Inspection on 09/05/07 for Ashbourne House

This inspection was carried out on 9th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Ashbourne House 06/12/05

Ashbourne House 12/07/05

Ashbourne House 07/02/05

Ashbourne House 08/09/04

Ashbourne House 24/02/04

Ashbourne House 17/06/02

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Ashbourne House 147/149 Gatley Road Gatley Stockport Cheshire SK8 4PD Lead Inspector Jacqueline Kelly Unannounced Inspection 9th May 2007 10:00 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 Ashbourne House DS0000008537.V339051.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. Ashbourne House DS0000008537.V339051.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashbourne House Address 147/149 Gatley Road Gatley Stockport Cheshire SK8 4PD 0161-491 1201 0161 491 1201 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) Casequest Limited Mr. Martin Sorrell Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places Ashbourne House DS0000008537.V339051.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 23 OP. Date of last inspection 6th December 2005 Brief Description of the Service: Ashbourne House is a care home for twenty-three older people, situated close to Gatley village. Public transport and the motorway network are within easy reach of the home. The accommodation within the home consists of nineteen single and two shared bedrooms. There are four domestic size lounges and a large dining room. The fourth lounge is used as a reading/visiting room and has no television. There is a loop system available for residents who are hearing impaired. The dining room overlooks a well-established, enclosed garden where garden furniture is available for residents and their visitors. The home provides a small, domestic sized kitchen in addition to the central kitchen, which is available for residents and their visitors to make hot drinks. There is a multi-purpose function room for hairdressing, chiropody and other consultations. The hairdresser visits the home on a weekly basis. Within the same room there is a public telephone available to residents. The fee ranges from £375.00 to £380.00 per week. Hairdressing, private chiropody and newspapers are not included in the price. For those residents who are funded by social services there is a ‘top up’ fee. An information pack is given to all prospective residents and a copy of the inspection report is available on request. The home has achieved the Investors in People Award. Ashbourne House DS0000008537.V339051.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place over four hours. Time was spent talking with the manager Mr Martin Sorrell and one of the owners Mr Terry Sorrell. Residents and staff were also spoken with; all said that they were happy with the care provided. The home had twenty-two residents on the day of the inspection. Care plans, risk assessments, and drug administration records were looked at all of which were satisfactory. Comment cards from the Commission for Social Care Inspection were sent to three GP’s. At the time of writing this report one had been returned which was positive and included the following comment; ‘Ashbourne House seems to be very well managed. The home manager is always very responsive, helpful and efficient.’ Twelve survey forms were sent to the home for distribution amongst the residents; three had been returned in time to include the comments in this report. The three forms had been completed with support of relatives. Comments received were:- ‘I have every confidence that my mother’s care is first class’; ‘staff listen and act on what is said; the staff always respond immediately to any questions or requests’. ‘Ashbourne, which is homely and clean and very fresh smelling.’ The home had received two complaints; one of which was substantiated and one partially substantiated. Both had been documented and dealt with in a satisfactory manner. None of the residents with whom the inspector had contact with or who completed a survey form had any complaints. The Commission for Social Care Inspection had received no issues of concern, or safe guarding adult referrals. What the service does well: The home is well maintained, homely and comfortable with a number of different areas for people to sit. The garden is well stocked with plants and has garden furniture for residents to use during the better weather. The home Ashbourne House DS0000008537.V339051.R01.S.doc Version 5.2 Page 6 was clean and free from any offensive odours. Residents were encouraged to personalise their bedrooms. The residents/relative kitchen was to be refurbished at the end of May. The manager carries out an assessment of prospective residents and provides people with information to help them make a positive choice. A varied programme of activities was available for residents to choose from. Outings were also arranged using the ‘Ring and Ride’ bus service. The home had a stable staff team of care workers, many of whom had worked at the home for a number of years. The inspector received favourable comments from the residents who were spoken with regarding the kindness and caring attitude of the staff group. The staff team respected the residents privacy and independence and their right to exert choice over their daily lives. Resident committee meetings took place regularly, which enabled residents to express their views and opinions. All the residents who were spoken with said that the food was good and had no complaints. The home has produced a monthly newsletter, which is good and informative. What has improved since the last inspection? What they could do better: The home had conducted surveys with residents; an analysis of the completed questionnaires should be included in the Quality Assurance Report, which is sent to the Commission. Ashbourne House DS0000008537.V339051.R01.S.doc Version 5.2 Page 7 The application form and recruitment process for employees who have left and wish to come back working at the home should be amended to further protect the residents from unsuitable staff. 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. Ashbourne House DS0000008537.V339051.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 Ashbourne House DS0000008537.V339051.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): Standards 3,6. Quality in this outcome area is good. The assessment process ensured prospective residents needs could be met. Sufficient information is provided to help people make a choice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three files for the most recently admitted residents were looked at. Evidence was seen on the three files of completed assessments prior to being offered a place. The survey forms returned to the Commission stated that they had received sufficient information about the home. The inspector suggested that the manager access an assessment form which was available on the Department of Health’s website which would improve on the current one being used. A monthly newsletter was available which was good and informative. Ashbourne House DS0000008537.V339051.R01.S.doc Version 5.2 Page 10 Standard 6 was not applicable, as the home did not have any intermediate care beds. Ashbourne House DS0000008537.V339051.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): Standards 7,8,9,10 Quality in this outcome area is good. The manager and the staff team met the health and personal care needs of the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans were in place, which had been devised from the assessment process and were reviewed at regular intervals. The care plans along with risk assessments contained information to assist the care workers in caring for the residents. The services of the District Nurse, opticians and others were obtained as and when necessary. The manager had revised the medication policy and procedure and had implemented all the requirements and recommendations of the previous report of February 2006. The charter of rights, which was included in the information pack, contained statements regarding the right of residents to have their dignity, privacy, independence and choices respected. Ashbourne House DS0000008537.V339051.R01.S.doc Version 5.2 Page 12 Ashbourne House DS0000008537.V339051.R01.S.doc Version 5.2 Page 13 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): Standards 12,13,14,15 Quality in this outcome area is good. The residents’ daily life and social activities are catered for. The food is good and the residents have some choice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The residents spoken with were happy with the leisure activities provided both in the home and out in the community. Those people who were partially sighted or had a hearing impairment were also catered for with the provision of talking books, radio, loop system and hearing aids. Resident committee meetings, which took place regularly, gave the residents the opportunity to express their views and opinions. All the people spoken with said that the food was good and should they not like what was on the menu they would be given an alternative. Ashbourne House DS0000008537.V339051.R01.S.doc Version 5.2 Page 14 Ashbourne House DS0000008537.V339051.R01.S.doc Version 5.2 Page 15 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): Standards 16,18 Quality in this outcome area is good. Residents and relatives were able to express their views and make a complaint should they wish to do so. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The two complaints that had been received were discussed with the manager. No further action was necessary and they had been dealt with in a satisfactory manner. The Commission for Social Care Inspection had received no complaints and there had been no safe guarding adult referrals. The survey forms and the residents who were spoken with said that should they have any complaints they knew who to approach; however no one had any issues of concern. The manager had received training in safe guarding adults and all care workers had completed the alerter training course. Ashbourne House DS0000008537.V339051.R01.S.doc Version 5.2 Page 16 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): Standards 19,26 Quality in this outcome area is good. The home is well maintained, clean, homely, and free from offensive odours. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home was clean, tidy, comfortable, homely and maintained to a good standard. The residents/relatives kitchen was due to be refurbished at the end of May 2007. The garden to the rear of the property is a reasonable size and was well kept with plants and a lawn for residents to sit out on. The manager had applied for a government grant to further improve the garden area. A ramp had been built to the front door, which allowed those people in wheelchairs easy access. Ashbourne House DS0000008537.V339051.R01.S.doc Version 5.2 Page 17 The environmental health department had inspected the kitchen recently; there were no problems. The home also complied with the fire safety regulations. A small number of bedrooms were seen during the inspection; all had been personalised. Ashbourne House DS0000008537.V339051.R01.S.doc Version 5.2 Page 18 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): Standards 27,28,29,30 Quality in this outcome area is good. The staff were skilled and trained to meet the needs of the Residents. Recruitment and selection procedures need some amendments to further protect the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There were sufficient staff employed to ensure that the residents health and personal care needs were met in a clean and comfortable home. The staff had received training in core skills such as, adult protection, medication administration, moving and handling and health and safety. Many had completed a National Vocational Qualification (NVQ) Level 2 and or Level 3. The staff files of the last three members of staff to be employed were looked at. The application form was discussed with the manager where it was suggested that the ‘employment history’ section be amended. The full recruitment process for previous staff members who re-apply for employment must be instigated; this includes completion of application form and references. Ashbourne House DS0000008537.V339051.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,33,35,38 Quality in this outcome area is good. The residents were kept safe through procedures and staff training. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager had the necessary experience and qualifications and was a director of the company. He had also commenced training for the Registered Managers Award. There was a business plan and SWOT (strengths, weakness, opportunity, threat) analysis in place, copies of which were given to the inspector. The requirement to write a quality assurance report, which is sent to the Commission and made available to residents, was discussed with the manager. Ashbourne House DS0000008537.V339051.R01.S.doc Version 5.2 Page 20 Questionnaires were distributed to residents in order to obtain their views and opinions. An analysis of the information received should be included in the annual quality assurance report. The manager was not responsible for any of the residents’ finances. Formal staff supervision and annual appraisal took place on a regular basis and was recorded. The manager was also a National Vocational Qualifications (NVQ) assessor for the care workers who were in the process of doing their NVQ. The care workers who were spoken with said that the manager was approachable and fair. Ashbourne House DS0000008537.V339051.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 3 3 x x x x x x 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 3 x 2 x 3 x x 3 Ashbourne House DS0000008537.V339051.R01.S.doc Version 5.2 Page 22 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. Standard Regulation Requirement Timescale for action 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 OP29 Good Practice Recommendations The manager should amend the application form and ensure that the same recruitment and selection procedures are implemented for all staff and staff who have worked previously at the home are not treated differently. The manager should produce an annual quality assurance report, part of which contains an analysis of any resident or relatives’ surveys. A copy should be made available to residents and relatives and to the CSCI. 2 OP33 Ashbourne House DS0000008537.V339051.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Manchester Local Office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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 Ashbourne House DS0000008537.V339051.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. 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