CARE HOMES FOR OLDER PEOPLE
Ash House Residential Home Ash House Lane Dore Sheffield South Yorkshire S17 3ET Lead Inspector
Mrs Janis Robinson Unannounced Inspection 7th December 2005 09:00 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 House Residential Home DS0000044374.V268622.R01.S.doc Version 5.0 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 House Residential Home DS0000044374.V268622.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Ash House Residential Home Address Ash House Lane Dore Sheffield South Yorkshire S17 3ET 0114 2621914 0114 2356107 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) Ash House (Yorkshire) Limited Ms Julie Elizabeth Shaw Care Home 40 Category(ies) of Dementia - over 65 years of age (15), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (15), Old age, not falling within any other category (25) Ash House Residential Home DS0000044374.V268622.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The 15 DE/E / MD/E beds are in a separate wing. Date of last inspection 27th April 2005 Brief Description of the Service: Ash House is a home that provides care for 40 people (over the age of 65) of which there are 15 beds for people with dementia and 25 personal care beds. The home is situated in the Dore area of the city.The detached building is in its own grounds, which were very pleasant and well maintained.There was an outside sitting area that is easily accessible and overlooked the grounds. Local amenities were a short drive away, providing a range of shops, pubs and a picnic area close by. All but two of the rooms were single and service users were able to bring their own possessions into the home with them.There were pleasant communal areas for the service users to sit and a large separate dining room. Ash House Residential Home DS0000044374.V268622.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over 7.45 hours from 8.45 am to 4.30 pm. An inspection of a proportion of the environment was undertaken, and records were sampled, including; staff training, health and safety, rotas, complaints and fire records. Interactions between residents and staff were observed. The inspector spoke with ten residents, and every member of staff on duty was interviewed. Discussions with the homes manager and owner took place The majority of standards were assessed and met at the last inspection. What the service does well:
All of the comments made by residents were positive. Residents said ‘the staff take care of us’, ‘I am lucky to live here’, and ‘the staff are smashing’. Residents had been provided with a service user guide, to give them information about the home. Trial visits to the home, to enable prospective residents and their representatives to make an informed decision, were encouraged. Access to health care professionals was available, to maintain residents health. Residents confirmed that the staff were respectful towards them. The routines at the home were flexible, some activities were available, and residents were able to choose how to spend their day. There was an open visiting policy, to encourage contact with family and friends. All residents said the food provided was ‘very good’ and confirmed that choices were offered. A varied menu was provided. There was a complaints procedure, each resident had been provided with a copy to inform them of their rights. All spoken with said they had confidence in the staff at the home, who would listen to any concerns and take them seriously. Adult protection procedures were in place. The environment was well maintained. The majority of the home was clean and free from odours. Homely touches were provided in communal areas to create a comfortable environment. Bedrooms were well decorated and individually personalised with possessions residents brought in with them. Agreed levels of staff were being maintained. The home had a commitment to National Vocational Qualifications (NVQ), to ensure staff had the skills needed to meet the needs of residents.
Ash House Residential Home DS0000044374.V268622.R01.S.doc Version 5.0 Page 6 Residents’ finances were safely managed. Health and safety systems were in place at the home, fire equipment had been checked and serviced. Mandatory training took place. 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 House Residential Home DS0000044374.V268622.R01.S.doc Version 5.0 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 House Residential Home DS0000044374.V268622.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 5 The Statement of Purpose and Service User Guide provided sufficient information for prospective service users to make an informed decision about admission to the home. Trial visits to the home were encouraged and supported. EVIDENCE: The homes Statement of Purpose and Service User Guide were informative and up to date. Copies of the service user guide had been provided in each bedroom. A number of residents spoken to said that prior to admission they were encouraged to visit the home to meet people, see the facilities available and sample the hospitality. Ash House Residential Home DS0000044374.V268622.R01.S.doc Version 5.0 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): 8 and 10 Residents’ health care was monitored and access to health professionals was available. Residents were treated with respect and their privacy was upheld, which helped to make them feel comfortable and ‘at home’. EVIDENCE: Discussion with residents identified that a range of health professionals visited the home to assist in maintaining health care needs. Residents confirmed that they had access to a chiropodist, dentist and optician. They said that they saw their doctor when needed and could always see their health professional in private. Staff were observed interacting well with service users. Residents spoken to said staff were ‘very kind’ and ‘helpful’ and their right to privacy was always upheld. Ash House Residential Home DS0000044374.V268622.R01.S.doc Version 5.0 Page 10 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 and 15 A variety of activities were available to residents. There were no restrictions on visiting times and service users were able to receive visitors in private. Meals were of a high standard and served in pleasant surroundings. EVIDENCE: Since the last inspection the range of activities on offer had improved. Various visiting entertainers visited the home on a weekly or fortnightly basis to provide music and movement, singing and exercise. All of the residents spoken with said that they really enjoyed the activities available and ‘they keep us going’. Residents felt that enough activities were provided. One resident said ‘we share laughter in this home’. Residents confirmed that their relatives and friends were able to visit at any time, and that they could always see them in private, if they chose. All of the residents spoken to said the food provided was good, they said the food was ‘plentiful, nothing is too much trouble’. Choices were offered. The homes menu was varied. Staff had access to food supplies at all times, to cater for residents needs.
Ash House Residential Home DS0000044374.V268622.R01.S.doc Version 5.0 Page 11 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 A clear and accessible complaints procedure was in place, to ensure residents’ rights were protected and any concerns listened to and taken seriously. An Adult protection procedure was in place. EVIDENCE: Each resident and representative had been provided with a copy of the homes complaints procedure contained within the service user guide. This contained relevant detail and informed the reader of who to contact outside of the home to make a complaint, should they wish to do so. All of the residents said they had no concerns and could go to the manager and staff to sort out any worries they had. The home kept a record of complaints. The home had not received any complaints since the last inspection. The homes adult protection procedure contained all of the required information, to ensure staff were fully informed of the action to take if any allegation was made. An allegation had been made the week of this inspection. Correct procedures had been followed, the provider was instructed to investigate and report back to the CSCI. All of the residents said that they felt very safe at the home. Ash House Residential Home DS0000044374.V268622.R01.S.doc Version 5.0 Page 12 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21 and 24 The location and layout of the home was suitable for its stated purpose. Communal areas appeared comfortable. Residents’ bedrooms met individual’s needs in a comfortable and homely way. The patio area outside the DE wing had been replaced to greatly improve the facilities available. Sufficient and suitable bathrooms and toilets, which had adaptations installed to maximise independence were not made available. EVIDENCE: The grounds around the home were very welcoming and residents said they enjoyed sitting outside during the nice weather. The patio area outside the DE wing had been replaced and provided with planters and seating. This would enable all residents to safely enjoy time outside in fine weather.
Ash House Residential Home DS0000044374.V268622.R01.S.doc Version 5.0 Page 13 All areas of the home were clean and tidy. Lounge and dining areas were domestically furnished. The bedrooms seen were comfortable and homely. Residents spoken to said that they had all they wanted in their rooms. It was identified during the previous inspection that the floor covering in the DE wing was worn and would benefit from replacement to enhance the environment. This had not been undertaken, however, the manager confirmed that this had been identified within the homed maintenance plan. Refurbishment work to the bathrooms and toilets that had been required at previous inspections had not been completed. Consequently the majority of residents were utilizing one bathroom and one shower room. Residents said that this was not causing them any difficulty at present, although it would be better if there were an assisted bath available on the first floor, near to their bedrooms. Ash House Residential Home DS0000044374.V268622.R01.S.doc Version 5.0 Page 14 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 and 28 Staff were employed in sufficient numbers to meet the needs of residents in accordance with agreed staffing levels. Staff undertook NVQ training. EVIDENCE: The manager stated that agreed staffing levels were being maintained. This assisted in making sure that service users needs were met. Residents spoken to said that staff were kind and helpful. The homes rota indicated that agreed levels of staff were maintained. 50 of the care staff had not achieved NVQ level 2 in care. At the time of this inspection two staff had achieved level 2 in care, and one staff level 3. A further seven staff were undertaking the award at level 2, and six staff at level 3. Once these awards have been achieved, required targets will be met. Ash House Residential Home DS0000044374.V268622.R01.S.doc Version 5.0 Page 15 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): 33, 35, 36 and 38 A quality assurance system was in place. Residents’ monies were handled safely. Provider reports were not undertaken. Staff supervision did not take place at the required frequency. Health and safety systems were maintained. Some staff required refresher training. Some staff had not participated in a fire drill at the required frequency. EVIDENCE: Surveys were undertaken with residents and their representatives to ensure they were consulted formally, and their views taken into account. Whilst the provider visited very regularly, formal monthly monitoring visits and records were not undertaken. These are important as they ensure a systematic and organised monitoring of the service takes place.
Ash House Residential Home DS0000044374.V268622.R01.S.doc Version 5.0 Page 16 Staff supervision, to support and inform staff, was not undertaken on a regular basis. Records examined evidenced that staff did not receive supervision at the minimum frequency of six times each year. A health and safety system was in operation, to ensure residents were safe. Fire fighting equipment was checked and serviced. Fire records indicated that some staff had not participated in a fire drill within the last six months to ensure they were aware of how to respond in an emergency. A programme of mandatory staff training was in place to enable staff to maintain their skills and meet residents’ needs. However, some staff were out of date with food hygiene and moving and handling. Ash House Residential Home DS0000044374.V268622.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X X X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 2 X X 3 X X STAFFING Standard No Score 27 3 28 2 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 2 X 2 Ash House Residential Home DS0000044374.V268622.R01.S.doc Version 5.0 Page 18 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 OP19 Regulation 23 Requirement The floor covering on the EMI corridor must be replaced. (Previous timescales of 1.10.04, 1.08.04 not met) Bathrooms must be refurbished and suitable adaptations installed to assist service users that are old, infirm or physically disabled. (Previous timescales of 01.09.05, 1.8.04, 1.10.03, and 1.3.03 not met) Visits by the Registered Provider must take place as detailed in Regulation 26 of the Care Homes Regulations and comprehensive reports must be provided. (Previous timescale of 01.07.05 not met) Staff supervision must be provided a minimum of six times each year. Staff must participate in a practice fire drill a minimum of two times each year. An audit of staff fire drill training must be undertaken. Where gaps are identified training must be provided.
DS0000044374.V268622.R01.S.doc Timescale for action 31/03/06 2 OP21 19 31/03/06 3 OP33 26 31/01/06 4 5 OP36 OP38 18 13 31/01/06 31/01/06 Ash House Residential Home Version 5.0 Page 19 6 OP38 18 An audit of staff mandatory training must take place. Where gaps are identified, relevant training must be provided. Refresher training in food hygiene and moving and handling must be provided to identified staff. 28/02/06 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 Refer to Standard OP28 Good Practice Recommendations 50 of care staff should achieve NVQ level 2 in care by 2005. Ash House Residential Home DS0000044374.V268622.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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