their interactions with service users. Ash Croft I56_IO5_s17750_Ash_Croft_v219098_ui260505_Stage4.doc Version 1.30 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) 13 & 15. Service users were able to maintain contact with family, friends and the local community as they wished. Service users received a wholesome, appealing balanced diet. 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. A number of service users received visitors on the day of inspection. Discussions with the homes cook, along with the examination of records and the observing 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 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 I56_IO5_s17750_Ash_Croft_v219098_ui260505_Stage4.doc Version 1.30 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) 18. 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. Discussions with the assistant manager and staff indicated that issues relating to the identification and prevention of abuse were understood and the home had appropriate Protection Of Vulnerable Adults protocols in place. Ash Croft I56_IO5_s17750_Ash_Croft_v219098_ui260505_Stage4.doc Version 1.30 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, 20, 21, 22, 23, 24, 25 & 26. The environment was safe and well maintained and service users had access to safe and comfortable indoor and outdoor communal facilities, although the environment had not been assessed for risks. There were sufficient lavatories and washing facilities, although the temperature of the hot water delivered to one bath was excessive. Specialist equipment was provided as required, service users’ own rooms were appropriate for assessed needs and bedrooms were comfortable with the service users own possessions in place. Surroundings were safe and comfortable and the home was clean, pleasant and hygienic. EVIDENCE: An environmental tour provided evidence that the home was safe and well maintained although the decor in some areas could benefit from refreshing. However, there was no evidence available to confirm that environmental risk assessments had been conducted and these must be completed to ensure the on-going safety of service users. The temperature of hot water delivered to one bath at the home was measured on the day of inspection as being 49’C and presented a risk to the health and safety of service users. The home must Ash Croft I56_IO5_s17750_Ash_Croft_v219098_ui260505_Stage4.doc Version 1.30 Page 13 take immediate action to ensure the delivery of hot water at or around 43’C. There were no unpleasant odours noticed at the home on the day of inspection. Ash Croft I56_IO5_s17750_Ash_Croft_v219098_ui260505_Stage4.doc Version 1.30 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 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, 29 & 30. The numbers 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 did not adequately serve 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. Although there were records of staff receiving training, staff files examined did not provide evidence of appropriate checks, references and identity confirmation being undertaken prior to the appointment of staff. Ash Croft I56_IO5_s17750_Ash_Croft_v219098_ui260505_Stage4.doc Version 1.30 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 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) 31, 33, 36, 37 & 38 The home was run and managed by a person suitable to be in charge and the home is run in the best interests of the service users. Not all staff were appropriately supervised, service users rights and best interests were not safeguarded by the homes record-keeping and the health, safety and welfare of service users and staff were not adequately promoted and protected. EVIDENCE: The home was run and managed by Mrs Crowley who is registered with the Commission for Social Care Inspection as the proprietor/manager. Discussions with staff and service users as well as direct observations gave evidence that the home is run in the best interests of the service users. Examination of staff records showed that although a system of staff supervision had been introduced, this has yet to be implemented for all care staff. Staff and service user records did not contain the information required Ash Croft I56_IO5_s17750_Ash_Croft_v219098_ui260505_Stage4.doc Version 1.30 Page 16 under Regulation 17, Schedules 3 and 4, and Regulation 19, Schedule 2, of the Care Homes Regulations 2001, thus compromising the safeguarding of service users rights and best interests. There were no environmental risk assessments available for examination on the day of inspection and this, as well as the previously mentioned hot water temperature, gave the Inspector reason to believe that the health, safety and welfare of service users and staff was inadequately promoted and protected. Ash Croft I56_IO5_s17750_Ash_Croft_v219098_ui260505_Stage4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 2 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 2 3 3 3 3 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 Standard No 16 17 18 Score x x 3 3 x 3 x x 2 2 2 Ash Croft I56_IO5_s17750_Ash_Croft_v219098_ui260505_Stage4.doc Version 1.30 Page 18 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 OP2 Regulation 17(2) Schedule 4 13(4)(a) & (c) 19(4)(c) Requirement The home must provide each service user with an individually costed contract/statement of terms and conditions of residence. The registered person must ensure that hot water to sinks and baths is delivered at a safe temperature of around 43C The registered person must ensure that two written references are received before appointing a member of staff and that new staff are confirmed in post only following completion of a satisfactory criminal records check. This is a repeat requirement. The registered person must ensure that staff receive appropriate formal supervision on a minimum of six occasions per year and that this is recorded. This is a repeat requirement. The registered person must ensure that records required in respect of Regulation 17, Schedule 4 and Regulation 19, Schedule 2, of the Care Homes Regulations 2001 are Timescale for action 30/09/05 2. OP21 Immediate 3. OP29 30/09/05 4. OP36 18(2) 30/09/05 5. OP37 17(1)(a) &2 19(4) 30/09/05 Ash Croft I56_IO5_s17750_Ash_Croft_v219098_ui260505_Stage4.doc Version 1.30 Page 19 6. OP38 12(1) 13(4)(a) & (c) maintained. This refers specifically to the issues raised in the main body of the report. This is a repeat requirement The registered person must 30/09/05 ensure the health, safety and welfare of service users and staff are promoted and protected at all times and that all necessary environmental risk assessments are undertaken and risk management strategies implemented. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard Good Practice Recommendations Ash Croft I56_IO5_s17750_Ash_Croft_v219098_ui260505_Stage4.doc Version 1.30 Page 20 Commission for Social Care Inspection Fairfax House Causton Road Colchester 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. Extracts may not be used or reproduced without the express permission of CSCI Ash Croft I56_IO5_s17750_Ash_Croft_v219098_ui260505_Stage4.doc Version 1.30 Page 21 - 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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