Inspection on 21/08/07 for Ashcroft Nursing Home

This inspection was carried out on 21st August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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 Nursing Home 30/08/06

Ashcroft Nursing Home 07/10/05

Ashcroft Nursing Home 24/05/05

Ashcroft Nursing Home 14/02/05

Ashcroft Nursing Home 09/07/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Ashcroft Nursing Home 18 Lee Road Hady Chesterfield Derbyshire S41 0BT Lead Inspector Ray Coonan Key Unannounced Inspection 21st August 2007 09:40 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 Nursing Home DS0000002038.V341635.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 Nursing Home DS0000002038.V341635.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashcroft Nursing Home Address 18 Lee Road Hady Chesterfield Derbyshire S41 0BT 01246 204956 01246 555524 ashcroft@fshc.co.uk www.fshc.co.uk Tamaris Healthcare (England) Limited (wholly owned subsidiary of Four Seasons Health Care Limited) Mrs Lynda Hodgkinson Care Home 42 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) Category(ies) of Dementia - over 65 years of age (42), Old age, registration, with number not falling within any other category (20) of places Ashcroft Nursing Home DS0000002038.V341635.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Tamaris Healthcare (England) Ltd is registered to provide personal care with nursing for service users whose primary care needs fall within the following categories :Dementia aged 65 years and over, not falling within any other category DE(E) 42 Old age, not falling within any other category (OP) 20 To be able to admit the named person of category dementia under 65 years of age (identified in the registration report dated 20/06/06) for the duration of their stay. To be able to admit the named person of category dementia under 65 years of age (identified in the registration report dated 11/03/07) for the duration of their stay The maximum number of persons to be accommodated at Ashcroft Nursing Home is 42 30th August 2006 2. 3. 4. Date of last inspection Brief Description of the Service: Ashcroft care home provides nursing and personal care for up to 42 people aged 65 years and over, 22 with dementia and 20 not falling within any other category. The home is purpose built and is located on the outskirts of Chesterfield close to a main bus route. The home comprises two units on two floors. Willow View unit is on the ground floor and Lea View unit is on the first floor. Stairs and a passenger lift access the floors. Each unit has it’s own staff group. The kitchen and laundry facilities are shared. Residents have access to a garden. Current fees at the home range from £457.55 to £509.55 per week. Privately funding charges are £500 per week. The fees do not include hairdressing, chiropody, toiletries and newspapers. This information was provided by the Home’s administrator. Ashcroft Nursing Home DS0000002038.V341635.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over a period of seven hours on the 21st August and covered all the key national minimum standards. The Home’s registered manager was away on holiday at the time of the visit. However, the administrator, Brenda Whitworth, and one of the unit managers, Jayne Kidgell, were present throughout and were able to provide assistance as necessary. There was also the opportunity to speak with several of the care staff, one of the nurses on duty and the Home’s cook. There were discussions with several visiting relatives during the course of the day and also several residents were spoken to, either individually or in small groups. One hour was spent observing the care being given to a small group of three people in the first floor lounge. The care plans for these residents were examined in detail together with one for a resident living on the ground floor. A range of other documentation was viewed including health and safety records, a sample of staff files, training records and relevant policies and procedures. Most parts of the premises were also seen. The Home had completed an Annual Quality Assurance Assessment. Unfortunately, due to the Home being given the wrong date for its return, this had not been received prior to the inspection visit. Thus this information and any resident surveys were not taken into account during the planning process for the inspection. What the service does well: What has improved since the last inspection? The Home has continued to address ongoing maintenance issues with several bedrooms redecorated and areas detailed for re carpeting. The décor of corridor areas has been upgraded with the orientation needs of residents in Ashcroft Nursing Home DS0000002038.V341635.R01.S.doc Version 5.2 Page 6 mind. New assessment and care planning systems are being introduced though this process is not yet completed. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ashcroft Nursing Home DS0000002038.V341635.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 Nursing Home DS0000002038.V341635.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 was not covered as the Home does not provide an intermediate care service. 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 systematic and comprehensive approach to assessing the needs, capabilities and interests of prospective residents so that their care can be properly planned on admission. EVIDENCE: A sample of four care files was examined in detail. These showed that the Home undertakes a suitable pre admission assessment of the needs of prospective residents, which includes information on a wide range of physical and emotional health needs and capabilities. There was also evidence of care plans and assessment documentation obtained from social service departments Ashcroft Nursing Home DS0000002038.V341635.R01.S.doc Version 5.2 Page 9 and health services, which help to inform subsequent planning. The Home has documentation that provides initial information on personal preferences, daily living routines and social interests, which is obtained from residents and/or their families. Areas of potential risk are also identified so that relevant risk assessments can be developed. Ashcroft Nursing Home DS0000002038.V341635.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Home thoroughly assesses the individual needs of each resident and plans their care in a purposeful manner so that their physical, social and emotional welfare is enhanced. EVIDENCE: Each resident has an individual care plan and a sample of four plans was examined on this occasion. The Home is currently in the process of introducing new care plan and assessment systems, though not all of the plans seen had been transferred to the new documentation. However, the plans were generally well organised and informative providing a good sense of each resident as an individual. Some staff have undertaken training in dementia care ‘mapping’, Ashcroft Nursing Home DS0000002038.V341635.R01.S.doc Version 5.2 Page 11 and there was evidence that a clear person centred approach was now being translated onto care files through ‘well being profiles’ and individual profile sheets, which provided details of each residents experience and how their needs can be met within this context. The Home has also developed ‘story boards’ for each resident, which are placed outside a resident’s bedroom and provided a narrative that gives a sense of that person’s life experience. The care plans contained clear guidance for staff on working with each resident and staff spoken to felt plans were accessible. There was evidence that care plans were monitored on a regular basis. Staff demonstrated suitable insight into resident needs, their rights and interests. The care plans underscored the need to value residents’ individuality and staff were observed interacting with residents in a generally attentive, warm and supportive manner that enhanced their dignity. However, staffing levels were down on the day of the inspection visit and it was clear that staff were also somewhat stretched. For example, the care plan for one resident indicated that at lunchtime she became weepy and required a lot of reassurance. It was observed that staff were busy with other residents at this time and not able to follow through with this guidance. Care files also demonstrated that a wide range of risk assessments are undertaken as necessary and can include areas such as skin care, continence, mobility and falls, oral health assessment and nutrition. These assessments were also kept under review. An overall dependency assessment is developed and reviewed regularly. The Home also undertake a social care assessment and records of participation in activities are maintained. Clear records are kept of health service contacts such as G.P., dental, optician and chiropody. Any wound details are clearly recorded and closely monitored as are any unexplained bruising or injuries and accident records are maintained. Medication at the Home was stored securely and suitably maintained with systems in place for the receipt and disposal of medicines. Examples of medicine administration records were seen and were generally correctly completed. However, there was one example of a handwritten entry for medication directly obtained from a G.P that had not been signed. Ashcroft Nursing Home DS0000002038.V341635.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Home provides an overall stimulating and open environment that is in line with the social and recreational needs of residents. EVIDENCE: The Home had an open and informal atmosphere with no undue emphasis on routines. Staff had access to a wide range of information that detailed individual likes and dislikes and preferences around daily activities, including particular dietary requirements or tastes. Although many residents were highly dependent staff were observed regularly checking out individual wishes. There were many relatives visiting the Home on the day of the inspection and conversations with many of them confirmed that the Home welcome their involvement and maintain good ongoing communication. The Home’s manager arranges regular meetings with relatives. Ashcroft Nursing Home DS0000002038.V341635.R01.S.doc Version 5.2 Page 13 The Home employs an activity coordinator (30 hours per week), who also has experience as a care worker. An activity programme has been developed though this is not necessarily adhered to all the time. The coordinator explained that she often works with residents on a 1:1 basis and looks to obtain personal histories from residents and their family. Reminiscence and memory work is undertaken. Gentle physical exercise was currently not offered as the coordinator felt she would need specific training in this area. Entertainments are arranged at the Home on a regular basis and the Home also has a snoezelen room, which provides a calming, quiet facility for residents if they wish. At the time of the inspection the activity coordinator was working full shifts as a care worker due to current pressures on staffing levels and recently the Home has not been able to provide organised activities as much as usual. The Home has clear policies regarding equality and diversity, though there were no residents with specific cultural needs. Religious interests are respected and local clergy visit the Home. Discussions with residents and relatives indicated satisfaction with the meals provided at the Home. Care plans showed that dietary requirements are monitored and residents are supported in feeding when appropriate. Menus were varied and nutritious and are reviewed regularly. The cook had a clear knowledge of individual preferences and alternatives were offered. Ashcroft Nursing Home DS0000002038.V341635.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Home has clear policies and procedures for receiving complaints and any concerns regarding protection so that the safety and interests of residents are satisfactorily promoted. EVIDENCE: The complaints procedure was displayed in the main entrance area. Relatives confirmed that they received information on the Home’s policy at the point of admission. Relatives interviewed also said that they would feel comfortable in raising any issues with the management at the Home, either at relative meetings or individually. Records of complaints were not immediately available. There have been no complaints made direct to The Commission since the last inspection. The Home had appropriate policies in place concerning the safeguarding and protection of vulnerable adults. Staff spoken to confirmed that they have received awareness training in this area and evidence was also seen on individual training records. Ashcroft Nursing Home DS0000002038.V341635.R01.S.doc Version 5.2 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. 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 environment was well maintained and decorated so as to meet the needs of residents through promoting their comfort, safety and orientation. EVIDENCE: The Home was satisfactorily maintained and furnished with regular maintenance checks undertaken of the building as part of general health and safety audits. Communal areas were comfortably furbished and decorated. Since the last inspection there has been new carpeting in some of the bedrooms and new carpets are planned in the near future for both lounge Ashcroft Nursing Home DS0000002038.V341635.R01.S.doc Version 5.2 Page 16 areas and possibly corridors. It was noted that the kitchen area is in need of upgrading through redecoration and attention to the floor surface. The Home had appropriate aids and adaptations in place in order to assist residents’ mobility around the premises and different areas such as bathrooms and toilets are appropriately signed and have their own colour scheme. In the past year there has been specific work undertaken to make for a more stimulating environment for residents through developing ‘themed’ corridor areas. Each corridor is imaginatively decorated with pictures and tactile objects relating to different themes such as sport, music, the seaside and domestic kitchens and cooking. Externally there is an attractively maintained garden and sitting area, which is accessible from the ground floor lounge, though the remedial work to the fencing near the culvert has yet to be completed. The premises were clean and hygienically maintained on the day of the inspection, and the Home has managed to deal with previously identified odour problems in the first floor lounge. The Home has its own laundry, which is satisfactorily equipped and maintained. Ashcroft Nursing Home DS0000002038.V341635.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. 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 thorough approach to the recruitment and training of staff that enhances resident safety and the quality of support provided. However, current turnover of staff is somewhat disruptive and can affect continuity of care. EVIDENCE: The Home has had significant turnover of both nursing and care staff in the past few weeks, which has led to an increase in the use of agency staff. Although generally managing to maintain the usual staffing levels there have been occasions, such as on the day of this inspection, when the Home has had to operate on reduced numbers. There was some feedback from staff that this situation could be stressful and discussions with relatives indicated that there was some concern about the staffing situation and a lack of continuity. Interviews with agency staff on duty indicated that they felt they were provided with good induction and guidance at the Home and were supported well by other staff, though inevitably it took time to develop knowledge of individual resident’s needs and routines. It was stated that interviews for care Ashcroft Nursing Home DS0000002038.V341635.R01.S.doc Version 5.2 Page 18 staff and a unit manager have taken place and the vacancies should be filled in the near future. A sample of staff files was examined, including one for a staff member who had started at the Home in the past few months. These demonstrated that necessary recruitment practices are followed with clear interview records kept and written references obtained. Evidence of Criminal Record Bureau checks was not seen on this occasion as they were kept in a safe to which only the manager had access. Staff interviewed confirmed that these were obtained. Staff training records, including induction records, were kept on these files and there was evidence that the Home provide a wide rage of training programmes for staff. Basic mandatory care courses in such areas as moving and handling and food hygiene were arranged on a regular basis. Other areas such as working with dementia, challenging behaviour, infection control were also covered and NVQ training actively promoted. Feedback from staff was very positive regarding the extent of training opportunities made available. Ashcroft Nursing Home DS0000002038.V341635.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Home is generally effectively managed in the interests of residents and their health and safety is satisfactorily safeguarded and monitored. EVIDENCE: The manager of the Home has been in post for several years and is suitably qualified and experienced. Discussions with staff at all levels, and also relatives, indicated that management at the Home is viewed as open, Ashcroft Nursing Home DS0000002038.V341635.R01.S.doc Version 5.2 Page 20 accessible and supportive. There are regular established communication systems in place that include regular meetings with residents’ relatives. The Home has a range of systems in place for monitoring the quality of services. A Team Audit Process has also been introduced this year, which is undertaken by staff at the Home and a linked Remedial Action Plan for dealing with priority issues has been formulated. This contained good detail covering the general functioning of the Home. The Home continues to monitor Health and Safety matters on a regular basis and keeps up to date information regarding the checking of utilities and the servicing of equipment. A fire risk assessment had taken place towards the end of last year and included each resident’s bedroom. Fire safety records were up to date and regular fire drills take place. The Home handles personal spending monies for many of their residents. A detailed and secure system is in place for recording any financial transactions. The Provider Company has an audit system in place to check these arrangements. Ashcroft Nursing Home DS0000002038.V341635.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Ashcroft Nursing Home DS0000002038.V341635.R01.S.doc Version 5.2 Page 22 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 OP19 Regulation 23 (2) Requirement The Home’s kitchen must be redecorated and the floor surface made safe. Timescale for action 31/10/07 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. 2. 3 Refer to Standard OP9 OP12 OP27 Good Practice Recommendations Handwritten records of prescribed medicines should be appropriately signed. The training needs of the activities coordinator should be reviewed. The deployment and levels of care staff for day shifts should be kept under review so that the ratio between established staff and agency workers is more balanced. Ashcroft Nursing Home DS0000002038.V341635.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ashcroft Nursing Home DS0000002038.V341635.R01.S.doc Version 5.2 Page 24 - 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. 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