Inspection on 23/01/06 for Ashcroft House

This inspection was carried out on 23rd January 2006.

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

Ashcroft House 01/02/10

Ashcroft House 17/11/09

Ashcroft House 23/06/09

Ashcroft House 25/06/08

Ashcroft House 27/06/07

Ashcroft House 12/06/06

Ashcroft House 11/10/05

Ashcroft House 02/08/04

Ashcroft House 14/04/04

Ashcroft House 11/02/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Ashcroft House Fairview Close Wilderness Hill Cliftonville CT9 2QE Lead Inspector Clair Brown Unannounced Inspection 23rd January 2006 10.45 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 House DS0000040622.V274610.R01.S.doc Version 5.1 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 House DS0000040622.V274610.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Ashcroft House Address Fairview Close Wilderness Hill Cliftonville CT9 2QE 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) 01843 296626 01843 571551 Mr C Osman Care Home 88 Category(ies) of Dementia - over 65 years of age (49), Old age, registration, with number not falling within any other category (39) of places Ashcroft House DS0000040622.V274610.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. To admit one (1) Service User, under the category of LD, whose date of birth is 10/11/1932. 11th October 2005 Date of last inspection Brief Description of the Service: Ashcroft House is an exceptionally large detached property, which was previously a hospital, with three floors, which have additional wings; currently the top floor is closed whilst the company considers refurbishment requirements. The Home offers a mixture of care provisions; residential, nursing and dementia. The home is situated within walking distance of local amenities. There is a shaft lift to access the upper levels. Ashcroft House DS0000040622.V274610.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the home’s unannounced inspection. The inspection was conducted by two inspectors and the duration of the inspection was 5.5 hours over one day. The Homes the acting manager and a company representative were not available therefore the inspection was conducted with the head of care. Additional time was spent in planning the inspection and report writing. Some staff were actively involved in the inspection. Time was also spent observing interaction between staff and service users. A partial tour of the premises was conducted, documents and records were examined, service users files were case tracked and one floor had medications checked. What the service does well: What has improved since the last inspection? What they could do better: There has been little progress made to comply with the previously made requirements. The assessment of prospective service users needs to be developed into a thorough assessment that is recorded in detail. Care plans need to be developed further to include specific details about the care needed, fluid intake, skin integrity and movement & handling needs. Proper reviews of these documents need to be conducted regularly. Detailed reports of care Ashcroft House DS0000040622.V274610.R01.S.doc Version 5.1 Page 6 provided should be kept. The registered persons still need to develop a plan for the renewal of the old worn out furniture. The procedures for the recruitment of new staff should be improved to ensure that they are fully vetted before starting work. The induction of new staff should be more in depth and the training of staff should include dementia care. Staffing levels have been reduced, these need to be reviewed to ensure sufficient numbers of care staff are provided. Medication procedures need to be improved to ensure they are administered safely and recorded correctly. 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 House DS0000040622.V274610.R01.S.doc Version 5.1 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 House DS0000040622.V274610.R01.S.doc Version 5.1 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): 3,4 Some prospective service users are assessed but information gathered and recorded is insufficient. Service users are admitted outside of the registration of the home. EVIDENCE: A recently admitted service users file was assessed. A detailed care manager’s assessment had been obtained however the homes own assessment was not signed and dated and contained very little information. Another service user was admitted without any formal pre-admission assessment being conducted. A service user has been admitted outside of the homes registration both in age and category, the full details of this persons needs was not shared with the Commission when seeking permission to admit them. Ashcroft House DS0000040622.V274610.R01.S.doc Version 5.1 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): 7,8,9 The care planning system does not adequately provide staff with the information they need to satisfactorily meet service users needs. Medicines are not being handled or managed effectively and this could potentially place service users at risk. EVIDENCE: The service user admitted outside of the homes registration care plan failed to identify how the care staff are to manage and respond to the aggressive behaviour and alcohol dependency, these needs were identified and recorded in the care managers assessment. One lady recently admitted was blind in one eye and deaf yet the care plan stated there was no problems with communication. The care managers’ assessment stated that she had a poor appetite and needs lots of encouragement, the care plan recorded; no problems eats normal diet. The nutritional assessment had not been reviewed for two months. Medication records showed that the procedure for handling and recording of control drugs does not comply with current requirements. There were some gaps in the records of medication administered. Following the previous additional visit, requirements were made relating to the poor Ashcroft House DS0000040622.V274610.R01.S.doc Version 5.1 Page 10 practices for the handling of controlled drugs, sharing other service users prescribed medication and poor record keeping. Ashcroft House DS0000040622.V274610.R01.S.doc Version 5.1 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): EVIDENCE: Ashcroft House DS0000040622.V274610.R01.S.doc Version 5.1 Page 12 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 The policies and procedures are not accessible for staff to refer to. EVIDENCE: The head of care was unable to find the policies and procedures relating to complaints and adult protection. Ashcroft House DS0000040622.V274610.R01.S.doc Version 5.1 Page 13 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): 19,26 No significant improvements have occurred with the environment since the last inspection, although the overall décor’ is pleasant. Infection control procedures place service users at risk. EVIDENCE: Infection control practices by staff were observed these were unacceptable and very poor. A carer entered the bedroom wearing gloves, then proceeded to handle both the commode and urinal which had been used but did not remove them for cleaning; the carer then removed the gloves but did not throw them away but continued to hold them in their hand, then proceeded to handle the service users dinner plate and pudding bowl (the service user had not eaten their desert) then carried the dirty plate and gloves out of the room. At no stage did the carer wash their hands and she was planning to take the plate to the kitchen. When discussing with the carer what she had done she demonstrated that she had no understanding of infection control procedures. The carer also said she had worked at the home for a year and had not received any form of infection control training. Ashcroft House DS0000040622.V274610.R01.S.doc Version 5.1 Page 14 Ashcroft House DS0000040622.V274610.R01.S.doc Version 5.1 Page 15 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): 27,29,30 The deployment and number of staff provided during the 24-hour day is not sufficient to meet the needs of the service users. Staff do not have the skills required to fulfil their roles. The recruitment procedures do not protect the welfare of the service users. EVIDENCE: Carers expressed their concerns and were obviously distressed by the decreased numbers of staff and the increased workload. This was confirmed when comparing the current and past duty rotas. The home has admitted service users with complex needs but this is not reflected in the staffing numbers. On the first floor (dementia wing) there are four carers; on the ground floor there is one registered nurse and an average of 5 carers although between 2-4pm this is reduced to 1 registered nurse and 3 carers. There is 1 registered nurse and 4 carers for both floors at night. At the time of the inspection there were 56 service users. The training matrix reflects that some staff have not completed the mandatory courses and only two carers have completed the NVQ training. The staff files demonstrated poor recruitment procedures, written references are not obtained and records of verbal references reflected concerns relating to the ability and suitability of the person. Staff are employed without the receipt of a POVA first checks and before the CRB has been returned. Ashcroft House DS0000040622.V274610.R01.S.doc Version 5.1 Page 16 Ashcroft House DS0000040622.V274610.R01.S.doc Version 5.1 Page 17 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): 32,33 The management structure of the home fails to ensure consistency and leadership. EVIDENCE: The acting manager was away on the day of the inspection; therefore the head of care took the inspection. Although she has care knowledge and skills, she was not aware of the overall management processes of the home and demonstrated little understanding of the National Minimum Standards. The acting manager had not informed the head of care of changes of locations of some documents and therefore they could not be located. It was not possible to inspect the quality assurance programme due to the absence of the acting manager. Ashcroft House DS0000040622.V274610.R01.S.doc Version 5.1 Page 18 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 2 1 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 x COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 1 2 X X X X X X 1 STAFFING Standard No Score 27 1 28 1 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 2 1 X X X X X Ashcroft House DS0000040622.V274610.R01.S.doc Version 5.1 Page 19 Yes 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 OP1 Regulation 4 5 sch 1 Requirement The Statement of Purpose and Service Users Guide must be amended to include all of the required information. previous requirement:31.12.03,11.04.04, 28.02.05,13.01.06 Thorough and detailed preadmissions assessments must be conducted and recorded for all prospective service users. previous requirement: 30.11.04 & 13.01.06 Service user D.O.B 24/06/43 admitted since the last inspection, outside of the current registration for both age and history of substance/alcohol abuse, an application for a condition on the registration must be made including full details on how the home will meet their needs. Service users must not admitted outside of the homes registration. Care plans must be more detailed in some areas; for example, skin integrity assessments and specific details DS0000040622.V274610.R01.S.doc Timescale for action 31/03/06 2 OP3 14,15 31/03/06 3 OP4 12,14,18 31/03/06 4 OP7OP8 12 13 14 15 16 31/03/06 Ashcroft House Version 5.1 Page 20 5 OP9 12 13 16 17 23 sch 3 6 OP9 12 13 16 17 23 sch 3 7 OP9 12 13 16 17 23 sch 3 12 13 16 17 23 sch 3 8 OP9 about providing care, such as fluid intake, personal care, movement & handling needs. Reviews must be conducted regularly and be a true review of assessed needs. Daily reports must record all aspects of care provided and be linked to the care plan. previous requirement: 31.12.04 & 31.03.06 Medication must not be shared between service users, including controlled drugs. Staff must not accept instructions from General Practitioners to give service users medicines to other service users. 09/12/05 Medication administered via syringe driver must be recorded showing; 1) the name and strength of medicine and dosage, 2) what solution the drug was diluted with, 3) total volume & syringe size, 4) batch numbers, 5) rate the syringe driver is set at and duration. 6) time of new or refill of syringe driver is commenced and ceased, 7) amount wasted when changed or discontinued, 8) record of administration site, with condition of site observed. 9) name & signatures of staff administering. 09/12/05 Clear and accurate records of administration must be kept of all medication administered with written evidence of them being prescribed. 09/12/05 The manager is required to conduct a full medication audit and submit a detailed report with an action plan to the Commission (CSCI). DS0000040622.V274610.R01.S.doc 31/03/06 31/03/06 31/03/06 28/02/06 Ashcroft House Version 5.1 Page 21 9 OP16OP18 12 13 20 22 23 10 OP19 11 OP24 12 OP27 13 14 OP28 OP29 15 OP30 Both complaints & adult protection procedures and complaints records must be made accessible to all staff at all times. 13,23 A new schedule of accommodation must be submitted the CSCI whenever changes are made to the environment. 12 13 14 An action plan including 16 23 timescales must be submitted to the CSCI for the replacement of old, worn out furniture. To include wardrobes, beds, drawer units, bedside tables and chairs. Sufficient numbers of adjustable beds must be provided for those needing nursing care. 17,18 sch The registered provider & 4 manager are required to review staffing levels and provide sufficient numbers of care staff. Evidence is to be sent to the CSCI by 28.02.06 18 50 of care staff must have the NVQ Level 2 in care qualification. 7,9,19 sch (1)Recruitment procedures must 2 be thorough, exploring gaps in employment history, interview records must be completed and POVA and CRB checks must be completed before employment starts. (2)To contact the Home Office to confirm the need to identify work place on the work permits. Evidence of compliance to be submitted to the CSCI 12,18 (1)Induction programmes must be completed by all new staff with topics covered in depth. Previous requirement: 14.04.04 (2) All staff must have completed basic dementia training. Care staff must complete a more advanced DS0000040622.V274610.R01.S.doc 31/03/06 31/03/06 31/03/06 28/02/06 31/12/06 31/03/06 31/03/06 Ashcroft House Version 5.1 Page 22 16 17 OP31 OP33 7,9,10,12 10, 12, 15,24 18 OP38 12 13 16 17 23 sch 4 dementia training programme. Previous requirement: (1) 13.01.06 (2) 30.06.06 An application must be made to register a manager with the CSCI For the Home to develop and implement an annual quality monitoring system. Producing a report, copy must be sent to the Commission. Previous requirement: 30.04.05 The fire risk assessment and environmental risk assessments must be more detailed and kept under regular review. 13.01.06not inspected. 31/03/06 31/03/06 31/03/06 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 OP15 Good Practice Recommendations To review meal times, so that meals are provided more evenly throughout the day. For a review of the service users food budget to be conducted, to ensure appropriate nourishment and choice. That the training programmes recently developed and introduced are developed further. The procedures to be reviewed for the management of service users monies. DS0000040622.V274610.R01.S.doc Version 5.1 Page 23 2 3 OP30 OP35 Ashcroft House 4 5 OP36 OP8OP9 To reintroduce formal supervision on a regular basis for all staff. The staff should follow procedures for ensuring service users levels of pain are monitored and appropriate prescribed analgesia administered. Ashcroft House DS0000040622.V274610.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Kent and Medway Area Office 11th Floor International House Dover Place Ashford Kent TN23 1HU 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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