Inspection on 17/01/07 for Ashdale Care Home

This inspection was carried out on 17th January 2007.

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 Care Home 03/01/06

Ashdale Care Home 24/10/05

Ashdale Care Home 03/03/05

Ashdale Care Home 24/09/04

Ashdale Care Home 01/03/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Ashdale Care Home 42 The Park off Park Avenue Mansfield Nottinghamshire NG18 2AT Lead Inspector Roger Harrison Key Unannounced Inspection 17th January 2007 09:00 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 Care Home DS0000024623.V315939.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 Care Home DS0000024623.V315939.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashdale Care Home Address 42 The Park off Park Avenue Mansfield Nottinghamshire NG18 2AT 01623 631838 01623 631838 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) Mr A J Verjee Mrs S A Verjee Mrs Jean Dawson Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26), Terminally ill (4) of places Ashdale Care Home DS0000024623.V315939.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users may be within categories OP (26) or TI (4) within a total registration of 26 3rd January 2006 Date of last inspection Brief Description of the Service: Ashdale is a two-storey, privately run, 26-bedded care home providing nursing and residential care for people of both sexes over the age of 65 years. The home is a converted residential property that has been extended in keeping with the surrounding properties, providing 18 single bedrooms and 4 double bedrooms. It is situated in a quiet, residential cul-de-sac, away from the main road leading into the town centre of Mansfield, less than one mile away. This is the nearest area for shops, pubs, leisure facilities and entertainment. Access to the first floor is by a passenger lift and staircase. There are an adequate number of bathrooms, one with assisted facilities, and communal toilets for the number of residents. At the rear of the property is a small conservatory. At the front and rear of the property there are quiet, pleasant gardens. There is a car park for visitors. The manager confirmed that charges made by the home on 17/01/07 currently range from £283.00 - £434.00pw. Ashdale Care Home DS0000024623.V315939.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was undertaken by the inspector reviewing all the Inspection records and information provided by the Manager about Ashdale, and through undertaking a visit to the home, with the inspector using a method of inspection called “case tracking”. This involved identifying three residents who currently live at the home and tracking the experience of the care and support they have received during the time they have lived at Ashdale Care Home. The inspection visit was also used by the inspector to talk to the manager and home owner, look at information on care plans and files, and to talk to residents, family members and care staff while observing day-to-day care practice within the home. What the service does well: What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Ashdale Care Home DS0000024623.V315939.R01.S.doc Version 5.2 Page 6 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 Care Home DS0000024623.V315939.R01.S.doc Version 5.2 Page 7 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 [Standard 6 N/A]. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager undertakes an assessment of need for all new residents, which is used to ensure all identified care needs can be met. EVIDENCE: The manager provided information on care plan files for new and established residents, which showed that she had carried out an assessment of need before any move took place to the home. A service user guide and statement of purpose was available for residents who said that they had been provided with the information they needed in advance of any move. One resident said, “Matron came to the hospital where I was and gave me a brochure. It helped me to know where I was going” and another said, “I was pleased with the information I got when I came here”. Ashdale Care Home DS0000024623.V315939.R01.S.doc Version 5.2 Page 8 The manager confirmed that trial periods are agreed to ensure any needs not identified on admission can be reviewed to make sure all changing care needs can be met. Records available for one new resident showed the manager has a full assessment form in place, which she completes when carrying out her visit to meet any new resident and their family carers. The manager uses this assessment form as part of the following review of care. Ashdale does not provide an intermediate care service. Ashdale Care Home DS0000024623.V315939.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents health, personal and social care needs are set out in a care plan, which residents said that the staff team use to meet their needs safely and in the way they wish. EVIDENCE: The manager provided care plans and information about the care needs of residents, which clearly showed how needs are currently being met. Plans had separate review sheets, which are updated each month by the manager. All plans are kept in an organised locked cabinet in the manager’s office. Daily record sheets are completed by care staff, which are linked to care plans. Nurse team members said they transfer information from daily records to care plans as part of the review process. Ashdale Care Home DS0000024623.V315939.R01.S.doc Version 5.2 Page 10 Care plans were well documented easy to read and described the full needs of each resident. Risk assessments are also recorded and updated as part of the review carried out by the manager and senior team. Residents and family carers said that the staff team respect their needs and wishes and one resident said, “I like it here because I can be myself. They help me to dress how I like to and I am always clean and tidy. The manager said that senior and nursing staff who had received training provided support for residents with their medication needs. Training and nurse registration records kept by the manager showed that the staff member providing support on the day of the inspection visit was qualified to carry out the role. Medicines were stored in a locked room and records of medicines stored were kept fully updated by the senior staff team. Family carers commented that staff manage support with medicines well and one carer said, “The help Mum gets is second to none”. Medicine and Care records also link to comprehensive tissue viability management plans for each resident and are updated regularly to show changes and improvements made. When it is needed the manager confirmed she seeks and receives additional support from community health nurses as part of a nursing review of needs. Ashdale Care Home DS0000024623.V315939.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14, and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported to take part in activities and maintain full control over their own lives. Residents receive a varied and balanced diet, which is provided in the way each individual wishes. An activity programme should be developed byt the manager, which shows how the choices and changing needs of all residents are met. EVIDENCE: The manager and care team take responsibility for planning and arranging activities together. There is currently no dedicated time for this but the manager said she fits it in as part of her management role. The manager plans to develop activities further using reviews with residents to explore life histories together in order to identify any additional social needs that are currently not being met. Once this work has been completed a programme will be produced to ensure activities are organised to meet identifies and changing needs. The manager said that this work has currently not been possible because the she needs to use some of her time to provide support as part of the care team. Ashdale Care Home DS0000024623.V315939.R01.S.doc Version 5.2 Page 12 However, residents made positive comments about how they are supported to do what they want to and when they want to do it. One resident commented that, We love it here its our home. Like to do what we want. Yes there are singers and Mr Motivator comes. We do what we want Current activities described by residents and staff included; music to movement, reminiscence bingo, music afternoons, games and one to one talking time between residents and staff. Many residents have high dependency needs and receive additional social support from family visitors. During the visit two family visitors were observed visiting the home. Both were made welcome and one said, Can you give a home a hundred per cent? This is my score. Mum is always clean and there is never any smell here. I eat my meals with Mum and I cant fault the support and care she receives. If I need support the manager will always make time to listen to me. The cook, who is an established team member, provides meals at the home. The cook said she plans meals in advance using information gathered during the assessment process. Menus available showed a wide choice with alternatives and residents were complimentary about the food. One resident commented that, “I can always say I am happy here and the cook is good. Ashdale Care Home DS0000024623.V315939.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with information to help them raise concerns or make complaints about the service they recieve. The manager provides training information and support to staff to ensure they are able to act to protect residents from abuse. EVIDENCE: The Manager provided a full complaints policy and procedure which is described in detail in the user guide and statement of purpose. A visitors comments book was available in reception and the manager keeps a written record log of any complaints received. The manager said she always encourages feedback from residents and their carers and said that any concerns are dealt with as soon as they arise. One informal complaint made by a family carer was recorded in detail in the complaints log along with the action taken by manager to resolve concerns. Residents said they could raise any concerns with the manager direct. Staff team members said they would report any concerns to manager and described in detail how they would share information regarding any adult protection concerns direct with the manager immediately. Ashdale Care Home DS0000024623.V315939.R01.S.doc Version 5.2 Page 14 Both new and experienced team members said they had a good understanding of the need to protect residents from abuse of any kind and the manager said she is arranging further training as part of her plans for the year. Staff said they had recived NVQ training, which one staff member felt had helped her to understand the importance of protecting residents from harm. Staff members were also aware that the local authority had an adult protection policy and the manager provided a copy of the policy with a front sheet, which had been signed by staff to show they had seen it and understood its contents. Ashdale Care Home DS0000024623.V315939.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a safe, comfortable and homely environment which is well maintained. EVIDENCE: During the inspection visit a tour of the building was completed. The home was well furnished and residents rooms were set out with personal posessions in the way each resident said they wished them to be. The home has a family feel, with visitors coming and going and residents receiving care support through the use of equipment or taking part in individual activities of their choice. All rooms have call-bells, which residents indicated they knew how to use when they needed help, and the staff team described the fire safety action they Ashdale Care Home DS0000024623.V315939.R01.S.doc Version 5.2 Page 16 would take in the event of a fire. Fire alarms are tested by the manager regularly and there are policies and procedures available for staff to follow. The home has a large garden area which residents said they use when its warm enough to go out. One resident said ,I regard this as my home and would not want to be anywhere else but here. The staff team were observed throughout the visit supporting residents in a safe way using aprons, gloves and care plan records for reference. Spacious communal bathrooms are available for residents use and are well signed. Equipment, which included bath hoists, rails, toilet seats and mobility equipment had been serviced and the manager and staff team said that the homes space and layout helps them to provide care in a safe way. Water temperatures are monitored to make sure residents are sfae when bathing and sluice facilities are available for the staff team to use to ensure the hygiene standards set by the manager are maintained. Ashdale Care Home DS0000024623.V315939.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are currently sufficient numbers of trained and senior care staff to ensure residents physical needs are met. The manager should have more staff time available to enable her to spend an additonal day a week on management duties. EVIDENCE: The manager provided information on staff files to show that references and checks are obtained in advance of any new staff member starting in post. One new staff member said she was not allowed to start without providing this information. The new staff member said she had a full induction, which helped her to familiarise herself with the residents and the role expected of her. Staff members described how training is used to provide physical care and the importance of building trust with the residents they care for. One staff member said, “Its two way process we need to know about residents needs but it is important that they have a chance to get to know us as well so that they can trust us and the support we provide. Staff rotas provided by the manager showed that there is a staff team in sufficient numbers to meet the needs of the current group of residents. Rotas Ashdale Care Home DS0000024623.V315939.R01.S.doc Version 5.2 Page 18 also showed that the manager and registered nursing staff members are always available as part of each shift. Staff members said there is time to support residents with their physical needs and that the manager helps them to do this. The manager has two days a week allocated for specific management duties and also has a role in providing physical care alongside the team, which she said does limit the time available for managing the development of activities and developing care practice. The staff rotas available indicate that staff hours would need to increase to allow an additional day for the manager to focus on developing her role and practice further. The manager said she would discuss this with the home owner so that options for increasing staff hours can be agreed together. Training is made available through the manager using supervision to identify the needs of each staff member. Supervision and training records available showed that more than half of the current staff team are undertaking or have completed NVQ training. The manager is developing a training plan which she said is to be used to identify each staff members achievements and any gaps in training for idividuals. Ashdale Care Home DS0000024623.V315939.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a well established manager in post who supports staff and encourages feedback from all those who use the service to ensure residents physical, emotional and financial needs are met in the way residents wish them to be. The manager should have more management time available to her in order to support the further development activities and staff practice. EVIDENCE: The manager is registered to undertake her role and residents, carers and staff commented that they felt she is trustworthy and supportive. One resident said “I think the manager is excellent and is always available when I need to ask Ashdale Care Home DS0000024623.V315939.R01.S.doc Version 5.2 Page 20 anything but I see how busy she is” and a family carer said, “The manager makes me feel like I’m part of the family here, I cant fault her”. During the inspection visit the home owner visited and confirmed he provides regular support to the manager as often as it is needed. He also said that he felt the manager provided a consistent level of support to ensure the ongoing development of the home practice. The manager provided copies of monthly reports, which the home owner completes to show that he monitors the quality of services. The home owner has not always been consistent in sending copies of his reports to the Commission but said he would ensure this happens on a regular basis from now on. The manager also provided records, which confirmed that she undertakes supervision sessions for all staff. The manager said she encourages residents to be as independent as possible but when requested does provide support for residents to help them manage their personal finances. Personal allowance records were looked at with the manager and a random sample checked was found to be accurate. The manager provided details to confirm she has carried out two quality assurance questionnaires with residents and carers. The latest one was carried out in November 2006. The information obtained was used by the manager to review services and to confirm that overall the current resident group are very happy with the support they receive. The manager said she has time to carry out support tasks to staff and to ensure all residents’ needs are met. However the manager did recognise that the balance of care and management duties can sometimes be difficult. Staff rotas showed that if the manager had access to an additional days management time a week she could take action to raise standards further and to ensure the plans she has in place for activities and life history work could be completed. Ashdale Care Home DS0000024623.V315939.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Ashdale Care Home DS0000024623.V315939.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? NO. 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. Standard Regulation Requirement Timescale for action 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 OP12 Good Practice Recommendations It is strongly recommended that the manager plans and develops a written activity programme together with residents in order to show that all existing and changing social and cultural needs are being fully met. In order for the manager to have time to further develop her responsibilities as a registered manager it is strongly recommended that she should have an extra full day available for additional staff cover. 2. OP27 Ashdale Care Home DS0000024623.V315939.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Care Home DS0000024623.V315939.R01.S.doc Version 5.2 Page 24 - 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. 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