Inspection on 22/07/05 for Ashdown House

This inspection was carried out on 22nd July 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 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

Ashdown House 25/06/07

Ashdown House 11/04/06

Ashdown House 26/01/06

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 ASHDOWN HOUSE 13 Ashworth Street Daventry Northants NN11 4AR Lead Inspector Keith Charlton Unannounced 22nd July 2005 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. ASHDOWN HOUSE C51 C08 S63536 Ashdown House V233021 220705 Stage 2.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Ashdown House Address 13 Ashworth Street Daventry Northants NN11 4AR 01327 879276 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) Mr Dhiren Parmar, S & P Group Limited, 6 Kingsend, Ruislip, HA4 7DA N/A CRH 17 Category(ies) of OP Old Age - 17 places registration, with number of places ASHDOWN HOUSE C51 C08 S63536 Ashdown House V233021 220705 Stage 2.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: No additional conditions Date of last inspection 3/12/2004 Brief Description of the Service: The home, run by Mr. Parmar, the new owner, is situated close to the centre of Daventry, and offers twenty-four hour personal care for up to 17 older people. The home is set in a residential street close to all the public facilities. There are gardens laid to lawn and flower beds with off road parking to the rear of the building ASHDOWN HOUSE C51 C08 S63536 Ashdown House V233021 220705 Stage 2.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced Inspection. The Home’s Acting Manager was on duty to assist with the inspection process. Planning for the Inspection included assessing notifications of significant events sent to the Commission for Social Care Inspection by the home. There was no Pre-Inspection Questionnaire from the Registered Provider or Comment Cards from service users, relatives, GPs etc on this inspection visit. The Inspection took place between 9.30 and 14.00 and included a tour of the building, inspection of records and direct and indirect observation of care practices. The Inspector spoke with eight residents, two members of staff and the Acting Manager. A relative was spoken with who said staff were kind and helpful and were always welcoming to visitors. She was very satisfied with all services. The acting Manager said that she had applied to be the Registered Manager. What the service does well: The last Inspection Report is available to service users and visitors in the hallway. It keeps up to date Care Plans for most service users, with life histories of individual service users so staff can understand all important aspects, which are reviewed on a monthly basis. It ensures that staff read the Care Plans. Service users generally reported that staff were attentive and helpful. Staff welcome visitors to the Home. Service users generally liked the food provided to them. Second helpings of food are offered to service users. Facilities are kept in a clean and tidy condition. The Registered Provider is being proactive in the intention to install a loop system for service users with hearing difficulties and to install a shower room to give service users more choice. The gardens are well maintained and look attractive. ASHDOWN HOUSE C51 C08 S63536 Ashdown House V233021 220705 Stage 2.doc Version 1.30 Page 6 Water temperatures are kept with the National Standard of 43c to prevent service users being scalded. What has improved since the last inspection? What they could do better: Make sure that all service users have care plans. Draw up an Activities Programme based on service users preferences to extend the existing activities and have frequent outings. Ensure that privacy is maintained. Always offer two choices for main meals. Ensure that staff know the complete whistle blowing procedure in case of abuse. Offer bedroom keys and at least one easy chair per service user in bedrooms, and record this choice on Care Plans. Install corridor railing for service users without Zimmer frames to assist their mobility and safety. Ensure that odour is swiftly dealt with if it arises. Confirm in writing with the Fire Officer that it is satisfactory to have a fire door to the dining room wedged open during the day. It is recommended that an approved safety device be instead fitted. Ensure that staff know the complete fire procedure in case of an incident. ASHDOWN HOUSE C51 C08 S63536 Ashdown House V233021 220705 Stage 2.doc Version 1.30 Page 7 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. ASHDOWN HOUSE C51 C08 S63536 Ashdown House V233021 220705 Stage 2.doc Version 1.30 Page 8 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 ASHDOWN HOUSE C51 C08 S63536 Ashdown House V233021 220705 Stage 2.doc Version 1.30 Page 9 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) 3 The Manager properly assesses Service users needs before there is an admission to ensure that needs can be met within the home. EVIDENCE: There was evidence on file of a pre-admission assessment for service users. The manager usually carries out assessments with the local council if they are arranging the placement. The assessments are robust and protect both service users and staff. ASHDOWN HOUSE C51 C08 S63536 Ashdown House V233021 220705 Stage 2.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) 7,10 Personal care needs are generally well met but need to be reviewed and strengthened. EVIDENCE: The care plans for 2 service users were looked at. Generally these were well set out and provided detailed information for staff. Nutritional assessments were undertaken and plans developed where intervention was necessary. Service users or their representative had signed the full care plan to agree its contents. Two service users recalled their care needs being discussed with them. There were no Care Plans for some service user who had been in the home for a long time. The acting Manager said these were planned to be carried out. Generally service users were satisfied with staff protecting their privacy and dignity and said staff were friendly and caring though one service user said she was spoken to very sharply by a staff member when she used her call bell one morning. The acting Manager said she would follow this up, as it was unacceptable that service users were spoken to in this fashion. ASHDOWN HOUSE C51 C08 S63536 Ashdown House V233021 220705 Stage 2.doc Version 1.30 Page 11 The Inspector noted a practice of asking service users private and sensitive information in a communal setting, which could well infringe on the dignity and privacy of service users. The kind of information asked should have already been detailed, that the staff should have checked, in the daily service user records. ASHDOWN HOUSE C51 C08 S63536 Ashdown House V233021 220705 Stage 2.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) 13,14,15 The Manager needs to make clear to service users that they are free to pursue their lifestyles without undue restrictions. The food is generally good though some aspects need to be reviewed. EVIDENCE: Service users spoken with on the inspection said they thought that visitors could visit at any time and were welcomed by staff. The relative spoken to was full of praise for the staff. A service user is able to come and go from the home as he wished accessing community facilities. Service users generally said they were able to exercise choices in their day-today lives feeling able to retire as they wished though some thought that staff wanted them up by 8.00am for breakfast. The acting Manager said this was not so and she would ask service users individually when they wanted to get up and record it in their Care Plans. Service users were seen to be sitting in their rooms or the communal areas, as they wished. Some service users had their own television, which they were able to use in their bedrooms. Service user said that they were generally satisfied with the food though two said meat could be tough on occasion. The acting Manager said this would be ASHDOWN HOUSE C51 C08 S63536 Ashdown House V233021 220705 Stage 2.doc Version 1.30 Page 13 looked into. There is a four-week menu plan and a choice offered if service users do not like the main meal. It is recommended that service users are always offered two choices for main meals and to ask service users which one they want before so as to make meal planning easier. The acting Manager said the meal supplied to the service user who does not like meat would be recorded to monitor the food supplied. Every service user was offered further helpings of food at the dinner table. This situation is commended. ASHDOWN HOUSE C51 C08 S63536 Ashdown House V233021 220705 Stage 2.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) 16,18 Systems are generally good though need to be strengthened. EVIDENCE: Service users thought that their complaints would be listened to, taken seriously and acted upon. The Complaints Procedure in the Statement of Purpose needs to receive amendments to state the complainant can go directly to the Commission for Social Care Inspection if they wish, and not the Registered Provider, and that complaints received by the home will be dealt with within twenty eight days. Staff were able to demonstrate to the inspector that they would recognise acts of abuse and act appropriately should an incident occur though they were unsure of all the Agencies to contact (i.e. Police and Social Service Department). The acting Manager is to draw up a simple statement to cover this. ASHDOWN HOUSE C51 C08 S63536 Ashdown House V233021 220705 Stage 2.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 Facilities present as generally attractive and well maintained. EVIDENCE: Facilities present as generally clean, tidy and attractive. Service users said they liked their bedrooms though some would like their own room (the Manager said service users who shared were offered single rooms when they became available). The gardens are well maintained and look attractive. Water temperatures are kept with the National Standard of 43c to prevent service users being scalded. The Manager is to offer service users bedroom keys, bed side lighting and offer at least one easy chair per service user in bedrooms, and record this choice on Care Plans. The Manager will look at installing corridor railing for service users without Zimmer frames to assist their mobility and safety, ask service user if they wish to have window panes above bedroom doors blocked off to prevent light ASHDOWN HOUSE C51 C08 S63536 Ashdown House V233021 220705 Stage 2.doc Version 1.30 Page 16 entering and disturbing service users and installing easier to use curtain screening in double bedrooms where appropriate. A blind is needed to one window in room 15. There was an odour in one bedroom. Odours need to be swiftly dealt with if they arise. The Manager said the Fire Officer had approved a fire door to the dining room being wedged open – this Risk Assessment is in the fire risk assessment. It was agreed that the Manager would confirm in writing with the Fire Officer that it is satisfactory to have a fire door wedged open during the day. (It is recommended that an approved safety device be instead fitted). ASHDOWN HOUSE C51 C08 S63536 Ashdown House V233021 220705 Stage 2.doc Version 1.30 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 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) 27,29 Staffing levels are currently satisfactory. Recruitment practices need to be strengthened. EVIDENCE: There were 3 staff plus the manager on duty for the morning shift. This is the case until approx. 5.00pm when there are two staff until 10.00pm. The Manager said that as service users are largely self caring this staffing level deals with all needs at present but this level would be increased if needs were greater in future. The home has one member of night staff on waking duty with a second person on call but not on the premises. It is recommended that a second person on site would assist in alleviating the risk of a delay in the event of an accident, either to a resident or the member of staff, or in the event of a fire. Recruitment procedures were discussed with the acting Manager. Two references and satisfactory Protection of Vulnerable Adults first check need to be undertaken prior to care staff commencing employment. ASHDOWN HOUSE C51 C08 S63536 Ashdown House V233021 220705 Stage 2.doc Version 1.30 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 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) The last Inspection Report covered these issues. EVIDENCE: - ASHDOWN HOUSE C51 C08 S63536 Ashdown House V233021 220705 Stage 2.doc Version 1.30 Page 19 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 x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 2 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x x STAFFING Standard No Score 27 2 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 3 x x x x x x x x ASHDOWN HOUSE C51 C08 S63536 Ashdown House V233021 220705 Stage 2.doc Version 1.30 Page 20 No 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. 2. Standard 7 14 Regulation 15 12 Requirement Timescale for action 22/9/05 3. 16 22 4. 29 19 Care plans are needed for 3 service users. The Manager to action an 29/7/05 allegation that a service user was sharply spoken to by a staff member and to cease asking service users private and sensitive information in public. The Complaints Procedure in the 22/9/05 Statement of Purpose needs to receive amendments to state the complainant can go directly to the Commission for Social Care Inspection if they wish, and not the Registered Provider, and that complaints received by the home will be dealt with within twenty eight days. Two references and satisfactory 22/7/05 Protection of Vulnerable Adults first check need to be undertaken prior to care staff commencing employment. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. ASHDOWN HOUSE C51 C08 S63536 Ashdown House V233021 220705 Stage 2.doc Version 1.30 Page 21 No. 1. 2. Refer to Standard 15 19 Good Practice Recommendations It is recommended that service users are always offered two choices for main meals. It is recommended that the Manager offers service users bedroom keys, bed side lighting and at least one easy chair per service user in bedrooms, and record this choice on Care Plans, to look at installing corridor railing for service users without zimmer frames to assist their mobility and safety, ask service user if they wish to have window panes above bedroom doors blocked off to prevent light entering and disturbing them, and installing easier to use curtain screening in double bedrooms where appropriate. It is recommended that an approved safety device is fitted to the dining room door. It is recommended that a second person on site would assist in alleviating the risk of a delay in the event of an accident, either to a resident or the member of staff or in the event of a fire. 3. 4. 19 27 ASHDOWN HOUSE C51 C08 S63536 Ashdown House V233021 220705 Stage 2.doc Version 1.30 Page 22 Commission for Social Care Inspection Newland House, First Floor Campbell Square Northampton NN1 3EB 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 ASHDOWN HOUSE C51 C08 S63536 Ashdown House V233021 220705 Stage 2.doc Version 1.30 Page 23 - 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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