Inspection on 30/06/05 for Ashcroft Hollow Nursing Home

This inspection was carried out on 30th June 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.

Other inspections for this house

Ashcroft Hollow Nursing Home 07/11/07

Ashcroft Hollow Nursing Home 08/08/06

Ashcroft Hollow Nursing Home 17/11/05

Ashcroft Hollow Nursing Home 08/11/04

Ashcroft Hollow Nursing Home 05/05/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Ashcroft Hollow Nursing Home 18a Stafford Road Huntington Cannock Staffordshire WS12 4PD Lead Inspector Joanna Wooller Unannounced 30 June 2005 10:30 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 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 E51-E09 S22307 Ashcroft Hallow V235703 30.06.05 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Ashcroft Hollow Nursing Home Address 18a Stafford Road Huntington Cannock Staffordshire WS12 4PD 01543 574551 Telephone number Fax number Email 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 Ltd Mrs Pamela Marcello Williams CRH 45 Category(ies) of DE- 3 registration, with number OP- 45 of places PD- 3 PD(E)-3 TI- 4 Ashcroft Hollow Nursing Home E51-E09 S22307 Ashcroft Hallow V235703 30.06.05 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: PD Minimum age 50 years Conditions for Palliative Care 2 All Staff involved in the care of service users who are IT must receive appropriate training 3 The care home should employ a nurse who has achieved the care of the Dying ENB931 This should be achieved within 6 months TI- minimum age 60 years Date of last inspection 18/12/04 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. Ashcroft Hollow Nursing Home E51-E09 S22307 Ashcroft Hallow V235703 30.06.05 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on Thursday 29th June 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 4hrs. The registered care manager Mrs Williams was in charge of the home accompanied by her Deputy Manager and seven care assistants. The ancillary staff on duty included; cook, catering assistant, an activity organiser, a laundry person and four domestics. These staffing levels were adequate to meet the needs of current 38 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 November 2004; there had been no changes to the management of the home, one complaint had been received and no additional visits had been necessitated. It was 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. 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 well documented. Privacy, dignity and choice aspects for residents were being upheld. The home was evidenced as fit for purpose and provided a safe environment for the residents and staff. A very homely atmosphere had been created, and the premised 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 adequately provided. Health and safety aspects had been given a high priority and no shortfalls were noted. Ashcroft Hollow Nursing Home E51-E09 S22307 Ashcroft Hallow V235703 30.06.05 Stage 4.doc Version 1.40 Page 6 Recruitment and retention of staff aspects were 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. The home appeared to be managed well 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: Although redecoration is ongoing, the home is perhaps in need of a colour change in some areas. Please contact the provider for advice of actions taken in response to this Ashcroft Hollow Nursing Home E51-E09 S22307 Ashcroft Hallow V235703 30.06.05 Stage 4.doc Version 1.40 Page 7 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 E51-E09 S22307 Ashcroft Hallow V235703 30.06.05 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Ashcroft Hollow Nursing Home E51-E09 S22307 Ashcroft Hallow V235703 30.06.05 Stage 4.doc Version 1.40 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 standard(s) 3 Each service user had been pre-assessed prior to admission, to ensure their individual needs could be met at the home. 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 service user or their relative. There are no Intermediate Care beds at the home. (Standard 6) Ashcroft Hollow Nursing Home E51-E09 S22307 Ashcroft Hallow V235703 30.06.05 Stage 4.doc Version 1.40 Page 10 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 standard(s) 7,8,9 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. There was evidence of a safe system for the receipt, storage, administration and disposal of medicines. EVIDENCE: The inspector spoke to one service user for quite some time and received very positive comments about the care being provided. The service user plans and associated documentation was well written, meaningful and reflected the current condition of residents. 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. Ashcroft Hollow Nursing Home E51-E09 S22307 Ashcroft Hallow V235703 30.06.05 Stage 4.doc Version 1.40 Page 11 It was observed 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 inspector evidencing care staff knocking on doors before entering bedrooms. Ashcroft Hollow Nursing Home E51-E09 S22307 Ashcroft Hallow V235703 30.06.05 Stage 4.doc Version 1.40 Page 12 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 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 are high and no issues were raised. EVIDENCE: A full time activity organiser has been employed at the home and a number of service users confirmed that they have different forms of activities and entertainment; sometimes one to one, small groups or an entertainer would visit the home. Service users confirmed that the staff would take them outside if they so wished. A trip to the garden centre the week before had proved very successful. Plans were well underway for the summer fete, which was to be held in the grounds. Staff and relatives were arranging stalls and fund-raising events. A number of service users choose to stay in their own rooms. Other service users were evidenced listening to radios or watching televisions. The service users confirmed that church services were held on occasions. Ashcroft Hollow Nursing Home E51-E09 S22307 Ashcroft Hallow V235703 30.06.05 Stage 4.doc Version 1.40 Page 13 Several residents spoke of their satisfaction with the meals and choices offered. The menus and catering records were examined and evidenced that the dietary requirements of service users were met. The cook spoke to service users to establish his or her choice of food, and this was seen documented. The menu was displayed in the dining room. Ashcroft Hollow Nursing Home E51-E09 S22307 Ashcroft Hallow V235703 30.06.05 Stage 4.doc Version 1.40 Page 14 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 standard(s) 16 to 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 dealt with in the correct manner. Since the last inspection one complaint had been brought to the attention of this commission and dealt with accordingly. Many ‘thank you’ and complimentary cards 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 E51-E09 S22307 Ashcroft Hallow V235703 30.06.05 Stage 4.doc Version 1.40 Page 15 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 standard(s) 19 and 26 The home provides a safe and adequately maintained environment for residents. The home was clean, warm and tidy, and had a very welcoming and friendly atmosphere. EVIDENCE: A short 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. Staff when asked told the inspector of their knowledge on infection control, and showed him the relevant documentation. Adequate hand washing facilities were available throughout the home. The laundry facilities were seen to be fully compliant. The records evidence that maintenance of the premises was given high priority. Painting and re-decorating was ongoing. Ashcroft Hollow Nursing Home E51-E09 S22307 Ashcroft Hallow V235703 30.06.05 Stage 4.doc Version 1.40 Page 16 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 Fire Prevention or Environmental health departments. Ashcroft Hollow Nursing Home E51-E09 S22307 Ashcroft Hallow V235703 30.06.05 Stage 4.doc Version 1.40 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30 Recruitment procedures had been correctly addressed which had contributed to the protection of service users. Staff training had been given high priority. The assessed needs of service users had been met by an adequate number of suitably trained staff. EVIDENCE: Ashcroft Hollow Nursing Home E51-E09 S22307 Ashcroft Hallow V235703 30.06.05 Stage 4.doc Version 1.40 Page 18 Staffing levels were being maintained as 1st April 2002 and the staff confirmed that the cover was adequate for the existing service users 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 service users who when asked said that staff were available when they wanted them, and that the staff seemed 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. 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 been provided for staff in the awareness and management of dementia related conditions, and staff outlined this to the inspector. Ashcroft Hollow Nursing Home E51-E09 S22307 Ashcroft Hallow V235703 30.06.05 Stage 4.doc Version 1.40 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35 and 38. The home appeared to be well managed and there was evidence that safeguards were in place to protect to service users. 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 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 E51-E09 S22307 Ashcroft Hallow V235703 30.06.05 Stage 4.doc Version 1.40 Page 20 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. No issues were raised by the inspector. Ashcroft Hollow Nursing Home E51-E09 S22307 Ashcroft Hallow V235703 30.06.05 Stage 4.doc Version 1.40 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 4 x x x HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 4 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION 4 x x x x x x 4 STAFFING Standard No Score 27 4 28 x 29 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 4 4 x x 4 x 4 x x 4 Ashcroft Hollow Nursing Home E51-E09 S22307 Ashcroft Hallow V235703 30.06.05 Stage 4.doc Version 1.40 Page 22 Are there any outstanding requirements from the last inspection? 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 Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Ashcroft Hollow Nursing Home E51-E09 S22307 Ashcroft Hallow V235703 30.06.05 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection Stafford - 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. 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