Inspection on 07/06/06 for Ashdale

This inspection was carried out on 7th June 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

Ashdale 14/06/07

Ashdale 21/12/05

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 7th June 2006 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.V298800.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. Ashdale DS0000063124.V298800.R01.S.doc Version 5.2 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.V298800.R01.S.doc Version 5.2 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. 21st December 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. The fees for Ashdale are £323.66 for all service users. Ashdale DS0000063124.V298800.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. For the purpose of this inspection two service users were interviewed in private, as were two relatives of service users. Additionally discussions took place with the manager and one staff member was interviewed. 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 and the complaints log. This key inspection included an unannounced site visit to the home. All key standards were assessed. What the service does well: What has improved since the last inspection? Several areas of the building had benefited from redecoration. Care plans had improved, as had the application of the medication procedure. Both these areas would still benefit from further improvement. Some areas of recording had improved. Ashdale DS0000063124.V298800.R01.S.doc Version 5.2 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. Ashdale DS0000063124.V298800.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 Ashdale DS0000063124.V298800.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 and 6. Quality in this outcome area is adequate. Service users are only admitted to the home after an appropriate assessment to ensure the home can meet their needs. This judgement has been made using available evidence, including a visit to the service. EVIDENCE: A selection of service users files was scrutinised. All had a copy of an assessment undertaken by an appropriate professional. There was also documentary evidence that the manager complemented external assessments with the home’s own ‘pre admission’ assessment. The home has a written policy which encourages prospective service users, or their representatives, to visit the home before making a decision to move in. Ashdale DS0000063124.V298800.R01.S.doc Version 5.2 Page 9 One relative spoken to confirmed that they had taken advantage of this opportunity. There was documentary evidence that the home considered its ability to meet the needs of any individual service user and confirmed their ability to, in writing. Not all files seen had a copy of the home’s terms and conditions. Ashdale does not offer intermediate care. Ashdale DS0000063124.V298800.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10. Quality in this outcome area is adequate. Service users’ have individual plans of care which are regularly reviewed to ensure they reflect current physical needs. Service users have appropriate access to health care professionals. This judgement has been made using available evidence, including a visit to the service. EVIDENCE: A selection of service users’ files was inspected. All had a written copy of a care plan and there was documentary evidence that the plan was reviewed at appropriate intervals. Care plans varied in detail, but presented, overall, as having improved from the previous inspection. In spite of this improvement, there were still areas which did not appear to be given a high enough priority. This particularly related to cultural and social aspects of care. Ashdale DS0000063124.V298800.R01.S.doc Version 5.2 Page 11 Documentary evidence of service users involvement in the care planning process was inconsistent. The manager reported that in practice this was done. One relative confirmed that they were involved in discussion about the care plan. Shortcomings in the care planning process presented as being predominantly in connection with administrative issues. Service users, relatives and staff who were spoken to all reported positively on the standard of care offered at Ashdale. Service users and relatives were confident that appropriate medical support was accessed when necessary. There was documentary evidence of access to the full range of medical and para medical services in the community. The manager reported that no service users had pressure sores at the time of this site visit. The manager reported that she was working to up date the medication policy and procedure. She was able to provide documentary evidence of this. Medication was seen to be stored appropriately. Service users confirmed that medication was administered at appropriate times during the day. A sample of medication administration records was scrutinised. These presented as predominantly appropriate maintained. However, in one example seen there was confusion relating to the dates on which medication was administered. This medication administration record had not been provided by the home’s usual pharmacist and was not easy to read. None the less, the initial error should have been identified at an earlier stage. Observation and discussion with service users visitors and staff indicated that service users were treated with respect, and that their dignity was maintained. The manager reported that all care staff had a copy of the appropriate code of practice. Ashdale DS0000063124.V298800.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, and 15. Quality in this outcome area is good. An appropriate range of activities was available for service users to participate in if they wished, which enhanced their fulfilment and social stimulation. Visitors are welcome in the home to maintain community and family links for the benefit of service users. Service users are able to maximise their autonomy within the context of community living. Dietary needs of service users are well catered for with a balanced and varied selection of food that meets service users’ tastes and choices. This judgement has been made using available evidence, including a visit to the service. EVIDENCE: A wide range of social activities are available for service users to participate if they wish. These are mainly organised by a dedicated activities coordinator. Ashdale DS0000063124.V298800.R01.S.doc Version 5.2 Page 13 Activities are well publicised in the home. Service users spoken to confirmed that they could participate, or not, in any of the activities provided. As mentioned elsewhere in this report, greater emphasis on this aspect of care in the care planning process may further improve this aspect of the service. The skills and approach of the activities coordinator was recognised and valued by service users and staff. The home has written policies to enable visiting at any reasonable time. This was confirmed as practice by the manager, service users and visitors. Visitors spoken to described the staff as making them feel welcomed into the home. Service users spoken to confirmed that they were able to chose what to do during the day. Some preferred to spend most of the time in their own rooms and this was facilitated by the home. One service user described how she liked to be outside and was confident that staff remained attentive to her by regularly checking that she was alright. This was also observed. One meal was sampled during the site visit. This was tasty and pleasantly presented. All service users spoken to were positive about the provision of food at Ashdale. One visitor made the, positive, observation that their relative had put on weight since moving to the home. An alternative to the main menu is provided. One service user who has specific dietary needs was observed complimenting the manager on her meal. Another service user commented “I like the food, not the beef, but they don’t make me eat it.” Ashdale DS0000063124.V298800.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. Service users are confident that any complaint they may have would be dealt with appropriately. Service users are protected from abuse or exploitation by the homes policies and practices. This judgement has been made using available evidence, including a visit to the service. EVIDENCE: Ashdale has an appropriate complaints procedure which is made available to service users and relatives. The log of complaints presented as being appropriately maintained. All service users and visitors who were asked, were confident that any complaint would be responded to appropriately by staff and management in the home. All service users spoken to expressed the view that they were safe at Ashdale. Visitors and staff also expressed the view that service users were safe. The manager reported that training in the protection of vulnerable adults (POVA). Ashdale DS0000063124.V298800.R01.S.doc Version 5.2 Page 15 Not all staff had received specific training in issues relating to POVA. However, staff who were spoken to understood the need for vigilance and their responsibility to ‘whistle blow’ if necessary. Ashdale DS0000063124.V298800.R01.S.doc Version 5.2 Page 16 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 and 26. Quality in this outcome area is good. The home is predominantly appropriately maintained to provide a safe and homely environment for service users. The home is clean tidy and hygienic to promote the comfort of service users. This judgement has been made using available evidence, including a visit to the service. EVIDENCE: A tour of the building and grounds was undertaken. This included a selection of service users’ own rooms. There was documentary evidence of routine maintenance being undertaken. Some bedrooms and one lounge had been redecorated since the last inspection. The standards of the décor varied throughout the home. Ashdale DS0000063124.V298800.R01.S.doc Version 5.2 Page 17 The manager reported that there were plans to refurbish all areas of the building where necessary. There was clear evidence of gradual physical improvement throughout the home. The only specific issue identified for remedial action, other than those of which the manager was aware, was the need to replace a bathroom tap handle. During this unannounced site visit the home was visited by a company representative and a builder to fully assess the necessary improvement to the accessibility of the grounds and repair to some window frames. Service users bedrooms showed clear signs of personalisation. The home presented as being clean and tidy throughout. This was confirmed as the usual state of the home by service users, visitors and staff spoken to. Ashdale DS0000063124.V298800.R01.S.doc Version 5.2 Page 18 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. Quality in this outcome area is adequate. Minimum staffing levels are maintained to ensure the health and safety of service users. Recruitment procedures are not applied with sufficient rigour to minimise the risk to service users of inappropriate staff being employed. Not all mandatory training had been updated which could put service users at risk from poor practice. This judgement has been made using available evidence, including a visit to the service. EVIDENCE: The staff rota for the week beginning 28th May 2006 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 carers on duty. It was reported that the home was not at full occupancy during the period covered by the rota. Ashdale DS0000063124.V298800.R01.S.doc Version 5.2 Page 19 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 twelve care staff at the home, five hold NVQ II or higher. This was verified by seeing a random selection of staff’s certificates. It was also reported by the manager that other staff have enrolled on appropriate NVQ courses. Two staff files were examined in connection with the home’s recruitment practices. One provided evidence that all appropriate vetting had been undertaken. The other demonstrated that all but one aspect of vetting had been undertaken. A full employment history had not been obtained. The manager reported that she maintained a training matrix to identify any training needs for individual staff. It was reported that all staff had appropriate basic training, including basic training in mandatory areas such as moving and handling. The manager also reported that she was aware that several staff needed updating in their basic training and provided a written training plan covering the period July 2006 to October 2006, which addressed this issue. Staff confirmed that they had received basic training and that professional development was an area of discussion at supervision sessions. Visitors and service users were complimentary about the attitude and approach of the staff team. One service user observed that some staff were better than others, but even the staff who they considered less good were “good enough”. One visitor commented positively on the consistency of the staff team and cited “the way staff look after them” [service users] and “they [staff] have always got time, never too busy to stop and chat,” as the best thing about the home. Another visitor commented that the staff were always observing the service users. Ashdale DS0000063124.V298800.R01.S.doc Version 5.2 Page 20 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): 31,33,35 and 38. Quality in this outcome area is adequate. The manager is appropriately qualified and experienced to run a care home. Some systems are yet to be put in place to more effectively promote the health and safety of service users. This judgement has been made using available evidence, including a visit to the service. 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. Ashdale DS0000063124.V298800.R01.S.doc Version 5.2 Page 21 The manager reported that Quality Audit questionnaires had been distributed to service users and sent off to her head quarters for analysis in February 2006. At the time of this site visit she reported that the analysis and action plan had not been made available. Questionnaires had also been produced for relatives and professionals. A random selection of records relating to money held by Ashdale on behalf of service users was inspected. These presented as being predominantly well maintained. One example was seen where a receipt was not available. Discussion with the manager indicated this was an oversight in not placing the receipt in the file. There had been some improvement in health and safety records. A lift service contract was in place, hoists had been serviced and the fire detection system had been serviced. However there was no record of weekly checks of the means of escape, nor visual check on fire extinguishers. Neither was there evidence of fire drills having taken place or a fire risk assessment. No specific environmental hazards were observed within the building during this site visit. Ashdale DS0000063124.V298800.R01.S.doc Version 5.2 Page 22 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 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 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 X X 2 Ashdale DS0000063124.V298800.R01.S.doc Version 5.2 Page 23 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 OP19 Regulation 23 (2)(b) Requirement 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 medication administration records are rigorously maintained. The registered person must 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. (Timescale of 01/03/06 not met). The registered person must ensure that staff, receive mandatory training at the required intervals. (Timescale of 01/03/06 not met). The registered person must ensure that records are kept of all safety checks undertaken. Timescale of 01/03/06). Timescale for action 01/08/06 2. OP9 13 (2) 01/08/06 3. OP29 19 01/08/06 4. OP30 13 01/09/06 5. OP38 17 01/08/06 Ashdale DS0000063124.V298800.R01.S.doc Version 5.2 Page 24 6 OP2 5 7 OP7 15 8 OP9 13 9 OP28 18 The registered person must ensure that all service users receive a written copy of the home’s terms and conditions. The registered person must ensure that written care plans fully address service users’ cultural, spiritual and social needs. The registered person must ensure that the medication procedure is redrafted to accurately reflect the practice and procedure in Ashdale. The registered person must ensure that staff attainment of appropriate NVQ’s is monitored. 01/08/06 01/09/06 01/09/06 01/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations The registered person should ensure that service users, or their representatives, sign to confirm that they are in agreement with their care plans and any amendments made to the care plan. Ashdale DS0000063124.V298800.R01.S.doc Version 5.2 Page 25 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. Extracts may not be used or reproduced without the express permission of CSCI Ashdale DS0000063124.V298800.R01.S.doc Version 5.2 Page 26 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!