Inspection on 17/06/08 for Ash Hall Care Home

This inspection was carried out on 17th June 2008.

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

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 Hall Care Home 15/06/09

Ash Hall Care Home 20/09/06

Ash Hall Care Home 15/11/05

Ash Hall Care Home 20/04/05

Ash Hall Care Home 15/09/04

Ash Hall Care Home 21/04/04

Ash Hall Care Home 18/09/03

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Ash Hall Care Home Ash Bank Road Ash Bank Stoke-on-Trent Staffordshire ST2 9DX Lead Inspector Yvonne Allen Key Unannounced Inspection 17th June 2008 09:30 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 Hall Care Home DS0000026935.V366488.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 Hall Care Home DS0000026935.V366488.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ash Hall Care Home Address Ash Bank Road Ash Bank Stoke-on-Trent Staffordshire ST2 9DX 01782 302215 01782 305088 Ashhall@ashbank.fsnet.co.uk 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) Geoff Bowker Limited Care Home 61 Category(ies) of Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (61), of places Physical disability (41), Physical disability over 65 years of age (41), Terminally ill (5) Ash Hall Care Home DS0000026935.V366488.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 41 Physical Disabilities (PD) - Minimum age 60 years on admission Date of last inspection 30th January 2008 Brief Description of the Service: The establishment is an extended two storey Grade II listed building situated in Ash Bank, within easy access to Werrington and Bucknall through good road and rail links, and a regular bus service. The establishment has an impressive vista in spacious, well-attended gardens. There is adequate parking and vehicle loading space, The establishment provides accommodation to people requiring 24 hour care, including nursing care to elderly persons requiring personal and/or nursing care, the home may also accept up to five elderly people who suffer with Dementia. A provision is approved for the care of up to five terminally ill elderly people. Thirty-Eight single (13 with en-suite) and 11 double bedrooms (4 en-suite) are located on the ground and first floors. First floor accommodation is accessed via stairs and shaft lift. Internally the home provides spacious accommodation, which is furnished to a grand and homely style. Communal accommodation on the ground floor provides three lounge facilities and three separate dining rooms. The approach to care in the home is based on integration of individuals admitted under the above categories with all the people using the full range of communal space. The range of fees charged by this home are from £ 344.00 to £630.00 and this will be included in the Service User Guide. Services available at extra cost consist of hairdressing, toiletries and newspapers. Ash Hall Care Home DS0000026935.V366488.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 2 star. This means that the people who use this service experience good quality outcomes. We, the commission, carried out this Key inspection visit over one day. All of the Key minimum standards were assessed and for each outcome a judgement has been made, based on the evidence gathered. These judgements tell us what it is like for the people who live in this home. Prior to the inspection visit the Providers had completed a self-assessment tool, which is known as the Annual Quality Assurance Assessment (AQAA). Completion of the AQAA is a legal requirement and it enables the service to under-take a self-assessment, which focuses on how well outcomes are met for people using the service. Information from this AQAA was used to plan the inspection visit and references to it have been included in this report. The ways in which we gathered evidence to make our judgements were as follows – We looked at any information we had received about the home since the last Key Inspection. This included any compliments, complaints and Safeguarding referrals we had received. We spoke with the people who live in the home We spoke with the staff who work at the home Discussions were held with the manager of the home We spoke with professionals who are involved with the home. This included a nurse specialist. We examined relevant paperwork and documentation at the home. We walked around the home and we visited all the communal areas and a selection of bedrooms. We looked at how staff interact with and care for the people who live at the home. At the end of the inspection visit we discussed our findings with the manager. There were no immediate requirements made. One requirement and five recommendations have been made as a result of this inspection. This was a good inspection with most of the Key minimum standards fully met and the remainder partially met. Ash Hall Care Home DS0000026935.V366488.R01.S.doc Version 5.2 Page 6 The outcomes for the people who live in this home are mostly good with just a few areas highlighted for improvement. What the service does well: What has improved since the last inspection? What they could do better: In order to ensure the safety of the people living in the home, CRB checks must be done for all new staff as CRB checks are non transferable. Ash Hall Care Home DS0000026935.V366488.R01.S.doc Version 5.2 Page 7 The Registered Manager application should be completed without further delay in order to ensure safe management of the home. Also more dedicated management hours should be provided in order to ensure that standards are maintained and necessary improvements implemented. Quality Assurance should be further developed to ensure that the views and suggestions of the people who live at the home are obtained. General care plans should be reviewed and developed in order to reflect that individual choices and preferences are upheld and care plans should be made more person centred. The home needs to reflect individual choices with regards to – having a lock fitted to their bedroom door and a key provided and having a choice of 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 Hall Care Home DS0000026935.V366488.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ash Hall Care Home DS0000026935.V366488.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): We assessed standards 1,3 and 4. Standard 6 is not applicable. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The assessment process adopted by the home helps to ensure that the needs of individuals are met. The Statement Of Purpose and Service User Guide need to be updated in order to ensure that the information given to individuals about the home is current and up to date. EVIDENCE: Ash Hall Care Home DS0000026935.V366488.R01.S.doc Version 5.2 Page 10 In their AQAA the Providers tell us – “we provide information and informal visits. All potential residents have their needs assessed by qualified staff. Trial visits and intermediate care can be arranged.” The home provides information about the services it offers in the form of a Service User Guide and Statement Of Purpose. These documents explain what the home offers and what is and is not included in the charges. We looked at these documents and found that the information contained in them was not current and in need of updating. Also the range of fees charged by the home could not be identified in the Service User Guide and this will need to be included. These documents should then be made available to prospective residents, representatives and funding bodies. We looked at several care plans where it was identified that individual needs had been assessed prior to admission to the home. The assessment tool is comprehensive and provides a clear assessment of needs. The manager told us that a further, more comprehensive assessment of needs is then undertaken which forms the basis of the care plan. This was seen recorded on the computerised system. Discussions with some of the people who live in the home identified that they or their representatives had been involved in the admission process. One lady said –“my daughter came to look around as I was unable to”. Discussions with manager also confirmed that she is the trained individual who goes out to assess the needs of an individual when she gats a referral from Social Services or an enquiry from an individual. She showed us the enquiry form, which she completes – then the assessment form, which she takes out with her. The manager also told us that she has to be sure that the home will be “suitable for the individual” and if not then she refuses to accept the placement. Ash Hall Care Home DS0000026935.V366488.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): We assessed standards 7,8,9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal and healthcare needs are met and care is delivered with dignity and respect. EVIDENCE: In their AQAA the Providers say –“ Our service user plan is excellent and incorporates 7-11. We have robust policies re same which are maintained and updated.” Personal healthcare needs including specialist health, nursing and dietary requirements are clearly recorded in each person centred plan or health action Ash Hall Care Home DS0000026935.V366488.R01.S.doc Version 5.2 Page 12 plan. They give a comprehensive overview of their health needs and act as an indicator of change in health requirements. Staff are very much supported by visiting healthcare professionals who come and give advice, support and training. This helps to ensure that personal and nursing care received by individuals in the home is current and best practice. Staff respect privacy and dignity and are sensitive to changing needs. People are supported and helped to be independent and can take responsibility for their personal care needs. Staff listen and take account of what is important to them. There was limited evidence of personal choice demonstrated in plans. It is therefore recommended that general care plans be reviewed and developed in order to reflect individual choices and preferences to become more person centred. Residents have access to healthcare and remedial services. Staff make sure that those who are fit and well enough are encouraged to be independent, have regular appointments and visit local health care services. The health care needs of residents unable to leave the home are managed by visits from local health care services. Residents have the aids and equipment they need and these are well maintained to support them and staff in daily living. Staff have access to training in health care matters and are encouraged and given time to attend seminars on specialist areas of work. The aims and objectives of the home reinforce the importance of treating individuals with respect and dignity. The home has an efficient medication policy supported by procedures and practice guidance, which staff understand and follow. Medication records are fully completed, contain required entries, and are signed by appropriate staff. Regular management checks are recorded to monitor compliance. The home respects and understands the rights of residents in the area of health care and medication. They work with individuals regarding any refusal to take medication. Residents are given the support they need to manage their medication. If individuals prefer or where they lack capacity, care staff can manage medication on their behalf. Thought has been given to providing safe but sensitive facilities for keeping medication. The home has a good record of compliance with the receipt, administration, safekeeping, and disposal of controlled drugs. Staff have completed and passed an appropriate medication course. An assessment has been carried out to ensure each member of staff is competent to handle, record and administer medication properly. Ash Hall Care Home DS0000026935.V366488.R01.S.doc Version 5.2 Page 13 Staff work to clear and robust practices when caring for individuals who have degenerative conditions and terminal illnesses. These “Supportive” care plans are person centred and contain clear information about the individual’s wishes, choices and decisions as their health deteriorates. Care staff work to a very high consistent standard and constantly monitor pain, distress and other symptoms to ensure individuals receive the care they need. Ash Hall Care Home DS0000026935.V366488.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): We assessed all the standards for this outcome. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a very good programme of activities and entertainment provided the home, which is geared around meeting the preferences and abilities of individuals. The menus should be reviewed in order to demonstrate that individuals are helped to exercise choice in this area. EVIDENCE: In their AQAA the Providers tell us – “We encourage choice and preferences. There is active community contact. Autonomy and choice in lifestyles and meals is promoted.” Ash Hall Care Home DS0000026935.V366488.R01.S.doc Version 5.2 Page 15 The home has a strong commitment to enabling residents to develop or maintain their skills, including social, emotional, communication, and independent living skills. Individuals are supported to identify their goals, and work to achieve them. People who live in the have the opportunity to develop and maintain important personal and family relationships. The staff practices promote individual rights and choice, but also consider the protection of individuals in supporting them to make informed choices. The home respects the human rights of people using the service with fairness, equality, dignity, respect and autonomy underpinning the care and support being provided. The staff team help with communication skills, both within the service and in the community, to enable residents to fully participate in daily living activities. Residents are involved in meaningful daytime activities of their own choice and according to their individual interests, diverse needs and capabilities. They have been fully involved in the planning of their lifestyle and quality of life. Residents can access and enjoy the opportunities available in their local community, such as using public transport, library services, the local pub, and local leisure facilities. The home is committed to the principles of inclusion and promotes and fosters good relationships with neighbours and other members of the community. The home has the added facility of a social club attached – where residents, families and friends can hold social events. We received some very positive comments in respect of the activities coordinator, which have been highlighted at the beginning of this report. The menu is varied and the meals are balanced and nutritious and cater for the varying dietary needs of individuals. However choice could not be demonstrated in respect of the main menu. This should be developed in order to ensure that the people who live in the home are offered an alternative to the main dish on a daily basis. Care staff are sensitive to the needs of those residents who find it difficult to eat and give assistance with feeding. They are aware of the importance of feeding at the pace of the resident, making them feel comfortable and unhurried. Ash Hall Care Home DS0000026935.V366488.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): We assessed standard 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals who live in this home are kept safe from harm or abuse by the systems in place and any concerns they might have are listened to and taken seriously. EVIDENCE: In their AQAA the Provider tell us – “We uphold the complaints procedure and always respond quickly to resolve any problems. All residents have rights/choices and wishes upheld. Robust staff training is given in POVA.” The home has an open culture that allows residents to express their views and concerns in a safe and understanding environment. Residents and others involved with the home say that they are happy with the service provided, feel safe and well supported by an organisation that has their protection and safety as a priority. Ash Hall Care Home DS0000026935.V366488.R01.S.doc Version 5.2 Page 17 The home has a complaints procedure that is clearly written and easy to understand. The complaints procedure is supplied to everyone living at the home and is displayed in a number of areas within the service. Residents and others involved with the home understand how to make a complaint and are clear about what will happen if a complaint is made. The home keeps a full record of complaints and this includes details of the investigation and any actions taken. Unless there are exceptional circumstances the manager always responds within the agreed timescale. We, the commission, have received two concerns about the home since the last inspection, both of which have been resoled effectively by the manager. The policies and procedures for safeguarding adults are available and give clear specific guidance to those using them. Staff working at the home know when incidents need external input and who to refer the incident to. There is a clear system for staff to report concerns about colleagues and managers. Staff that ‘blow the whistle’ on bad practice are supported by the home. The home understands the procedures for safeguarding adults and will always attend meetings or provide information to external agencies when requested. There are a low number of referrals made as a result of lack of incidents, rather than a lack of understanding about when incidents should be reported. The outcomes from any referral are managed well and issues resolved to the satisfaction of all involved. Training of staff in safeguarding is regularly arranged by the Home. Other training around dealing with physical and verbal aggression is also made available to staff as needed. All staff understand what restraint is and alternatives to its use in any form are always looked for. Equipment that may be used to restrain individuals such as bed rails, keypads, recliner chairs and wheelchair belts are only used when necessary. People are involved in the decision making process about any limitations to their choice in this area. Individual assessments are always completed which involve the individual where possible, their representatives and any other professionals such as the care manager or GP. Ash Hall Care Home DS0000026935.V366488.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): We assessed standards 19, 20, 22, 23, 24, 25 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a clean, safe, secure and homely place to live. The communal and private rooms have been adapted to meet the needs of the people who live there. EVIDENCE: In their AQAA the Providers tell us – “We have a beautiful environment which is well maintained. We have suitable adaptations and equipment Staff receive infection control training which is monitored daily.” Ash Hall Care Home DS0000026935.V366488.R01.S.doc Version 5.2 Page 19 The home provides a physical environment that is appropriate to the specific needs of the people who live there. The well-maintained environment provides specialist aids and equipment to meet their needs. The home is a very pleasant, safe place to live the bedrooms and communal rooms meet the NMS or are larger. Some bedrooms have en-suite facilities. Where appropriate the lay out and design of the home allows for small clusters of people to live together in a non-institutional environment, although this might not consistently be translated in practice. Bedrooms are only shared in limited situations and when this happens it is only by agreement with the people concerned. They are always given the choice to move into a single room when one becomes vacant. Screens are provided for privacy and the rooms reflect the chosen décor and personal belongings of both people. The service is open and honest with people when discussing the use of shared rooms and the prospect of having their own room. The choices of people who have more limited communication are just as valued as the more vocal people. Residents are encouraged to personalise their bedrooms. All the home’s fixtures and fittings meet the needs of individuals and can be changed if their needs change. The environment promotes the privacy, dignity and autonomy of residents. The shared areas provide a choice of communal space with opportunities to meet relatives and friends in private. The bathrooms and toilets are fitted with appropriate aids and adaptations to meet the needs of the people who use the service, and are in sufficient numbers and of good quality. The home is well lit, clean and tidy and smells fresh. The management has a good infection control policy. They seek advice from external specialists, such as NHS infection control staff, and encourage their own staff to work to the home’s policy to reduce the risk of infection. Since the last inspection we received a concern from the Infection Control Nurse Specialist in respect of staff knowledge and awareness of a particular infection type. Since then, the manager has welcomed the nurse specialist into the home to give staff training in this area. Since the last inspection we have received one concern in respect of an individual wishing to have a lock fitted to their bedroom door. This facility is not provided but should be available on request as some individuals may feel that being unable to lock their bedroom door compromises their privacy. Ash Hall Care Home DS0000026935.V366488.R01.S.doc Version 5.2 Page 20 This was discussed with the manager at the time of the visit and it is recommended that individuals are given the choice of having a lock fitted to their door and, following a suitable risk assessment, a key is provided for the individual to keep. The lock must be of the type recommended by the fire safety officer, which can be accessed by staff in the event of an emergency. Ash Hall Care Home DS0000026935.V366488.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): We assessed all the standards for this outcome. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live in the home are cared for by a skilled staff team who have the qualifications and experience to meet their needs. In order to ensure the safety of individuals, the Providers will need to carry out a new CRB check on all staff commencing employment at the home. EVIDENCE: In their AQAA the Providers tell us – that they meet this outcome by good “Recruitment/retention and training.” People have confidence in the staff who care for them. Rotas show that the home is staffed efficiently, with particular attention given to busy times of the day and changing needs of the people who use the service. Ash Hall Care Home DS0000026935.V366488.R01.S.doc Version 5.2 Page 22 Staff members undertake external qualifications beyond the basic requirements. The manager encourages and enables this and recognises the benefits of a skilled, trained workforce. Accurate job descriptions and specifications clearly define the roles and responsibilities of staff. People who use the service report that staff working with them are very skilled in their role and are consistently able to meet their needs. All staff receive relevant training that is focussed on delivering improved outcomes for residents. The home puts a high level of importance on training and staff report that they are supported through training to meet the individual needs of the people who live there. There is a good recruitment procedure that clearly defines the process to be followed. This procedure is followed in practice with the home recognising the importance of effective recruitment procedures in the delivery of good quality services. It was identified that not all staff have a current Criminal Records Bureau (CRB) check in place in respect of “Ash Hall” and this will need to be implemented without delay as CRB checks are non transferable. Staff recruited confirm that the home was clear about what was involved at all stages and was robust in following its procedure. There are clear contingency plans for cover for vacancies and sickness and there is little use of any agency or temporary staff. Staff meetings take place regularly. Supervision sessions are regular and staff find them helpful with a focus on improving outcomes for people using the service. Notes and action points are taken of meetings and sessions, and progress is regularly reviewing. Ash Hall Care Home DS0000026935.V366488.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): We assessed standards 31,32,33,35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well run and managed in the best interests of the people who live there. The manager must complete her application to become “Registered Manager” in order to ensure the ongoing safety and well being of the people who live in the home. EVIDENCE: Ash Hall Care Home DS0000026935.V366488.R01.S.doc Version 5.2 Page 24 In their AQAA the Providers told us – “Our service is well managed. The QA system well maintained and financial interests are safely maintained. Safety is paramount. We communicate well with all in verbal and written format we have changed the activity plans.” The manager has started the process of Registration with us. This should now be seen through without delay. The manager is qualified and has the necessary experience to run the home. She is aware of and works to the basic processes set out in the National Minimum Standards. Although at the time of the visit the manager did not have a copy of these to hand. The manager is aware of the need to keep up to date with practice and continuously develop management skills, although it may be difficult to attend regular formal training courses. Staff, residents and relatives were all very complimentary about the manager of the home and how she has brought about positive changes. They tell us that she is approachable and accessible and runs an open door policy. Staff tell us that the manager is supportive of them. The manager trains and develops staff who are generally competent and knowledgeable to care for the residents. The home focuses on the individual, takes account of equality and diversity issues, and generally works in partnership with families or close friends, as appropriate, and professionals. The manager is improving and developing systems that monitor practice and compliance with the plans, policies and procedures of the home. More work is needed in this area. There was evidence of Quality Assurance procedures including audits and meetings. However there was limited evidence that the views and suggestions of the people who live in the home are obtained. It is a recommendation that this area is developed in order to be able to show how the views of the people who live in the home have brought about changes and improvements. The manager told us that she has limited management hours and works as the second nurse on the floor as well. It is a recommendation that the dedicated “management” hours be increased in order to ensure that areas of improvement are addressed. The AQAA was completed and the information gives a reasonable picture of the current situation within the service. The evidence to support the comments made is satisfactory, although there are areas where more supporting evidence would have been useful to illustrate what the service has done in the last year, Ash Hall Care Home DS0000026935.V366488.R01.S.doc Version 5.2 Page 25 or how it is planning to improve. The AQAA gives us some limited detail about the areas where they still need to improve. The ways that they are planning to achieve this are briefly explained. The home provides a secure facility where individuals can deposit monies for safekeeping. Individuals have access to their monies and records whenever they wish. The maintenance of personal allowances is open and transparent and audit trails are easy to follow. The manager is aware of the need to promote safeguarding and has developed a health and safety policy that generally meets health and safety requirements and legislation. The maintenance and servicing of equipment is ongoing at the home and tests are recorded. Individual and environmental risk assessments have been developed to ensure the on going safety of individuals who live and work in the home. Staff receive regular training updates in Health and Safety. Ash Hall Care Home DS0000026935.V366488.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 1 x 3 3 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 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 x 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 x 3 x x 3 Ash Hall Care Home DS0000026935.V366488.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP29 Regulation 19(1)(b) Requirement In order to ensure the safety of the people living in the home, CRB checks must be done for all new staff as CRB checks are non transferable. Timescale for action 17/08/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 Refer to Standard OP7 OP15 Good Practice Recommendations It is recommended that general care plans be reviewed and developed in order to reflect individual choices and preferences and for plans to become more person centred. Individual choice could not be demonstrated in respect of the main menu. This should be developed in order to ensure that the people who live in the home are offered an alternative to the main dish. It is recommended that individuals be given the choice of having a lock fitted to their door and, following a suitable risk assessment, a key is provided for the individual to keep. It is a recommendation that the dedicated “management” hours be increased in order to ensure that areas of DS0000026935.V366488.R01.S.doc Version 5.2 Page 28 3 OP10 4 OP31 Ash Hall Care Home 5 OP33 improvement are addressed and standards maintained. It is a recommendation that Quality Assurance be further developed in order to show how the views and suggestions of the people who live in the home have been sought and listened to. Ash Hall Care Home DS0000026935.V366488.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 Hall Care Home DS0000026935.V366488.R01.S.doc Version 5.2 Page 30 - 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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