Inspection on 08/08/06 for Ashcroft Hollow Nursing Home

This inspection was carried out on 8th August 2006.

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 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 17/11/05

Ashcroft Hollow Nursing Home 30/06/05

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 Mrs Joanna Wooller Key Unannounced Inspection 8 August 2006 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ashcroft Hollow Nursing Home DS0000022307.V306443.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. Ashcroft Hollow Nursing Home DS0000022307.V306443.R01.S.doc Version 5.2 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.V306443.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. PD Minimum age 50 years Conditions for Palliative Care All staff involved in the care of service users who are TI must receive appropriate training The care home should employ a nurse who has achieved the Care of the Dying ENB931 or University Course K260 Death & Dying. TI - minimum age 60 years. TI - Permission to admit one service user aged 46 years on admission 3. 4. Date of last inspection 17th November 2005 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.V306443.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Lead Inspector carried out this Unannounced Key Inspection with the assistance of a Co-worker, Kath Marks. The Home Manager was on duty supported by Her Deputy Manager and six Carers. The inspection included the following elements; A 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. The Inspectors were made very welcome in the home and all assistance was given to gain the evidence required for the report. Fees – Highest £575. Lowest £375. One complaint had been dealt with by Commission for Social Care Inspection since the last inspection and this was now resolved. Service Users spoken to at the visit were complimentary about the home as were the comments received on the Feedback cards, which were returned. The Providers also visited the home during the Inspection to meet with the Inspector. One relative spoke of the “excellent care that the staff had delivered to her mother and she was delighted with the choice they had made regarding the home”. What the service does well: The home offers a caring environment to Service Users requiring 24hr Nursing Care. The staff assists the Service Users to maintain as much independence as possible. The home is very clean and tidy and maintained in good order and appearance. The Manager holds the Care of the dying qualification and the Registered Managers Award. Palliative care is offered in the home and many Thank You cards are displayed from appreciative relatives. The Nursing staff has made good links with many Nurse Specialists to ensure high quality care is delivered when meeting the Service Users individual needs. Ashcroft Hollow Nursing Home DS0000022307.V306443.R01.S.doc Version 5.2 Page 6 All the staff has received ongoing training in all areas specific to their role in the home and NVQ Training and Internal promotion is encouraged and supervised. 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. Ashcroft Hollow Nursing Home DS0000022307.V306443.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 Ashcroft Hollow Nursing Home DS0000022307.V306443.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 This quality outcome is good. This judgement has been made using available evidence including a visit to this service. Service Users are individually assessed prior to admission, which ensures that their needs can be met whilst at the home. EVIDENCE: A Registered Nurse prior to admission individually assesses each Service User. Clear notes are recorded and an admission is only organised once the home can ensure that the Service Users needs can be met. This is agreed in writing. Potential Service Users and their representatives have the opportunity to visit the home, read the Statement of Purpose and look around the home with a chance to speak to other Service Users. One relative spoken to confirmed that they had been included in this procedure and had found the staff most helpful and sympathetic. Ashcroft Hollow Nursing Home DS0000022307.V306443.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 to 11 This quality outcome is good. This judgement has been made using available evidence including a visit to this service. Service Users health, personal and social care needs are set out in care plans to ensure their needs can be met. Service Users are treated with respect and their privacy respected. Service Users are assured that at the time of their death, staff will be respectful to them and their relatives. EVIDENCE: As before and at many previous inspections the inspector spoke to the same Service User 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 Service Users during the visit. The Service Users 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.V306443.R01.S.doc Version 5.2 Page 10 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. There was evidence of Boots audit forms confirming that a safe medication administration system was in place, and that the comprehensive medicines policy documentation seen was being followed. One relative spoke of the “excellent care that the staff had delivered to her mother and she was delighted with the choice they had made regarding 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. Privacy and dignity were being afforded to Service Users, 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.V306443.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 - 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Management and staff of the home provide a warm comfortable relaxed environment for vulnerable older people. Service Users were encouraged to continue with their chosen life style. They were prepared a balanced diet with choices on a daily basis. Visitors continue to be made welcome at the home and the staff encouraged service users to exercise choice. Individual records are maintained of all activities taking place. EVIDENCE: Service Users at Ashcroft Hollow experience a varied lifestyle with lots of activities taking place. The activities organiser has recently terminated her employment at the home due to personal issues and staff were carrying on with activities while the management recruit to the post. Religious needs are met by visiting ministers or residents attending church. Visitors were moving freely in and out of the home and were positive in their comments to inspectors. One service user has an advocate who visits her weekly. The home does not deal with service users finances this is dealt with by relatives or solicitors. Ashcroft Hollow Nursing Home DS0000022307.V306443.R01.S.doc Version 5.2 Page 12 Menus covered four weeks; the qualified cooks were on duty throughout the day and prepared balanced nutritional homemade food. Dining room tables were attractively set with tablecloths and serviettes. Relatives felt the meals and choice were excellent and the Service Users spoken to agreed with this. Ashcroft Hollow Nursing Home DS0000022307.V306443.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 - 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints system with some evidence that resident’s feel their views are listened to. In house awareness training takes place to protect residents from abuse. EVIDENCE: As at the previous inspection 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. No incidents of neglect or abuse of any kind has been reported. Staff training and observations of service users ensured that they are protected from all forms of abuse. A large number of thank you cards from service users relatives were on display on the notice board. One relative said she would be able to talk to the Manager before making any type of complaint and felt that it would not be an issue. Ashcroft Hollow Nursing Home DS0000022307.V306443.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment within this home is good providing service users with an attractive and homely place to live. EVIDENCE: As at the previous inspection the home generally is well maintained and suitable for its stated purpose. There is a programme of routine maintenance and renewal of soft furnishings and equipment. Externally there are attractive gardens a patio area tables, chairs, and umbrellas had been provided. There is a lawn and parking to the front of the home. Ashcroft Hollow Nursing Home DS0000022307.V306443.R01.S.doc Version 5.2 Page 15 Service Users bedrooms are comfortable and have been personalised as they wish. The Inspector when walking around the home found the environment clean attractive homely and odour free. Specialist equipment is purchased as required to support the Service Users needs. Ashcroft Hollow Nursing Home DS0000022307.V306443.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 to 30 This quality outcome is good. This judgement has been made using available evidence including a visit to this service. Service Users needs are met by the staff that is suitably trained. Service Users are protected from abuse by the policies and procedures carried out within the home. EVIDENCE: Staffing levels were being maintained as 1st April 2002 on the Notice of Staffing issued by the Health Authority. Staffing rosters and levels were checked and in order. The home employs adequate numbers of ancillary staff to carry out domestic and kitchen duties. The inspector spoke to a few Service Users and one visitor. The Service Users said that staff was wonderful and always available when they wanted them. The relative spoken to had much praise for the home, the staff and the care that her mother received. She felt reassured that she was in a safe place and well cared for. There were no changes in the homes recruitment policy, procedures and documentation. Staff had been subject to POVA/CRB comprehensive checks, and these were being recorded. Training had been given a high priority and the training records of individuals were seen. Ashcroft Hollow Nursing Home DS0000022307.V306443.R01.S.doc Version 5.2 Page 17 Relatives spoken to said the staff were all very welcoming and friendly. 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 and palliative care. Ashcroft Hollow Nursing Home DS0000022307.V306443.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 This quality outcome is good. This judgement has been made using available evidence including a visit to this service. Service Users live in a well managed home, which has the Service Users best interests at the forefront of the individualised care. The health, safety and welfare of all the Service Users and staff is protected. EVIDENCE: From observations made by the inspectors, the discussions with service users and one relative, and discussions with the manager and staff, it was evident that the home was generally being run in the interests of service users. Relatives spoke very highly of the Management at the home and felt that the Manager was very open and approachable. The Inspector checked all relevant records required to meet the National Minimum Standards and a discussion with both Service Users and Ashcroft Hollow Nursing Home DS0000022307.V306443.R01.S.doc Version 5.2 Page 19 representatives evidenced that all service users had the opportunity to handle their own finances and all Service Users and their families had chosen to do so. The documentation evidenced by the Inspector for servicing and examination of machinery and equipment was all correct and up to date. The staff spoken to confirmed that health and safety issues are given a high priority and the evidence seen by the Inspector supported this. The records requested by the Inspector were well kept, in order and up to date. Ashcroft Hollow Nursing Home DS0000022307.V306443.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 4 X X X HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 4 10 4 11 4 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 X X X X X X 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 X 4 X 4 X X 4 Ashcroft Hollow Nursing Home DS0000022307.V306443.R01.S.doc Version 5.2 Page 21 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. 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. Refer to Standard Good Practice Recommendations Ashcroft Hollow Nursing Home DS0000022307.V306443.R01.S.doc Version 5.2 Page 22 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.V306443.R01.S.doc Version 5.2 Page 23 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!