Inspection on 12/09/07 for Ashcott Lawns

This inspection was carried out on 12th September 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Ashcott Lawns 01/05/09

Ashcott Lawns 29/04/09

Ashcott Lawns 28/01/09

Ashcott Lawns 25/01/08

Ashcott Lawns 14/11/06

Ashcott Lawns 11/10/05

Ashcott Lawns 17/05/05

Ashcott Lawns 19/10/04

Ashcott Lawns 21/05/04

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

CARE HOMES FOR OLDER PEOPLE Ashcott Lawns Chapel Hill Ashcott Bridgwater Somerset TA7 9PJ Lead Inspector Kathy McCluskey 12 & 14 th th Unannounced Inspection September 2007 10:30 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 Ashcott Lawns DS0000015999.V350745.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. Ashcott Lawns DS0000015999.V350745.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashcott Lawns Address Chapel Hill Ashcott Bridgwater Somerset TA7 9PJ 01458 210149 01458 210932 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) MRS MONICA DIANA CORBETT MRS MONICA DIANA CORBETT Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places Ashcott Lawns DS0000015999.V350745.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th November 2006 Brief Description of the Service: Ashcott Lawns is registered with the Commission for Social Care Inspection to provide personal care only for up to 17 people over the age of 65 years. The home is not registered to provide nursing care. The registered provider/manager is Mrs M. Corbett. Mrs Corbett lives on the premises. The home has been converted from two Grade II cottages to provide a homely environment for service users. It has been adapted as far as possible to meet the needs of older people however, service users need to be ambulant as there are further steps to most first floor bedrooms and assisted bathing facilities are very limited at this time. This period house is full of character and furnishings and fittings are in keeping with this. The home is located in the village of Ashcott where there are some amenities and village activities. Attractive gardens surround the home and there is ample parking. The current fee range is £430 to £530 per week. Additional charges include; hairdressing, chiropody, personal items and some staff escorts to appointments. Ashcott Lawns DS0000015999.V350745.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of this inspection visit was to inspect relevant key standards under the Commission’s ‘Inspecting for Better Lives 2’ framework. This focuses on outcomes for service users and measures the quality of the service under four general headings. These are; - excellent, good, adequate and poor. The home’s last key inspection was carried out on 14th November 2006. A further unannounced inspection took place on 25th July 2007 and concerns were raised regarding the home’s procedures relating to staff recruitment. This key unannounced inspection was conducted over two days (7hrs) by CSCI regulation inspector Kathy McCluskey. The registered provider/manager was available for the first part of day one of the inspection and for the duration of the second day. At the time of the inspection, seven service users were living at the home and the inspector was able to meet with all of them. All staff on duty were spoken with. As part of this key inspection, the Commission sent comment cards to the home for service users, staff and relatives. No comment cards were received from service users or relatives. Five staff completed comment cards. All parts of the home were seen and records were examined relating to service users, staff and health and safety. The inspector would like to thank service users, staff and the provider/manager for their time and cooperation with the inspection process. The following is a summary of the inspection findings and should be read in conjunction with the whole of the report. What the service does well: Ascott Lawns provides a very homely and comfortable environment for service users. Service users are encouraged to personalise their bedrooms. Service users stated that the ‘staff are kind’ and that the ‘food is excellent’. Ashcott Lawns DS0000015999.V350745.R01.S.doc Version 5.2 Page 6 Service users benefit from a small and stable staff team. The home has not had to use agency staff. Prospective service users are assessed by the registered person and prospective service users have the opportunity to ‘test drive’ the home before making a decision to move there. This was confirmed by service users spoken with. Service users confirmed that their visitors are always made to feel welcome, The registered person stated that visitors are welcome to stay for meals and that accommodation can be provided where required. During the inspection, service users were observed moving freely around the home, deciding where and how they spent their day. What has improved since the last inspection? What they could do better: Service user care plans need to be improved so that they provide up to date information about the assessed needs of an individual. The home needs to ensure that service users are involved in the care planning process and that their preferences/wishes are identified. The home needs to devise assessments relating to service users’ moving & handling needs & reducing the risk of falls and pressure sores. Bathing facilities in the home need to be reviewed as not all service users are able to access the bath in use. The bath is domestic in style and has a ‘bath knight’ lowering aid which requires a service user to be able to step in and out of the bath. Work in progress is on-going in two upstairs bathrooms to provide a domestic shower and further bath. Neither are assisted. The home’s complaints procedure does not contain sufficient information and it was found to contain out of date information. The complaints procedure, once updated needs to be displayed in the home. Ashcott Lawns DS0000015999.V350745.R01.S.doc Version 5.2 Page 7 The home’s procedures for the management and administration of service users medication were generally good but action must be taken to ensure that the room storing the medicines does not exceed the safe upper limit of 25C. Staff record medicines received into the home on individual records for service users. These handwritten entries are confirmed with two staff signatures. It has been recommended that this process is repeated for additional medicines received into the home. The registered person has not taken action to devise a policy for staff on abuse. Three previous timescales have not been met. Following the last inspection, the inspector provided the registered person with information on how to obtain a copy of Somersets revised policy (May 2007) on Safeguarding Adults. No action has been taken by the registered person. Staff have not received training in abuse. Requirements have been raised regarding the home’s procedures for reducing the risk of the spread of infection. Cloth towels and bars of soap must be replaced with pump action liquid soap and paper towels in all communal bathrooms/toilets, laundry, kitchen and any en-suite toilet where service users require staff assistance with personal care needs. The laundry area needs attention. The home’s induction programme for new staff is basic and does not meet with the Skills for Care Common Induction Standards. Formal supervision for staff is not taking place. There does not appear to be a system in place to ensure that staff receive appropriate and up to date training. The registered person has not implemented a quality assurance programme aimed at seeking the views of service users, relatives and other interested stakeholders. The registered person needs to ensure that they keep themselves up to date with all relevant changes in legislation. A number of requirements have been raised relating to health and safety. 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 Ashcott Lawns DS0000015999.V350745.R01.S.doc Version 5.2 Page 8 be made available in other formats on request. Ashcott Lawns DS0000015999.V350745.R01.S.doc Version 5.2 Page 9 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 Ashcott Lawns DS0000015999.V350745.R01.S.doc Version 5.2 Page 10 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): 2, 3, 4 and 5. Standard 6 is not applicable as the home is not registered to provide intermediate care. Quality in this outcome area is Good This judgement has been made using available evidence including a visit to this service. Prospective service users are assessed prior to moving to the home and are encouraged to visit the home prior to making a decision to move there. The home is aware that it can only provide accommodation to service users who are mobile and relatively independent. Service users are provided with a contract/statement of terms and conditions EVIDENCE: The home’s Statement of Purpose was not examined at this inspection. The provider stated that prospective service users are provided with the home’s brochure at the point of enquiry. Ashcott Lawns DS0000015999.V350745.R01.S.doc Version 5.2 Page 11 The inspector was able to meet with the most recent service user. The service user informed the inspector that prior to making the decision to move to Ashcott Lawns, the registered provider/manager visited them in their own home to ascertain their needs. The service user confirmed that they had been provided with sufficient information to enable them to make an informed choice about moving to the home. A relative viewed the home on behalf of the service user. The care plan contained a pre-admission assessment which had been completed by the provider/manager. This covered personal care needs, mobility, diet, past medical history and information about how needs were currently being met. Prospective service users are encouraged to visit the home prior to making a decision to move there. The home offers a day care and respite facility. Another service user informed the inspector that they had stayed at the home for short respite periods prior to making a decision to move there permanently. The inspector was able to see evidence that service users are provided with a contract/statement of terms and conditions. This also identifies the room number and fees to be charged. Staff spoken with did not raise any concerns about being able to meet the needs of current service users and all service users spoken with felt that there needs were being met. One service user did express their disappointment at not being able to have a bath given the lack of assisted bathing facilities (refer to standard 22). The home would not be suitable for service users with mobility difficulties as it does not have any hoists and, as previously mentioned, does not provide suitable assisted bathing facilities. A stair lift gives access to the first floor. The registered provider/manager stated that the home would not accept service users who required the use of a hoist, assistance to use the toilet or assistance to turn in bed. Although the home aims to provide service users with a ‘home for life’, the registered provider/manager was very clear that where the needs of a service user became more dependant, a reassessment would be arranged. The inspector was provided with examples where service users had moved to a nursing home. Ashcott Lawns DS0000015999.V350745.R01.S.doc Version 5.2 Page 12 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): 7, 8, 9 and 10 Quality in this outcome area is Adequate This judgement has been made using available evidence including a visit to this service. The home’s care planning systems require improvement to ensure that they are fully reflective of assessed needs and preferences. No assessments are in place relating to mobility, risk of falls or pressure sores. The home takes appropriate steps to ensure that healthcare needs are met. Procedures relating to the management and administration of medication would benefit from improvements. Service users confirmed that staff treated them with respect. EVIDENCE: The care plan for the most recent service user was examined at this inspection. Assessed needs which had been recorded were confirmed by the service user. Ashcott Lawns DS0000015999.V350745.R01.S.doc Version 5.2 Page 13 The care plan stated that the service user ‘liked to have a bath and required staff assistance’. On discussion with the service user it was apparent that the service user could not access the home’s only assisted bath as the bath aid in place required the service user to be able to step in and out of the bath. The care plan needs to be updated to reflect this and appropriate measures must be in place to ensure that personal care needs are fully met. Staff complete daily entries at the end of every shift. Information recorded was good. Daily records for one service user identified that a commode should be placed by their bed at night. This had not been reflected in the plan of care. The care plan contained detailed information relating to visits from healthcare professionals. Weights are recorded monthly. The care plan examined did not provide evidence that the service user had been involved in this process. Preferences relating to waking, going to bed, drinks and diet had not been identified. This was discussed with the provider/manager at the time of the inspection. The home needs to develop appropriate assessments relating to mobility, risk of falls and reducing the risk of pressure sores as no assessments are currently in place. No care plan was in place to reflect how oral hygiene needs were to be met. The inspector examined the home’s procedures for the management and administration of service users’ medication. Medicines were found to be securely stored. The medicine cupboard is located in a room which also houses central heating boilers. The exact temperature of the room could not be ascertained though it felt very warm. The inspector discussed the need to ensure that medicines were not stored above 25C. It has been required that a suitable thermometer is sited in this room and that daily temperatures are recorded. Appropriate action must be taken should temperatures exceed 25C. The home does not use pre-printed medication administration records. Medicines received into the home are recorded on a sheet by a staff member. Entries are checked and confirmed by an additional staff member. As this staff member only signs once to confirm all entries, it has been recommended that additional entries are confirmed by two signatures as they are recorded. No service users are currently prescribed controlled drugs. All service users were spoken with at this inspection and all stated that they were treated with respect and that their privacy was respected by staff. Bedroom doors are not fitted with locks. The registered person needs to ensure that this is reflected in the home’s Statement of Purpose and brochure (These records were not examined at this inspection). Bathrooms and toilets are fitted with appropriate locks. Ashcott Lawns DS0000015999.V350745.R01.S.doc Version 5.2 Page 14 Staff were heard communicating with service users in a kind manner. Staff were observed giving service users their mail to open. Ashcott Lawns DS0000015999.V350745.R01.S.doc Version 5.2 Page 15 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): 12, 13, 14 & 15 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home does not have a formal programme of activities for service users though service users were satisfied with this. The home needs to seek regular feedback from service users. Visitors are made to feel welcome at the home. Service users choose how and where to spend their day. The home provides a wholesome menu. Independence and choice could be improved by providing serving dishes on tables and by making a menu accessible for service users. EVIDENCE: All service users were spoken with at this inspection and all confirmed that they could choose how and where to spend their day. Service users were Ashcott Lawns DS0000015999.V350745.R01.S.doc Version 5.2 Page 16 observed moving freely around the home. Some were utilising the lounge area and some had chosen to spend time in their rooms. The home does not have a formal programme of activities. The registered provider informed the inspector that an outside entertainer visited the home on a monthly basis. This was also confirmed by service users spoken with. A selection of board games are available to service users. During both days of this inspection, service users appeared content to choose how they spent their day. Service users stated that they were happy to ‘sit quietly’, ‘read’, ‘knit’, ‘watch television’ or ‘have a nap’. None expressed a wish for a formal programme of activities. The registered provider informed the inspector that she had recently given service users a questionnaire to complete on activities. Unfortunately, the provider/manager had ‘destroyed’ completed forms as ‘everybody had said they were happy and did not want any formal activities’. The registered provider/manager was advised by the inspector to maintain these records as they form part of the home’s quality assurance programme. The views of service users relating to activities should be sought on a regular basis with records maintained. The home welcomes visitors in line with the preferences of service users. Service users confirmed that their visitors were always made to feel welcome and were offered refreshments. The registered provider/manager stated that visitors are always welcome to stay for meals and overnight stays can be arranged. Examples were given to support this. All bedrooms were seen at this inspection and it was apparent that service users are able to personalise their bedrooms. On the first day of this inspection, the inspector was able to see lunch being served in the dining room. The dining room is homely and furnishings appeared comfortable. Service users were observed entering the dining room and choosing where they wanted to sit. Condiments and napkins were available. Meals are prepared by staff at the home. Service users were very positive about the meals at the home. Many service users commented that ‘there was always too much’ and that they ‘hated wasting food’. The inspector observed staff serve plated meals to service users. The roast meal being served did appear wholesome and portions were very generous. Given that current service users living at Ashcott Lawns do appear to be independent, it has been recommended that the home considers the use of serving dishes to enable service users to help themselves. It has also been recommended that a menu is made available for service users as nobody was able to tell the inspector what was for lunch. Ashcott Lawns DS0000015999.V350745.R01.S.doc Version 5.2 Page 17 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): Quality in this outcome area is Poor. This judgement has been made using available evidence including a visit to this service. The home does not have a satisfactory complaints procedure in place. Procedures in place to enable staff to respond to abuse are insufficient. Staff have not received training in abuse. Staff recruitment procedures have improved and now provide better protection for service users. EVIDENCE: The home has a complaints procedure which requires updating. The current complaints procedure does not give assurances that they will be responded to within a maximum of 28 days. The procedure also makes reference to contacting a ‘care manager’ who no longer works at the home. Reference to the ‘National Care Standards Commission’ must be replaced with the contact details of the Commission for Social Care Inspection. The named inspector no longer with the Commission needs to be removed. It has been recommended that a copy of the revised complaints procedure is displayed in the home to ensure that it is easily accessible to service users and visitors. The inspector was informed that service users are currently provided with a copy of the complaints procedure when they move to the home. Ashcott Lawns DS0000015999.V350745.R01.S.doc Version 5.2 Page 18 All service users spoken with stated that they felt confident in raising concerns if they had any. None spoken with were aware that they could contact the Commission. The inspector was informed that the home have not received any complaints. No concerns have been raised directly with the Commission. The home has a whistle blowing policy which needs to be updated to include reference to the Public Interest Disclosure Act and the Department of Health Guidance ‘No secrets’. As per the home’s complaints procedure, the details for the Commission must be updated. At the last inspection, the inspector provided the registered provider/manager with information on how to obtain a copy of Somersets revised policy (May 2007) on safeguarding Adults. This has not yet been addressed and a requirement has been raised as the home does not have a policy for staff on abuse. The inspector was unable to see evidence that staff had received training in abuse. Five staff completed comment cards for the Commission and all confirmed that they knew how to raise any concerns. This was also confirmed by the three staff spoken with at the inspection. Following an immediate requirement raised at the last inspection, the registered provider/manager has taken action to ensure that the home’s staff recruitment procedures offer better protection for service users. The home has appropriate procedures in place which preclude staff from accepting gifts or legacies from service users or to be involved in assisting service users in the making of a will. Ashcott Lawns DS0000015999.V350745.R01.S.doc Version 5.2 Page 19 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): 19, 20, 21, 22, 23, 24 and 26 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Ashcott Lawns provides a homely and comfortable environment for service users. The home is not suitable for service users with mobility difficulties. Assisted bathing facilities are limited and this provision should be reviewed to ensure the personal care needs of all current service users can be fully met. Bedrooms are comfortable and pleasantly furnished. Service users can personalise their rooms. The home should ensure that service users have the provision of lockable facilities in their rooms. The home is not currently taking appropriate steps to reduce the risk of the spread of infection. The standard of cleanliness is good. Ashcott Lawns DS0000015999.V350745.R01.S.doc Version 5.2 Page 20 EVIDENCE: Ashcott Lawns is an attractive detached Grade II listed property which was originally two cottages. The property is situated in a quiet area in the village of Ashcott and it sits within its own gardens. The home appears to be well maintained. A level garden area is available at the front of the property and this area has seating and tables for service users. The main garden is situated at the rear of the house. This area is sloping and access may be difficult for some service users. Given the layout of the home and that the home does not have any hoists, the home would not be suitable for service users who required any assistance with their mobility. The inspector viewed all bedrooms and communal areas at this inspection. All service users were spoken with and without exception, all confirmed that they enjoyed living at Ashcott Lawns and that they were very happy with their bedroom. The lounge and dining room are situated on the ground floor. The lounge is of a good size and promotes a ‘homely’ feel. Furnishings appeared comfortable. A large plasma television has recently been provided for service users. The beamed dining room is pleasantly furnished and decorated. A smaller seating area is available between the lounge and dining room. Two communal toilets are available on the ground floor. Two further communal toilets are situated upstairs but are not yet accessible to service users as these bathrooms are currently being upgraded. All bedrooms have en-suite toilet facilities with a wash hand basin. The home currently only has one bath in use. This bathroom is located on the ground floor and is small and domestic in style. The bath is fitted with a ‘bath knight’ lowering aid. This requires service users to be able to step in and out of the bath as the aid only provides assistance to lower service users into the bath. Currently, this is the only assisted bathing facility available to service users and it does require service users to be fairly independent. Work is currently on-going to update two bathrooms upstairs. A shower will be available in one bathroom though this is domestic in style and will require a service user to be able to ‘step in’ and stand whilst showering, without staff assistance. The other bathroom is a very spacious room though the bath provided is again, domestic in style and does not provide an assisted bathing facility. Although the registered provider/manager informed the inspector that the home would not accept a service user who’s needs they could not meet, the home’s current bathing facilities do require a high level of independence on the Ashcott Lawns DS0000015999.V350745.R01.S.doc Version 5.2 Page 21 part of service users and it was apparent that some service users at the home are experiencing difficulties in accessing the bath. This arrangement should be reviewed to ensure that all service users can access appropriate bathing/showering facilities. Grab rails are appropriately sited. A stair lift gives access to the first floor. There are some small steps on the first floor corridor and also in the doorways to some bedrooms. As previously mentioned, the home does not have any hoists or moving and handling aids. Bedrooms were found to be comfortably furnished and had been personalised by service users. Call bells were available in all bedrooms. As previously mentioned, bedroom doors are not fitted with locks and the inspector could not see the provision of lockable space for service users. A recommendation has been raised. All areas of the home were very clean and there were no malodours. To reduce the risk of the spread of infection, it has been required that cloth towels and bars of soap are removed and replaced with liquid pump action soap and paper hand towels. This provision should also be made available for staff in en-suite toilets where service users require staff assistance with personal care needs. The laundry area is located in a ‘lean-to’ area with plastic corrugated roof. The floors are concrete and walls are painted bricks. To reduce the risk of the spread of infection action should be taken to ensure that the laundry floor is covered with an impermeable covering and that walls can be readily cleaned. Liquid soap and paper hand towels must be made available in this area for staff. Staff have access to disposable aprons and gloves. Ashcott Lawns DS0000015999.V350745.R01.S.doc Version 5.2 Page 22 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): 27, 28, 29 and 30 Quality in this outcome area is Poor This judgement has been made using available evidence including a visit to this service. Staffing levels at the home appear adequate for the current needs and numbers of service users. On-call arrangements should be reviewed. The home does not promote NVQ training for staff. Staff recruitment procedures have improved and now offer better protection for service users. There is no evidence that staff are appropriately trained. The induction programme for new staff requires improvement. EVIDENCE: The home has a small stable staff team of eight, and does not use agency staff. Seven service users currently live at Ashcott Lawns and the inspector was informed that staffing levels were as follows; AM – 3 carers PM – 2 carers Ashcott Lawns DS0000015999.V350745.R01.S.doc Version 5.2 Page 23 Night – 1 waking carer. The registered provider/manager lives on the premises and informed the inspector that she is available at the home each day and is on-call at night. It has been recommended that an on-call rota is devised to ensure that the provider/manager is not providing on-call cover 24hrs a day and seven days a week. Service users and staff spoken with did not raise any concerns about staffing levels at the home. The inspector was able to talk with a member of staff who worked at night who stated that the current service users did not require assistance at night and that they ‘very rarely’ used their call bell at night. The home does not employ catering or domestic staff. These duties are currently undertaken by the care staff on duty. No concerns were raised by staff spoken with during the inspection. The home does not promote NVQ training for staff. The registered provider/manager stated as all staff are mature in years, ‘they did not want to do NVQ training’. This was confirmed by some staff spoken with. The home currently has one member of staff with an NVQ qualification and the provider/manager stated that two staff are soon to be employed both of whom have an NVQ level 3. Progress will be followed up at the next inspection. The registered provider/manager was aware of the recommendation of the National Minimum Standards that 50 of the care team obtain an NVQ level 2. At the last inspection, an immediate requirement was raised for the home’s staff recruitment procedures. At this inspection, the inspector was able to see evidence that the provider/manager had taken appropriate actions to address this. References and CRB and POVA checks were in place for the two staff identified. The inspector was informed that no staff had been employed since the last inspection. The provider/manager gave her assurances that all required information would be obtained before new staff commenced employment. The inspector was informed that there had been no staff training since the last inspection. This is concerning given the issues/requirements which were raised at the last inspection. Previous requirements remain unmet and the registered provider/manager must take appropriate action to address. The home has some training videos relating to health and safety. The provider also provides verbal instruction and discussion with staff. The home must document and evidence training provided in safe working practices. The home needs to ensure that staff receive mandatory training annually so that they are updated and equipped to meet the needs of residents (Refer to standard 38). Ashcott Lawns DS0000015999.V350745.R01.S.doc Version 5.2 Page 24 The staff induction programme is basic and does not meet with the Skills for Care Common Induction Standards. Following the last inspection, the inspector provided the registered provider/manager with extensive information on this but no further action has been taken by the registered provider. This recommendation remains unmet. Ashcott Lawns DS0000015999.V350745.R01.S.doc Version 5.2 Page 25 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): 31, 33, 36 and 38 Quality in this outcome area is Poor This judgement has been made using available evidence including a visit to this service. Service users and staff find the registered provider/manager approachable. The registered provider/manager needs to keep herself updated as to current legislation. The home does not have formal systems in place to seek the views of service users or other interested stakeholders. There are no formal systems in place to ensure that staff are appropriately supervised. The home’s arrangements for ensuring the health and safety of persons at the home are poor. Ashcott Lawns DS0000015999.V350745.R01.S.doc Version 5.2 Page 26 EVIDENCE: The registered provider/manager Mrs Corbett has owned Ashcott Lawns for over 19 years. Mrs Corbett lives on the premises and is available at the home on a daily basis. Service users and staff spoken with were very positive about Mrs Corbett stating that they found her very approachable. Mrs Corbett has stated that she does not intend to complete an NVQ level 4 in care or management ‘at her time of life’. At this inspection and the last inspection, it was concerning that the registered/provider manager had not kept herself updated with regard to changes in legislation. This was discussed with Mrs Corbett at the time of the inspections. A requirement has been raised. The registered provider/manager was able to show the inspector a questionnaire template for service users to seek their views but that these ‘had never been given out’. Meetings are not currently organised for service users. The registered provider/manager stated that she talks to the service users every day. The registered person must introduce a quality assurance programme which will seek the views of service users. Feedback should also be sought from relatives and other stakeholders such as healthcare professionals. Standard 35 was not assessed as the inspector was informed that the home does not currently manage any monies on behalf of service users. Staff at the home do not receive formal supervision. The registered provider/manager stated that she ‘talks to staff on a daily basis to ascertain whether they have any issues’. Records relating to informal discussion are not maintained. The registered provider/manager must ensure that staff receive regular formal supervision (this should be at least 6 times a year). Appropriate records must be maintained. Several breaches in regulations were noted at this inspection relating to health and safety. FIRE SAFETY – The inspector was able to see documented evidence that inhouse weekly checks are made on the home’s fire alarm systems and emergency lighting. The last check was recorded as 11/09/07. Annual servicing by an external contractor last took place on 19/04/07. There was no evidence that all staff had received up to date training in fire safety. Records were available for three staff and were dated September 2006. Ashcott Lawns DS0000015999.V350745.R01.S.doc Version 5.2 Page 27 The registered provider/manager was unable to provide the inspector with the home’s fire risk assessment. Requirements have been raised. ELECTRICAL SAFETY – Up to date annual servicing stickers were seen to be in place on portable electrical appliances around the home. These were dated 26/03/07. The home has a valid electrical hardwiring certificate dated 28/04/05 and valid for 10yrs. GAS SAFETY – The registered provider was unable to provide evidence that the home’s gas boilers/heating/water, had been serviced by a CORGI registered company/person. It has been required that appropriate action is taken and that a copy of the Landlords Gas Safety Certificate be forwarded to the Commission within a given timescale. STAIR LIFT – The registered provider/manager stated that this was installed 18months ago and had not been serviced since. It has been required that action is taken to ensure that this is serviced within a given timescale and thereafter on a 6 monthly basis, in accordance with Health & Safety Executive and LOLER regulations. Evidence that this has been addressed must be forwarded to the Commission. HOT WATER OUTLETS – The temperature of the hot water outlet on the only available bathroom was checked at this inspection. The temperature was 52C which is in excess of the HSE recommended safe upper limits. Appropriate action must be taken to ensure service users are not placed at risk. At the time of this inspection, the provider/manager agreed to lock the bathroom until appropriate action could be taken. ACCIDENTS – The home maintains records of accidents. Records from September 2006 to date were examined. There had been 23 recorded incidents. The inspector noted that a high number related to one service user. On discussion with the registered provider/manager, the inspector was informed that the service users was reassessed and had moved into nursing care. The majority of accidents related to un-witnessed falls. No traits were noted by the inspector. At the last inspection it was noted that the registered provider/manager had not been informing the Commission of reportable incidents as required and detailed in Regulation 37 of the Care Homes Regulations 2001. A requirement was raised and had not been addressed. At this inspection, it appeared that two service users had passed away and notification had not been forwarded to the Commission. These were made available to the inspector at the time of this Ashcott Lawns DS0000015999.V350745.R01.S.doc Version 5.2 Page 28 inspection. The inspector reiterated the importance of informing the Commission of all detailed incidents in future, without delay. FIRST AID – The registered provider has not taken action to ensure that staff receive appropriate training in first aid. No staff currently at the home have received this training. Five staff completed comment cards for the Commission and all indicated that they had received training in moving and handling. No records were available at the home to confirm this and it was not clear when staff had last received training or of the content of the training. Ashcott Lawns DS0000015999.V350745.R01.S.doc Version 5.2 Page 29 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 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 x 18 1 3 3 3 2 3 2 x 1 STAFFING Standard No Score 27 2 28 1 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 1 x x 1 x 1 Ashcott Lawns DS0000015999.V350745.R01.S.doc Version 5.2 Page 30 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15(1) Requirement The registered person must ensure that care plans are fully reflective of an individual’s assessed needs. Unless impracticable, the service user must be involved in devising their care plan. The registered person must devise appropriate assessments for service users relating to moving & handling, risk of falls and reducing the risk of pressure sores. The registered person must provide a thermometer in the room storing medicines and record daily temperatures to ensure that the temperature does not exceed 25C. Appropriate action must be taken where the temperature exceeds this upper limit. The registered person must update the home’s complaints procedure to include clear timescales for action and the correct contact details of the Commission. Names of staff no longer employed by the home or DS0000015999.V350745.R01.S.doc Timescale for action 26/10/07 2 OP7 13(4)(c) 26/10/07 3 OP9 13(2) & 13(4)(c) 28/09/07 4 OP16 22 01/10/07 Ashcott Lawns Version 5.2 Page 31 5. OP18 13(6) the Commission must be removed. The registered person must devise a policy for staff relating to the protection of vulnerable adults. Previous timescales of 11/02/06, 14/02/07 & 10/09/07 not met. A copy of Somerset’s Safeguarding Adults policy (May 2007) should be available in the home. 26/10/07 6. OP18 13(6) 7. OP26 13(3) 8. OP30 18(1)(a) & (c)(i)&(ii) The registered person must make suitable arrangements to ensure that all staff received appropriate training in abuse. To reduce the risk of the spread of infection, the registered person must replace cloth towels and bars of soap with pump action liquid soap & paper hand towels. This applies to all communal toilets/bathrooms, kitchen, laundry and any ensuite toilet where staff assist service users with personal care. Foot operated bins must also be made available in these areas. The registered person must ensure that staff have the skills and training they need to meet the needs of service users. Previous timescale of 30/10/07 not passed. 15/12/07 28/09/07 30/10/07 9. OP31 9(2)(i) & 10(1)(3) The registered provider/manager must ensure that they are up to date with changes in legislation and that they undertake periodic training as is appropriate to ensure that they have the skills necessary for managing the care home. DS0000015999.V350745.R01.S.doc 10/12/07 Ashcott Lawns Version 5.2 Page 32 10. OP33 24 11. OP36 18(2) 12. OP38 13(4) The registered person must establish and maintain an effective quality assurance system which will seek the views of service users, their representatives and any other interested stakeholders The registered person must develop a documented system to ensure that staff receive formal supervision at least 6 times a year. The registered person must devise a policy for staff relating to safe moving and handling. Previous timescales of 11/02/06, 14/02/07 & 10/09/07 not met. 28/12/07 30/12/07 15/10/07 13. OP38 13(4) The registered person must take 10/10/07 appropriate action to ensure the health, safety and welfare of service users - staff must receive appropriate training in moving and handling with at least annual updates. - All staff involved in the preparation or serving of food must receive appropriate training in food hygiene. - Suitable arrangements must be made for the training of staff in first aid. - All staff must receive regular training in fire safety. Previous timescale of 10/10/07 not passed. 14. OP38 37 The registered person is required 26/09/07 to notify the Commission without delay of the occurrence of: (a) the death of any service user, including the circumstances (b) the outbreak of any DS0000015999.V350745.R01.S.doc Version 5.2 Page 33 Ashcott Lawns infectious disease (c) any serious injury to a service user (d) serious illness of a service user (e) any event in the care home (f) any theft, burglary or accident (g) any allegation of misconduct. You are required to forward any outstanding notifications to the Commission by the given date and submit any future notifications as they occur. Previous timescale of 06/08/07 not met. 15. OP38 13(4) & 23(2)(c) The registered person must arrange for the home’s gas boilers/systems to be serviced by a CORGI registered engineer. The Landlords annual Gas Safety Certificate must be forwarded to the Commission by the date shown. The registered person must ensure that the home’s stair lift is serviced in accordance with HSE and LOLER regulations. Evidence that this has been addressed must be forwarded to the Commission by the date shown. Thereafter, servicing should take place at 6 monthly intervals. After consultation with the fire authority, the registered person must devise a satisfactory fire risk assessment which meets with current requirements which came into force on 01/10/06. The registered person must take appropriate steps to ensure that service users are not placed at risk of scalding in the identified DS0000015999.V350745.R01.S.doc 05/10/07 16. OP38 13(4) 05/10/07 17. OP38 13(4) & 23(4)(a) 22/10/07 18. OP38 13(4) 27/09/07 Ashcott Lawns Version 5.2 Page 34 bathroom. Bath hot water outlets should not exceed HSE upper limits of 44C 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 OP7 Good Practice Recommendations To promote a person centred approach to care, the registered person should ensure that individual preferences of service users are identified in their plan of care. To reduce the risk of errors, the registered person should ensure that all hand written entries on the medication administration records, are confirmed with two staff signatures. To promote independence and choice, the registered person should give consideration to the use of serving dishes on tables at meal times. A menu should be displayed for service users. The registered person should regularly seek the views of service users relating to activities. Records should be maintained. It is strongly recommended that the registered person displays in a prominent position, an up to date copy of the home’s complaints procedure. It is strongly recommended that the registered person reviews the home’s provision of assisted bathing/shower facilities to ensure that they are accessible to all current service users. The registered person should provide lockable space for service users in each bedroom. To reduce the risk of the spread of infection, the registered person should take action to ensure that the laundry floor is replaced with an impermeable covering and that walls can be easily cleaned. The registered person should devise an on-call staff rota to ensure that this role is not undertaken by one person. The registered person should take steps to ensure that at least 50 of the care staff achieve a minimum of NVQ level 2 care. DS0000015999.V350745.R01.S.doc Version 5.2 Page 35 2. OP9 3. OP15 4. 5. 6. OP12 OP16 OP22 7. 8. OP24 OP26 9. 10. OP27 OP28 Ashcott Lawns 11. OP30 The registered person should give serious consideration to reviewing the staff induction programme to ensure that it meets with the Skills for Care Common Induction Standards. Ashcott Lawns DS0000015999.V350745.R01.S.doc Version 5.2 Page 36 Commission for Social Care Inspection Taunton Local Office Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Ashcott Lawns DS0000015999.V350745.R01.S.doc Version 5.2 Page 37 - 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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