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Inspection on 17/11/05 for Ashcroft Hollow Nursing Home

Also see our care home review for Ashcroft Hollow Nursing Home for more information

This inspection was carried out on 17th November 2005.

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The suitably trained nurses and community nurse specialists continue to support residents requiring specialist treatment for palliative care. The home providers have purchased a house to support staff that require some living accommodation. Training continues to be given high priority and training schedules are in place. The development of a new post at the home for a carer has been filled. The NVQ 3 trained candidate undertakes the role as a mentor. She has settled well in the position as is enjoying the work.

What has improved since the last inspection?

What the care home could do better:

Fire prevention safety checks must be carried out at all times by vigilant suitably trained staff. Wedges of varying types were seen propping open several doors throughout the home. These doors had door retainers fitted to them but they appeared faulty and unable to hold the door open. Several wedges were discarded with at the time of the inspection and the maintenance man was checking the doors as the inspector left the building.

CARE HOMES FOR OLDER PEOPLE Ashcroft Hollow Nursing Home 18a Stafford Road Huntington Cannock Staffordshire WS12 4PD Lead Inspector Mrs Joanna Wooller Announced Inspection 17th November 2005 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 Ashcroft Hollow Nursing Home DS0000022307.V261757.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ashcroft Hollow Nursing Home DS0000022307.V261757.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ashcroft Hollow Nursing Home Address 18a Stafford Road Huntington Cannock Staffordshire WS12 4PD 01543 574551 01543 574778 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) Leacroft Lodge Limited Mrs Pamela Marcello Williams Care Home 45 Category(ies) of Dementia (3), Old age, not falling within any registration, with number other category (45), Physical disability (10), of places Physical disability over 65 years of age (3), Terminally ill (4) Ashcroft Hollow Nursing Home DS0000022307.V261757.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. PD Minimum age 50 years Conditions for Palliative Care 2 All staff involved in the care of service users who are TI must receive appropriate training 3 The care home should employ a nurse who has achieved the Care of the Dying ENB931 or University Course K260 Death & Dying. This should be achieved within 6 months. TI - minimum age 60 years. Date of last inspection Brief Description of the Service: Ashcroft Hollow is a purpose built 45-bedded Care Home offering 24 hour nursing care. The home is located on the edge of Cannock Town set back from the main road / bus route. Registered Nurses and a team of fully trained care staff deliver care to the individual service users. Specialist equipment is available as required. Each service users has the benefit of en-suite w c facilities in their bedrooms. There are 4 separate day / quiet rooms and a dining room. Facilities are available for one rapid response service user. Community support services can be arranged as desired. Each service user has a named nurse and a key worker. The home is registered to admit four palliative care service users. The home has successfully received the Investors in People Award and the 1st home in the country to receive the Matrix award. Ashcroft Hollow Nursing Home DS0000022307.V261757.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was carried out on Thursday 17th November 2005 by one inspector. The National Minimum Standards were used as a reference for the visit. The total time spent for the inspection, including pre and fieldwork, amounted to 8hrs. The registered care manager Mrs Williams was in the home accompanied by the providers. The Deputy Manager and trained nurse and six care assistants were on duty. The ancillary staff on duty included; the administrator, the cook, a catering assistant, a laundry person and four domestics. These staffing levels were adequate to meet the needs of current 36 service users in the home. The inspection included the following elements; a short tour of the building, Observation and inspection of records relating to provision of care, Discussions with several service users, Discussions with all the staff members on duty, Observation and sampling of other services provided such as catering and laundry, and an inspection of the managerial aspects such as staffing issues and health & safety. Since the last inspection in June 2005; there had been one change to the management of the home as a new Deputy manager had been recruited, no complaints had been received and no additional visits had been necessitated. It was again clearly evident that necessary aspects of care had been addressed well, with residents able to choose the home following an assessment and invitation to visit the home. A family arrived at the home to view it during the inspection. Service user plans had been well written, based on the community care plans completed by social workers. Health, personal and social care needs had been met and documented. Privacy, dignity and choice aspects for residents were being upheld. The home was evidenced as providing a safe environment for the residents and staff except for the door wedges, which were seen propping open doors to several bedrooms. Ashcroft Hollow Nursing Home DS0000022307.V261757.R01.S.doc Version 5.0 Page 6 A very homely atmosphere had been created, and the premises were clean, warm and tidy. Adequate areas for residents were provided including; communal space, dining/activity space, bathing/toilet facilities, and bedrooms. Services and facilities, including catering and laundry, were provided in the home. General Health and safety aspects had been given a high priority. Recruitment and retention of staff aspects remains good with little staff turnover. Staff training had been given a high priority, with induction training being followed by NVQ training, and staff had received regular supervision. At this visit the home was found to be continuing to be well managed by a qualified and competent care manager. General management aspects were good with quality assurance taking place. Records had been correctly filed and stored. Assurances were given regarding the positive financial viability of the home, and that suitable accounting/business procedures are adopted. What the service does well: What has improved since the last inspection? What they could do better: Ashcroft Hollow Nursing Home DS0000022307.V261757.R01.S.doc Version 5.0 Page 7 Fire prevention safety checks must be carried out at all times by vigilant suitably trained staff. Wedges of varying types were seen propping open several doors throughout the home. These doors had door retainers fitted to them but they appeared faulty and unable to hold the door open. Several wedges were discarded with at the time of the inspection and the maintenance man was checking the doors as the inspector left the building. 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. Ashcroft Hollow Nursing Home DS0000022307.V261757.R01.S.doc Version 5.0 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 Ashcroft Hollow Nursing Home DS0000022307.V261757.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3 Each resident had been pre-assessed by a trained nurse prior to admission, to ensure his or her individual needs could be met at the home. Documentation seen was individual and personalised. EVIDENCE: Admission policy and procedures were in place and adhered to. Each service user had a pre-admission assessment completed and conformation that the individuals’ needs could be met was given in writing by the home to the resident or their relative. Those care records seen were evidence that this is carried out and the procedure followed precisely. Nurses assess the residents and discuss their findings with the manager prior to admission. Some visitors were in the home at the time of the visit having a look around the home before deciding if the home was suitable for their relative. A member Ashcroft Hollow Nursing Home DS0000022307.V261757.R01.S.doc Version 5.0 Page 10 of staff was seen showing them around the home and sensitively discussing their procedure for admission. There are no Intermediate Care beds at the home. (Standard 6) Ashcroft Hollow Nursing Home DS0000022307.V261757.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 10 The individually assessed health and personal care needs of service users had been well documented and were being met, with good standards of care being delivered. Care of the dying was covered through in house training. There was audited evidence of a safe system for the receipt, storage, administration and disposal of medicines. EVIDENCE: As at the last inspection the inspector spoke to the same resident accompanied by her son, for quite some time and again received very positive comments from both about the care being provided. The inspector spoke to several other residents during the visit. The resident care plans and associated documentation was well written and reflected the current condition of residents. Some assessments as identified to the nurse on duty were out of date and must be updated annually to be meaningful. Ashcroft Hollow Nursing Home DS0000022307.V261757.R01.S.doc Version 5.0 Page 12 The documentation seen enabled the inspector to evidence that health and personal care needs were being well met. The local GP’s practice and a Boots pharmacist service the home. NHS facilities and professionals including community nurses, medical consultants and clinical nurse specialists had all been accessed when required, and these events were seen recorded. It was observed through Boots audit forms that a safe medication administration system was in place, and that the comprehensive medicines policy documentation seen was being followed. Privacy and dignity were being afforded to residents, and the inspector evidenced good interaction with staff. Care staff were able to demonstrate this by the inspector evidencing care staff knocking on doors before entering bedrooms. Ashcroft Hollow Nursing Home DS0000022307.V261757.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 to 15 Visitors continue to be made welcome at the home and the staff encourage service users to exercise choice. Structured activity plans are in place and this is well recorded with photographs. Catering standards remain high and no issues were raised. EVIDENCE: An activity organiser is employed at the home and a many residents confirmed that they joined in activities and entertainment; sometimes one to one, small groups or an entertainer would visit the home. Residents confirmed that the staff would take them outside, when it was warm enough if they so wished. Christmas shopping trips were being arranged. Plans were being made foe Christmas parties and events. A number of residents continue to choose to stay in their own rooms. Other residents were evidenced in an activity session with the organiser or watching television. Ashcroft Hollow Nursing Home DS0000022307.V261757.R01.S.doc Version 5.0 Page 14 The residents confirmed that church services were held on occasions. Several residents spoke of their satisfaction with the food and they said they enjoyed the variety of meals and choices offered. The menus were examined and evidenced that the dietary requirements of residents were being met. The cook spoke to service users to establish his or her choice of food, and this was seen documented. A letter from Environmental Health Department confirmed that they were satisfied at their last inspection. The menu was displayed in the dining room on a chalkboard. Ashcroft Hollow Nursing Home DS0000022307.V261757.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Complaints are dealt with according to the home policies, procedures and staff training, protected residents from aspects of abuse. EVIDENCE: An examination of the complaints book, the relevant policy and procedure documentation, and a discussion with staff and service users, evidenced that complaints were listened to and continue to be dealt with in the correct manner. Many ‘thank you’ and complimentary cards and delightful letters were seen in the home from appreciative relatives. No incidents of neglect or abuse of any kind has been reported. The policy documentation seen, and a discussion with staff confirmed that residents are protected from all forms of abuse. Documentation seen evidenced that the above issues had been discussed at length during staff induction, training and on-going supervision. Ashcroft Hollow Nursing Home DS0000022307.V261757.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22, 23, 25 and 26 The home continues to provide an adequately maintained environment for residents. The home was clean, warm and tidy, and had a very welcoming and friendly atmosphere. The home has systems in place to ensure the safety of residents, staff and visitors is maintained. EVIDENCE: A tour of the building, and a check on the maintenance documentation, verified to the inspector that the premises were fit for purpose, clean and tidy. The areas were well ventilated. The duty rosters evidenced that adequate ancillary staff were employed. Laundry staff when asked told the inspector of their knowledge on infection control and COSHH. The laundry facilities were seen to be fully compliant. Adequate hand washing facilities were available throughout the home. Ashcroft Hollow Nursing Home DS0000022307.V261757.R01.S.doc Version 5.0 Page 17 The records evidence that maintenance of the premises was given high priority. Painting and re-decorating was ongoing. Hot water temperature checks, and emergency lighting/fire alarm testes were seen up to date and correct. There are no outstanding issues known from the Environmental health department. Specialist equipment is available for residents who require assistance. Ashcroft Hollow Nursing Home DS0000022307.V261757.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 to 30 Residents’ needs are met by the staff who are suitably trained. Residents are protected from abuse by the policies and procedures carried out within the home. EVIDENCE: Staffing levels were being maintained as 1st April 2002 and the staff were able to discuss and confirm that the cover was adequate for the present residents needs. Staffing rosters and levels were checked and were in order. Adequate ancillary staff had been provided each week The inspector spoke to a few residents and their visitors who when asked said that staff were available when they wanted them, and that the staff continued to be very dedicated. The homes recruitment policy, procedures and documentation were examined and recruitment issues had been handled correctly. Staff had been subject to POVA/CRB comprehensive checks, and these were seen recorded. Training had been given a high priority and the training records of individuals were seen. Ashcroft Hollow Nursing Home DS0000022307.V261757.R01.S.doc Version 5.0 Page 19 The records evidenced that all staff had benefited from ‘in house’ and external training, which had covered the needs of the client group. Training had again been provided for staff in the awareness and management of dementia related conditions. Ashcroft Hollow Nursing Home DS0000022307.V261757.R01.S.doc Version 5.0 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 35, 37 and 38 The home continues to be well managed and there was evidence that safeguards were in place to protect to service users. Most Health and safety issues had been given a high priority and managed well. EVIDENCE: From observations made by the inspector, the discussions with service users, and discussions with the manager and staff, it was evident that the home was generally being run in the interests of service users. A check on the records and a discussion with both residents and representatives evidenced that all service users had the opportunity to handle their own finances and all residents and families had chosen to do so. Inventories of valuables and belongings brought into the home were seen recorded. Ashcroft Hollow Nursing Home DS0000022307.V261757.R01.S.doc Version 5.0 Page 21 The documentation seen for checks and examination of plant and equipment was all correct and up to date. The staff spoken to confirmed that health and safety issues are given a high priority. A Requirement was made with regard to the use of door wedges in several bedroom doors. Those doors identified had been fitted with door retainers, which appeared faulty. This practise must stop immediately. The maintenance person was instructed at the time of the visit to attend to them. The inspector raised no other issues. A Recommendation was made with regard to record keeping and the recording of GP and other Professionals visits clearly within the care records. Ashcroft Hollow Nursing Home DS0000022307.V261757.R01.S.doc Version 5.0 Page 22 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 4 4 4 X X X HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 X 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 4 4 4 X 4 4 X 4 4 STAFFING Standard No Score 27 4 28 4 29 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 X X 3 X 3 2 Ashcroft Hollow Nursing Home DS0000022307.V261757.R01.S.doc Version 5.0 Page 23 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. 1. Standard OP38 Regulation 23 (4a) Sch 4 (14) Requirement Fire checks must be made throughout the day to ensure equipment linked with the fire alarm system is in working order. Under no circumstance must door wedges be used on Fire doors. Timescale for action 17/11/05 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 OP37 Good Practice Recommendations Care records should clearly show GP and other professionals visits within the care records. Ashcroft Hollow Nursing Home DS0000022307.V261757.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ashcroft Hollow Nursing Home DS0000022307.V261757.R01.S.doc Version 5.0 Page 25 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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