Inspection on 10/12/07 for Ash-Croft House Care Home

This inspection was carried out on 10th December 2007.

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 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

Ash-Croft House Care Home 12/06/08

Ash-Croft House Care Home 09/05/06

Ash-Croft House Care Home 06/02/06

Ash-Croft House Care Home 25/08/05

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-Croft House Care Home 10-12 Elson Road Formby Merseyside L37 2EG Lead Inspector Mrs Claire Lee Unannounced Inspection 10th December 2007 8:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ash-Croft House Care Home DS0000064981.V356705.R01.S.doc Version 5.2 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 House Care Home DS0000064981.V356705.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ash-Croft House Care Home Address 10-12 Elson Road Formby Merseyside L37 2EG 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) 01704 874448 01704 879260 Cedars Care Group Limited Mrs Susan Russell Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (31) of places Ash-Croft House Care Home DS0000064981.V356705.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 31 service users to include:*Up to 31 service users in the category of OP (Old age not falling within any other category). 9th May 2006 Date of last inspection Brief Description of the Service: Ashcroft House is a care home registered to provide nursing care for thirty one older persons. The home is situated in Formby and is privately owned. The owner has other homes in the Southport area and these are collectively known as Cedars Care Group. The area around the home is mainly residential and there are local areas of interest such as the squirrel reserve. There are local shops near to Ashcroft House and a main train and bus route within easy walking distance. The accommodation is converted from two previous houses. There are two main lounges - a quieter lounge and a lounge that also provides dining space. There are twenty five single rooms and three double rooms, two rooms have ensuite facilities. Five of the bedrooms are situated up a small number of staged steps called a link corridor. There is no ramp or a stair lift to access them. There are four bathrooms and three shower rooms with aids to assist residents who are less independent. Residents have the use of a call bell with an alarm when they require assistance. There are gardens to the front and the rear of the premises. A large car park area is located at the front. Ashcroft House is a non-smoking building and the fees for accommodation are £515.00 week. Ash-Croft House Care Home DS0000064981.V356705.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A site visit took place as part of the inspection and this was carried out for a duration of one day for approximately nine hours. Information for this inspection was gathered in a number of different ways. This included an unannounced site visit where time was spent reading service records and looking at different areas of the building. All of the key standards were inspected and also previous requirements and recommendations from the last inspection in May 2006 were discussed. Expert by Experience is a person who, because of their shared experience of using services and/or ways of communicating visits a service with an inspector to help get a picture of what it is like to live in or use the service. An Expert by Experience took part in the inspection process for approximately four hours. ‘Case tracking’ was used as part of the site visit. This involves looking at the support a resident gets from the manager and staff including their care plans, medication, money and accommodation. This was not carried out to the detriment of other residents who also took part in the inspection process. Time was spent meeting with residents, visitors and staff to gain their opinions of the overall service. ‘Have your Say’ Survey forms were distributed to residents, relatives, staff and health care professionals as another means of gaining their views. A number of comments included in this report are taken from interviews conducted and also survey forms received. An AQAA (annual quality assurance assessment) was completed by the manager prior to the site visit. The AQAA comprises of two self-questionnaires that focus on the outcomes for people. The self-assessment provides information as to how the manager and staff are meeting the needs of the current residents and a data set that gives basic facts and figures about the service, including staff numbers and training. What the service does well: There was a warm friendly atmosphere and staff were observed to aid residents with different aspects of care in an unhurried and friendly manner. Staff were polite and courteous in their approach and interviews with them Ash-Croft House Care Home DS0000064981.V356705.R01.S.doc Version 5.2 Page 6 confirmed their knowledge of the residents’ needs and wishes. Residents and relatives were complimentary regarding the staff. Comments included, “Very nice people”, “The staff are ok”, “They are lovely” and “We get on together”. Activities were being arranged for Christmas including a party and carol singing. Residents’ social wishes and interests had been recorded in their plan of care to ensure they could continue to enjoy their hobbies where possible. Family involvement is encouraged and visitors can visit at any time. A relative said, “When people are really poorly care and support is really very good”. The manager conducts full investigations of any complaints received in accordance with the complaint policy. The manager has regular contact with the residents and surveys are sent out to gain their views of the service. What has improved since the last inspection? The manager has developed a maintenance plan however the work identified must continue. This is noted under ‘What they could do better’. The carpets identified at the time of the last inspection were cleaned however some carpets were found to be dirty at the time of this site visit. This is noted under ‘What they could do better’. The grass was cut following the last inspection to enable residents to sit out in the garden during the summer. All staff have police clearance prior to commencing employment to ensure the ongoing protection of the residents. Staff receive an induction to ensure they are familiar with their role, the organisation and care practise relevant to the older person. The manager is now registered with the Commission for Social Care Inspection. Fire alarms are being tested each week to ensure the ongoing safety of the residents, staff and visitors. Ash-Croft House Care Home DS0000064981.V356705.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Ash-Croft House Care Home DS0000064981.V356705.R01.S.doc Version 5.2 Page 8 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 House Care Home DS0000064981.V356705.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 1 and 3 (Standard 6 was not assessed as intermediate care is not provided at Ash-Croft House) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information was available to residents, relatives and visitors to help them decide whether the service was suitable for them. Pre admission assessments help ensure that the manager and staff can meet the needs of the residents. EVIDENCE: The manager stated that there had been no changes to the Service User Guide. This is a document that provides details of the service. It was recommended that a copy be placed in the main entrance and also a copy of the most recent Commission inspection report for residents and visitors to view. This was provided. A resident interviewed stated that he was settling in gradually, sufficient information had been provided on admission and that the staff had made him welcome. Ash-Croft House Care Home DS0000064981.V356705.R01.S.doc Version 5.2 Page 10 Assessments for two new residents were viewed. The assessments had been completed with regards to health, personal and social care. Basic needs had been assessed in relation to sight, hearing, dental and foot care, which are very important for the older person. The assessments are used to provide an individual plan of care for each resident outlining their daily living needs and the preferred outcomes. The assessments include some reference to risk management, which demonstrates that the resident’s personal safety has been assessed. A separate document records contact details, for example next of kin, GP and reasons for admission. It would be beneficial to incorporate this in to the pre admission assessment document to ensure no information is lost or not sought. The manager does not have a nursing qualification and therefore a registered nurse assists with obtaining assessment information to ensure the needs of the residents can be met effectively. Care management assessments from social services and transfer letters from hospital provide further information for the staff as evidenced in the files viewed. Ash-Croft House Care Home DS0000064981.V356705.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All residents have a care plan, which identifies their care needs. Medicines are administered safely to the residents and they were seen to be treated in a respectful manner. EVIDENCE: Three resident care files were viewed as part of the ‘case tracking’ process. Residents have an individual care file and care plans viewed reflected current health, social and personal needs. A day and night care plan also gives an overview of each resident’s needs and preferred routine. This helps to provide good outcomes for people. The staff arrange medical appointments for residents who are unable to leave the home and there was evidence of consultations within the files read. A health care professional reported that sometimes requests for medical tests have not been followed though and the surgery not advised. Ash-Croft House Care Home DS0000064981.V356705.R01.S.doc Version 5.2 Page 12 Accurate communication between health professionals and staff in terms of medical intervention is important to maintain residents’ health. This was brought to the manager’s attention. A number of risk assessments had been completed as part of the care planning process and these identified any potential risk that may affect a resident’s well being, in areas such as, nutrition, moving and handling, personal care and care of skin. The risk of falls was identified in two care files however it was missing in one. This was brought to the nurse’s attention and rectified. Risk management helps to maintain residents’ independence with the support of the staff. Care of wounds was well managed with evidence of current treatment and medical intervention when needed. Care plans had been reviewed monthly to reflect changing needs. Some reviews were very brief however and record ‘no changes’. It is recommended that the evaluations be in more depth, as they should be a statement set against the main aim of the plan. The resident’s agreement and/or relative’s should be sought to the plan of care to ensure they are fully aware of the care provision by the staff. This was not seen in all files viewed. The majority of surveys received from residents and relatives reported favourably regarding the care and support provided by the staff. Concerns have been raised however regarding the staff being very busy and sometimes short staffed, which may affect the care provided. This is noted under Standard 27 of this report. Residents and relatives made the following comments regarding the care: “No complaints” (resident) “Often short staffed and nobody available” (resident) “Nursing care is excellent” (relative) “As a family we are extremely pleased with the care my mother receives at Ash-Croft Nursing Home” (relative) “The girls provide good care” (resident) Medications were reviewed and found to be satisfactory. Overall there are good standards of recording and residents interviewed reported that they receive their medicines on time. There are currently no residents who wish to administer their own medicines however the manager is aware that a risk assessment should be completed should they wish to undertake this practice. The training matrix evidenced medicine awareness training for two registered nurses in 2004, none has been arranged since this date. The manager should complete a competency assessment for all staff who administer medicines to ensure they are competent to do so. A number of prescribed creams were found in bathrooms, they were removed and stored appropriately. Ash-Croft House Care Home DS0000064981.V356705.R01.S.doc Version 5.2 Page 13 Residents and a relative spoken with confirmed that the staff treat them with dignity and respect when assisting with personal care, such as bathing and toileting. Staff were observed to knock prior to entering private rooms and were courteous in their approach. The staff were very busy however they were observed to chat with the residents when helping them. Signs are put in place when a resident is registered blind as a gentle reminder for all staff to ensure their approach is appropriate. A book with details of personal care for residents was found in the small dining room. This was removed and stored in accordance with Data Protection and to respect the resident’s right to confidentiality and privacy and dignity. Ash-Croft House Care Home DS0000064981.V356705.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can choose how they wish to spend their day and are provided with some activities suited to them. Residents are served well balanced meals. EVIDENCE: The manager and staff provide activities ‘in house’ and there is also a minibus which is used in the warmer weather for outings. Residents interviewed were satisfied with the social aspects of the service however surveys received do make reference to the need to providie a better activities programme as the existing one is limited. The manager should conduct a review of existing arrangmeents to ensure the programme is stimulating. Care staff were observed to escort residents for a walk around Formby and dates had been set aside for the Christmas party, bingo, charades and carol singing. Some residents are going home to have lunch on Christmas day with their families. The activity list was on display in the main hall along side photrographs of residents from the Halloween party. Preparations were in place to decorate the home for Christmas.The Cedars Group of Homes provides a newsletter for all parties to view with information regarding the homes. Ash-Croft House Care Home DS0000064981.V356705.R01.S.doc Version 5.2 Page 15 Visitors were seen to be made welcome by the staff and they can use the hairdressing room/chiropody room, which has chairs and a tea bar. Relatives also get together for a social evening at a local venue. Relatives made the following comments: “Office staff and carers always make time to chat to residents and family members” “Staff have the ability to make the patient relax and always make time available” “I am delighted with the level of service provided by the home” Holy Communion is offered and visiting Clergy attend the home to ensure residents can continue with their chosen worship. The menu was displayed in the main hall but not in the bedrooms, which would be beneficial for those who are unable to attend the dining rooms. Residents interviewed did however state that they were asked what they would like to eat and that the cooks were always willing to prepare something else if they were not happy with the meals. The menu offered a choice of foods at breakfast, lunch and tea with hot and cold drinks and snacks at other times. A tour of the kitchen and food stores was conducted and freezers were found to be well stocked. There was also plenty of fresh fruit and vegetables. Home cooking is served every day and ‘home made’ puddings are well received. A resident said, “The food is very good indeed”. A relative expressed a wish for a greater variety of food and the manager was advised of this. Some residents choose to have their meals in the privacy of their rooms and their choice is respected. Others attend the dining rooms and the Expert by Experience was able to have lunch with them. Ash-Croft House Care Home DS0000064981.V356705.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents know their complaints will be listened to and acted upon. Abuse policies and procedures help ensure the ongoing protection of the residents. EVIDENCE: The complaint procedure was displayed in the main entrance for people to read and access if they wish. A comprehensive file for the recording of any complaints or concerns received was seen and this evidenced details of investigations carried out by the manager and any action required. There were no outstanding complaints at this time. The Commission received one complaint earlier this year and this has been resolved to the satisfaction of all parties. A resident interviewed stated that they would speak to the manager if at all worried. Surveys received from residents and relatives also confirmed this however one person reported that they were unsure who they should approach with a complaint. The manager was advised. Relatives have access to a small complaint book in the main hall, which can be used for recording informal concerns. The manager when on duty checks this record and takes the necessary action. Ash-Croft House Care Home DS0000064981.V356705.R01.S.doc Version 5.2 Page 17 The manager and staff have an abuse policy however the information provided is limited with regard to the various types of abuse and the safe handling of an allegation. A copy of Sefton and Liverpool’s Protection of Vulnerable Adult Procedure was available. This should be incorporated in abuse training so that the locally agreed safeguarding protocols are known by the staff and dealt with in accordance with the local procedure. This will help ensure the ongoing protection of all parties. A number of staff have not had any abuse training, the last training was arranged in March 2007 for two staff. Ash-Croft House Care Home DS0000064981.V356705.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19,20,21,22,23,24,25, and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A lack of general maintenance of the overall accommodation affects the safety and well being of the residents. Residents do not live in comfortable safe accommodation. EVIDENCE: A partial tour of the premises was conducted. It was evident that the general maintenance of the home is affected by the lack of sufficient maintenance hours. There are two maintenance people for the four homes of the Cedars Care Group. A maintenance person conducts a visit once a week to Ashcroft House. A number of general repairs are identified by the manager each week and hazard or repair notifications forms details apparatus or equipment that are at fault. A number of these remain outstanding and serious consideration Ash-Croft House Care Home DS0000064981.V356705.R01.S.doc Version 5.2 Page 19 should be given to employing another person to assist with this programme. The manager has identified that a number of bedrooms and bathrooms require new furniture, floors, curtains and general decoration. This was evidenced as some bedroom furniture was old and a divan bed found to be stained. During the site visit a number of bedrooms were found to have no hot water, a temperature control for a shower was not working efficiently, carpets were stained, a radiator guard was broken, a hole in a bathroom floor was seen, absence of lampshades was noted and a window was boarded up on a stair case. The rooms were identified to the manager at the time of the site visit. A skip was also full of general waste, which had not been emptied. Action must be taken to resolve these issues. Relatives, residents and staff with regard to the environment made the following comments “New furnishings and improve décor” “Better call system” “Improve décor” “The ongoing improvements to the décor and structure must continue” “Improve the water system” “Provide double glazing to bedroom windows” “Bedrooms and communal areas very clean” “Some refurbishment needed in the home” “The garden is grass, not many seats and hardly any flowers” “Nice bedroom” The maintenance programme must continue to provide a better standard of accommodation. Two bedrooms were seen that have new furnishings and fittings and these had also been pleasantly decorated. Rooms shared by residents had screens to ensure the resident’s privacy was respected. Residents are able to bring items in from home to make their rooms ‘homely’ in appearance. One resident was very pleased with a change of room. Residents have the use of shower facilities or bath with bath hoists to assist those who are less able. One bath chair and bath were badly marked. A number of bedroom doors did not shut to their rebate and as these are fire doors this has the potential to affect the resident’s safety. This is noted under Standard 38 of this report. The temperature of the hot water to the baths was tested in October 2007 however there was no record for this in November 2007 or prior the site visit in December 2007. One bath temperature had been recorded at 58 degrees and sink temperatures at 50-59 degrees. The hot water must be delivered at a safe temperature to ensure the protection of the residents and staff. Ash-Croft House Care Home DS0000064981.V356705.R01.S.doc Version 5.2 Page 20 A record is to be kept to evidence this. Not all sinks have hot water signs above them to warn residents of the hot water risk. As previously stated a number of resident bedrooms had no water from their hot water tap, which is unacceptable. Residents accommodated in the rooms on the link corridor should have a risk assessment in place for their safe transfer from these rooms if they are not fully mobile. The hall had information regarding the service to welcome visitors and the lounge/dining room had new décor and furniture. Residents and relatives said it was a pleasant room to sit in. Dining room tables were laid for lunch. A smaller dining room is also available upstairs. It was noted that staff were not always present in the lounge as they were busy assisting people in other areas. Residents should be supervised as much as possible to ensure their ongoing safety. Emergency lighting is provided throughout the home and subject to ‘in house’ safety checks and an annual service contract. Records seen were valid. Residents and relatives stated that the accommodation was kept clean and tidy. Cleaning products are kept in the sluice areas; these were found to be unlocked and this was brought to the manger’s attention. The garden at the rear of the property is spacious but in need of landscaping to improve the overall grounds for the residents. The exterior paintwork of the premises is in need of attention and this should be incorporated in the maintenance programme. There is ample car parking space to the front of the premises. Ash-Croft House Care Home DS0000064981.V356705.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28,29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff do not receive ongoing training in safe working practices. A lack of an up to date training plan can put residents at risk. EVIDENCE: The staffing rota was viewed for the week of the inspection. Two registered nurses were on duty with five care staff as the dependencies of the residents are currently high. In the afternoon, one registered nurse was on duty with four care staff. At night there is a registered nurse and two care staff. New registered nurses and two care staff have been employed however there are number of staff vacancies for full and part time care staff, a registered nurse, weekend laundry assistant and cleaner for the weekends and a Monday. Staff confirmed that there is no cleaner or laundry assistant on duty over the weekend, which causes a high volume of work for a Monday. Bank staff or agency staff are used to fill vacant shifts. Surveys received from staff and relatives refer to the home being very busy and on occasions short staffed. Comments included, “Sometimes there’s not enough staff on duty”, “Short staffed frequently” and “Often short staffed and nobody available”. Ash-Croft House Care Home DS0000064981.V356705.R01.S.doc Version 5.2 Page 22 The manager is aware of these concerns and is making every effort to fill the vacancies. Care must be provided according to each resident’s assessed need and the manager must ensure that sufficient staff are on duty to provide the necessary care and support. Residents and relatives reported that the staff were helpful and worked very hard. Comments included: “Staff are very attentive to residents and family requests” (relative) “Staff welcoming and helpful” (relative) “The staff are lovely” (resident) “Found the staff to be very caring and patient” (relative) Staff files viewed demonstrated that recruitment procedures are in place to safeguard the residents. Protection of Vulnerable Adults (POVA) checks and Criminal Records Bureau (CRB) checks are available for staff employed. Two written references are sought prior to employment. New staff receive an induction, which provides them details of their role, the organisation they work for and care practices. The Skills for Care Induction Standards should be used for all new staff as part of their development. A new member of staff confirmed that they had been shown round the home when they started and had shadowed a member of staff. The AQAA confirmed the level of NVQ (National Vocational Qualification) training obtained at Level 2 and above. 59 have achieved this and three staff are undertaking NVQ studies. A copy of the training matrix was provided and this evidenced a lack of training in safe working practices (infection control, food hygiene, first aid, fire prevention) for staff. Only moving and handling was given to staff in December 2007 and a small number of staff attended infection control training in April 2007. There are staff identified with no training at all. Further moving and handling has been arranged for January 2008. Discussion with the manager confirmed that no other training dates were planned. The training programme must be brought up to date to ensure that staff are equipped with the skills to carry out their roles and meet the residents needs safely. Staff spoken with confirmed their commitment to providing quality of care to the residents. A number of staff have worked at the home for a long time and have an understanding of residents’ needs and routines. Ash-Croft House Care Home DS0000064981.V356705.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,33,35,36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of the home fails to protect the health, safety and well being of the residents. EVIDENCE: The registered manager is Mrs Susan Russell and she was appointed by the Commission in October 2006. Mrs Russell has completed NVQ Level 4 in Management and the Registered Manager’s Award. Mrs Russell confirmed that she needs to attend training in safe working practices with her staff. A deputy manager who is a registered nurse supports Mrs Russell. An operations manager provides external support. An administrative assistant is employed to deal with invoices and other paperwork in relation to the service. Ash-Croft House Care Home DS0000064981.V356705.R01.S.doc Version 5.2 Page 24 The manager provides an open door policy and staff made reference to the fact that she was always available, supportive and willing to listen. Quality assurance systems involve asking residents for their views of the service. This is carried out in the form of surveys, which had been completed as part of an external quality award. The manager had addressed a number of issues raised from the surveys however sorting out the hot water supply remains outstanding. The operations manager also completes a written report of their monthly visit to the home. This is in line with Regulation 26 of the Care Homes Regulations. The reports seen did not record any meetings with the residents. Talking to residents forms an integral part of the report. The manager has a compliments book which visitors can make entries in if they so wish. No resident meetings are arranged due to resident frailty however residents interviewed reported that they see Mrs Russell most days. Staff meetings are held and staff receive supervision as part of their staff development. Supervision dates and minutes were seen. The manager is not responsible for any resident monies. These are dealt with by the resident and/or their families or an advocate. The AQAA confirmed policies available to staff and these are subject to review by the operations manger to ensure they are current. Staff were aware of the location of these documents and a number were seen in relation to the management of the service. Equality and diversity is assessed through the assessment and care planning process for the residents. This could be addressed in more detail to ensure all needs are identified. Documents regarding sexuality for the ageing adult were available. A number of certificates for services and equipment were viewed. The electrical certificate is out of date and the work identified by the engineer on 19th November 2007 has not been undertaken. A new certificate has therefore not been issued and this places residents, staff and visitors at risk. This must be rectified with urgency and a copy of the certificate forwarded to the Commission. The previous certificate could also not be located. A fire risk assessment of the premises was in place and fire prevention equipment subject to ‘in house’ safety checks and an annual service contract. Fire alarms had bee tested weekly. Staff have not received any fire prevention training in 2007. This again places residents, staff and visitors at risk. This must be arranged for all staff with urgency. A number of bedroom doors did not shut to their rebate. Bedroom doors (fire doors) must close to minimise the risk of fire spreading. The manager audits accidents and records kept in line with Data Protection to protect the residents and staff. Ash-Croft House Care Home DS0000064981.V356705.R01.S.doc Version 5.2 Page 25 As stated in the staffing section above, the staff training programme fails to be up to date and this can result in residents being put at risk, as staff are unable to carry out their roles safely. Ash-Croft House Care Home DS0000064981.V356705.R01.S.doc Version 5.2 Page 26 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 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 2 3 3 3 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 X X 3 X 2 Ash-Croft House Care Home DS0000064981.V356705.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? NO 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 OP19 Regulation 23(1) (a) (b) 23 (2) (b) (c) (j) Requirement The registered provider must ensure the premises are suitable for the needs of the residents. A number of bedrooms were found to have no hot water, a temperature control of a shower was not working efficiently, carpets were stained, a radiator guard was broken, a hole in a bathroom floor was seen, absence of lampshades was noted and a window was boarded up on a stair case. The rooms were identified to the manager at the time of the site visit. Action must be taken to resolve these issues to provide residents with safe comfortable accommodation. Timescale for action 10/02/08 2. OP25 13 (4) (a) (b) (c) 3. OP38 18 (1) (c) The registered provider must 10/02/08 protect the residents from hazards that would affect their safety. The registered provider must ensure the hot water supply to the baths is maintained at a safe temperature to ensure the ongoing protection of the residents. The registered person must 10/02/08 DS0000064981.V356705.R01.S.doc Version 5.2 Page 28 Ash-Croft House Care Home 23 (4) (d) 4. OP38 13 (4) (a) 5. OP38 23 (4) (a) ensure that staff receive training appropriate to their work to enable them to care for the residents safely. The training must include the mandatory training- moving and handling, fire safety, first aid, food hygiene and infection control. This training must be kept up to date to protect the residents. This requirement also refers to Standard 30 (Staff training) The registered person must 10/02/08 protect the residents from hazards that would affect their safety. The registered provider must have a current electrical certificate for the home. The registered person must take 10/02/08 adequate precautions against the risk of fire. The registered person must ensure bedrooms doors (fire doors) shut to their rebate to minimise the risk of fire spreading. 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 OP3 OP7 Good Practice Recommendations Assessment information should be recorded on one document to prevent details being lost or not sought. It is recommended that care plan evaluations be in more depth, as they should be a statement set against the main aim of the plan. The resident’s agreement and/or relative’s should be sought to the plan of care and this will ensure they are fully aware of the care provision by the staff. A competency assessment should be completed for all staff who administer medicines to ensure they undertake this practice safely. A copy of the menu should be displayed in each resident’s DS0000064981.V356705.R01.S.doc Version 5.2 Page 29 3. 4. OP9 OP15 Ash-Croft House Care Home 5. 6. 7. 8. 9. OP18 OP19 OP20 OP30 OP33 room to enable them to decide on what to eat. Abuse training should be given to staff to ensure they are aware of the concept of abuse and how to deal with an allegation. The maintenance programme should continue and include refurbishment of bedrooms, bathrooms and painting the exterior of the premises. The gardens should be landscaped for the residents to enjoy. Staff induction should be given in line with Skills for Care Induction Standards. Regulation 26 visits should include meetings with residents and these should be recorded in the monthly report. Ash-Croft House Care Home DS0000064981.V356705.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Merseyside Area Office 2nd Floor South Wing Burlington House Crosby Road North Liverpool L22 0LG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 House Care Home DS0000064981.V356705.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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