Inspection on 21/12/05 for Ashdale

This inspection was carried out on 21st December 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

Ashdale 14/06/07

Ashdale 07/06/06

Ashdale 08/06/05

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Ashdale 235 Mottram Road Stalybridge Tameside SK15 2RF Lead Inspector Steve Chick Unannounced Inspection 21st December 2005 11:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ashdale DS0000063124.V271329.R01.S.doc Version 5.0 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. Ashdale DS0000063124.V271329.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ashdale Address 235 Mottram Road Stalybridge Tameside SK15 2RF 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) 0161 338 2621 0161 338 2621 Progressive Care Limited Mrs Helen Crowshaw Care Home 20 Category(ies) of Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (20), of places Physical disability over 65 years of age (4) Ashdale DS0000063124.V271329.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 20 service users to include: *up to 5 service users in the category of DE(E) (Dementia over 65 years of age). *up to 4 service users in the category of PD(E) (Physical disability over 65 years of age). *up to 20 service users in the category of OP ((Old age not falling within any other category). The service should at all times employ a suitably qualified and experienced manager who is registered with or who has a registration application pending with the Commission for Social Care Inspection. 8th June 2005 2. Date of last inspection Brief Description of the Service: Ashdale is a large Victorian detached building, located close to the centre of Stalybridge. It has been extended and adapted over the years to meet the needs of 20 older people. Aids and adaptations to meet the needs of the service users include: handrails, adapted baths and toilets, and a passenger lift. There are 18 single rooms, four of which have en-suite facilities, and on the ground floor there are a lounge and dining room. Car parking is to the front of the building and there are gardens to the side and rear of the house. Ashdale is owned by Progressive Care Ltd which also runs other care facilities in other parts of the country. Ashdale DS0000063124.V271329.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. During the inspection three service users were interviewed in private, as were two relatives of service users. Additionally discussions took place with the manager and some staff. The inspector also undertook a tour of the building and scrutinised a selection of service user and staff records as well as other documentation, including staff rotas, medication records, the complaints log and maintenance records. This inspection was unannounced. It is recommended that this report is read in conjunction with the previous report from the inspection undertaken in June 2005. What the service does well: What has improved since the last inspection? What they could do better: Several areas of administration and building maintenance, having been identified as requiring action need to actually have the action taken. Ashdale DS0000063124.V271329.R01.S.doc Version 5.0 Page 6 Several aspects of administration need to be more rigorously maintained to ensure the accountability of the home and to demonstrate good practice. Staff recruitment must be undertaken in line with the regulations relating to working with vulnerable adults. 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. Ashdale DS0000063124.V271329.R01.S.doc Version 5.0 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 Ashdale DS0000063124.V271329.R01.S.doc Version 5.0 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 and 5. Service users are only admitted to the home after an appropriate assessment. Written confirmation of the home’s suitability is not given to prospective service users. Prospective service users or their representatives are able to visit the home to assess its suitability. EVIDENCE: A selection of service users’ files was examined. All had documentary evidence of an assessment having been undertaken by an appropriate professional before the service user moved to the home. The manager also reported that where possible she undertakes her own assessment of any prospective service user. The manager reported that service users would not be admitted to the home unless she was confident that Ashdale could meet their needs. Written confirmation of this was not routinely given to prospective service users. Ashdale DS0000063124.V271329.R01.S.doc Version 5.0 Page 9 The home has a policy of encouraging service users or their representatives to visit the home before making a decision to move in. One relative confirmed that they had visited before making any decision about his father moving to Ashdale. Ashdale does not offer intermediate care. Ashdale DS0000063124.V271329.R01.S.doc Version 5.0 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 the following standard(s): 7, 8 and 9. Service users’ individual plans of care are not in sufficient detail to effectively inform care staff. Service users have appropriate access to health care professionals. Records of the administration of medication are not maintained with sufficient rigour. The medication procedure did not fully reflect the practice in the home. EVIDENCE: A random selection of service users’ files was scrutinised. All had a copy of a care plan. However, not all were in sufficient detail to inform staff of the way in which the individual’s care needs should be met. Daily records were maintained in respect of each service user. As with the care plans, these were not consistently sufficiently detailed to offer evidence of the care plan being implemented. Ashdale DS0000063124.V271329.R01.S.doc Version 5.0 Page 11 Verbal communication in the home presented as being more reliable in ensuring care staff were aware of the changing needs of service users. However, the lack of consistent and thoroughly documented guidance to staff undermines accountability and creates too great a reliance on less structured communication systems. Service users and visitors spoken to were positive about the standards of care offered by Ashdale. One service user commented that the staff were “so helpful, … [they will] do anything for you, nothing is too much trouble.” A relative observed that the staff were aware of “the ins and outs” of the service users and said that her mother was happy and settled and often complimented the staff. The manager reported that service users had full access to medical and para medical services available in the community. This was also confirmed by discussions with service users, relatives, staff and documentary evidence. Since the previous inspection the medication policy and procedure had been amended. However further amendment was necessary to make it fully applicable to the situation at Ashdale. Ashdale used a pre dispensed monitored dosage system to administer service users’ medication. Medication was seen to be appropriately stored. Medication administration records presented as being predominantly appropriate maintained. However one example was seen where the administration of medication, which was not in the pre dispensed system, was not accurately recorded. The effect of this was to undermine the credibility of the other medication records. Ashdale DS0000063124.V271329.R01.S.doc Version 5.0 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 the following standard(s): 12 and 13. An appropriate range of activities was available for service users to participate in if they wished. Visiting is encouraged at any reasonable time and visitors are made to feel welcome. EVIDENCE: A variety of social activities was available for service users to participate in at various times. These were advertised in the main entrance hall. The manager reported that activities ranged from embroidery and cake making to bingo, occasional entertainers visiting the home and occasional trips out. The manager also reported that she was planning to obtain the services of a dedicated ‘activities’ coordinator for several hours a week. Ashdale has a policy of encouraging visitors at any reasonable time. Visitors who were spoken to during the inspection confirmed that they could visit at any time. One relative said that “you can come and go when you please.” Another visitor said they were able to join their relative for a meal if they wished. Visitors also commented on the welcoming nature of the staff. Ashdale DS0000063124.V271329.R01.S.doc Version 5.0 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. Service users are confident that any complaint they may have would be dealt with appropriately. EVIDENCE: The home has an effective complaints procedure which is made available to service users in the service user guide. All service users and relatives who were asked, reported that they were confident that if they had a complaint it would be dealt with appropriately. One service user commented that “nobody need be afraid to approach them [staff] on any subject.” The home keeps a written record of complaints. These presented as predominantly well maintained, but would be improved by also recording if the complainant was satisfied with the outcome of the complaint. Whilst standard 18 (service users are protected from abuse) was not fully assessed, all service users and visitors spoken to expressed the view that service users were protected from abuse or exploitation at Ashdale. Ashdale DS0000063124.V271329.R01.S.doc Version 5.0 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 and 26. Some remedial work was necessary to some parts of the building and décor. The home was clean and tidy throughout. EVIDENCE: A tour of the building, including a random selection of bedrooms, indicated that it was predominantly reasonably well maintained. Some, but not all, of the requirements and the recommendation relating to the building, identified at the last inspection, had been undertaken. Work to the damaged window frames remained outstanding. The manager confirmed that there had been a delay in the planned improvement and refurbishment reported at the time of the last inspection. However, she understood that this work had been rescheduled to commence in early 2006. Ashdale DS0000063124.V271329.R01.S.doc Version 5.0 Page 15 Service users have safe access to a garden area to the side of the building. It was reported by staff that this was well used during the summer. The work to make the large rear garden accessible had not been progressed. The home presented as clean and tidy, with no unpleasant odours. Service users and visitors reported that this was the usual situation at Ashdale. One service user described the cleanliness as “superb …nothing is out of order.” Ashdale DS0000063124.V271329.R01.S.doc Version 5.0 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. Minimum staffing levels are maintained. Recruitment practices were not fully compliant with the required vetting procedures. Not all mandatory training had been updated. EVIDENCE: The staff rota for the week beginning 11th December 2005 was examined. This indicated that a minimum of two carers were on duty at all times. During the day (08:00 – 17:00) there was usually three or four carers on duty. It was reported that the home was not at full occupancy during the period covered by the rota. In addition to the care staff, the manager worked 09:00 – 17:00 during weekdays. The home also employs a cook, a Kitchen assistant and a cleaner. The manager reported that of the thirteen care staff at the home, six hold NVQ II or higher. This represents 46 of the carers holding an appropriate qualification. It was reported that only one member of staff had been appointed since the previous inspection. Scrutiny of their records indicated a failure to rigorously Ashdale DS0000063124.V271329.R01.S.doc Version 5.0 Page 17 adhere to the vetting procedures required for staff working with vulnerable adults. This related to Ashdale accepting a CRB (criminal record bureau) disclosure issued to a different employer one month before the member of staff commenced duties at Ashdale. A new disclosure should have been obtained before they started work at Ashdale. It was reported that staff had been involved in health and safety, Protection of Vulnerable Adults and medication training since the previous inspection. It was also reported that updated training on Moving and Handling, and First Aid for several staff was overdue, but planned for early 2006. A significant proportion of the care staff have several years experience of working at Ashdale. As mentioned elsewhere in this report, service users and relatives were complimentary about the attitude and approach of the staff team. Ashdale DS0000063124.V271329.R01.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33 and 38. The manager is appropriately qualified and experienced to run a care home. Quality Audit and Quality Monitoring systems are being developed. Some systems are yet to be put in place to more effectively promote the health and safety of service users. EVIDENCE: The registered manager holds an appropriate qualification and has several years experience of managing care homes. There are clear lines of accountability within the organisation. The manager reported that work was still in progress on Quality Audit and Quality Monitoring systems. These are required to be undertaken annually. At the time of this inspection the home had been owned by the present organisation for less than a year. Ashdale DS0000063124.V271329.R01.S.doc Version 5.0 Page 19 The manager reported that contracts for the routine maintenance of the hoists had not been finalised. Consequently no evidence was available to verify their current safety. There was evidence that the lift was subject to regular maintenance. Similarly a certificate relating to the gas supply was available, as was a report on the effective functioning of the fire alarm and fire extinguishers. No evidence of electrical equipment having been tested was available. Records demonstrated that fire alarm and detector systems were tested weekly. The manager reported that other fire safety checks were undertaken, but that a record of these was not kept. Ashdale DS0000063124.V271329.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 2 3 X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X N/a X X X X 2 Ashdale DS0000063124.V271329.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? Yes 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 OP4 Regulation 14(1)(d) Requirement The registered person must ensure that prospective service users are given written confirmation of the home’s ability to meet their needs. The registered person must ensure that the policy and procedures relating to the receipt, storage and administration of medication are redrafted to reflect the specific needs of the home. The registered person must ensure that medication administration records are rigorously maintained. The registered person must ensure that damaged window frames are repaired or replaced. (Time scale of 01/09/05 not met) The registered person must ensure that staff are encouraged and facilitated to complete appropriate NVQ training. (Time scale of 01/01/06 not exceeded at the time of this inspection) The registered person must DS0000063124.V271329.R01.S.doc Timescale for action 01/04/06 2. OP9 13 (2) 01/04/05 3 OP9 13 (2) 01/03/06 4. OP19 23 (2)(b) 01/04/06 5. OP28 18 (1)(a) 01/01/06 6 Ashdale OP29 19 01/03/06 Page 22 Version 5.0 7. OP30 13 8. OP38 13 (4) 9. OP38 17 ensure that all new staff are vetted in line with the requirements of the Care Homes Regulations 2001 as amended by the Care Standards Act 2000 (Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004. The registered person must 01/03/06 ensure that staff receive mandatory training at the required intervals. The registered person must 01/03/06 ensure that all required safety checks are undertaken on equipment in the home. (Time scale of 01/09/05 exceeded) The registered person must 01/03/06 ensure that records are kept of all safety checks undertaken. 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. Refer to Standard OP16 OP19 Good Practice Recommendations The registered person should ensure that any complaint record includes the complainant’s view of the outcome of the investigation. The registered person should ensure that consideration is given to redecorating some of the internal décor. Ashdale DS0000063124.V271329.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Ashton-under-Lyne Area Office 2nd Floor, Heritage Wharf Portland Place Ashton-u-Lyne Lancs OL7 0QD 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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