Inspection on 24/05/05 for Ashcroft Nursing Home

This inspection was carried out on 24th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 Nursing Home 21/08/07

Ashcroft Nursing Home 30/08/06

Ashcroft Nursing Home 07/10/05

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 Clinic 18 Lee Road Hady Chestefield S41 0BT Lead Inspector Marie Bonynge Unannounced Inspection Tuesday 24th May 2005 at 10:00am 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 Clinic C52 CO2 S2038 Ashcroft V222551 240505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Ashcroft Clinic Address 18 Lee Road Hady Chesterfield S41 0BT 01246 204956 01246 555524 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) Tamaris Healthcare (England) Ltd, (wholly owned subsidiary of Four Seasons Group) Vacancy Care Home with Nursing 42 Category(ies) of OP 20 registration, with number DE 22 of places Ashcroft Clinic C52 CO2 S2038 Ashcroft V222551 240505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: NONE Date of last inspection 14th February 2005 Brief Description of the Service: Ashcroft Clinic provides nursing and personal care and support for up to 42 older persons, 22 with dementia and 20 older persons not falling within any other category. The home is located on the north east outskirts of Chesterfield close to a main bus route. It comprises of 2 separate units, Lea View is for the 22 persons with dementia and the ground floor, Willow View is for the 20 older persons. Each unit has its own separate facilities and staff group. Kitchen and laundry services are centralised. Hotel services are centralised and includes maintenance and administrative support. Car parking space and gardens are provided. Ashcroft Clinic C52 CO2 S2038 Ashcroft V222551 240505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day in May 2005 to monitor the implementation of the home’s action plan and progress made following a protection of vulnerable adults investigation. The requirements and recommendations from the last inspection and a pharmacist’s inspection have also been followed up. A number of care plans were examined, including assessment information and medication records. Training records, staff recruitment records and staffing rotas were examined. Due to the mental health needs and general frailty of residents the inspectors were unable to verbally communicate with residents but observations of the care of residents were made and discussions held with management and staff. The home is required to keep the CSCI updated regarding staffing levels and this will be monitored via future inspections. What the service does well: What has improved since the last inspection? Improvements have been made regarding the replacement of bedroom carpets and redecoration. Care planning is better with reviews of the care plans taking place regularly. Training has been completed regarding pressure area care and care planning and the results of this are evident in the records. Audits of pressure ulcers and accidents and incidents are taking place resulting in improved monitoring of residents care. Ashcroft Clinic C52 CO2 S2038 Ashcroft V222551 240505 Stage 4.doc Version 1.30 Page 6 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 Clinic C52 CO2 S2038 Ashcroft V222551 240505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Ashcroft Clinic C52 CO2 S2038 Ashcroft V222551 240505 Stage 4.doc Version 1.30 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 standard(s) 3 and 4 Improvements have been made in systems for the assessment of residents and in recruitment to staff shortages. However continuity of care on the dementia unit cannot be consistent without additional Registered Mental Nurse input. EVIDENCE: Four care plans were examined, 2 from each unit. These indicated that progress had been made regarding the reassessment and reviewing of residents needs. Some care plans of residents who had been accommodated in the home for a number of years had been completely revised and updated to reflect their current situation. The home had not admitted any new residents whilst adult protection proceedings were ongoing. The home’s assessment tool had not been completed for all residents at that point. As these proceedings had now been closed the first new resident was being admitted today. A programme of staff training had been commenced to update the skills of staff (See standard 30) and new staff were in the process of being recruited to address the vacancies (See standard 27). These processes were not yet complete. This meant that Lea View, the specialist Dementia unit had one Ashcroft Clinic C52 CO2 S2038 Ashcroft V222551 240505 Stage 4.doc Version 1.30 Page 9 Registered Mental Nurse (RMN) who was the deputy unit manager. This did not provide with continuity of care throughout the 24 hour period for these residents. An additional RMN was due to commence employment in June 2005 to address the shortfall. The provision of a loop system had not been made as required at previous inspection reports. The acting manager agreed to contact the local information and advice group regarding hearing loss as to the most beneficial system for the home before the end of the month and to keep the CSCI informed of the outcome of this assessment. Ashcroft Clinic C52 CO2 S2038 Ashcroft V222551 240505 Stage 4.doc Version 1.30 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 and 9 The general health needs of service users appeared to be being met and improvements have been made in the recording and evidencing of pressure ulcer care with the aim of providing benefit to service users. EVIDENCE: Four care plans were examined. These had been reviewed and updated and described the care that residents needed to enable their health, personal and social care needs to be met. These were dated April and May 2005 and addressed the shortfalls identified through adult protection procedures. Risk assessments were also completed for moving and handling, pressure area care and falls. Two pressure sore audits had been completed for March 2005 and April 2005. These indicated that appropriate assessments had been done and that equipment had been provided in accordance with the risk assessment. Photographs had been taken of wounds during their treatment but not on a regular basis or when the pressure ulcer had healed. It is considered that the requirements made following adult protection procedures regarding the management of pressure ulcers have been met. The oral hygiene needs of residents was documented, a requirement made in respect of this at the last inspection has been met. Ashcroft Clinic C52 CO2 S2038 Ashcroft V222551 240505 Stage 4.doc Version 1.30 Page 11 A Pharmacist Inspector from the CSCI undertook an inspection of medication on 27th April 2005. Medication systems were examined on this visit that indicated that some of the requirements and recommendations had been met. Some of the timescales had not expired and the home had provided an action plan outlining how it would address the issues identified. These requirements have been carried forward. Five requirements had been met and two recommendations were met. There were no photographs on two of the Medication Administration Records (MAR charts) and there were no signatures for two medication instructions that had been handwritten. Ashcroft Clinic C52 CO2 S2038 Ashcroft V222551 240505 Stage 4.doc Version 1.30 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 The home has made some progress to improve the provision of a varied programme of leisure and social activities, however it does not fully meet with residents preferences and capacities, particularly residents with dementia. EVIDENCE: Residents were playing dominoes and other activities such as baking were in progress, the majority of residents were taking part. It was reported that activities took place on alternate days on the two units. Care staff were taking an active role in assisting residents to participate. Some entertainment had taken place, such as singers and musicians visiting the home. A review of the provision of services in respect of leisure and social activities was taking place. Some progress has been made since the last inspection, a requirement has been carried forward in respect of this standard where the timescale had not expired. Ashcroft Clinic C52 CO2 S2038 Ashcroft V222551 240505 Stage 4.doc Version 1.30 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 standard(s) 18 The management and staff have knowledge and understanding of Adult Protection issues that serves to assist in safeguarding residents. EVIDENCE: Adult protection proceedings had taken place since the last inspection. These were largely about the admission and assessment procedures of the home, care planning, staff shortages and the care of residents with pressure ulcers. Action plans have been produced by the home and where shortfalls have been identified and addressed these have been referred to in the main body of the report. The home complied fully with Derbyshire’s multi agency protection of vulnerable adult procedures. Additional in house training had taken place for all staff regarding adult abuse awareness. Ashcroft Clinic C52 CO2 S2038 Ashcroft V222551 240505 Stage 4.doc Version 1.30 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 standard(s) 19, 22, 24, 25 and 26 Recent replacement of carpets and the completion of works to the garden have contributed to an improvement in the appearance of the home thereby creating a generally comfortable environment for service users. EVIDENCE: The requirements from the last inspection were examined, however a full inspection of the premises was not carried out on this visit. Some of the timescales set at the last inspection in February 2005 have not yet expired. The home was generally well decorated and well maintained with the exception of those works previously identified. Work had been completed to the rear garden area of the home to enable residents to access this area. It was reported that residents had been able to sit outside and benefit from this. This requirement has therefore been met. The acting manager advised that a survey had taken place regarding the provision of lockable storage and locks on bedroom doors. However a programme of providing these facilities had not commenced for vacant rooms and no progress had made. This requirement is outstanding from the inspection of October 2004. Ashcroft Clinic C52 CO2 S2038 Ashcroft V222551 240505 Stage 4.doc Version 1.30 Page 15 A loop system has not been provided nor has an assessment of the needs of residents been completed as identified in standard 4. This requirement is outstanding from the inspection of October 2004. Some bedroom carpets have been replaced, 10 bedrooms had been decorated and a new carpet shampooer has been provided. This has largely alleviated the odour on Lea View, however some odour remains. A written programme for the replacement of carpets and redecoration with timescales for achievement had not been provided. A requirement has been carried forward in respect of this from the last inspection report. Evidence was provided that the Certificate of Chlorination was current until June 2005. Ashcroft Clinic C52 CO2 S2038 Ashcroft V222551 240505 Stage 4.doc Version 1.30 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 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, 28, 29 and 30 Deficits in the training of staff cannot ensure that staff fulfil the aims of the home and fully meet the changing needs of service users. EVIDENCE: There were 28 residents accommodated, 16 residents on Lea View (dementia unit) of which there were 7 high dependency and 9 medium dependency level. There were 12 residents on Willow View of which there were 6 high dependency and 6 medium dependency level. One new admission was expected today and a further new admission towards the end of the week on Lea View. Staffing levels were satisfactory on Willow View for the number of residents accommodated. However, it had been reported via adult protection proceedings that there had been staff shortages in the home. A visit by the CSCI on 29th April 2005 indicated that these shortfalls had been addressed. Staff duty rotas were provided for examination on this visit for the month of May 2005 and the first two weeks of June 2005 indicated that there had been 2 members of staff in addition to the trained staff to provide care for those residents accommodated on Lea View during the day. The guidance using the Residential Forum tool for care staffing indicated that there should be 3 members of staff to meet the needs of the number and dependency levels of residents. This was an issue, particularly in view of the new admissions expected this week. The acting manager was aware of this and recruitment had taken place, agency and bank staff were being used to address the shortfalls. Ashcroft Clinic C52 CO2 S2038 Ashcroft V222551 240505 Stage 4.doc Version 1.30 Page 17 A programme for the achievement of NVQ training was in place and this was expected to commence in July 2005. The recruitment files of two staff members were examined. These contained all the required information including 2 written references. Criminal Record Bureau checks had been completed for these members of staff. The requirement made at the last inspection has therefore been met. Some deficits in staff training had been highlighted via adult protection proceedings, this included pressure area care, care planning, and protection of vulnerable adults. Records were examined including a staff training and personal development plan. This indicated that although progress had been made with training, further developments were required. This included updates in moving and handling, food hygiene, infection control and fire safety. The acting manager had made arrangements for the completion of these. Ashcroft Clinic C52 CO2 S2038 Ashcroft V222551 240505 Stage 4.doc Version 1.30 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 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) 31 and 38 The acting manager has a good understanding of the areas that need to improve with plans in place to action the requirements made. This needs to be continued and implemented under the proposed new management. EVIDENCE: A new manager has been appointed and is expected to take up the post in June 2005. The acting manager has come from another Four Seasons home and is a Registered General Nurse. The new manager will be expected to submit an application to the CSCI and undergo the fit person process. Training was required as identified in standard 30. Ashcroft Clinic C52 CO2 S2038 Ashcroft V222551 240505 Stage 4.doc Version 1.30 Page 19 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 1 1 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 x COMPLAINTS AND PROTECTION 2 x x 2 x 2 3 2 STAFFING Standard No Score 27 2 28 1 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 2 x x x x x x 2 Ashcroft Clinic C52 CO2 S2038 Ashcroft V222551 240505 Stage 4.doc Version 1.30 Page 20 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 OP3 Regulation 14 Requirement The registered person must ensure that the needs assessment is fully completed and covers all of standard 3.3 in detail. The registered person must ensure that staff individually and collectively have the skills and experience to deliver the services and care which the home offers to provide including services for people with dementia. An assessment must be made as to the most appropriate and beneficial loop system for those residents accommodated in the home. Where medicines instructions are hand written onto the MAR chart, this must be signed and dated by the staff member responsible and countersigned and dated by a witnessing staff member. Sufficient secure storage for medication must be available at all times. This includes the times when medication is being administered from the medication trolleys. Medication prescribed and Timescale for action 30th June 2005 2. OP4 12, 18 1st August 2005 3. OP4 12, 23 1st August 2005 4. OP9 13 1st August 2005 5. OP9 13, 23 15 August 2005 6. OP9 13 15th June Page 21 Ashcroft Clinic C52 CO2 S2038 Ashcroft V222551 240505 Stage 4.doc Version 1.30 7. OP9 13, 17 Schedule 3 13, 23 8. OP9 9. OP9 13 10. OP12 12 11. OP19 23 12. OP22 23, 12 13. OP22 23, 12 14. OP24 16 labelled for one service user must not be administered to another service user. The eye(s) into which eye preparations are to be administered must be clarified on the MAR charts. All controlled drugs must be stored in a cupboard that meets The Misuse of Drugs (Safe Custody) Regulations 1973. Residents photographs must be attached to the MAR charts to assist in identification of the resident. The registered person must make suitable arrangements to ensure that the home is conducted with due regard to service users religious persuasion and disabilty. i) Make appropriate arrangements for the religious preferences of service users. ii) Develop recognised approaches to activities suitable for those persons with dementia. A carpet replacement and redecoration programme must be provided for service users bedrooms identifying reasonable timescales for achievement. From inspection report 14th February 2005. The registered person must provide disability equipment in accordance with service users assessed needs - in this instance a loop system. (30th April 2004). The registered person must make suitable arrangements to ensure that the care home is conducted with due regard to any disability of service users. (30th April 2004). Service users rooms, which remain without, must be provided with a lockable storage 2005 15th June 2005 15th August 2005 15th August 2005 31st August 2005 Previous timescale 1st April 2005. New timescale 1st August 2005 31st May 2005 31st May 2005 31st May 2005 Page 22 Ashcroft Clinic C52 CO2 S2038 Ashcroft V222551 240505 Stage 4.doc Version 1.30 facility. (30th April 2004). 15. OP24 12, 16 Suitable locks must be provided to all service users rooms, which do not have them. (1st October 2004) The premises must be free from offensive odours throughout. The registered person must ensure that at all times, suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for health and wefare of service users (From inspection report 14th February 2005). The registered person must provide staffing rotas for the month of June 2005 to the CSCI. The registered person must ensure that staff are provided with training appropriate to the work they are to perform. In this instance, the activities coordinator must be provide with training relevant to her role. The registered person must ensure that a minimum ratio of 50 of care staff have achieved NVQ level 2 or equivalent by 2005. Updates in training as identifed in the homes own training plan must be completed. All staff must receive infection control training and periodic updates. 31st May 2005 1st August 2005 1st June 2005 16. 17. OP26 OP27 23 18 18. 19. OP27 OP27 18 18 1st July 2005 31st August 2005 20. OP28 18 31st December 2005 1st September 2005 31.05.05 21. 22. 23. 24. OP30 OP38 18 13, 18 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Ashcroft Clinic C52 CO2 S2038 Ashcroft V222551 240505 Stage 4.doc Version 1.30 Page 23 No. 1. 2. 3. 4. Refer to Standard OP8 OP9 OP9 OP18 Good Practice Recommendations Photographs of wounds such as pressure ulcers should be taken on a monthly basis and upon healing of the area. The home should ask the dispensuing pharmacist what the expiry is of medication dispensed in a Monitored Dosage System. The maximum and minimum temperatures of the refrigerator for medication should be recorded daily and lie between 2 degrees Celsius and 8 degrees Celsius. Staff should attend Derbyshires multi agency training regarding adult protection procedures in addition to in house training. Ashcroft Clinic C52 CO2 S2038 Ashcroft V222551 240505 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection Cardinal Square Nottingham Road Derby DE1 3QT 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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