Inspection on 23/09/05 for Ash Grove House

This inspection was carried out on 23rd September 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

Ash Grove House 26/10/06

Ash Grove House 24/02/06

Ash Grove House 15/11/04

Ash Grove House 15/06/04

Ash Grove House 23/03/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

Pennine Camphill

Snydale Care Home

Muston Road (70)

Abbey The

Grayling

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

CARE HOMES FOR OLDER PEOPLE ASH GROVE HOUSE Ash Grove South Elmsall Pontefract WF9 2TF Lead Inspector Pat Pedley Unannounced 23 September 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 GROVE HOUSE J51J01_s34486_ ash grove_v254217_050905.dot Version 1.40 Page 3 SERVICE INFORMATION Name of service Ash Grove House Address Ash Grove South Elmsall Pontefract WF9 2TF 01977 723300 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) Wakefield MDC Mrs Irene McCombe Care Home - Personal Care only 27 Category(ies) of Older People - 27 registration, with number of places ASH GROVE HOUSE J51J01_s34486_ ash grove_v254217_050905.dot Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Conditions of this registration are listed on the registration certificate displayed at the service. Date of last inspection 15 November 2004 Brief Description of the Service: Ash Grove House is run by Wakefield Metropolitan District Council and is situated in South Elmsall. The home is a short walk from the bus and railway stations and close to all local amenities. Ash Grove House provides care for a range of service users with varying needs related to older age. One service user is under the age of 65. The home is able to admit service users for respite and interim care. Since the last inspection, there are fewer permanent beds as more are being used for respite care provision. The home has a well-established training programme for staff, with an emphasis on NVQ. The home has a varied activity programme for service users. The programme is administrated and implemented not just by the staff, but also by the service users. Consultation and user participation is the key to the success of the programme, and to the success of much of the work undertaken and provided at Ash Grove House. The home has a relaxed atmosphere. Staff and management are efficient, well trained, responsive and fully aware of the values and principles needed when working with older vulnerable people. The in-house facilities include a visitor’s room, bar area and a choice of several lounges. ASH GROVE HOUSE J51J01_s34486_ ash grove_v254217_050905.dot Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection of the home taking place over 5 hours. During the inspection, residents, visitors and staff spoke with the inspector, records were examined and some areas of the home were inspected. What the service does well: What has improved since the last inspection? What they could do better: It would be beneficial for care plans to be updated more regularly and also for care plans to be in place for residents receiving respite care. Staff would benefit from updated supervision and training on fire safety, adult abuse, moving and handling and first aid. A review of seating arrangements would be beneficial. ASH GROVE HOUSE J51J01_s34486_ ash grove_v254217_050905.dot Version 1.40 Page 6 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 GROVE HOUSE J51J01_s34486_ ash grove_v254217_050905.dot Version 1.40 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 GROVE HOUSE J51J01_s34486_ ash grove_v254217_050905.dot Version 1.40 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) 3, 4 and 5 Satisfactory arrangements are in place for admitting residents into the home. EVIDENCE: From sampling resident’s files it was seen that an assessment of need was carried out by the community team. A key worker is allocated to residents admitted for respite care and they visit the prospective service user to carry out a brief assessment if needs, likes and dislikes prior to their stay in the home. One relative said that they had looked around the home and liked what they had seen. Staff were welcoming and they liked the homely atmosphere. ASH GROVE HOUSE J51J01_s34486_ ash grove_v254217_050905.dot Version 1.40 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, 9 & 10 Those care plans sampled at the time of inspection were of a good standard although some need to be updated more regularly. There needs to be development of the care plans for residents who receive respite care, particularly on a regular basis so that staff both know and understand how to meet identified care needs. It would be useful to discuss with the community team the need to have a care plan and assessment identifying why the resident may need respite care in a residential home and identify to the homes staff the level of care where assistance is needed. EVIDENCE: Several care plans were examined belonging to permanent service users. These were found to be of a good standard with much pertinent information included including details of likes/dislikes, choices and preferences of residents. However, it was also seen on some that it was a number of years since the care plan had been updated. One sample was seen of a personal plan belonging to a resident receiving respite care. The notes showed that staff had made a visit to this resident’s home address to find out what care she needed and an Initial Respite Care and ASH GROVE HOUSE J51J01_s34486_ ash grove_v254217_050905.dot Version 1.40 Page 10 Risk Assessment Profile had been prepared. However, there was no full care plan e.g. Personal hygiene stated “needs assistance” but there was no indication of the assistance was needed. This was the same under each care plan heading therefore it was difficult to identify the needs presented or what staff needed to do to meet them. The care plan provided by the Community team was relevant to the care needed at home rather than the care needed in residential care therefore did little to assist the home in identifying care needs. From examining care plans it was ascertained that resident’s healthcare needs are met as records showed that there was good involvement from healthcare professionals including GPs, dentists and opticians. Residents said that they were always seen by the doctor should they feel unwell. The records for the administration of medication were found to be satisfactory. The treatment room was seen to be in good order with medication locked away appropriately. Staff were seen attending to residents in a sensitive and friendly manner. Residents said that they are always treated very well by staff who were very kind. ASH GROVE HOUSE J51J01_s34486_ ash grove_v254217_050905.dot Version 1.40 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 & 15 There are excellent opportunities for residents to take part in the decisionmaking processes of the home. There is a lively activities programme which staff are committed in supporting. Visitors are made welcome and are very satisfied with quality of life in the home. Residents enjoy a good choice of food in the home. EVIDENCE: From talking with residents and staff and examining the minutes of the social committee and social calendar it was found that there continues to be an excellent calendar of events which are enjoyed by residents. They said they really like going out on trips, having a drink in the homes bar and having visitors to join in with their prize bingo sessions from the sheltered accommodation next door. Residents said that the same visitors sometimes go out on trips with them and it was good to have friends from outside the home. Residents were looking forward to a visit from Motivation & Co in the afternoon. From looking at a sample of the minutes from the residents meeting it was seen that 15 of the 19 residents who were in the home in July attended the meeting. ASH GROVE HOUSE J51J01_s34486_ ash grove_v254217_050905.dot Version 1.40 Page 12 Visitors said that they were made welcome and always offered a drink by friendly and open staff. They said that their relatives were involved and active. They were very pleased that they had chosen this home for their relative. Residents said that the meals were very good. At teatime it was observed that there was a good choice on the menu. One resident said that she did not like what she had chosen and staff asked her if she would like an alternative. The meal was seen to be freshly made and of good quality. The cook said that she has recently reviewed the menu for the winter season with residents. ASH GROVE HOUSE J51J01_s34486_ ash grove_v254217_050905.dot Version 1.40 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18 There are good arrangements in place for handling complaints. It would be useful to check that all staff have received training on adult abuse although staff in general have a good awareness of how to keep vulnerable safe. EVIDENCE: The assistant manager said that there have been no recent complaints. The complaints procedure was seen. From examining staff records it was seen that there was no record for some staff of having received training on adult abuse. The assistant manager said that most staff have received this training and new staff received this at the point of induction and foundation training. He said that if staff have not received this training it would be arranged for them. Staff told the inspector how they would deal with an allegation of abuse to a resident. ASH GROVE HOUSE J51J01_s34486_ ash grove_v254217_050905.dot Version 1.40 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 22, 25 & 26 Staff are to be commended for maintaining the home to a very good standard. It was pleasing to hear that residents help in choosing new decorations, carpets and curtains. It would be useful to carry out a review of seating arrangements to make sure that they are appropriate for more independent service users and for staff to move and handle other less mobile residents. EVIDENCE: From walking around the home it was seen to be very well maintained and decorated. The outside of the home looked very nice and residents said that that they like “taking a turn around the garden”. Staff told the inspector that some of the settees in the main lounge and in the seating area in the corridor looked lovely but were very low therefore more independent residents had a struggle to get up from them and they themselves often found it difficult to assist less mobile residents through using good moving and handling methods. Residents were observed having some difficulty later in the afternoon. ASH GROVE HOUSE J51J01_s34486_ ash grove_v254217_050905.dot Version 1.40 Page 15 The handyman said that he takes responsibility for maintaining the gardens and minor repairs and redecoration of the home and reports major repairs to the home to the facilities manager and makes sure the work is completed. The handyman said that residents have a choice of colours and that this is discussed on an individual basis with their key workers. Corridors have been recently redecorated and new curtains fitted. One new resident said that she smokes and was pleased that there is an area where she can smoke in comfort. Several staff are currently going through the Infection Control workbook. Comments were seen in the minutes of the residents meeting that residents had commented on how well the domestic staff worked. From looking around the home this sentiment could be confirmed as the home looked clean, well presented with no offensive odours. ASH GROVE HOUSE J51J01_s34486_ ash grove_v254217_050905.dot Version 1.40 Page 16 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, 28 & 30 Staffing levels were satisfactory at the time of inspection. Staff were found to be well trained although there is some need for refresher training. It is pleasing that the home has achieved the national minimum standard for the number of staff to be trained to NVQ Level 2. EVIDENCE: At the time of inspection, staffing levels were found to be satisfactory. The assistant manager said that they will be realigning the staffing formula in the next few weeks since there are less permanent beds in the home and the number staying for respite and interim care can fluctuate. Staff said that the home is kept busy with respite service users coming to stay. The assistant manager discussed the staffing changes that were imposed prior to the last inspection, as these are not fully operational as yet. However, senior staff have been fully recruited and as some are from the current staff team the home has had to recruit new carers before putting the change in place. They are awaiting some recruitment checks to come back including criminal disclosure checks before finalising the staff changes. Training records were examined and training opportunities were discussed with the assistant manager. He said that many courses had been commissioned for staff to attend. From examining the training record there was good evidence that staff have attended a range of training including mandatory training such as First Aid, Moving and Handling and Basic Food Hygiene. Some staff have not attended such training for a while but the home is aware that they need ASH GROVE HOUSE J51J01_s34486_ ash grove_v254217_050905.dot Version 1.40 Page 17 refresher training and will ensure they catch up on this as soon as spaces are available on the internal training programme. Other training opportunities include mental health awareness, personal care, care planning, oral hygiene to mention only a few. Evidence was seen that new staff have received a full induction and foundation training. The assistant manager said that the home has achieved their target for NVQ training. ASH GROVE HOUSE J51J01_s34486_ ash grove_v254217_050905.dot Version 1.40 Page 18 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) 32, 33, 35, 36 & 38 Staff are motivated and demonstrate a very positive outlook, which is reflected on the time, spent ensuring that residents are offered choice and opportunities in all aspects of daily living. Generally, there are good arrangements for appraisal and supervision and whilst it is recognised that there has been difficulties caused through senior management changes supervision should be provided at least six times a year. Health and safety arrangements are again generally satisfactory although some staff need fire instruction. EVIDENCE: The assistant manager and other staff said that there was good morale within the staff team and that they were looking forward to getting the senior ASH GROVE HOUSE J51J01_s34486_ ash grove_v254217_050905.dot Version 1.40 Page 19 structure in place properly as this will then re-focus the home to move forward on quality issues for both residents and staff. Staff said there were good opportunities for team building and that they had good communication between team members, including staff handovers. The assistant manager showed the inspector the system for recording and administrating service users monies. This system was found to work well and there were good methods for monitoring the safekeeping of monies on behalf of service users. All staff have been fully appraised annually with six monthly reviews where relevant. The assistant manager said that it has been difficult keeping up with supervision due to the changes taking place in the management and senior staff in the home but that they were trying hard to maintain supervision on a regular basis. A sample of fire alarm and emergency lighting test records were seen and found to be satisfactory as were the records for the testing of portable appliances and water temperature checks. From examining the fire instruction records this was seen to be a bit behind. The assistant manager said that this would be dealt with to ensure training was up to date. Maintenance certificates were seen to be in place for fire safety, water treatment, gas safety, hoists and controlled waste. ASH GROVE HOUSE J51J01_s34486_ ash grove_v254217_050905.dot Version 1.40 Page 20 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 x x 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 4 COMPLAINTS AND PROTECTION 3 3 x 2 x x 3 4 STAFFING Standard No Score 27 3 28 3 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x 3 3 x 3 2 x 1 ASH GROVE HOUSE J51J01_s34486_ ash grove_v254217_050905.dot Version 1.40 Page 21 NO 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. 2. Standard OP7 OP38 Regulation Timescale for action Care plans must be in place for 30 respite service users. December 2005 All staff must receive fire training 30 twice in From walking around the DEcember home it was seen to be very well 2005 maintained and decorated. The outside of the home looked very nice and residents said that that they like “taking a turn around the garden”. From walking around the home it was seen to be very well maintained and decorated. The outside of the home looked very nice and residents said that that they like “taking a turn around the garden”. every twelve month period. Requirement 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. Refer to Standard OP7 Good Practice Recommendations It would be useful for discussion to take place with the community team about providing an assessment and care J51J01_s34486_ ash grove_v254217_050905.dot Version 1.40 Page 22 ASH GROVE HOUSE 2. 3. 4. 5. OP18 OP22 OP30 OP36 plan appropriate for the needs of the resident being admitted for residential care. It would be beneficial to check that all staff have been trained on adult abuse and for details of this training to be recorded on their personal file. A review of seating arrangements (settees and armchairs) should be carried out to ensure they are appropriate to the needs of residents and staff. Some staff may benefit from refresher training on moving and handling, first aid and other mandatory training. Staff should be supervised at least six times in every twelve month period. ASH GROVE HOUSE J51J01_s34486_ ash grove_v254217_050905.dot Version 1.40 Page 23 Commission for Social Care Inspection Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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 GROVE HOUSE J51J01_s34486_ ash grove_v254217_050905.dot Version 1.40 Page 24 - 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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