Inspection on 24/02/06 for Ash Grove House

This inspection was carried out on 24th February 2006.

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 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 Grove House 26/10/06

Ash Grove House 23/09/05

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 Patricia Pedley Unannounced Inspection 24th February 2006 11:30 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 Grove House DS0000034486.V284382.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ash Grove House DS0000034486.V284382.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Ash Grove House Address Ash Grove South Elmsall Pontefract WF9 2TF 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) 01924 723300 Wakefield MDC Mrs Irene McCombe Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Ash Grove House DS0000034486.V284382.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. One named person (learning disabilities) under 65 years of age Respite provision for 2 service users The work required to meet the recommendations of the latest Fire Officers report is completed by 31 March 2004 or within an earlier timescale if this is stipulated by the Fire Service The care staffing hours are calculated by the provider using the Residential Forum staffing model and the number of full time equivalent staff appointed is in accordance with this calculation or otherwise as agreed in writing with the NCSC The Commission is notified when the named person who has a learning disability is no longer resident at the home 23rd September 2005 5. Date of last inspection 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 wellestablished 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 visitors room, bar area and a choice of several lounges. Ash Grove House DS0000034486.V284382.R01.S.doc Version 5.1 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 communal areas of the home were inspected. The inspector would like to take this opportunity to thank residents and staff for their assistance during this inspection visit. What the service does well: What has improved since the last inspection? Action has been taken to address some of the requirements and recommendations of the previous report, particularly fire training and staff supervision. The last inspection report had many positive comments about life in the home. Ash Grove House DS0000034486.V284382.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ash Grove House DS0000034486.V284382.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Ash Grove House DS0000034486.V284382.R01.S.doc Version 5.1 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 the following standard(s): 1, 3, 4 & 5 There is good information available to potential residents to inform them of what they might expect from living in the home. Action needs to be taken to obtain assessments and care plans which identify why individual residents need to be admitted for residential care as this information will help staff prepare for that residents admission and to prepare their own care plan. The Conditions of Registration need to be amended. EVIDENCE: One resident said that he had read the Statement of Purpose and thought it was a good idea to have this information to hand as it lets newcomers now what the aims of the home are and who will be looking after them. He said that it had been updated recently. The Statement of Purpose was available in the foyer and had been updated in February 2006. Ash Grove House DS0000034486.V284382.R01.S.doc Version 5.1 Page 9 The home supports respite and interim residents as well as permanent residents. As at the last inspection, the core assessment from the funding authority for one service user was examined and it was found that the assessment and care plan related to the need for homecare and not for residential services. This needs to be discussed with senior managers as the home needs to be certain that they can meet the identified need of each resident so that they can write to them advising that they can meet the prospective residents needs. This can only be done effectively should they know and understand what these needs are in the first instance. Relatives said that they had come to look around the home on behalf of their parent before they moved in. They had no regrets about the decision and said how nice it was to have a home close to where they lived so that they could visit often. Two visitors came at least once a day. At the time of inspection there were 19 permanent residents. The assistant manager said that another six residents were receiving respite or interim care. The conditions of registration include two respite care beds. It is recommended that if this number needs increasing then the home must apply in writing to amend the conditions of registration. There are other conditions on the certificate of registration, which need to be removed as these conditions have been met. Removal of these conditions must be applied for in writing too. Ash Grove House DS0000034486.V284382.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 & 10 There are good care plans and risk assessments in place for permanent service users, which ensure their welfare and safety. It would be beneficial for care plans to be in place for those receiving respite care. Residents and their visitors are very happy with the way care is provided. EVIDENCE: Those care plans examined for permanent residents contained a lot of god information and were holistic in nature. They showed that certain goals had been achieved such as ensuring that the optician visited. Some had a good personal history. Residents or their designated representative had not signed these care plans. At the last inspection it was required that care plans were put in place for respite residents. This has yet to be achieved. The assistant manager said that the home has been very busy and change had been delayed with the staff changes. The senior carer on duty has just taken on responsibility for care plans and said that she would make sure that these were prepared. Ash Grove House DS0000034486.V284382.R01.S.doc Version 5.1 Page 11 Staff said that a couple off residents were not very well. One of the visiting relatives said that her relative was receiving excellent care and that they had no concerns that they would not get the right healthcare. She said that the home were in constant contact so that she could visit the home straight away if she was worried. She also said that all of the staff were very good at their job, her relative’s personal care was getting attended to properly. A good number of residents were spoken with. All of them were happy with the way their care was delivered. All said the staff were lovely and looked after them well. Ash Grove House DS0000034486.V284382.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 An excellent and enjoyable activity programme is in place. There is a good choice of good quality food. EVIDENCE: Residents said that there are lots of activities arranged for them. Some were looking forward to going out for lunch to a Harrogate restaurant. A visit to see a Colliery band and a fashion show has been arranged. Other activities include crafts, bingo, reminiscence, shopping and quizzes. Any arrangements are fully discussed with the residents activity committee. Evidence was seen in service user’s files of the activities they have participated in. Some residents said they prefer their own company and don’t like joining in but are pleased to see others enjoy themselves. Visitors said that they were always made to feel welcome and were offered a drink. One whose relative was ill said that staff had told her to use their staff room to make a drink and asked her if she needed a meal. There is also a visitor’s room available. Everyone said that the food was very good. The cook was seen asking residents what they would like for their meal the following day. The weekly menu was seen displayed in the foyer. The lunchtime meal was seen to be Ash Grove House DS0000034486.V284382.R01.S.doc Version 5.1 Page 13 plentiful and well presented. There was a good choice on offer, including home baked buns. The cook said that there were fresh seasonal vegetables and fruit on offer and that the winter menu would be changing soon and the new summer menu introduced. Residents said they were asked about menus at resident’s meetings. Ash Grove House DS0000034486.V284382.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Complaints are dealt with in a satisfactory manner. Staff would benefit from refresher training on adult abuse. EVIDENCE: The assistant manager said that only one complaint had been received and this had been dealt with properly. The complaints policy is displayed. At the last inspection a recommendation was made for management to check the status of the adult abuse training and to record it on file if staff have attended such training. According to current records no change has been made although it appears that most staff have received training in the past. The recommendation from the last report still applies. Ash Grove House DS0000034486.V284382.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 25 & 26 The home has a very positive and happy atmosphere. The home is comfortable, clean and well maintained and decorated. EVIDENCE: Only communal areas were visited. These were found to be comfortable, clean and well decorated. The handyperson said that the home had been redecorated over the last couple of years and he keeps up with minor repairs and decorating. Residents said that their bedrooms were very comfortable and had lots of their own personal possessions around them. One relative said that her mother had only recently moved in permanently and she had begun to bring a few bits from home for her room. Another relative said that he was pleased with the comfort and cleanliness of the home. A few residents were sitting in the bar area as they are able to smoke there. This room does have a ventilating fan but was still rather smoky. Staff have to go through this room to visit staff lockers and toilet facilities. Ash Grove House DS0000034486.V284382.R01.S.doc Version 5.1 Page 16 One resident said that he likes watching birds at the bird table outside his bedroom window. He said that a relative had put out some bird food that morning. He also enjoys the view from his bedroom. Ash Grove House DS0000034486.V284382.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Staff are competent and committed to their role in the home. Although recruitment policies are followed the outcome needs to be evidenced fully by the records for new staff being made available for inspection. A number of staff need updated mandatory training. EVIDENCE: A new senior member of staff said that she was getting used to her new role and was enjoying the challenge. Staff demonstrated a good understanding of their role and responsibilities. Staff said that they were short staffed. However, there were three staff, a senior carer and an assistant manager on duty for 22 residents, which is sufficient to meet the needs of service users. The computerised staff records were accessed so that the records of new staff could be examined. However, it was found that there were no records online for the two most recent members of staff and it would appear that the system had not been updated with their records. The records for a longer serving member of staff were available and were satisfactory. One of the home’s volunteers discussed her role. She said that she did not get involved in personal care but helped serve meals, talk with residents and help with activities and outings. She said that she loved helping in the home and Ash Grove House DS0000034486.V284382.R01.S.doc Version 5.1 Page 18 found everybody to be helpful. Residents said that she was “a good worker when she doesn’t get paid anything for it”. The assistant manager said that one of the other assistant managers has recently taken over responsibility for organising staff training. Training records were examined and some were found to be in need of updating as the assistant manager said that some dates needed to be added. This made it difficult to carry out a complete overview but from the records seen there was evidence to suggest that several staff needed moving and handling and first aid refresher training. Some staff have attended training relevant to the care of older people and NVQ training is ongoing. Ash Grove House DS0000034486.V284382.R01.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 36 & 38 The home is led by an experienced and competent managerial team. Service users are at the focus of the service and they are consulted regularly about life in the home. EVIDENCE: The manager was not available for this inspection. The assistant manager assisted. When examining a resident’s file it was seen that there had been admissions to hospital but the Commission had not been informed. The requirements under Regulation 37 were explained to the assistant manager who said this would be carried out in the future. A resident’s meeting had just finished before arriving for inspection. The senior carer had held the meeting and said that it had gone well. Quite a number of Ash Grove House DS0000034486.V284382.R01.S.doc Version 5.1 Page 20 residents had chosen to attend as they thought it was a good chance to have their say about everything. At the last inspection a recommendation had been made to have more regular supervision. Records should that improvements had been made most staff having been supervised recently. Much of the homes record keeping is maintained to a very good standard. As mentioned previously computerised staff records need to be updated and care plans must be prepared for respite service users. The maintenance file showed that equipment is serviced regularly and certificates were up to date. Fire alarm, emergency lighting and water temperature checks are carried out properly and a record made of the outcome. Records showed that most staff have taken part in a fire drill. Ash Grove House DS0000034486.V284382.R01.S.doc Version 5.1 Page 21 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 1 1 3 X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 X X X X 3 3 STAFFING Standard No Score 27 3 28 3 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 3 3 X X 3 1 3 Ash Grove House DS0000034486.V284382.R01.S.doc Version 5.1 Page 22 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 OP37 Regulation 15(1) Requirement Care plans must be in place for respite service users. The above requirement is outstanding from the last report. The assessment and care plans received from the funding authority must identify the need for a residential care service. The potential resident must be informed in writing that the care home is able to meet their identified care needs. The Commission must be informed in writing of any incident that affects the wellbeing of service users. Staff must receive refresher training on moving and handling, first aid and any other relevant health and safety course if this proves to be out of date. The records for new staff must be updated on the computerised record system. Schd 2 Timescale for action 31/05/06 2 OP3 14(1)(ad) 30/04/06 3 OP31 37(1)(e) 24/02/06 4 OP30 13(4)(5) 31/05/06 5 OP29 OP37 17(2) Schd 4(5) 19(1) 31/05/06 Ash Grove House DS0000034486.V284382.R01.S.doc Version 5.1 Page 23 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 plan appropriate for the needs of the resident being admitted for residential care. Residents or their designated representatives should sign and agree their care plan. 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. 2 OP18 Ash Grove House DS0000034486.V284382.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Brighouse Area Office 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 DS0000034486.V284382.R01.S.doc Version 5.1 Page 25 - 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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