Inspection on 12/06/08 for Ash-Croft House Care Home

This inspection was carried out on 12th June 2008.

CSCI found this care home to be providing an Adequate service.

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-Croft House Care Home 10/12/07

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 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Ash-Croft House Care Home 10-12 Elson Road Formby Merseyside L37 2EG Lead Inspector Mrs Claire Lee Key Unannounced Inspection 12th June 2008 09:15 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.V362751.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.V362751.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 ashcroft@cedarscaregroup.co.uk Cedars Care Group Limited 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.V362751.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). 10th December 2007 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. The weekly fee ranges from £535.00 for a room at the rear of the house without an ensuite facility to £545.00 at the front of the house with an ensuite. For residents who are funded there is a top up fee from £37.10 to £47.10. Ash-Croft House Care Home DS0000064981.V362751.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. 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 December 2007. The manager was present for the inspection. ‘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. Three residents were case tracked, however 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 and staff as another means of gaining their views. A number of comments from interviews and surveys have been included in the report. An AQAA (annual quality assurance assessment) was completed for the last key inspection in December 2007. As this is an annual document an AQAA was not completed for this inspection. For reference, 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. Ash-Croft House Care Home DS0000064981.V362751.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: A number of care plans did not reflect the care and support residents needed. The manager and staff had not recorded the relevant health issues within the plan of care and there is therefore a risk that staff are unaware of the care Ash-Croft House Care Home DS0000064981.V362751.R01.S.doc Version 5.2 Page 7 needed and that residents do not receive the care they need. More attention is needed to meet the changing needs of residents to maintain their health and provide good outcomes for them. Residents and relatives reported that there is no structured activities programme and this includes no trips out from the home since April 2007. Residents should be given the opportunity to take part in a variety of activities linked to their preferred social interests and hobbies. This will ensure their well being and enjoyment. At present only an exercise class is arranged on a Wednesday. Comments included: “It would be good to have more things going on” (resident) “Would like to be taken out in wheelchair in a morning for a change of scenery. Have not been out since April 2007. Or outings in a mini bus” (resident) “My dad would have liked to have gone out more often in the last year. Minibus last used in April 2007” (relative) “There is only exercise on a Wednesday if staff member is available. We have not been out for 12 months” (resident) New boilers have been installed to improve the hot water supply however no maintenance checks of the hot water to the baths has taken place since April 2008. This is required to ensure the hot water is delivered at safe temperature. This remains an outstanding requirement from the last key inspection. The timescale of 10/02/08 was not met. Not all baths have safely valves either to regulate the temperature to reduce the risk of accidents from hot water. The bedrooms doors are fire doors and number were found not to shut to their rebate. This is required to ensure the accommodation is compliant and in accordance with fire regulations. The maintenance staff were able to correct a number of faults however there are some doors that still require attention. This remains an outstanding requirement from the previous inspection. The timescale of 10/02/08 was not met. The maintenance of the building should continue to improve the overall accommodation. Work that needs doing to bedrooms and bathrooms is highlighted in the main report. A record of induction must be kept for all new staff to evidence their learning and show that they have the necessary skills and knowledge to undertake their job role. The induction should also be given in accordance with the Skills for Care Induction standards, which provide good information regarding care practices. Fire alarms had not been tested each week. This is required to protect people using the service. A small number of staff require fire training to ensure they are aware of the correct procedures to be followed in the event of a fire. The manager should apply to the Commission for Social Care Inspection for the position of registered manager. Ash-Croft House Care Home DS0000064981.V362751.R01.S.doc Version 5.2 Page 8 A number of good practice recommendations are made in the main report to help improve the service. These are made in relation to care practices, maintenance of the premises, staff training, information provided regarding the service and the menu. 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.V362751.R01.S.doc Version 5.2 Page 9 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.V362751.R01.S.doc Version 5.2 Page 10 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): Standards 1 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive information regarding the service. Residents are admitted following an assessment so that the staff are able to ensure that care needs can be met. EVIDENCE: The Service User Guide provides details of the service for residents and relatives. This now needs to be updated with the new manager’s details to ensure people who use the service have up to date information. Two assessments were seen for residents who have recently taken up residency at the home. The assessment had been completed by the manager prior to their admission to ensure staff were able to provide the necessary care and support. They were completed to satisfactory standard and gave a clear indication of the residents’ needs and what they could and could not do for themselves. This included areas such as mobility, eating and drinking, Ash-Croft House Care Home DS0000064981.V362751.R01.S.doc Version 5.2 Page 11 sleeping, communication, medicine and social background. The assessment detail is then used to form the plan of care. Standard 6 was not assessed, as intermediate care is not provided at Ashcroft House. Ash-Croft House Care Home DS0000064981.V362751.R01.S.doc Version 5.2 Page 12 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 adequate. This judgement has been made using available evidence including a visit to this service. The health care needs of the residents are not set out in a plan of care to ensure staff provide the necessary support and care required. EVIDENCE: Individual care plans were in place for each resident. The care plans cover areas such as, mobility, sleep, communication, independence, social background and washing and dressing. The care plans of three residents were looked at as part of the case tracking process. Two care files did not contain information regarding specific conditions that affected their general health. One was in relation to prescribed medical treatment following a visit by the resident’s GP. Staff were therefore not provided with the information on how best to provide the necessary care and support to the resident and the means to monitor their health efficiently and effectively. This is needed to provide good outcomes for the residents. Ash-Croft House Care Home DS0000064981.V362751.R01.S.doc Version 5.2 Page 13 The care files showed that staff complete risk assessments in relation to eating and drinking, mobility and frail skin. This helps to identify any problem in these areas and staff look at providing special measures to reduce risk. Not all residents had been weighed on admission as part of assessing their general health. Care plans seen had been looked at regularly to ensure the information was accurate. However as previously stated there was information missing which was relevant to the residents’ health and well being. This had not been ‘picked up’ by the staff when reviewing the care files. The staff monitor wound care and the records seen showed the current treatments being applied to promote healthy skin. Equipment, for example, special mattresses are used to provide comfort to residents who need to spend long periods of time in bed. Residents are able to see their own GP and care records showed that hospital appointments are attended and also advice is sought from other health professionals to keep the resident in good health. Private referrals are also made if requested by a resident. A resident said, “I am pleased with the treatment I am getting and feel better for it.” There was no resident and/or relative agreement to the plan of care and this should be obtained where possible to ensure the resident and/or relative is involved with the decisions on how the personal care is to be given. The registered nurses write up the daily care they give and records seen were up to date. A resident said they were pleased with the care and help they received. Medicines are administered using a ‘blister’ pack and this helps staff administer medicines in an organised safe way. A spot check of a number of medicines evidenced that they were given as prescribed. There were clear records for medicines received in the building, administered and also those that were disposed of. No residents were administering their own medicines however there is documentation in place should a resident wish to do this. An audit (quality check) of medicines administered has taken place previously and this should continue to ensure medicines are given in accordance with the medicine policy and procedure. Staff were observed helping residents in various ways, for example, assisting them with meals and with various aspects of personal care. The help was given in a polite and respectful manner. A resident said, “The staff are always polite.” Bathroom doors have locks in place to promote privacy for the residents when Ash-Croft House Care Home DS0000064981.V362751.R01.S.doc Version 5.2 Page 14 using this facility. Staff knocked on bedroom doors before entering. A resident spoken with had a preferred name and staff were using this form of address. Ash-Croft House Care Home DS0000064981.V362751.R01.S.doc Version 5.2 Page 15 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 adequate. This judgement has been made using available evidence including a visit to this service. Social activities should be promoted and developed to improve daily life and to satisfy the needs and expectations and preferences of residents. EVIDENCE: On admission staff record resident’s preferred daily routine and also their hobbies and social interests they enjoy. Time of getting up in the morning or retiring at night was recorded in a day and night care plan. Although interests are assessed a number of comments have been received through the surveys and also at interview with regard to a lack of social arrangements and input from the residents as to what they would like to do each day. Comments included: “I would love to go out for a walk”(resident) “It would be good to have more things going on” (resident) “Would like to be taken out in wheelchair in a morning for a change of scenery. Have not been out since April 2007. Or outings in a mini bus” (resident) “ Ash-Croft House Care Home DS0000064981.V362751.R01.S.doc Version 5.2 Page 16 “Little time for staff to spend with residents and take them out in a wheelchair or to sit in garden” (relative) “Not aware of any activities” (resident) “Not enough activities, often cancelled, when a guest feel fairly well they are often bored” (relative) “My dad would have liked to have gone out more often in the last year. Minibus last used in April 2007” (relative) “There is only exercise on a Wednesday if staff member is available. We have not been out for 12 months” (resident) An activities sheet was posted on the notice board however this refers to the exercise class and hairdressing service. The manager agreed that this needs to be looked at urgently as there is no regular entertainment arranged for the residents to enjoy. Staff should look to gather information regarding community based events and also arrange a variety of events within the home to help keep the residents happy, content and to promote their independence. Improvements to the social arrangements for the residents is stated as a very strong recommendation in this report. The Cedars newsletter informed the residents and relatives of the appointment of a new manager. Visitors were seen throughout the day and a relative said that the staff were always welcoming and made themselves available for a chat. A relative said, “I am always made most welcome.” There have been recent changes to the menu to improve the choice. For example, different choice of fillings for sandwiches, which residents had requested. Food supplies were plentiful and this included fresh fruit and vegetables. Three staff members are responsible for the cooking and residents were pleased with the standard of meals. The menu was not displayed in the dining room or resident rooms however residents confirmed that staff do ask them what they would like to eat. A copy of the menu should be displayed to help residents decide and to take an interest in the meals cooked. A resident said “The food is very good.” Comments from surveys received included concerns regarding lack of drinks in bedrooms for the residents. At the time of the site visit the residents seen had drinks and staff offered refreshments throughout the day. Discussion took place with staff regarding a resident who needs special help with meals and how this support is given. Staff were knowledgeable regarding the assistance they provide. Ash-Croft House Care Home DS0000064981.V362751.R01.S.doc Version 5.2 Page 17 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. Policies and procedures are in place to protect people using the service. Staff however, need to be fully away of local contact details to ensure full understanding of the processes involved so that residents are protected. EVIDENCE: The complaint procedure was displayed in the main hall and a complaint policy available in the office. One complaint has been received since the last inspection and the manager has just completed an investigation in a timely manner. A written response has been sent to the complainant. Staff interviewed said they would report a concern to the manager. Residents and relatives had no complaints however they raised concerns at the time of the site visit regarding the inadequate social programme. This is stated under Standards 12-15 of this report. The training plan evidenced dates for training in safeguarding adults. Staff also have a safeguarding policy and local guidelines to refer to. Staff interviewed were aware of the concept of abuse however were unsure of the role of the Commission for Social Care Inspection or social services or the contact details for ‘Careline’ when reporting an alleged incident. Perhaps contact details for reporting an alleged incident can be advertised more readily and further Ash-Croft House Care Home DS0000064981.V362751.R01.S.doc Version 5.2 Page 18 safeguarding training be given to staff. Everyone must be conversant with these procedures. Ash-Croft House Care Home DS0000064981.V362751.R01.S.doc Version 5.2 Page 19 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 19,20,21,22,24,25 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Inadequate maintenance of services and equipment places residents as risk as they do not live in safe accommodation. EVIDENCE: The maintenance of Ashcroft House remains an ongoing concern and requirements and recommendations have been raised at the previous inspection regarding this. Maintenance staff attend the home once a week to complete jobs however staff have commented that the day to day jobs build up and that the maintenance staff could do with more hours to complete their work. A relative commented that it takes some time to for jobs to be carried Ash-Croft House Care Home DS0000064981.V362751.R01.S.doc Version 5.2 Page 20 out. The owner should look to increasing the allocation of maintenance hours in the home to ensure jobs are completed in a more responsive manner. New boilers were installed in February and May 2008 to improve the hot water supply to the bedrooms however a number of bathrooms do not have safety valves in place to control the temperature of the hot water. Maintenance checks of the hot water to the baths has also not taken place since April 2008 and staff have not recorded temperatures prior to bathing residents. One record was dated January 2008. At the request of the inspector the maintenance people were asked to attend the home to test the fire alarms and at this time they tested the hot water to the baths and sinks. Whilst touring the home a number of bedroom doors were found not shut to their rebate (shutting correctly). The bedrooms doors are fire doors and need to function correctly in accordance with fire regulations. The maintenance staff were able to correct a number of faults however there are some doors that still need attention. The bathrooms are domestic in style and could do with new fittings. A small hole remains in the floor in the ground floor bathroom; residents can still use the bath. The manager stated that the refurbishment of the bathrooms would be included in the overall maintenance plan for the premises as they are in need of attention. Residents have the use of bath hoists and adapted showers to help them with bathing. Staff said the temperature of one shower still fluctuates which demonstrates the importance of recording water temperatures. Comments were received from a relative regarding the need to improve the toilet facilities. There are two lounges; the residents mainly use the ground floor lounge and this has dining space. The dining room tables were laid for lunch and there were plenty of comfortable armchairs. The lounge overlooks the garden and the room was pleasantly decorated and bright and airy. Bedrooms seen were satisfactory. They are old in style but comfortable. A new carpet is going to be fitted in one bedroom, as the carpet is uneven due to water spillage. Residents interviewed said they liked their rooms and they had items from home to make their feel special to the individual. Screens were available in double rooms to ensure privacy. A bedside cabinet needs replacing in one room and wallpaper in another. The bedrooms were identified with the manager at the time of the site visit and will be included in the maintenance plan. Emergency lighting checks were up to date and the laundry room was found to be clean and organised. Staff were using gloves and aprons to help maintain good hygiene standards. Ash-Croft House Care Home DS0000064981.V362751.R01.S.doc Version 5.2 Page 21 A grumbles book kept in the main hall had entries from people regarding dayto-day jobs that need attention. There was no signature to say this work had been completed. The garden at the rear of the premises is spacious but not landscaped. It is devoid of any colour. A resident and relative commented on the need for flowers to make it pleasant to sit out in. The grass had been cut by a staff member recently however this needs to be done regularly to maintain the upkeep. Ash-Croft House Care Home DS0000064981.V362751.R01.S.doc Version 5.2 Page 22 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 good. This judgement has been made using available evidence including a visit to this service. There is no record of induction for the new staff to evidence they have the skill and knowledge to undertake their work safely. EVIDENCE: Talking with the manager, staff and residents and visitors confirmed that there were sufficient number of staff on duty to provide the necessary care and support to the residents. The duty rotas seen also provided evidence of this. Two registered nurses are on duty each morning to help the care staff. During the inspection the staff were kept busy helping residents with various aspects of care and also chatting to them on an individual or group basis. The staff were caring and respectful in their approach. Comments from residents and relatives included: “Staff are very caring, nurses are very attentive” (relative) “Staff are very good” (resident) “The staff appear to know each resident well. Time is made to chat and listen to individuals” (relative) “Staff are excellent” (resident) Ash-Croft House Care Home DS0000064981.V362751.R01.S.doc Version 5.2 Page 23 The training plan provided details of NVQ (National Vocational Qualifications) for staff. Over 50 have achieved an NVQ in Level 2. The training plan also gave dates of mandatory courses for staff such as moving and handling, first aid, food hygiene and infection control. This demonstrates that staff have the knowledge and skills to undertake their work. A date is being planned for moving and handling for two new staff. The manager is new in post and has yet to address any outstanding training for staff however a rolling programme is in place. Staff interviewed said they had received regular training and support with their roles. Dementia awareness training was given to staff in August 2007 as staff care for a number residents with short-term memory loss. New staff were seen to have commenced employment following the necessary police checks and references being received. The staffing rota showed that two new staff had worked supernumerary with senior staff to help get to know the residents and what is expected of them within their job role. There was however no written evidence to support the induction and the learning they had received. A record of this must be kept to evidence their skills and knowledge. The induction should also be given in accordance with the Skills for Care Induction standards, which provide good information regarding care practices. Ash-Croft House Care Home DS0000064981.V362751.R01.S.doc Version 5.2 Page 24 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. Residents may be placed at risk by inadequate health and safety practices and procedures. EVIDENCE: A new manager was appointed for the service in May 2008. Mrs Diane Furnivall has previously held a manager’s position for a nursing home and she has many years experience in caring for the older person. Mrs Furnivall holds the necessary management qualifications and she should now apply to the Commission for Social Care Inspection for the position of registered manager. To ensure good outcomes for residents, work is needed to improve the care plans and. Care plans must be person centred and provide staff with good Ash-Croft House Care Home DS0000064981.V362751.R01.S.doc Version 5.2 Page 25 detail as to the care and support each resident needs. Where the resident and/or a relative should agree possible the plan of care. Equality and diversity is looked at through the initial assessment by respecting a resident’s right to choice, privacy, dignity and promoting independence. This can be further addressed through the care planning process as improvements are made to recording information. At the time of the inspection there were no residents of any ethnic minority. There was nobody who needed any special diet due to his or her religious or cultural beliefs. As the manager is new post there has been no quality reviews of the service. In the past residents and relatives have been given satisfaction questionnaires so they can comment on what the staff do well and what areas need improving. The manager said that these would be sent out soon and that resident and relative meetings would be held. A relative said she would very much like to attend a meeting to discuss the social arrangements in the home. A senior manager from Cedars Group conducts a monthly visit of the service and a Regulation 26 form records the findings. Regulation 26 forms seen included interviews with residents and staff to discuss the service. The manager and staff are not accountable for any monies held on behalf of the residents. Finances are dealt with by residents and/or their families and invoices for any expenditures dealt with by the accounts office. Staff interviewed said they had received supervision to enable them to discuss their individual training needs and issues relevant to the care of the residents. These sessions have not been arranged of late due to a change of management. Staff said they have a handover at each shift where the residents’ care is discussed and they are told of any changes in the residents’ health. Evidence was seen of polices and procedures relating to care, employment and health and safety to help protect the residents and to support staff in their work. A small number of staff require fire training and to ensure they are aware of the correct procedures to be followed in the event of a fire. No dates have been arranged for this as yet. An annual contract was in place for servicing the fire prevention equipment however the fire alarms had not been tested since May 2008. They must be tested each week to ensure they protect people against fire. A check of the fire alarms was requested at this time to evidence they were working on that day. Certificates for the gas, electric and moving and handling equipment were found to be in date. Ash-Croft House Care Home DS0000064981.V362751.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 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 3 3 3 X 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 2 X 3 X 3 3 X 2 Ash-Croft House Care Home DS0000064981.V362751.R01.S.doc Version 5.2 Page 27 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 OP7 Regulation 15 (1) (2) (b) Requirement Timescale for action 12/08/08 2. OP19 23 (4) (a) (c) (iv) 3. OP25 13 (4) (a) (b) (c) 4. OP30 18(1)(c) (i) The health and personal care of the resident must be recorded in a plan of care. This will ensure staff are aware of their current needs and will provide the necessary care and support. The fire doors must shut to their 12/08/08 rebate to minimise the risk of a fire spreading. This will help ensure the protection of the residents from fire. This remains an outstanding requirement from the previous key inspection. Timescale of 10/02/08 not met. The hot water supply to the 19/07/08 baths must be maintained at a safe temperature to ensure the ongoing protection of the residents. These records will help protect them from hot water hazards. This remains an outstanding requirement from the previous inspection, timescale of 10/02/08 not met. A written record of induction is 12/08/08 required for staff. This evidences DS0000064981.V362751.R01.S.doc Version 5.2 Ash-Croft House Care Home Page 28 5. OP38 23 4 (c) (ii) (iv) (v) 23 4 (d) 6. OP38 their learning to ensure they have the skills and knowledge to undertake their work safely. Fire alarms must be checked 19/07/08 each week to ensure they are working correctly. This will help protect people who use the service. Staff must receive fire training to 12/08/08 ensure they are aware of the correct procedures to be followed in the event of a fire. This will help protect people who use the service. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. 7. 8. 9. Refer to Standard OP1 OP7 OP12 OP15 OP18 OP19 OP20 OP30 OP31 Good Practice Recommendations The Service User Guide should be updated with the new manager’s details. 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. It is strongly recommended that a structured activities programme be introduced for the residents according to individual preference. A copy of the menu should be displayed in each resident’s room to enable them to decide on what to eat. Staff need to be aware of the agencies involved with safeguarding procedures and also contact details for ‘Careline’. Refurbishment of bedrooms and bathrooms should take place and maintenance staff be allocated more hours for the completion of day-to-day jobs. The gardens should be landscaped for the residents to enjoy. Staff induction should be given in line with Skills for Care Induction Standards. The manager should apply to the Commission for Social Care Inspection for the position of registered manager. DS0000064981.V362751.R01.S.doc Version 5.2 Page 29 Ash-Croft House Care Home 9. OP33 Residents and relatives should be given satisfaction questionnaires to complete to gain their views of the service. Ash-Croft House Care Home DS0000064981.V362751.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Merseyside Area Office North West Regional Contact Team Unit 1, 3rd Floor Tustin Court Port Way, Preston PR2 2YQ 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.V362751.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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