Inspection on 20/04/05 for Ash Hall Care Home

This inspection was carried out on 20th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Ash Hall Care Home 15/06/09

Ash Hall Care Home 17/06/08

Ash Hall Care Home 20/09/06

Ash Hall Care Home 15/11/05

Ash Hall Care Home 15/09/04

Ash Hall Care Home 21/04/04

Ash Hall Care Home 18/09/03

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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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Ash Hall Care Home Ash Bank Home Ash Bank Stoke on Trent Staffordshire Lead Inspector Yvonne Allen Unannounced 20 April 2005 09.00 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ash Hall Care Home E09 E51 S26935 Ash Hall V223599 200405 Stage 4.doc Version 1.30 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 01785 305088 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Geoff Bowker Limited Mrs Wilhemina Thomas Care Home 61 Category(ies) of 5 DE(E) registration, with number 61 OP of places 41 PD 41 PD(E) 5 TI Ash Hall Care Home E09 E51 S26935 Ash Hall V223599 200405 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 41 Physical Disabilities (PD) Minimum age 60 Years on admission Date of last inspection 15 September 2005 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 service users requiring 24 hour care, including nursing care to elderly persons requiring personal/nursing care, the home may also accept up to 5 service users who suffer with Dementia. A provision is approved for the care of up to 5 terminally ill service users.Thirty-Eight single (13 with en-suite) and eleven double bedrooms (one 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 in a homely style. Communal accommodation on the ground floor provides three lounge facilities and a separate dining room adjacent to the kitchen. An additional lounge facility is located on the first floor of the establishment.The approach to care in the home is based on integration of service users admitted under the above categories with all service users using the full range of communal space Ash Hall Care Home E09 E51 S26935 Ash Hall V223599 200405 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over four hours by two inspectors. A tour of the home was conducted and discussions were held with service users, visitors and staff. Discussions were also held with the registered manager of the home. Relevant records and documentation was examined. A great deal of the inspection time was spent talking to service users and staff at the home. There were also some visitors present with whom the inspectors spoke. What the service does well: What has improved since the last inspection? Staff training has improved at the home. The home employs the services of a training co-ordinator who works closely with the manager. Individual training records have improved as well as the development of induction training for new starters. The number of care staff trained to NVQ level 2 or above is now at around 80 per cent. It was pleasing to see that risk assessments had been developed for the use of bedrails and that these are checked daily and records maintained. Regular auditing of services had taken place with records maintained. Ash Hall Care Home E09 E51 S26935 Ash Hall V223599 200405 Stage 4.doc Version 1.30 Page 6 The development and workability of the “Resmin” IT system had improved. Records were easily accessible and had been well maintained. The availability of activities had 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 Hall Care Home E09 E51 S26935 Ash Hall V223599 200405 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Ash Hall Care Home E09 E51 S26935 Ash Hall V223599 200405 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3,and 4. Service users and their representatives felt assured that the home would be able to meet their assessed needs. EVIDENCE: Each service user has an assessment of his or her needs carried out before admission to the home. The registered or deputy manager usually undertakes this assessment. There was written evidence of this contained within care plans. This assessment usually involves the next of kin who provides information, which is then transferred to the plan of care. In most instances there has been an assessment by another professional such as a Social worker. The service users are informed in writing that their assessed needs will be met by the home. The service users and visitors spoken to at the time of the inspection confirmed this. There was evidence of specialist advice and treatment contained within care plans. Ash Hall Care Home E09 E51 S26935 Ash Hall V223599 200405 Stage 4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8 and 10. The Health and Personal Care needs of service users in the home were being assessed and monitored. Service users were satisfied that their needs were being met and their dignity respected. EVIDENCE: There was evidence that the health and personal care needs for each service user was documented based on their individual needs. As part of ‘case tracking’ service users spoken to felt content in the home and well cared for. GP visits were documented, as were the Chiropodist, Dentist and the Optician. One resident had not received an annual review by the GP over the last twelve months. Annual reviews must be undertaken for all residents and documented. Ash Hall Care Home E09 E51 S26935 Ash Hall V223599 200405 Stage 4.doc Version 1.30 Page 10 Service users, relatives and representatives confirmed to the inspector that they were encouraged to be involved with the care plans, however their preference must be documented in the care records. Service users when asked stated they were treated with dignity and their privacy respected. Those service users stated that the carers were gentle and kind to them, and they did not feel rushed. Ash Hall Care Home E09 E51 S26935 Ash Hall V223599 200405 Stage 4.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 14 and 15. The routines of daily life, activities, meals and mealtimes were made flexible and varied to suit service users’ expectations, preferences and capacities. EVIDENCE: There was evidence from talking to service users that most activities were planned around individual choice and preferences. Group activities were organised with seasonal themes throughout the year. Some service users spoken to were content with the amount of activities but commented that they would not like to be doing things everyday. The inspector evidenced the meal served at lunchtime, which was well presented and enjoyed by the residents. The inspector highlighted that the menu was not displayed and some of the residents spoken to were not aware what was on offer. There was a choice on offer daily and this was varied and well balanced. The staff had introduced a ‘two sitting’ arrangement for meal times to allow able service users to have their meal first and those service users who required more time and assistance to eat their meal, 15 to 20 minutes later. Ash Hall Care Home E09 E51 S26935 Ash Hall V223599 200405 Stage 4.doc Version 1.30 Page 12 Relatives spoken to were impressed by the staff at the home, the staff had befriended the service users as soon as they were admitted and made them feel at home. Service users commented that their individual preferences were familiar to the staff and considered at all times. Ash Hall Care Home E09 E51 S26935 Ash Hall V223599 200405 Stage 4.doc Version 1.30 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18. Systems were in place for the protection of service users and service users felt safe in the home. It was identified that the complaints procedure was in need of amending. The CSCI is concerned about the number of complaint issues, which have been upheld in the last twelve months at the home. EVIDENCE: The Commission For Social Care Inspection had received three complaints since the last inspection. A complaint received recently by the CSCI had been investigated and mostly upheld. The issues were concerning lack of documentation in care plans, lack of communication with family and issues relating to the delivery of adequate fluids to an individual service user. The manager had taken the comments from the all three complaints seriously and they were being acted upon. Service users and relatives spoken to had no cause to complain at present but commented that they would speak to the home manager or one of the nurses. They were aware that a complaints procedure was in the home. Ash Hall Care Home E09 E51 S26935 Ash Hall V223599 200405 Stage 4.doc Version 1.30 Page 14 It was identified that the complaints procedure needed amending and reviewing and discussions with the manager identified that she would be addressing this in the near future. Service users spoken to told the inspector that they felt safe and secure in the home. Staff had received some insight into abuse/vulnerable adults training. This was to be further developed. The staff interviewed stated that they were aware of the whistle blowing policy and explained the procedure for the reporting of abuse. Staff were carefully selected to work in the home and had undergone CRB and POVA checks before being offered employment. Ash Hall Care Home E09 E51 S26935 Ash Hall V223599 200405 Stage 4.doc Version 1.30 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 standard(s) 19, 20, 21, 22,23,24, 25 and 26. The location and layout of the home is suitable for its stated purpose. Service users live in a comfortable environment, which has been adapted to suit their lifestyle, and individual needs. EVIDENCE: A tour of the home was conducted including inspection of all the communal areas and a selection of bedrooms. The home was found to be clean and well presented throughout. Bedrooms had been adapted to suit the needs of the service users and there was evidence of personal effects in bedrooms. Various aids and adaptations were in place including chair lifts in baths, mobile hoists and other equipment used for moving and handling of service users. There was a nurse call bell in operation, which was heard to be working at the time of the inspection. Ash Hall Care Home E09 E51 S26935 Ash Hall V223599 200405 Stage 4.doc Version 1.30 Page 16 Bedrails were used following a risk assessment. Bumpers were used with these. There was evidence of daily bedrails safety checks in operation. There was no evidence of a formal programme of redecoration and refurbishment. It is recommended that this be commenced and records kept. Ash Hall Care Home E09 E51 S26935 Ash Hall V223599 200405 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29 and 30. Staff are present in sufficient numbers and have the necessary skills, competencies and experience to care for the service users. Staff are carefully recruited to work at the home and service users are protected and supported. EVIDENCE: At the time of the inspection there was a total of 45 service users living in the home, 19 of who were receiving nursing care. The manager was supernumery and there was a Registered Nurse on duty throughout the whole 24-hour shift. During the morning shift from 8am-2pm there were 7 care staff on duty and from 2pm-4pm there were 6 care staff. From 4pm-9pm there were 5/6 care staff on duty. On night duty from 8pm-8am there were 4 care staff working alongside the nurse. Over mealtimes there were dining room assistants on duty. There was one staffing vacancy at the time of the inspection; this was for one full time care assistant for night duty. The skill mix of care staff was good with the home being well over 50 per cent NVQ trained. There were 2 domestic staff on duty and 1 laundry assistant. Ash Hall Care Home E09 E51 S26935 Ash Hall V223599 200405 Stage 4.doc Version 1.30 Page 18 The kitchen assistant was on duty from 7.30am until 2pm. The cook came on at 8am until 4pm. An evening kitchen assistant worked from 4.15pm until 6.30pm daily. There was a part time activities co-ordinator employed. There was full time administration support. The proprietor was responsible for the maintenance of the home. The home also contracts a training co-coordinator who was present at the time of the inspection. The senior care assistant interviewed stated that she acts as mentor for new starters and overseas some of the induction training. She explained what she discusses with the new starters during induction training. She is also a moving and handling trainer along with another senior care assistant. She has completed NVQ level 3 training and is planning to start NVQ level 4 in management. Examination of her personal training record identified that she had undergone a significant amount of training over the last twelve months. The new starter interviewed confirmed that she had received induction training and support from staff at the home. She explained that she had worked alongside a mentor until her induction was completed. She had also received instruction on fire safety and fire drills and moving and handling training. Examination of her training records confirmed this. A sample of employee files was examined and there was evidence of a thorough recruitment procedure including 2 written references, CRB and POVA check. All prospective employees are interviewed and employment history is obtained. Ash Hall Care Home E09 E51 S26935 Ash Hall V223599 200405 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 36, and 38. Quality assurance was in place but will need to include the views of the service users. Staff induction training is effective but further evidence of staff supervision is required. The registered manager will need to improve procedures and records in relation to ensuring the promotion of Health and Safety within the home. EVIDENCE: The manager carries out regular quality control audits at the home and there was written records of this done on a monthly basis. These audits looked at housekeeping, kitchen and laundry services, and the welfare of service users. It was recommended that the views of service users be sought, recorded and acted upon. There was little evidence of staff supervision and the staff interviewed had not received this since the last inspection. This had been commenced but now needs developing into a structured programme. Ash Hall Care Home E09 E51 S26935 Ash Hall V223599 200405 Stage 4.doc Version 1.30 Page 20 Records relating to the servicing and maintenance of equipment in the home were examined and found to be in order. Fire detecting and fire fighting equipment had been appropriately serviced and tested. There was a current Legionella test certificate in place. The radiators were uncovered but the temperature was automatically controlled at source to an acceptable level. The Health and Safety Executive had inspected these radiators previously and were satisfied with the precautions taken. The risk assessments for individual radiators will need to be expanded as discussed with the manager at the time. In bedroom number 5 there was exposed hot water pipe work underneath the radiator and this must be suitably covered. In the toilet next door to the kitchen staff toilet waste bags containing clinical waste were stored inappropriately on the floor next to the toilet. The manager stated that this was not used as a toilet. This room was identified as a toilet and the function of this room must be made clear and used as either a toilet only or a sluice room. The temperature of the hot water in the bathroom next to room 9 was too hot. This was reading 49 degrees centigrade. The manager stated that there were safety valves on all baths and showers. The manager stated that the proprietor carried out regular tests on the hot water temperatures but these were not readily available for inspection at the time. In some of the bedrooms on the second floor the window restrictors were allowing the window to open to about 8 inches. This should be no more than 4 inches (100mms) in accordance with Health and Safety Requirements. Accidents had been recorded as required and audited on a regular basis. Evidence was seen of regular staff mandatory health and safety training including regular fire drills and the staff spoken to confirmed this. Ash Hall Care Home E09 E51 S26935 Ash Hall V223599 200405 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 x 3 x 3 3 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x x 2 x 2 Ash Hall Care Home E09 E51 S26935 Ash Hall V223599 200405 Stage 4.doc Version 1.30 Page 22 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 8 Regulation 13 (1) (a) Requirement The management must ensure that each service user has a documented annual review by the GP. Formal staff supervision needs to be further developed with records maintained. The risk assessments for radiators will need to be further developed to identify the risk involved to individual service users. The exposed hot water pipework located in bedroom 5 must be suitably covered. The function of the room located next door to the kitchen staff toilet must be made clear and used as either a toilet only or a sluice room The temperature of the hot water from the bath outlet in the bathroom next door to room 9 must be adjusted to register no more than 43 degrees centigrade. Hot water temperatures must be tested and recorded and records available for inspection The windows on the second floor should be allowed to open no Timescale for action By 20/6/05 2. 3. 36 38 18 (2) 13 (4) By 20/6/05 By 20/6/05 4. 5. 38 38 13 (4) 16 (2) (j) By 20/5/05 By 20/5/05 6. 38 13 (4) Immediate and on going 7. 8. 38 38 13 (4) 13 (4) Immediate and on going Immediate and on Page 23 Ash Hall Care Home E09 E51 S26935 Ash Hall V223599 200405 Stage 4.doc Version 1.30 more than 100mms in accordance with Health and Safety Requirements going 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 12 15 19 33 7 Good Practice Recommendations To consider the use of the third lounge so as to avoid incidences identified by the inspector, when the radio and television were both on at the same time in one area. The daily menu and choice is to be displayed. There was no evidence of a formal programme of redecoration and refurbishment. It is recommended that this be commenced and records kept. It was recommended that the views of service users be sought, recorded and acted upon as part of the quality assurance system The preference of the service user and/or their representative to become involved in the care plan should be documented in the care records. Ash Hall Care Home E09 E51 S26935 Ash Hall V223599 200405 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection Stafford - Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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. 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