Inspection on 20/04/06 for Ashgrove Care Home

This inspection was carried out on 20th April 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Ashgrove Care Home 11/10/05

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

Norbury Crescent (30)

Edenvale

Wadham Avenue

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 Mrs Rekha Bhardwa Unannounced Inspection 20th April 2006 10:20 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.V290580.R01.S.doc Version 5.1 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.V290580.R01.S.doc Version 5.1 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.V290580.R01.S.doc Version 5.1 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 11th October 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.V290580.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the regulatory process. A total of 7 hours was spent on the inspection process. The Inspector carried out a tour of the home, and service user plans, medication records, staff records, financial records, management records, administration records, maintenance and servicing records were viewed. 6 service users, 5 staff and 3 visitors were spoken with part of the inspection process. The pre-inspection questionnaire, given to the home at the time of inspection, was also used to inform this report. It must be noted that it is sometimes difficult to ascertain the views of service users with dementia or mental health care needs. At the time of the inspection there were no vacancies. What the service does well: What has improved since the last inspection? Some improvements were noted in the signing and dating of documentation, however minor shortfalls have been identified at this inspection. Bedrail assessments are being completed in full with agreed consents being obtained from the service users representatives. Ashgrove Care Home DS0000010939.V290580.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ashgrove Care Home DS0000010939.V290580.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ashgrove Care Home DS0000010939.V290580.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4 & 5. The home does not provide intermediate care. Service users and their representatives are provided with written information about the home, thus enabling service users and their representatives to make informed choices. Full information on the service users needs is not always obtained and service users are at risk of not having their needs fully. Prospective service users and their representatives are encouraged to visit the home in order to allow them to make an informed choice. EVIDENCE: A Statement of Purpose and Service User Guide were available. This was comprehensive and available to all service users and their representatives. One pre-admission assessment viewed was incomplete; this had been completed by the end of the inspection. Ashgrove Care Home DS0000010939.V290580.R01.S.doc Version 5.1 Page 9 Other pre- admission assessments viewed were generally well completed and those viewed were comprehensive and gave a clear picture of the service users needs. Social Services needs led assessments were not always available and the need to ensure that these are obtained prior to any assessment for service users referred through care management was discussed with the Registered Manager. The Registered Manager has a post graduate qualification in care of people with dementia care needs. The Deputy Manager is a Registered Mental Nurse. Staff have also undertaken training in dementia care. Service users and their representatives are encouraged to visit the home prior to admission to see if it meets their needs and expectations. One service users representative who spoke with the Inspector confirmed that they had been able to visit the home prior to admission. Ashgrove Care Home DS0000010939.V290580.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 9 The service user plans are well formulated and updates take place, thus ensuring that the information required by staff to meet the service users needs is clear and up to date. Medications are generally well managed in the home and safeguard service users. Shortfalls identified should be easy to address. EVIDENCE: A sample of service user plans were viewed on both floors. These were generally comprehensive and provided information on the needs of the service user and how these were to be met. There was evidence of regular reviews of the documentation, plus the formulation of new care plans for new care needs that had been identified. For one service user on Chestnut unit the social and physical assessment had not been signed. One bedrail assessment viewed had been completed and consent had been obtained from the service users representative for their use. Ashgrove Care Home DS0000010939.V290580.R01.S.doc Version 5.1 Page 11 Pressure sore risk assessments, nutritional assessments, continence assessments, risk of falling assessments and moving and handling assessments were available in the files sampled. These were being regularly reviewed and updated as required. Care plans were in place and had been formulated in line with the assessments undertaken. There was evidence of weekly and monthly weight recordings. Records viewed also indicated involvement of other health care professionals to include Chiropodist, Optician, Community Psychiatric Nurse, GPs and allocated Social workers. The Registered Manager stated that the home had a good relationship with the local Community Mental Health Team. Daily logs were generally well detailed and contained information on the actual care provided. Samples of the medication administration records were viewed on each floor. These were well completed and had been fully signed for. The home had started to use the Boots Monitored Dosage System. This had only come into place on the day of the inspection. A photograph plus allergy information was available. Controlled drugs were securely stored and records were accurate and up to date. A list of nurse signatures were available on each floor. Dates of opening had been recorded on liquid medications on the first floor. No dates of opening had been recorded on liquid medications on the ground floor. Records were being maintained of medication that had been disposed. Receipts and quantities of medication received into the home had been recorded. The Registered Manager stated that medication audits take place monthly and that any shortfalls are addressed. Staff were observed to address service users in a courteous and gentle manner. Service users who were able to communicate with the Inspector commented that they were well looked after and were happy at the home. Ashgrove Care Home DS0000010939.V290580.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13 and 14 Activities are provided that meet the service users collective and individual needs. Visiting is encouraged and this enhances the service users lives and keeps them in touch with their families and friends. EVIDENCE: The home has an activities co-ordinator and a programme of activities was displayed. The home has an activities room and service users observed in this room appeared to be happy with the activity that was being partaken. Trips outside of the home have been planned and these include visits to Kew Gardens and Hounslow Urban Farm. It was recommended at the time of inspection that the Activities Co-ordinator undertake training specific to activities for older people. Some service users choose not to participate in activities and spend time in their bedrooms with their televisions and books. Service users are able to receive visitors in private or in the communal areas of the home. Visitors spoken with confirmed that they are made to feel welcome at the home. Information on relatives and friends involvement in the home is detailed in the homes Statement of Purpose. Ashgrove Care Home DS0000010939.V290580.R01.S.doc Version 5.1 Page 13 Information on how to contact local advocacy groups is available in the main entrance of the home. Service users are encouraged to bring in personal possessions and some of the rooms viewed were personalised. Ashgrove Care Home DS0000010939.V290580.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The home has a satisfactory complaints system with evidence that service users and representatives concerns are listened to and acted upon. Staff have knowledge and understanding of adult protection issues which protect service users from abuse. EVIDENCE: The home has a detailed complaints procedure, which is freely available and also detailed in the Service User Guide. The complaints records viewed clearly recorded the action taken by the home to investigate the complaint, address any shortfalls, the outcomes and copies of all correspondence. The Registered Manager stated that the home follows the Hounslow Safeguarding Adults Procedures. Staff have received training about adult protection, and staff were clear that that they would report any concerns of this nature. Ashgrove Care Home DS0000010939.V290580.R01.S.doc Version 5.1 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 the following standard(s): 19,20,21 and 26 The standard of the décor, environment and furniture and fittings within the home is good and presents as a homely, safe and comfortable environment for service users. The home was clean and systems for the prevention of the spread of infection were being adhered to, thus safeguarding service users. EVIDENCE: A tour of both floors was carried out. The bedrooms viewed were well maintained and in good decorative order. The grounds were well maintained and tidy. The Registered Manager stated that there was an ongoing programme for the decoration of bedrooms. A full time maintenance man is employed by the home. Maintenance audits are carried out and any shortfalls are addressed. Ashgrove Care Home DS0000010939.V290580.R01.S.doc Version 5.1 Page 16 All lounge and dining areas had been repainted and new carpets had been fitted in Chestnut and Beech unit. There is a secure garden that can be accessed by the service users from the ground floor. The bath and shower areas were clean, tidy and well maintained. All the bedrooms are single and have en suite facilities to include a toilet and wash hand basin. The home has a mixture of height adjustable and divan beds throughout the home. The need to ensure that all service users with a moving and handling need are provided with a height adjustable bed was discussed with the Registered Manager at the time of the inspection. Bedroom doors are lockable and several service users choose to keep their bedroom doors locked. Laundry facilities are sited away from service user areas. The pre-inspection questionnaire detailed that policies on infection control were available. Protective clothing to include aprons and gloves were seen in areas throughout the home. The home was clean, hygienic and odour free. Ashgrove Care Home DS0000010939.V290580.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 The home is appropriately staffed to meet the needs of service users. Staff recruitment procedures are robust and safeguard service users. Staff undergo training to provide them with the skills to meet the needs of the service users. EVIDENCE: Duty rotas for trained staff and care staff were viewed. The Registered Manager stated that there had been no changes to the staffing levels since the last inspection. There are four units over two floors. Beech and Alder are located on the ground floor and Chestnut unit is located on the first floor. On Beech unit for the waking day there is one Registered Nurse and two care staff on duty. On Alder unit there is one Registered Nurse and one care staff on duty. On Chestnut unit there are two Registered Nurses and three care staff on duty in the morning. For the afternoon shift there is one Registered Nurse and four care staff on duty. At night there are two Registered Nurses and three care staff for on duty for the home. The home was clean and tidy on the day of the inspection and appropriate numbers of domestic and ancillary staff are employed at the home. Ashgrove Care Home DS0000010939.V290580.R01.S.doc Version 5.1 Page 18 The pre-inspection questionnaire detailed that 8 staff have an NVQ in care at level 2 or above. The Registered Manager also reported that 3 staff are in the process of starting their NVQ level 2 training. At the time of the inspection 33 of care staff were trained to NVQ level 2 or equivalent. The inspector sampled two staff employment records during the course of the inspection, these contained the information as required by the Care Homes Regulations 2001. Induction and foundation training programmes are in place and these meet the Skills for Care core standards. A training matrix completed by the Registered Manager was forwarded to the CSCI following the inspection and this detailed the training undertaken by staff and details of future training planned. Ashgrove Care Home DS0000010939.V290580.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 The Registered Manager has the knowledge and experience to manage the home. Systems for quality assurance are in place, thus providing an ongoing process of review and feedback. Service users monies are well managed and secure procedures are in place, thus safeguarding service users. Systems for the management of health and safety throughout the home are good, thus safeguarding service users, staff and visitors. EVIDENCE: The Registered Manager is a first level registered nurse with a post -graduate qualification in dementia care. The Registered Manager is due to complete her Registered Managers Award has in July 2006. Lines of accountability within the home are clear and the management structure for the Company is in the Statement of Purpose. Ashgrove Care Home DS0000010939.V290580.R01.S.doc Version 5.1 Page 20 The Statement of Purpose details the arrangements for consultation with service users and their representatives. This includes monthly relatives meetings, weekly home managers surgery, and service user/representatives satisfaction surveys. Service users representatives are encouraged to be involved in the care planning process. Regulation 26 Visits are undertaken monthly and a copy of the visit report is sent to the Commission. Auditing systems are in place and this included audits of medication, pressure sores, maintenance and the environment. The Inspector viewed some of the records for service users personal monies. These were up to date and the income and expenditure was clearly recorded and receipts were available. The home has a safe facility. Servicing and maintenance records were viewed at random and those viewed were up to date. This included fire records and fire drill training records. There were no obvious health & safety issues noted at the time of inspection. The pre inspection questionnaire detailed dates of servicing of equipment in the home. Generic risk assessments on safe working practices were available. Ashgrove Care Home DS0000010939.V290580.R01.S.doc Version 5.1 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 3 x 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X X X X 3 STAFFING Standard No Score 27 3 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 Ashgrove Care Home DS0000010939.V290580.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14 Requirement Where a service user has been referred via care management a copy of the Needs Led Assessment must be obtained. Assessment documentation relating to the healthcare needs of service users must be signed and dated (previous timescale 01/11/05 not met) Liquid medications must be dated when opened. Timescale for action 01/06/06 2 OP8 12(1)(b) 01/06/06 3 OP9 13(2) 01/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP12 Good Practice Recommendations Further activity provision should be explored to meet the specific needs of service users. Ashgrove Care Home DS0000010939.V290580.R01.S.doc Version 5.1 Page 23 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.V290580.R01.S.doc Version 5.1 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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