Inspection on 06/04/05 for Ashgrove Care Home

This inspection was carried out on 6th April 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 11/10/05

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 Paula Eaton Announced 6 April 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. Ashgrove Care Home Version 1.10 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 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 Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 4/10/04 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 Version 1.10 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 manager, four staff and eight 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 full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ashgrove Care Home Version 1.10 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 Standards Statutory Requirements Identified During the Inspection Ashgrove Care Home Version 1.10 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 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. Ashgrove Care Home Version 1.10 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 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. For example, a care plan for one individual stated that the service user should be given time for prayers before being assisted to bed. 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 and staff were observed discussing forthcoming appointments with health care professionals. The medication administration systems in the home were adequate. Records maintained for the administration of medication were satisfactory. It was Ashgrove Care Home Version 1.10 Page 9 noted that a fridge used for the storage of medication was frosted up inside and the thermometer reading was inaccurate. This could lead to medication being stored at inappropriate temperatures. Staff were observed treating service users respectfully and the service users spoken to all said that the staff were ‘kind’ and ‘helpful’. Issues regarding the privacy of service users raised at the last unannounced inspection had been resolved. Ashgrove Care Home Version 1.10 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 standard(s) 12, 13, 14 and 15 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. The meals in the home are good offering both choice and variety and catering for special dietary needs. EVIDENCE: Notice boards and the walls inside the passenger lift displayed brightly coloured posters 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. Staff spoken to said that the activities provided at the home had improved. One service user spoken to said that he takes a walk to the shops every morning to buy a newspaper and that he likes being able to do this to get out and “get some fresh air”. 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 Ashgrove Care Home Version 1.10 Page 11 to said that visitors were welcome at any time. Encouraging visits from family and friends was also incorporated into care plans. All the people spoken to who live at the home said that they were happy with the food provided. One person said that he now receives “more food from home, like rice and curry”. The Chef confirmed that specific meals for ethnic groups are prepared three or four times a week to meet the cultural needs/preferences of service users. She also confirmed that vegetarian choices are provided and special diets catered for. The menus viewed were balanced and interesting. Ashgrove Care Home Version 1.10 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 The home has 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. The complaints record showed that there had not been any complaints since the last 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. One adult protection strategy meeting had taken place but the matter had been resolved. Ashgrove Care Home Version 1.10 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 22, 25 and 26 Some improvements to the décor had been made since the last inspection. Appropriate aids and equipment are available to meet service users needs. The home was generally clean, safe and comfortable for the people living there. EVIDENCE: Since the last inspection new carpets and flooring have been provided in some of the communal areas much improving the surroundings. There has also been some redecoration in these areas and new chairs had also been purchased. The manager said that the programme of redecoration would continue and that the remaining communal areas would also be improved. Grab rails are appropriately situated throughout the home and adequate numbers of assisted bathing and toilet facilities are provided. There is a suitable call alarm system in the home that was being responded to promptly during the inspection. Ashgrove Care Home Version 1.10 Page 14 All areas of the home were generally clean and tidy, however malodour was noted in one of the bedrooms viewed. It was noted that the lighting was poor in the first floor hallways, this could put service users at risk of falling especially if they suffer from any visual impairment, and it could also be disturbing for service users who have some confusion or are disorientated. The home was warm and naturally ventilated and safety measures were in place to ensure that service users were not at risk from the hot water temperatures or radiators being too hot. Ashgrove Care Home Version 1.10 Page 15 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, 30 The numbers and skill mix of the staff team was adequate and the recruitment process was satisfactory. Staff training provided was adequate. EVIDENCE: The home has a relatively stable staff team. The 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 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. The staff records viewed showed that robust recruitment procedures were in place and all the necessary recruitment checks had taken place. The home has a training programme in place and records are maintained so that attendance at mandatory training sessions can be monitored. Staff spoken to said that regular training was provided at the home but that the home did not always support staff when they showed an interest in participating in external training courses relevant to their role or their career development. For example, staff are expected to attend such courses on their days off and pay for them. Ashgrove is a large home and the deputy manager would benefit from some management training as he is expected to deputise in the absence of the Registered Manager. Ashgrove Care Home Version 1.10 Page 16 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) 32, 33, 35 and 38 The management approach of the home has improved and the home has appropriate systems in place to ensure the health, safety and welfare of service users and staff are promoted and protected. EVIDENCE: Staff spoken to said that they felt that they were being listened to and that when they approached the manager regarding issues in the home these were eventually acted upon. At the last inspection staff had felt that their views were not being considered. Clear lines of accountability were observed within the home. The home has systems in place for the self-monitoring of the home. Monthly audits of systems take place including an audit of accidents, medication and the occurrence of pressure ulcers. The Operations Manager also carries out monthly inspections of the home and writes a report outlining her findings. Ashgrove Care Home Version 1.10 Page 17 There was very little evidence that the views of service users, their friends and families and outside agencies involved in the home were sought. A clear system was in place for dealing with service users finances. The records and monies seen all corresponded and there was a clear audit trail. Health and safety records were up to date and in order. All other equipment was being regularly serviced. Staff receive regular training on matters relating to health and safety and risk assessments had been carried out and reviewed to ensure safe working practices. Ashgrove Care Home Version 1.10 Page 18 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. Where there is no score against a standard it has not been looked at during this inspection. 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 x 3 x x 2 2 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x 3 3 x 3 x x 3 Ashgrove Care Home Version 1.10 Page 19 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. Standard 9 Regulation 13(2) Timescale for action The medication fridge on the first 22/04/05 floor should be defrosted and the thermometer checked to ensure the reading is accurate. Sufficient lighting must be 6/04/05 provided in all areas of the home at all times Any malodour in the home must 1/05/05 be addressed. Requirement 2. 3. 4. 25 26 23(2)(p) 23(2)(d) 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. 2. 3. Refer to Standard 12 30 33 Good Practice Recommendations Further activity provision should be explored to meet the specific needs of service users. Individual training needs for personal staff development should be explored and improvement encouraged. The views of service users, their families and friends and other visitors to the home should be actively sought. Ashgrove Care Home Version 1.10 Page 20 Commission for Social Care Inspection Ground Floor 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 Version 1.10 Page 21 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!