Inspection on 11/10/05 for Ashgrove Care Home

This inspection was carried out on 11th October 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

Ashgrove Care Home 20/04/06

Ashgrove Care Home 06/04/05

Ashgrove Care Home 04/10/04

Ashgrove Care Home 05/05/04

Ashgrove Care Home 02/02/04

Similar services:

Ashlong House

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Edenvale

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Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOMES FOR OLDER PEOPLE Ashgrove Care Home Firtree Road, Off Martindale Road Hounslow Middlesex TW4 7HH Lead Inspector Paula Eaton Unannounced Inspection 11th October 2005 09:30 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 Ashgrove Care Home DS0000010939.V253197.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ashgrove Care Home DS0000010939.V253197.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ashgrove Care Home Address Firtree Road, Off Martindale Road Hounslow Middlesex TW4 7HH 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) 020 8577 6226 020 8577 9229 Southern Cross Healthcare Services Limited Mrs Remedios Chico Care Home 50 Category(ies) of Dementia (0), Learning disability (0), Learning registration, with number disability over 65 years of age (0) of places Ashgrove Care Home DS0000010939.V253197.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. A maximum of 10 beds for adult/elderly patients of either sex with `Challenging Behaviour` A maximum of 40 beds for the elderly mentally infirm of either sex over the age of 60 years 6th April 2005 Date of last inspection Brief Description of the Service: Ashgrove Care Home is a purpose built home, which provides care for fifty older people with mental health care needs. The home is situated in a residential area of Hounslow and is close to local transport links. There are some local shops close by and the home is a short distance from Hounslow town centre. There are three floors in the home and a passenger lift providing access to all floors. The bedrooms are situated on the ground and first floors. All bedrooms are single and have en suite facilities. There are two communal lounge/dining rooms on each floor. The people living at the home also have access to a well maintained garden to the rear of the home. Ashgrove Care Home DS0000010939.V253197.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over four hours as part of the annual inspection process. The Registered Manager, two members of staff and six service users were spoken to and records, policies and procedures were examined. 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. Ashgrove Care Home DS0000010939.V253197.R01.S.doc Version 5.0 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 Ashgrove Care Home DS0000010939.V253197.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 The home carries out satisfactory assessments of service users prior to admission to ensure the home is able to meet their needs. EVIDENCE: The home carries out a pre-admission assessment and a more detailed assessment once a service user is admitted to the home. The information contained in the assessment documentation inspected covered all areas of need for each service user. The home had also obtained any Care Management assessments that had been completed. The homes assessment and the Care Management assessments had been used to develop care plans for the service users. All assessments had been carried out by a qualified member of staff. The home was in the process of introducing a new format for assessing and recording service user information. This new format includes comprehensive assessment documentation. Ashgrove Care Home DS0000010939.V253197.R01.S.doc Version 5.0 Page 8 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 Assessed needs had been incorporated into individual plans of care. Health care needs had been assessed and were being met. The systems for administration of medication were satisfactory. Service users were being treated respectfully. EVIDENCE: Individual plans of care were available and were comprehensive. They were up to date and were being regularly reviewed. They covered all areas of need including specific detail regarding cultural and religious needs. Risk assessments had been completed including risk assessments regarding falls. Health care needs were outlined in the records examined and were incorporated into the care plans. Care plans had been updated where a service users condition had changed to ensure their needs were met. Any health care appointments attended or treatment received had been recorded clearly. It was noted that some of the healthcare needs assessment documentation such as continence assessments had not always been signed and dated. Risk assessments were in place for the use of cot sides, however some of the risk assessments viewed did not contain enough detail regarding the reasons for using the cot sides or how the situation was to be managed. It was also noted Ashgrove Care Home DS0000010939.V253197.R01.S.doc Version 5.0 Page 9 that these risk assessments had not always been signed by the service users family and/or representative. At the time of the inspection the home was transferring the information in care plans to a new format. The medication store and records were viewed on the first floor. The medication administration systems in the home are adequate. Records maintained for the administration of medication were satisfactory. The issue regarding the medication fridge that was raised at the last inspection had been addressed. Staff were observed treating service users respectfully and the service users spoken to said that the staff treated them well. Ashgrove Care Home DS0000010939.V253197.R01.S.doc Version 5.0 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 13 Social activities are provided for the people living in the home, however more variety could be provided. Maintaining contact with family and friends is encouraged. EVIDENCE: Notice boards around the home display an activities programme telling service users about activities taking place in the home. However, the activities recorded in the care plans viewed were very limited. More creativity could be used with regard to activities to meet the specific needs of the people living at the home. There was very little social activity taking place with service users throughout the duration of the inspection. The Registered Manager said that the Activities Co-ordinator for the home was not at work that day. It was noted that preferences regarding daily routines were recorded in the records viewed and incorporated into care plans. One care plan included a list of Indian words and the English translation to aid with communication and to help the service user make choices. Visitors are welcomed in the home and Registered Manager, staff and service users spoken to said that visitors were welcome at any time. Encouraging visits from family and friends was also incorporated into care plans. Ashgrove Care Home DS0000010939.V253197.R01.S.doc Version 5.0 Page 11 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 The home has a satisfactory complaints system with information available to service users, staff and visitors to the home. The home has adequate systems in place for the protection of service users from abuse. EVIDENCE: The home has a satisfactory complaints procedure in place that provides all of the relevant information for someone wishing to make a complaint. One complaint had been made regarding the home since the last inspection. This complaint was made to the Commission for Social Care Inspection and had not yet been resolved at the time of this inspection. The home has satisfactory procedures in place for the protection of service users and clear guidelines for staff regarding the action they should take if they witness or suspect abuse is taking place or if an allegation is made. This information was readily available in the office on each floor of the home. No allegations had been made since the last inspection. Ashgrove Care Home DS0000010939.V253197.R01.S.doc Version 5.0 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20 and 26 The home was generally clean, safe and comfortable for the people living there. EVIDENCE: There were no maintenance issues noted during this inspection. All areas of the home were clean and tidy and comfortably furnished. The home has four units, each has it’s own lounge/dining area for service users, that also contain a small kitchen area. All of these areas are light and airy and comfortably furnished. The home has appropriate laundry facilities in place that are kept clean and tidy. There were no malodours in the home. Ashgrove Care Home DS0000010939.V253197.R01.S.doc Version 5.0 Page 13 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 The numbers and skill mix of the staff team was adequate and staff training provided was satisfactory. EVIDENCE: The home has a relatively stable staff team. The Registered Manager said that the home had no staff vacancies and that there were bank staff available to cover any staff absences to avoid the use of agency staff. The Registered Manager said that two qualified nurses and two carers had been recruited since the last inspection. The staffing rotas viewed showed satisfactory numbers of staff on duty and the numbers on duty during the inspection were satisfactory to meet the needs of service users. Ashgrove Care Home DS0000010939.V253197.R01.S.doc Version 5.0 Page 14 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 The management arrangements for the home are satisfactory. EVIDENCE: The home has a well established Registered Manager in place who is supported by an experienced Deputy Manager. Both of them are qualified nurses with many years experience. The Registered Manager has completed her NVQ level 4 training and the Deputy Manager was in the process of commencing his NVQ level 4 training at the time of the inspection. Ashgrove Care Home DS0000010939.V253197.R01.S.doc Version 5.0 Page 15 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 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 X 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 X 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X X X x Ashgrove Care Home DS0000010939.V253197.R01.S.doc Version 5.0 Page 16 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. 1 Standard OP8 Regulation 12(1)(b) Requirement Assessment documentation relating to the healthcare needs of service users must be signed and dated. Risk assessments must be fully completed and provide detailed information regarding the risk and its management. Timescale for action 01/11/05 2 OP8 12(1)(b) 01/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP12 Good Practice Recommendations Further activity provision should be explored to meet the specific needs of service users. Ashgrove Care Home DS0000010939.V253197.R01.S.doc Version 5.0 Page 17 Commission for Social Care Inspection West London Area Office 58 Uxbridge Road Ealing London W5 2ST 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 Ashgrove Care Home DS0000010939.V253197.R01.S.doc Version 5.0 Page 18 - 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. 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