Inspection on 23/02/06 for Ashcroft Rest Home

This inspection was carried out on 23rd February 2006.

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 Rest Home 29/05/08

Ashcroft Rest Home 01/11/07

Ashcroft Rest Home 24/04/07

Ashcroft Rest Home 24/11/06

Ashcroft Rest Home 28/06/06

Ashcroft Rest Home 12/04/05

Ashcroft Rest Home 07/12/04

Ashcroft Rest Home 02/07/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Ashcroft Rest Home, 27-29 Chadwick Road Leytonstone London E11 1NE Lead Inspector Sheelagh Doherty Unannounced Inspection 23rd February 2006 09:40a 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 Rest Home, DS0000007230.V284641.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 Rest Home, DS0000007230.V284641.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Ashcroft Rest Home, Address 27-29 Chadwick Road Leytonstone London E11 1NE 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) 020 8530 6072 Ms Hyacinth Valeska Sandilands Mrs Neva Bernice Gilpin Ms Hyacinth Valeska Sandilands Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15) of places Ashcroft Rest Home, DS0000007230.V284641.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th April 2005 Brief Description of the Service: Ashcroft Rest Home is a care home providing personal care, support and accommodation to upto 15 older people. The home is privately owned and operated which is located in a residential area of Leytonstone in East London. There is easy access to local shops and other amenities. The property is two storey with bedrooms situated on both the ground and first floor. There are two double rooms with the remainder for single occupancy. Some bedrooms have a small en-suite providing toilet and handwashing facilities. There is a stair lift available on one set of stairs with a separate staircase for those who are more mobile. Because of the configuration of the building the home would not be suitable for wheelchair users. There is a rear garden available and accessible to residents. Ashcroft Rest Home, DS0000007230.V284641.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place during the morning and afternoon of a weekday. The inspection was unannounced and the main focus was to assess the implementation of the requirements and recommendation of the previous inspection. The manager was not present at the start of the inspection but arrived during it. There were 13 residents living in the home at the time of the inspection. The inspector was able to observe the daily routine and to talk freely to residents, two visiting relatives and a health professional carrying out a review of care for one resident. She was also able to speak to the staff on duty during the inspection. As part of the inspection process the inspector looked at some policies and procedures. The inspector would like to thank all the residents, the staff and the manager for their assistance throughout the inspection. What the service does well: What has improved since the last inspection? What they could do better: A number of requirements and one recommendation remain outstanding from the previous inspection and these have been re-stated with new timescales. There is an urgent need to review the medication systems to ensure that Ashcroft Rest Home, DS0000007230.V284641.R01.S.doc Version 5.1 Page 6 residents are not put at risk because of inconsistent implementation of the policy and correct prcedures. An immediate requirement was made about this during the inspection. Although the inspector was satisfied that appropriate action is taken when residents have accidents, the manager must also ensure that records support this as two recent accidents had not been recorded in the accident book and there was insufficient documentation in the residents’ records. A new care planning system has been implemented which includes sections for review of care. However, these sections were not being completed and there was no other evidence that care was being reviewed as required. 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 Rest Home, DS0000007230.V284641.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 Rest Home, DS0000007230.V284641.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): 2, 3, 4 and 5 Not all outcomes for those standards tested were being achieved for all residents. More needs to be done to ensure that the service is able to show that it can meet prospective service users needs before admission. Standard 6 is not applicable to this home. EVIDENCE: One service user who had been resident in the home for some time [Mrs B] did not have a contract/ statement of terms and conditions with the home. A social services contract was available. Although the manager receives a copy of the social services assessment prior to the admission of a resident there was no documentary evidence that the manager carries out her own assessment of whether the home can meet the need, nor that this is confirmed to the prospective service user and/ or their relatives. Discussion took place as to how this can be achieved using current documentation available in the home. One resident and one relative confirmed that they were able to visit the home prior to admission. Ashcroft Rest Home, DS0000007230.V284641.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): 7,8,9,10 Residents’ needs are appropriately set out in individual care plans. Reviews of care need to be undertaken regularly and recorded appropriately. Urgent action needs to be taken to ensure that medication systems and daily practice safe guard residents. Service users are treated in a respectful manner which protects their privacy and dignity. EVIDENCE: A new care planning system has been introduced recently which provides more detailed information than those previously used. However, some parts of the care planning documentation were not being completed – e.g. regular reviews are not being carried out. In discussion staff were familiar with the care needs of individual service users and how these were being met. A daily plan of care was available in each service user’s room as an aide-memoir. Medication systems and daily practice do not sufficiently protect service users from risk of harm. There was evidence that medication for one service user had not been given or had not been signed for and staff, including the manager, were not able to provide a satisfactory explanation of the apparent discrepancies in records for this service user. Some medication charts had not Ashcroft Rest Home, DS0000007230.V284641.R01.S.doc Version 5.1 Page 10 been signed for in the appropriate space. An immediate requirement was made about these two issues at the time of the inspection. No service users are able to manage their own medication. The manager stated that, through time constraints, she was not always able to oversee and/ or audit medication records and carte plans as she would wish to. See also sections on staffing and management and administration. Residents said that they felt that staff respected them as individuals and treated them with kindness. Staff were observed to be interacting with residents in a polite and friendly manner and to handle situations with care and consideration for the resident’s dignity and privacy. Ashcroft Rest Home, DS0000007230.V284641.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): 12, 13, 14 and 15 Residents are encouraged and assisted to maintain contact with relatives and friends. There are few opportunities for residents to be involved in stimulating activities or in contributing to the running the home. More needs to be done in order to offer opportunities for residents to engage in fulfilling and meaningful activities during the day. EVIDENCE: The inspector spoke with two visitors who were complimentary about the service offered by the home and who stated that they were able to visit freely and the manager stated that some relatives keep in contact by telephone if they are not able to visit. Records of significant conversations with residents and their relatives are not currently made. There was little evidence that residents are actively involved in choosing how to spend their day but there is a programme of activities offered including an exercise session each week, conducted by an external provider. There are also bible reading sessions, conducted by the manager of the home, and church services on a weekly basis. There was a small activities room attached to the main lounge though this was in use for a review meeting in the early part of the inspection and was not used by residents at all during the rest of the inspection. Ashcroft Rest Home, DS0000007230.V284641.R01.S.doc Version 5.1 Page 12 The lunchtime meal is the main meal of the day. Normally this is cooked by the manager with the assistance of a staff member. Chicken casserole was served to all residents on the day, though the manager stated that if a resident did not like what was on offer other choices were available. Dessert was tinned fruit and cream. Residents were all very complimentary about the food provided. The Commission would expect there to be a named alternative to the dish of the day so that residents can make an active choice about their meal and that specific food preferences could be catered for. There is also an issue about the number of ancillary staff employed in the home and whether these are sufficient to meet the needs of the residents. See also sections on staffing and on management and administration for further comment. Ashcroft Rest Home, DS0000007230.V284641.R01.S.doc Version 5.1 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 and 18 A written complaints procedure is available. Recording of accidents and injuries to residents needs to be improved. Falls risk assessments must be carried out for all residents at risk of falling. Staff need to receive further training and support in order to ensure that they know what action to take to protect residents. EVIDENCE: Staff, residents and relatives were aware of the complaints procedure and knew who to approach if they wished to raise concerns. All were confident that the staff and manager would address complaints in a proactive manner and take appropriate action to address them within the timescales. Examination of care plans and accident records identified that not all accidents to residents are recorded as required with sufficient detail and any follow up action. It was evident that the accident record book is not readily available to staff as it took some time for the manager to locate it. In discussion not all staff were familiar with the appropriate action to take if they witnessed an abusive act. The manager stated that some staff had had appropriate training but that others had not – though this was being arranged. Ashcroft Rest Home, DS0000007230.V284641.R01.S.doc Version 5.1 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, 20, 23, 24 and 26 Generally the home was comfortable, clean and well maintained. Some areas are in need of redecoration and refurbishment. Attention needs to be paid to ensure that infection control achieves the required standard and that equipment ‘unfit for purpose’ is disposed of and/ or replaced in a timely manner. Residents have access to all the communal areas of the home including the garden. Due to the constraints of the building the home is not suitable for those who use wheelchairs. EVIDENCE: Generally the home provides a welcoming, homely atmosphere without being institutional. Some of the furnishings and fittings need to be mended or replaced, e.g. the dining room chair which had a loose arm and the stair carpet in No. 27 which is becoming worn. The carpet in room 8 requires replacement as there is a large hole in it which constitutes a trip hazard. The house is Ashcroft Rest Home, DS0000007230.V284641.R01.S.doc Version 5.1 Page 15 generally in need of redecoration in the near future and the manager was aware of this. In bathroom 29 there was a bath chair in use which had a rubber non-slip mat covering the seat. The mat had perished leaving a hard residue on the bath seat which would have been uncomfortable for any resident sitting on the chair. The mat was disposed of whilst the inspection was in progress. Such bath mats also present an infection control risk unless they are appropriately cleaned after each resident. Ashcroft Rest Home, DS0000007230.V284641.R01.S.doc Version 5.1 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, 28, 29 and 30 The manager needs to ensure that there are always sufficient staff on duty and that their roles are clearly defined. The rota needs to reflect all the staff who work in the home, including the manager, all the hours worked by each member of staff and in what capacity. All staff involved in care work must be appropriately trained and inducted. The requirements for staff recruitment are clearly laid down in the Care Standards Act, the accompanying regulations and the National Minimum Standards. They must be adhered to. EVIDENCE: At the start of the inspection there were three staff on duty – two care assistants and one domestic. One care assistant had qualified as a nurse abroad and had not yet gone through the process of registering as a nurse in this country. Both care staff were familiar with the residents and the routines of the home. They were able to assist the inspector until the manager arrived at approximately 11.00. As the domestic started preparing and cooking lunch it was clear that staff fulfil a number of roles as required. This was confirmed by the manager, who said that she normally prepared the lunch and does the shopping. Examination of the duty rota identified the following: The manager’s hours of work are not recorded on the rota Ashcroft Rest Home, DS0000007230.V284641.R01.S.doc Version 5.1 Page 17 The rota does not identify in what capacity staff are working Night staff are not all shown on the main monthly rota but on a separate, weekly rota – although the weekly rota reflects that there are always two staff on duty the monthly rota does not show this It is clear from the rota that the domestic staff also do care work on night duty and that not all hours worked are shown on the monthly rota – e.g. on Thursday 09/02/06 according to the weekly rota a staff member worked both a morning and an evening shift though only the evening shift is recorded on the monthly rota Some staff appearing on days on the weekly rota do not appear at all on the monthly rota Examination of the weekly rota for the three weeks between 05/02/06 – 25/02/06 showed that for approximately 79 of the time there were only two staff on an early shift with no ancillary support. The manager stated that she is normally on duty as well though as previously stated this is not recorded on the rota. Though staff files showed evidence of training they did not contain all required information such as two references for each member of staff. Staff confirmed that they were given opportunities for training and that the manager was very supportive on this issue. One member of staff has NVQ 2 and one has NVQ 3. This does not meet National Minimum Standards. Ashcroft Rest Home, DS0000007230.V284641.R01.S.doc Version 5.1 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, 36,37 and 38 The manager has considerable experience in managing the home. The atmosphere of the home was very relaxed and calm on the day and the manager and staff were observed to work well together. Lack of ancillary staff and the need to manage her time across many aspects of both the running of the home and day to day tasks do not allow the manager to discharge her responsibilities as manager as fully as necessary. Informal supervision takes place – formal supervision sessions are not held as necessary. Record keeping in a number of areas needs to be improved including accident recording, care plan documentation. Ashcroft Rest Home, DS0000007230.V284641.R01.S.doc Version 5.1 Page 19 EVIDENCE: Since the last inspection there has been an improvement in the day to day management of the home in that the joint owner is no longer so involved in the day to day operation and the staff have a clear understanding about who to approach for direction during their shift. The manager said that she is currently recruiting for a deputy manager in order to enable her to manage the home more effectively. She was aware that she was not able to keep on top of some management tasks such as auditing drug charts, providing effective supervision and ensuring care plans are reviewed as required. The fire service had recently undertaken an inspection at the home and the manager was awaiting a report. She was requested to provide a copy of this report to the Commission when available. As previously reported not all accidents are appropriately recorded or satisfactory explanations recorded for bruising or injury to residents. The manager stated that all residents who sustain injury are sent to hospital to have their injury checked out and this was substantiated in the case of one resident who had required stitches to her arm – information about the District Nurse visiting to provide stitch removal was available. Ashcroft Rest Home, DS0000007230.V284641.R01.S.doc Version 5.1 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 2 2 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 X X 3 3 X 2 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X 2 2 2 Ashcroft Rest Home, DS0000007230.V284641.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? YES Ashcroft Rest Home, DS0000007230.V284641.R01.S.doc Version 5.1 Page 22 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 OP2 Regulation 5 Requirement Each service user must receive a written contract / statement of terms and conditions with the home. Prior to admission each prospective service user must be assessed and written evidence of this must be kept on file. The manager must confirm in writing that the home is suitable and able to meet the assessed needs of the prospective service user. All care plans must be fully completed and reviewed on a regular basis and/or when the resident’s needs change. [Timescale of 30/09/05 not met] The manager must ensure that all medication systems are implemented in daily practice to safeguard residents from harm. [Immediate requirement made during the inspection] Residents must be given the opportunity to make decisions about their daily lives and to participate in stimulating activities according to their needs and wishes. Residents must be offered choice at meal times so that they can actively decide what they wish to DS0000007230.V284641.R01.S.doc Timescale for action 30/06/06 2. OP3 14 30/04/06 3. OP4 14 30/04/06 4. OP7 15 31/05/06 5. OP9 13 23/02/06 6. OP14 12 31/05/06 7. OP15 16 31/05/06 Ashcroft Rest Home, Version 5.1 Page 23 8. OP18 12 9. OP26 16 10. OP27 18 11. OP29 19 12. 13. 14. OP36 OP37 OP38 18 17 13 eat. The manager must ensure that all staff are aware of the correct action to take, according to their level of responsibility, if abuse is witnessed or suspected. Appropriate action must be taken to ensure that infection control standards are maintained. There must always be a sufficient number of staff on duty, including ancillary staff, to meet the needs of the residents. All required checks must be made prior to staff commencing employment. Documentary evidence to support this must be available. All staff must receive supervision as laid out in National Minimum Standards. All records laid out in the Regulations and Schedules must be maintained as required. The manager must ensure that health and welfare of service users is promoted and protected at all times. 31/05/06 31/05/06 31/05/06 31/05/06 31/05/06 31/05/06 31/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Ashcroft Rest Home, DS0000007230.V284641.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection East London Area Office Gredley House 1-11 Broadway Stratford London E15 4BQ 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 Rest Home, DS0000007230.V284641.R01.S.doc Version 5.1 Page 25 - 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. 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