Inspection on 08/06/05 for Ashdale

This inspection was carried out on 8th June 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Ashdale 14/06/07

Ashdale 07/06/06

Ashdale 21/12/05

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 Announced 8 June 2005 th 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. Ashdale F54 F04 63124 Ashdale v223765 080605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Ashdale Address 235 Mottram Road, Stalybridge, Tameside, SK15 2RF 0161 338 2621 0161 338 2621 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) Progressive Care Limited 51 Attercliffe Common, Attercliffe, Sheffield, S9 2AE CRH Care Home 20 Category(ies) of DE(E) Dementia - over 65 Number 5 registration, with number OP Old Age Number 20 of places PD(E) Physical disability over 65 Number 4 Ashdale F54 F04 63124 Ashdale v223765 080605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 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. Date of last inspection N/A 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 facilitities in other parts of the country. Ashdale F54 F04 63124 Ashdale v223765 080605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. During the inspection six service users were interviewed, as was one visitor, and two staff members. Additionally, discussions took place with the manager and the representative of the owner. The inspector also undertook a tour of the building and scrutinised a selection of service users’ files. Other records examined included staff rotas, accident records, fire precaution records and maintenance records. A meal was sampled. Comment cards were returned by one relative, three General Practitioners and six service users. This was the first inspection since the purchase of the home by Progressive care in April 2005. What the service does well: What has improved since the last inspection? This was the first inspection since the home had been taken over by its new owners in April 2005. There was good evidence that the new owners were upgrading the physical facilities of the home, including extensive work to make the grounds more accessible. Ashdale F54 F04 63124 Ashdale v223765 080605 Stage 4.doc Version 1.30 Page 6 The new owners and manager presented as making a good start in addressing administrative omissions inherited from the previous owners. While it was too soon to assess fully changes created by the new owners, the initial response from service users and staff was positive. 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 F54 F04 63124 Ashdale v223765 080605 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 Ashdale F54 F04 63124 Ashdale v223765 080605 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) 1 and 5. The home provides appropriate information for prospective service users. The home enables prospective service users to visit before making a decision to move in. EVIDENCE: Ashdale has produced a new service user guide and statement of purpose as a consequence of the new ownership. Scrutiny of these documents indicated that the service user guide gave appropriate and useful information. Each service user in the home had a copy of the service user guide. Some very minor amendments to the statement of purpose were suggested, although these did not have any material impact on the significant information contained in the document. It was reported by the manager that no service user had been admitted to the home since April 2005 when the new owners took over. There was written evidence that any prospective service user or their representative would be encouraged to visit the home before making a decision to live in the home. Ashdale F54 F04 63124 Ashdale v223765 080605 Stage 4.doc Version 1.30 Page 9 Ashdale does not offer intermediate care. Ashdale F54 F04 63124 Ashdale v223765 080605 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) 8, 9, and 10 Service users had their health needs appropriately met. Written policies and procedures regarding medication were not appropriate to the home. Service users were treated with respect and dignity. EVIDENCE: There was written evidence of the appropriate involvement of medical support for service users at Ashdale. All service users spoken to were confident that medical support would be called if necessary. All GP comment cards received expressed confidence that the home worked in partnership with them and were satisfied with the overall care provided. Similarly all service users’ comment cards received stated that they felt well cared for. Staff who were interviewed also expressed confidence that good support was available from the District Nursing service and that Doctors were contacted when necessary. Ashdale F54 F04 63124 Ashdale v223765 080605 Stage 4.doc Version 1.30 Page 11 The home used a pre dispensed monitored dosage system to administer service users’ medication. Medication was seen to be stored appropriately, although it was reported by the manager that the security of medication storage was to be improved. At the time of the inspection there were no service user administering their own medication (other than one person with an inhaler), and that there were no controlled drugs on the premises. Medication administration records presented as being appropriately maintained to ensure accountability and a full ‘audit trail’ of medication received into the home. The written medication policy and procedure was not specific to Ashdale. It was reported that this was in the process of being revised. The manager demonstrated an appropriate level of understanding of medication procedures in a home for older people, and revision of the written procedures was to bring them in line with the existing practice in the home. At the time of this inspection no service user was sharing a room, this would serve to enhance individuals’ privacy. All rooms had locks, to which the service user could hold a key. The three GPs who returned comment cards all confirmed that they could see their patients in private. All service users’ comment cards reported that their privacy was respected. Similarly service users who were spoken to during the inspection confirmed that staff treated them with respect and dignity. One service user said “ … every body [is] friendly and the girls keep asking if you need anything.” Ashdale F54 F04 63124 Ashdale v223765 080605 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) 13, 14 and 15. There are no unreasonable restrictions on visitors to the home. Service users can exercise choice and control over their lives within the context of communal living. The home provides good food in pleasant surroundings. EVIDENCE: The one relative’s comment card and the visitor spoken to confirmed that there were no unreasonable restrictions on visiting. This was also confirmed by service users and staff spoken to during the inspection. Discussion with service users and staff indicated that choice and autonomy for service users was valued in the home. One service user who was asked about choice of how or where she spent her time within the home, thought for a while and pointed out that, … “ nobody ever stopped me.” One meal was sampled during the inspection which was pleasantly presented and tasty. One service user described the food as “not marvellous” , and one comment card said they liked the food “sometimes”. However all other comment cards and service users spoken to were positive about the provision Ashdale F54 F04 63124 Ashdale v223765 080605 Stage 4.doc Version 1.30 Page 13 of food in the home, with one citing it as one of the best things about Ashdale. It was reported by the manager that the menus had recently been reviewed in consultation with the service users. Ashdale F54 F04 63124 Ashdale v223765 080605 Stage 4.doc Version 1.30 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 standard(s) 16 and 18. The home has an effective complaints procedure which is made available to service users and their representatives. The home provides appropriate safeguards to minimise the risk of service users being abused or exploited. EVIDENCE: The home has an appropriate written complaints procedure, which is included in the service user guide, and is available for all service users and potential service users. All service user comment cards indicated that the service user liked being in the home, were well cared for and were treated well by the staff. All service user comment cards indicated the service user knew who to talk to if they were unhappy with their care. Service users spoken to during the inspection expressed the view that any complaint would be taken seriously and dealt with appropriately. The home had a protection of vulnerable adults procedure, which included information on ‘whistle blowing’ (action to be taken by staff if poor practice was not appropriately dealt with within the home). Staff demonstrated a good understanding of the need to protect service users and were aware of action they should take if they were concerned for the safety of any service user. Ashdale F54 F04 63124 Ashdale v223765 080605 Stage 4.doc Version 1.30 Page 15 All service user comment cards reported that they felt safe in the home, and this was confirmed by service users spoken to. One service user commented that “… this is a good place, no danger here.” Similarly the one visitor spoken to had never seen anything to cause him concern about the care of the service users at Ashdale. Ashdale F54 F04 63124 Ashdale v223765 080605 Stage 4.doc Version 1.30 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 standard(s) 19, 20, 21, 23, 24, 25 and 26. Some remedial work was necessary to some parts of the building and décor. Communal areas were appropriately maintained, with improvements evident to the external facilities. Service users’ bedrooms were appropriately personalised. 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 maintained, with evidence of the new owners improving the physical facilities. It was reported that several new beds had been purchased, new carpets had been provided in several bedrooms and others were to be replaced on a rolling program of refurbishment. One bedroom window on the ground floor needed repair or replacement. Water had caused some damage to the ceiling of bedroom number 9, and some of Ashdale F54 F04 63124 Ashdale v223765 080605 Stage 4.doc Version 1.30 Page 17 the internal décor was looking tired. Discussion with a representative of the owner indicated that all this work had been identified by themselves and plans were in hand to rectify it. Service users’ bedrooms presented as being appropriately personalised. The manager confirmed that subject to space and health and safety considerations, service users were encouraged to bring their own possessions into their rooms. Service users spoken to confirmed that they liked their rooms. Communal areas in the home presented as homely and appropriately maintained. Significant work was underway on the grounds to maximise the safe use of the gardens which had previously been overgrown and inaccessible for service users. Appropriate bathing and toilet facilities were available. Ashdale presented as clean and tidy with no unpleasant odours. Service users, staff and the visitor spoken to during the inspection confirmed that this was the usual state of the home. Ashdale F54 F04 63124 Ashdale v223765 080605 Stage 4.doc Version 1.30 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 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 and 28. Staffing levels are provided to at least the minimum level necessary. More staff need to obtain appropriate professional qualifications. EVIDENCE: The staff rota for the week beginning 30th May 2005 was examined. This demonstrated that a minimum of two staff were on duty, with occasional periods where there were more. It was reported by the manager that during the period covered by the rota, only twelve service users were resident at the home. Five care staff held NVQ II, one of whom also held NVQ III. This represents 36 of the care staff holding an appropriate qualification. It was reported by the manager that staff training and completion of the NVQ program to achieve or exceed the National Minimum Standards target of 50 was a priority in the new owner’s planning. All respondents to the service user comment cards reported that they liked living at the home, felt well cared for and believed they were treated well. One service user commented that “they take care of you really well … “, while another said “ … [they] are not saints, [but are] kind,” and a third talked about the “very good staff”. Ashdale F54 F04 63124 Ashdale v223765 080605 Stage 4.doc Version 1.30 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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) 35 and 38. The financial interests of service users are protected by the systems in place at the home. More time is needed to demonstrate full compliance with all health and safety requirements. EVIDENCE: At the time of this inspection it was too early to assess how effective many of the ‘new’ managerial and administrative systems would be. However, discussions with staff and service users all indicated a feeling of optimism for the future under the ‘new’ regime. A selection of records relating to money held by Ashdale on behalf of service users was examined. These presented as being maintained appropriately, to protect the interests of service users. Ashdale F54 F04 63124 Ashdale v223765 080605 Stage 4.doc Version 1.30 Page 20 Records were seen which indicated that fire protection and detection equipment were checked and serviced at appropriate intervals. Staff confirmed the availability and mandatory use of disposable gloves and aprons when necessary to minimise the risk of cross infection. It was reported by the manager and representative of the organisation, that minimal records were available relating to the period of the previous owners. The manager reported that the organisation was prioritising training for staff in aspects of health and safety, such as moving and handling and first aid to ensure they could be confident that staff had up to date training. Similarly the new owners were actively perusing up to date safety checks on all necessary equipment. Ashdale F54 F04 63124 Ashdale v223765 080605 Stage 4.doc Version 1.30 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x x x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 3 3 x 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x 3 x x 2 Ashdale F54 F04 63124 Ashdale v223765 080605 Stage 4.doc Version 1.30 Page 22 N/A 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 9 Regulation 13 (2) Requirement 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 damaged window frames are repaired or replaced. The registered person must ensure that the cause of the leak in one bedroom ceiling is explored and rectified. The registered person must ensure that staff are encouraged and facilitated to complete appropriate NVQ training. The registered person must ensure that all required safety checks are undertaken on equipment in the home. Timescale for action 01/09/05 2. 3. 19 19 23 (2)(b) 23 (2)(b) 01/09/05 01/08/05 4. 28 18 (1)(a) 01/01/06 5. 38 13 (4) 01/09/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Ashdale Refer to Good Practice Recommendations F54 F04 63124 Ashdale v223765 080605 Stage 4.doc Version 1.30 Page 23 1. Standard 19 The registered person should ensure that consideration is given to redecorating some of the internal décor. Ashdale F54 F04 63124 Ashdale v223765 080605 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection 2nd Floor, Heritage Wharf Portland Place Ashton under Lyne 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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