Inspection on 14/11/06 for Ashcott Lawns

This inspection was carried out on 14th November 2006.

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 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 12/09/07

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 Alison Philpott Unannounced Inspection 14th November 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ashcott Lawns DS0000015999.V317055.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.V317055.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.V317055.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th October 2005 Brief Description of the Service: Ashcott Lawns provides residential care for up to 17 older people. The home is owned and managed by Mrs. Corbett, who lives on the premises. The accommodation is an attractive Grade 2 listed house, which were originally two cottages. It has been adapted as far as possible to meet the needs of older people, however, some service users need to be ambulant as there are a further steps to most first floor bedrooms. 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 £385 to £485 per week. Ashcott Lawns DS0000015999.V317055.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The previous inspection took place on 11 October 2005. This unannounced key inspection took place over 6.5 hours on 14 November 2006. Mrs Monica Corbett, the provider and manager was available throughout the inspection. There were eight residents living in the home. During the inspection, seven residents and three members of staff were spoken with. The Inspector viewed the home. There was a comfortable and homely atmosphere. Staff were friendly and were observed being kind and caring toward residents. Records viewed included care plans; accidents; medication; staff recruitment & training. The Inspector would like to thank the residents and staff for their involvement and participation in the inspection process. As a result of this inspection the home has four requirements and one recommendation. What the service does well: Residents benefit from a homely environment and are able to choose how they spend their time. Residents were very positive and comments included “if you’ve got to be in a home you couldn’t have a better one” and “you can’t fault the place”. All residents spoken with confirmed that the food at the home is ‘very good’ or ‘excellent’. Care plans contain a good level of detail and person centred information to enable staff to meet each resident’s healthcare & social needs. Staff are friendly and caring. Staff respect resident’s privacy and were observed offering support and choices to residents. Ashcott Lawns DS0000015999.V317055.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Ashcott Lawns DS0000015999.V317055.R01.S.doc Version 5.2 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 Ashcott Lawns DS0000015999.V317055.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home undertakes a pre-admission assessment to ensure it can meet the needs of prospective residents. EVIDENCE: The home has not admitted any new residents since the previous inspection. However, the home has a comprehensive personal needs assessment that would be completed for a prospective resident. The manager visits prospective residents in their own home or in hospital to undertake the needs assessment and ensure that the home can meet the individual’s needs appropriately. The home has not introduced intermediate care since the last inspection. Ashcott Lawns DS0000015999.V317055.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are comprehensive and detailed. The home’s medication procedures protect residents. Staff respect resident’s privacy and dignity. Ashcott Lawns DS0000015999.V317055.R01.S.doc Version 5.2 Page 10 EVIDENCE: The Inspector viewed two care plans. These contained a good level of detail and person centred information to enable staff to meet each resident’s healthcare & social needs. Individual care plans are reviewed monthly and a written summary is provided. Residents have access to a range of professionals including GP, District Nurse, Dentist, Social Worker, CPN, Optician and Chiropodist. The home keeps a record of professional visits. Medication is stored securely. Each resident has a medication box. There were no gaps in the Medication Administration Record (MAR) Sheets. Hand transcribed MAR Sheets contained two signatures and were dated. The application of prescription creams was recorded on the MAR sheet. The home has recorded variable doses on the MAR Sheet. The controlled drugs were double locked. The Inspector checked the balance of one medicine and this was correct. The book contained two signatures. Where there had been a change in a resident’s medication, there was evidence that the GP had faxed the consent to the home. Staff spoken with demonstrated a good awareness of how to respect resident’s privacy and dignity. Residents confirmed that they are treated with respect. Some residents have chosen to have a private telephone line in their bedroom. Ashcott Lawns DS0000015999.V317055.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home offers activities for those residents who wish to participate. Visitors to the home are made to feel welcome. Residents choose how to spend their time. Residents are very happy with the food at the home. Ashcott Lawns DS0000015999.V317055.R01.S.doc Version 5.2 Page 12 EVIDENCE: Activities include games, jigsaw puzzles, and painting. Once a month, an entertainer visits to play the keyboard and organise a sing-a-long. During the inspection, residents were observed singing, watching television, reading, and chatting. One resident was observed enjoying laying the dining tables for lunch. Another resident confirmed that they like to take a short walk to the local post office and shop. The Inspector observed warm and friendly interaction between staff and residents. All residents spoken with commented on the kindness of the staff. All residents spoken to confirmed that their visitors are made to feel welcome at the home. Residents’ families are invited to special occasions at the home and lunch is offered to families when they are visiting. The Inspector observed staff offering resident choices throughout the day. Residents confirmed that they can spend their time as they want to and that they are given choices. Resident’s rooms are very homely and personalised with their own possessions. The home has a four week menu. Staff and residents confirmed that food is home cooked and a selection of fresh vegetables is provided. The tables in the dining room were laid attractively for lunch. Fresh flowers were on display in the room. The inspector joined the residents for lunch. The meal was chicken casserole, mashed potato, cauliflower, carrots and broccoli. There was a choice of rice pudding or yoghurt for dessert. The food was well presented and tasty. Residents confirmed that they enjoyed their lunch and all residents spoken with confirmed that the food at the home is ‘very good’ or ‘excellent’. Home made cake was available with afternoon tea. Ashcott Lawns DS0000015999.V317055.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are confident that any concerns will be addressed. Staff know what action to take should they discover abuse. However, the home does not have a policy relating to abuse. EVIDENCE: The home has not received any complaints since the last inspection. Residents spoken with confirmed that they knew who to speak to if they should have any concerns. The home has a whistleblowing policy. Staff spoken with demonstrated an awareness of the steps to take if they witnessed or discovered abuse. However, the home does not have a policy relating to abuse. The home must ensure that a policy is written and implemented so that staff feel confident in the action they need to take should the situation arise, in order to protect residents. Ashcott Lawns DS0000015999.V317055.R01.S.doc Version 5.2 Page 14 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, 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a homely and well maintained environment. The home is clean, pleasant and hygienic. Ashcott Lawns DS0000015999.V317055.R01.S.doc Version 5.2 Page 15 EVIDENCE: The Inspector viewed the home. The environment is well maintained and homely with comfortable furnishings. The home has a pleasant lounge and dining area. The gardens are attractive and well maintained. Since the last inspection, the home has re-decorated and re-carpeted several bedrooms. One of the bathrooms was being re-furbished and the toilet on the ground floor has been completed recently. The home was cleaned to a high standard and smelt fresh throughout. The inspector observed that the laundry was clean and tidy. Staff were observed wearing aprons. Gloves are available for staff. Ashcott Lawns DS0000015999.V317055.R01.S.doc Version 5.2 Page 16 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, 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home appeared to have sufficient staff on duty to meet resident’s needs. Staff recruitment procedures are not sufficiently robust to protect residents. Staff have a good knowledge of resident’s individual needs and preferences. Staff receive instruction and handouts but the home does not have a structured training programme. EVIDENCE: There were sufficient staff on duty during the inspection to ensure that resident’s needs were met. The home employs three staff in the morning; two staff in the afternoon; and one waking staff at night. The provider lives on site and provides additional support and on call cover. Residents confirmed that staff are available when assistance is required. Ashcott Lawns DS0000015999.V317055.R01.S.doc Version 5.2 Page 17 The home has a stable staff team. One new member of staff had been recruited since the last inspection. A Criminal Record Bureau (CRB) disclosure form had been completed. This had not yet been submitted to the CRB. The provider advised that she had been in discussion with the CRB as the home’s account had been suspended due to a lack of applications. The member of staff is currently on sick leave. The inspector explained Protection of Vulnerable Adult (POVA) first checks and how to apply. The member of staff must not recommence work in the home until a POVA first check has been received. The provider was unable to locate the documentation relating to the recruitment of the member of staff. The home must ensure it has obtained all of the documentation listed in Schedule 2 of the Care Homes Regulations 2001, to protect residents from the risk of harm. The home is required to submit a copy of the application form, two written references, POVA first check and completed CRB disclosure to the Commission for Social Care Inspection. The home has a folder containing information relating to its philosophy of care; code of conduct; confidentiality; gifts; equal opportunities; whistleblowing; Control of Substances Hazardous to Health; fire; medication; duties; how to use equipment and various policies. This information is used as part of the home’s induction. The home should ensure that induction training covers safe working practices including moving & handling; fire; first aid; food hygiene; and infection control. The home should ensure that staff sign off the areas they are trained in to evidence that the training has been completed. Staff spoken with demonstrated a good knowledge and understanding of residents’ needs and preferences. Staff spoken with have extensive experience of working in care. One member of staff at the home has completed an NVQ. The home has implemented a comprehensive fire training package. This includes a plan of the building, fire procedure, and information relating to the fire zones, fire alarm system and fire extinguishers. Knowledge is assessed through discussion and the use of a questionnaire. Staff sign and date the questionnaires. The home has some training videos and various handouts relating to health and safety. The provider also provides verbal instruction and discussion with staff. The home should document and evidence training provided in safe working practices, as above. The home needs to ensure that staff receive this mandatory training annually so that they are updated and equipped to meet the needs of residents. The provider advised that staff completed continence training in August 2006. Ashcott Lawns DS0000015999.V317055.R01.S.doc Version 5.2 Page 18 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, 35, 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed. The home seeks the views of residents. The health, safety and welfare of residents and staff are generally promoted and protected. Ashcott Lawns DS0000015999.V317055.R01.S.doc Version 5.2 Page 19 EVIDENCE: Mrs Corbett has owned and managed the home for 19 years. Residents were very positive and commented “she’s always there and knows all of the families”, “if you’ve got to be in a home you couldn’t have a better one” and “you can’t fault the place”. Staff spoken with were long serving employees and confirmed that they enjoy their work, find the manager approachable and feel involved in the day to day running of the home. The manager advised that a questionnaire was recently distributed to all residents to obtain feedback in relation to activities in the home. The manager speaks to residents on a daily basis. The home does not currently hold monies for any of its residents. Therefore, Standard 35 was not assessed at this inspection. The home tests its fire alarm system and emergency lights weekly. Fire extinguishers were serviced in April 2006. Where a resident chooses to have their bedroom door wedged open, the home has fitted doorguard release mechanisms to reduce the risk of harm in the event of a fire. Portable appliance testing was last carried out in March 2005. The home must ensure that this testing is undertaken as it is now overdue, in order to safeguard residents and staff. The home has purchased a new bath lift and stair lift. The inspector advised the home that these will need to be serviced every six months in accordance with The Lifting Operations and Lifting Equipment Regulations 1998. The home carries out regular checks on hot water temperatures and maintains a record. Accidents are recorded in the home’s accident book. Cleaning chemicals were stored securely. Ashcott Lawns DS0000015999.V317055.R01.S.doc Version 5.2 Page 20 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 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X N/A X X 2 Ashcott Lawns DS0000015999.V317055.R01.S.doc Version 5.2 Page 21 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 OP8 Regulation 13(4)(c) Requirement The home must devise a policy relating to pressure area relief. (This timescale was previously unmet). The home must devise a policy relating to the protection of vulnerable adults. (This timescale was previously unmet). When recruiting staff, the home must ensure it obtains all of the documentation listed in Schedule 2 of the Care Homes Regulations 2001. For one identified member of staff, the home is required to submit a copy of the application form, two written references, POVA first check and completed CRB disclosure to the Commission for Social Care Inspection (The member of staff must not recommence work in the home until a POVA first check has been received). • The home must ensure that Portable Appliance Testing is undertaken as it is now overdue. DS0000015999.V317055.R01.S.doc Timescale for action 14/02/07 2. OP18 13(6) 14/02/07 3. OP29 19 (b) (i) 15/11/06 4. OP38 13(4) 14/02/07 Ashcott Lawns Version 5.2 Page 22 • The home must devise a policy relating to safe moving and handling. (This timescale was previously unmet). 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 OP30 Good Practice Recommendations • The home should ensure that induction and mandatory training covers safe working practices including moving & handling; fire; first aid; food hygiene; and infection control. • The home needs to ensure that staff receive this mandatory training annually so that they are updated and equipped to meet the needs of residents. • The home should ensure that staff sign off the areas they are trained in to evidence that the training has been completed. Ashcott Lawns DS0000015999.V317055.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Somerset Records Management Unit 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. 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