Inspection on 26/10/06 for Ash Grove House

This inspection was carried out on 26th October 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 24/02/06

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 Bronwynn Bennett Unannounced Inspection 26th October 2006 08:25 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.V309750.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 Grove House DS0000034486.V309750.R01.S.doc Version 5.2 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) 01977 723300 01977 723300 www.wakefield.gov.uk 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.V309750.R01.S.doc Version 5.2 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 Officer`s 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 24th February 2006 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. The provider informed the Commission for Social Care Inspection on 06/09/06 that the fees are £459.51. Information about the home and the services provided are available from the home in the statement of purpose and the service user guide. Ash Grove House DS0000034486.V309750.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included an unannounced visit carried out by the inspector. The visit began at 8.25am and finished at 3.45 pm. During this visit the inspector spoke to some service users, some of the staff and the home’s manager Mrs Irene McCombe and a deputy manager. The inspector read care records, audited a sample of medications, reviewed staff recruitment and training records, and carried out a tour of the home. Prior to this visit the Commission for Social Care Inspection sent twelve questionnaires to service users living at Ash Grove House. Four completed questionnaires were returned. There were twenty-three service users living at the home on the day of this visit. Surveys were sent to eleven relatives, six GPs and five social workers. The inspector received responses from seven relatives and two GPs. There were no responses received from social workers. Other information used as part of this inspection process includes notifications from the home to the Commission for Social Care Inspection about deaths, illnesses, accidents and incidents at the home, and a pre inspection questionnaire completed by the manager. The inspector would like to thank everyone for their assistance during this inspection process. What the service does well: The service users said they received sufficient information about the home prior to admission. The hygiene standards in the home are good. The staff work hard to ensure the home is clean and well maintained. In addition there is a homely and welcoming atmosphere at Ash Grove House. The home benefits from a manager who is considered approachable and supportive by service users and the staff. The service users made positive comments regarding the standard of meals served in the home. Ash Grove House DS0000034486.V309750.R01.S.doc Version 5.2 Page 6 The home has an activity programme that extends to the surrounding community and service users benefit from activities and community contact. Sixty eight per cent of the care staff have achieved NVQ (National Vocational Qualification) level 2 or above. What has improved since the last inspection? 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.V309750.R01.S.doc Version 5.2 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.V309750.R01.S.doc Version 5.2 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): 3. The service users needs are assessed prior to admission into the care home. Quality in the outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: There was evidence of a social services assessment in one of the care records looked at. The manager confirmed that the needs of all potential service users are assessed prior to admission to the care home. Surveys received by the Commission for Social Care Inspection said that service users receive enough information before moving into the home. Ash Grove House DS0000034486.V309750.R01.S.doc Version 5.2 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 the following standard(s): 7,8,9 and 10. Not all service users health, personal and social care needs are set out in the individual plan of care. There is a risk of service users’ health care needs not being fully met. Greater care is required to ensure the service users are sufficiently protected by the homes medication policy and procedure. The service users are treated with dignity and respect. Quality in the outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The service users who responded to the survey said that they receive the care and support they need and that staff are available when they need them. Good relationships were observed between the service users and the staff. The GPs who responded to the survey said that they are always able to see their patients in private. Ash Grove House DS0000034486.V309750.R01.S.doc Version 5.2 Page 10 The service users spoken to during this visit said that they felt well cared for by the staff. Some good interaction was observed between service users and the staff. The service users were seen being treated in a dignified and respectful manner. The care records for three service users were audited. The manager said that the care records were in the process of being changed. Two of the care records looked at did not have a detailed plan of care. And the information that was available was confusing and difficult to follow. One of the care records looked at for a short stay service user had a care plan. Care plans should be person centred and specify the assistance that is required by the individual service user. None of the records looked at had been reviewed or updated, and there was no evidence that the service users, or a relative had been involved in their plan of care. There were risk assessments in place for some of the identified risks to service users, but these had not been reviewed and updated. A discussion with the manager showed that one service user did not have an up to date risk assessment for dietary needs and another service user did not have an up to date movement and handling assessment. Risk assessments must be in place for all identified risks and give sufficient detail for how the risk should be managed. The process of changing the care records for service users had resulted in a lack of accessible information being made available to the carer. The inspector discussed these issues with the management team, who agreed to ensure better management of the current changes being made. Care records must be clear and up to date and reflect the level of care that is to be provided for all the service users. The home’s medication system was audited and the medication for three service users was checked. Two of the medications could be fully reconciled with the records kept. One medication could not be fully reconciled with the records kept by the home. Ash Grove House DS0000034486.V309750.R01.S.doc Version 5.2 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 the following standard(s): 12,13,14 and 15. The service users cultural, religious, social and recreational needs are being met, and they are supported to maintain contact with their family and friends. The service users are able to exercise choice and control over their lives. The home provides the service users with a varied and nutritious diet. Quality in the outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: One of the service user surveys said that there is usually activities arranged by the home that they are able to take part in. One survey commented that there are no activities available to them. The home should consider expanding its activity programme to include all service users. There is a good range of activity available in the home. Activities such as, bingo, crafts, hairdressing, trips, motivation to music are available. Religious observance is respected for service users and there are religious services carried out at the home. The home has an activity group for service users and staff, with regular meetings being held. The home has a system to record service users interests Ash Grove House DS0000034486.V309750.R01.S.doc Version 5.2 Page 12 and activity, and up to date information about activities is available in the home. The service users spoken with said that their relatives and friends are always made welcome at the home. Seven relatives who responded to the questionnaire said that the staff welcomed them into the home at any time Private facilities are provided for visitors should these be required. The service users are supported to manage their own finances if they wish and lockable facilities are provided in service users rooms. Individual rooms were seen during a tour of the home and service users had personalised their rooms. The home has a five weekly menu that changes in the summer and winter months. A choice of food is made available to service users and specialist diets are provided. The service users spoken with said that the food served at the home is good and there is a varied menu. One service user commented that “ The food is nice and there is a choice.” The staff were supporting service users appropriately and in a relaxed manner at meal times. The dining area provides a comfortable and relaxed environment for service users to enjoy their meals. Ash Grove House DS0000034486.V309750.R01.S.doc Version 5.2 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 the following standard(s): 16 and 18. Generally service users and their relatives are confident their complaints will be listened to and acted upon. Service users are protected from abuse but this protection will be further enhanced when all staff has completed adult protection training. Quality in the outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: There has been one recorded complaint during the last twelve months that is now resolved. The method for recording complaints received by the home; has been reviewed and updated. The service users spoken with said they knew who to speak to should they have any concerns or complaints. Four service users who responded to the survey said that they usually knew who to speak to should they have a concern or wish to make a complaint. Three of the relatives that responded to the survey said they were not aware of the home’s complaints procedure. The manager was reminded to clearly display the policy and procedure for complaints clearly within the home. The staff spoken with had a good understanding of adult protection issues and the necessary action that must be taken should there be any allegations of abuse. Ash Grove House DS0000034486.V309750.R01.S.doc Version 5.2 Page 14 Some staff has completed adult protection training and the manager said that this training is planned for the remaining staff. Ash Grove House DS0000034486.V309750.R01.S.doc Version 5.2 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 and 26. Service users live in a safe and well-maintained environment that is clean and comfortable. Quality in the outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The service user surveys said that the home is fresh and clean. During this visit the home was noted to be clean and well maintained. The residents said that they were satisfied with their bedrooms and had their own personal possessions around them. The laundry facilities were clean and well organised. Washing machines have disinfection and sluicing facility. Ash Grove House DS0000034486.V309750.R01.S.doc Version 5.2 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 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): 27,28,29 and 30. Staff are employed in sufficient numbers and receive induction and ongoing training. Recruitment policies are followed but the outcome must be evidenced in the records kept. These records must be made available for inspection. Quality in the outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: There are sufficient numbers of care staff employed to meet the needs of the service users. The service users who responded to the survey said there are usually staff available when they are needed and they receive the care and support they need. One relative commented that the staff are caring and cheerful and they are always informed of any problems. 68 of the care staff working in the home has achieved NVQ (National Vocational Qualification) level 2 or above in care. A further three staff are working towards this qualification. The computerised staff records were accessed so as to audit three staff files. No records were available online for the staff files requested. These issues Ash Grove House DS0000034486.V309750.R01.S.doc Version 5.2 Page 17 were raised at the last visit by the Commission for Social Care Inspection and must be addressed. Evidence was seen that staff undertake induction training and the manager said that all the staff has completed this training. Many staff has completed First aid, Food Hygiene and Manual Handling Training. The remainder of staff will undertake this training by January 2007. Ash Grove House DS0000034486.V309750.R01.S.doc Version 5.2 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 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): 31,33,35,37 and 38. The service users live in a home run by a manager who is fit to be in charge. The home is generally run in the best interests of the service users. The financial interests of the service users are safeguarded. Generally the health, safety and welfare of the service users is promoted and protected. The home’s current arrangements for record keeping do not safeguard the best interests of the service user. Quality in the outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The home has a registered manager Mrs Irene McCombe. The service users and staff spoken to said that the manager was approachable and supportive. Ash Grove House DS0000034486.V309750.R01.S.doc Version 5.2 Page 19 Some quality monitoring is carried out within the home. Service users hold regular meetings and are supported to have a say in what happens within the home. A representative of the organisation carries out regular visits to the home. In addition the organisation should ensure there is an effective quality monitoring system that seeks the views of service users, family and friends and other relevant professionals. The results of such surveys should be published and available to service users and other interested parties. The financial records for three service users were audited. These records were correct. Service users are supported to handle their own finances should they wish to do so and locked facilities are available in individual rooms for this purpose. The standard of record keeping in care records and computerised staff records is not acceptable. These records must be accurate, up to date and made available to the Commission for Social Care Inspection (CSCI). The information received by the CSCI shows that the equipment in the home is serviced regularly. The fire records were looked at. There is weekly testing of the homes fire alarm system and emergency lighting system. Staff take part in monthly fire drills. Ash Grove House DS0000034486.V309750.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 1 3 Ash Grove House DS0000034486.V309750.R01.S.doc Version 5.2 Page 21 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 Requirement Timescale for action 26/12/06 2. OP8 12.1 3. OP9 13.2 4. OP29 19.1(b) 6 (i) Written care plans must be in place for all service users. The service user plan must be available to the service user, or their representative. The plan must be kept under review and the service user notified of any such changes. Previous Timescale 31/5/06 not met. Where there is an identified risk 26/11/06 for the service user a risk assessment must provide sufficient detail about how to manage the risk and must be kept under review. The registered person shall make 26/10/06 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. The computerised system must 26/12/06 be updated to include the information for staff working in the care home. The information and documents specified in schedule 2 of the Care Homes Regulations DS0000034486.V309750.R01.S.doc Version 5.2 Ash Grove House Page 22 5. OP37 17.1.2 & 3 2001must be made available for inspection. Previous Timescale 31/5/06 not met. The registered provider must ensure accurate and up to date records are kept relating to service users, staff and any other records required for the effective and efficient running of the home. These records must be available at all times for inspection by the Commission for Social Care Inspection. 26/12/06 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. Refer to Standard OP12 OP16 OP18 OP30 OP33 Good Practice Recommendations The home’s activities should be extended to include all service users living in the home. The home’s complaints procedure should be clearly displayed. The protection of vulnerable adults training should continue until all staff has completed it. All staff should complete First Aid, Food Hygiene and Manual Handling Training by January 2007. The organisation should develop quality assurance and quality monitoring systems. Ash Grove House DS0000034486.V309750.R01.S.doc Version 5.2 Page 23 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.V309750.R01.S.doc Version 5.2 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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