Inspection on 15/07/08 for Ashgrove House

This inspection was carried out on 15th July 2008.

CSCI found this care home to be providing an Good service.

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 House 17/07/07

Ashgrove House 30/10/06

Ashgrove House 19/01/06

Ashgrove House 28/09/05

Ashgrove House 16/02/05

Ashgrove House 07/04/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Ashgrove House 72 Butterworth Lane Chadderton Oldham Lancashire OL9 8DX Lead Inspector Michelle Haller Unannounced Inspection 15th July 2008 08:45 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 House DS0000056308.V365557.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ashgrove House DS0000056308.V365557.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashgrove House Address 72 Butterworth Lane Chadderton Oldham Lancashire OL9 8DX 0161 681 2183 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) Ashgrove House Care Ltd Mrs Denise Jordan Care Home 32 Category(ies) of Dementia - over 65 years of age (8), Old age, registration, with number not falling within any other category (32), of places Physical disability over 65 years of age (8) Ashgrove House DS0000056308.V365557.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The services is registered for a maximum of 32 service users to include: *up to 32 service users in the category of OP (Old age not falling within any other category); *up to 8 service users in the category of PD(E) (Physical disability over 65 years of age); *up to 8 service users in the category of DE(E) (Dementia over 65 years of age). 17th July 2007 Date of last inspection Brief Description of the Service: Ash grove House is situated in a residential area of South Chadderton. The home is close to local amenities such as shops, churches and schools. The home is a large Victorian house, which has been extended and refurbished to provide 32 single rooms, 28 with en-suite facilities. Bedroom accommodation is provided on the ground and first floors. There is a passenger lift to the first floor. Bathing facilities include two assisted baths and two shower rooms. Easily accessible toilets are available on each floor. Communal areas include a large lounge and dining room and two smaller lounge areas one of which can be used by smokers. The home has ample parking a large courtyard style garden to one side. The current weekly rate charged at Ashgrove House ranges from £360 - £400. A copy of the previous Commission for Social Care Inspection (CSCI) report was available in the foyer. Ashgrove House DS0000056308.V365557.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This was a key inspection that included an unannounced visit to the service. This means the manager did not know in advance that we were coming to do an inspection. During the visit we looked around the building and talked to residents, relatives and staff, including the registered manager. We observed the interactions between people living at Ashgrove House and examined care plans, files and other records concerned with the care and support provided to people in the home. We also looked at all the information that we have received or asked for since the last inspection. This included: The annual quality assurance assessment (AQAA) that was sent to us by the service. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. Information we have about how the manager has managed any complaints and any adult protection issues that may have arisen. What the manager has told us about things that have happened in the home through ‘notifications.’ We also received nine Commission for Social Care Inspection (CSCI) surveys that were returned to us by people using the service and from other people with an interest in the service, such as staff and relatives. There have been no protection of vulnerable adult investigations and no complaints received by CSCI about the home since the previous inspection. The charge for living at Ashgrove House ranges from £390 to £400 each week. Ashgrove House DS0000056308.V365557.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Since the last inspection the manager has ensured that people are able to get up when they are ready. The manager has ensured that care plans fully reflect specific health needs. Since the last inspection the manager has ensured that staff receive sufficient training and information about specialist health needs so that appropriate monitoring and health care are provided. Ashgrove House DS0000056308.V365557.R01.S.doc Version 5.2 Page 7 The manager has ensured that all new employees are subject to the required vetting process so that people are safeguarded against unsuitable staff being employed. Since the last inspection the manager has ensured that new staff are provided with induction training in line with the recommendations from the Skills for Care organisation. Since the last inspection the majority of staff have received adult protection training. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ashgrove House DS0000056308.V365557.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Ashgrove House DS0000056308.V365557.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (standard 6 not applicable) Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. People at Ashgrove House benefit from support that is based on a comprehensive assessment of their needs that is carried out before they move into the home, thereby ensuring that the staff have the necessary skills to meet the person’s needs. EVIDENCE: Five care files were examined and each contained an assessment of needs that provided information about the health, social and psychological requirements of people. The pre-admission assessment for the most recent admission was detailed and showed that the manager had considered whether that person’s needs could be met at Ashgrove House. The information was clearly written and identified needs, including physical care, nutritional requirements, for example, diabetic diet, communication needs and medication. Ashgrove House DS0000056308.V365557.R01.S.doc Version 5.2 Page 10 Additional risk assessments were also completed for areas such as falls reduction and prevention of pressure sores. Information about the next of kin or contact person was also recorded. Most files also held a completed a social history indicating the family involvement, working life, current interests and hobbies and other life experiences. People who commented confirmed that they had visited Ashgrove House prior to deciding to move into the home. They said: ‘Yes we identified a small home - looked at reports - also visited and was happy.’ The manager of Ashgrove House stated that she continues to assess people who cannot visit prior to moving into the home. This assessment is carried out either in their home or if they are in hospital. Ashgrove House DS0000056308.V365557.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. People at Ashgrove House benefit from the provision of health and personal care that is based on detailed and comprehensive care plans and risk assessments, and is provided in a respectful and dignified manner. EVIDENCE: Five care files were examined and each contained a detailed care plan. These provided staff with information and instructions about the steps they should take to meet people’s needs. The plans were individualised and showed that people were encouraged to take control over when, where and how support was to be provided. Care plans were reviewed at least once a month. The progress records were read and these confirmed that routine and specialist health care was provided. Social Service reviews had also been completed and the attendance list showed that the relatives and the resident were present when possible. Ashgrove House DS0000056308.V365557.R01.S.doc Version 5.2 Page 12 Daily records are now completed. These were written respectfully and major events in people’s lives were recorded, though they did not always detail people’s experience in relation to daily living. Information in care plans continues to give detailed instruction about the support required for routine activities, such as moving and handling, oral hygiene, personal care and guidance concerned with specialist care, for example, diabetes care, pressure area care or problems with swallowing food. Records confirmed that routine health care, such as dental care, podiatry, opticians and routine general practitioner examinations occur. Specialist intervention from district nurses, continence service, dieticians and other health professionals is also facilitated. The optician was carrying out eye tests for people at Ashgrove House on the day of inspection. Detailed risk assessments were in place for people with swallowing difficulties these had been developed following referral to the speech and language therapist; it was also clear that the balance between the choice of the person, their quality of life and potential harm was fully assessed and considered before the risk management plan was completed. Records and care plans showed that people’s needs were reassessed in respect of falls, nutritional status and continence needs. The majority of relatives who returned surveys felt that the health needs were usually met, though respondents did not highlight any longstanding or serious omissions or problems in this area. People who were interviewed were satisfied with the health provision at Ashgrove House. They said: ‘Staff are ahead of the game- very observant’; ‘I was ill the other day and they couldn’t do enough for me’; and ‘Yes they are very prompt with health care.’ The medication round was observed and no problems were noted. Medication was stored and labelled correctly, the medication record sheets (MARS) were complete and medication was stored securely. Correspondence and daily records also confirmed that the effect of medication was monitored and further medical advice sought if a problem was suspected or identified. The need to purchase and installation of a controlled medication cabinet in keeping with current pharmacy guidelines was discussed with the manager, and it was agreed that would be done. She has purchased a controlled drug recording book so that it can be shown that these drugs are entered into the home and managed in full accordance with pharmacy guidelines. Ashgrove House DS0000056308.V365557.R01.S.doc Version 5.2 Page 13 Observation of the interaction between people during the day confirmed that people were treated with respect and discretion. Staff were jovial and friendly towards people. They participated in banter, were helpful and listened to what people said. People who were interviewed identified that staff were tactful and respectful when dealing with personal care needs. Comments included ‘Things are dealt with subtly – in private’ and ‘staff are very good indeed - all very nice.’ People who were observed throughout the day were well groomed and fully dressed. The ladies wore tights or stockings, and clean shoes or slippers, their hair was neatly brushed and some had had their fingernails manicured. Some men wore a shirt and tie, others a neat jumper, tops and trousers. Shoes or slippers were clean. People wore hearing aids and corrective glasses that were clean. Ashgrove House DS0000056308.V365557.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Meals and activities at Ashgrove House meet the needs of the people and there are opportunities for a varied lifestyle that matches expectations. EVIDENCE: People living at Ashgrove House and their families confirmed that activities provided are varied and culturally appropriate. Photographs and the activities record showed that people could play games such as bingo, dominoes, floor skittles and ball games, flower arranging, arts and crafts including jewellery making. People also have the opportunity to shop at the local supermarket and enjoy entertainers who visit the home. Pictures also confirmed that important dates such as birthdays, saint days and religious festivals are celebrated. The calendar and the manager also stated that people enjoyed books from the library; music and sing-alongs, and reminiscence talks. A hairdresser comes to the home on a weekly basis. Ashgrove House DS0000056308.V365557.R01.S.doc Version 5.2 Page 15 The residents who returned the survey confirmed that there was always an activity that they could participate in. Those who were interviewed stated ‘I enjoy speaking to people and I take part with the entertainment’ and ‘We enjoy ourselves, we have bingo and trips out now and again.’ Relatives’ comments included: ’Staff will go and speak to people and organise an activity in quiet moments.’ Staff said: ‘we do a lot - we have a weekly calendar - we have entertainers, arts and crafts, exercise, we go to the pub and trips out.’ The manager wrote in the information returned that there were plans to produce a newsletter and purchase a minibus for the residents. During the course of the inspection equipment and games were readily accessible. The atmosphere at Ashgrove House was relaxed. People with similar interests tended to sit together and observations of the interactions and discussions that occurred evidenced that people do develop friendships. At the previous inspection there was evidence that some people may have been getting up earlier than they wanted. On this inspection it was noted that a number of people were still in their rooms when the inspection commenced and people were at different stages of completing their breakfasts. In the morning, the people who were up were, for the most part, awake and alert. Staff commented that people were able to get up and go to bed when they pleased, although sometimes they needed staff to make the suggestion. People confirmed that visiting is unrestricted. Relatives and friends who returned surveys all felt that they were almost always helped to keep in touch with people living at Ashgrove House. People felt that visitors were made welcome. Comments included: ‘visitors can come and go when they want and are made very welcome.’ The main meals continue to be prepared from fresh ingredients. The food larder held a wide variety of well-known good quality branded foods. The fresh fruit and vegetable order list was exemplary in its indication of the variety offered. The menus at Ashgrove House are rotated monthly and dishes included cereal, porridge, grapefruit, cooked breakfast, toast and marmalade at breakfast, cottage pie, steak and mushroom and other traditional meat and fish dishes for lunch. At teatime a choice of pork pies, sausages, corned beef hash, crumpets and other meals were on offer. Afternoon tea in the home always included a selection of cakes and biscuits. Ashgrove House DS0000056308.V365557.R01.S.doc Version 5.2 Page 16 The lunchtime meal on the day of inspection was homemade chicken and vegetable pie or savoury mince and mushy peas, carrots and cabbage. People were offered a choice of meal at the time it was served. The meal looked appetising, was nicely presented and hot. Lunch was a pleasant social event. Everyone who wanted, was able to sit at a dining table and people were seen enjoying their meals and conversing over lunch. The dining areas were clean and well furnished. Staff were observed providing assistance in a dignified manner and with patience. The manager has also introduced a food chart so that staff can accurately record what people have eaten at each meal. Sit and weigh scales have been purchased and so accurate nutritional monitoring is now possible. People reported: ‘The food is very good’; ‘I enjoyed that-always enjoy something well made for you’ and ‘Food is very good - it pleases me anyway.’ Relatives commented: ‘… enjoys eating - we would say the food is good - it smells good and there is never a hurry at mealtimes.’ Staff were also observed checking that people had enjoyed the food or drink provided. Ashgrove House DS0000056308.V365557.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The manager ensures that complaints from people using the service are taken seriously and that systems are in place to protect people from abuse. EVIDENCE: The complaints record was examined and this held the details of complaints made by relatives and residents. The records were detailed and it was clear that these had been fully and fairly investigated. People who had complained were informed about the outcome and the manager ensured that they were satisfied. They said: ‘I’ve no complaints – if I had one, I would see the manager’ and ‘Oh, I’ve nothing to complain about - but I would talk to the owners’ and ‘Yes I have complained on the odd occasion and it has been sorted out - they are very good’. People who returned surveys indicated that they were aware of how to make minor complaints and were confident that action would be taken – even though, at times, problems could reoccur. The manager stated that there had been no adult protection investigations in the home since the last inspection. Ashgrove House DS0000056308.V365557.R01.S.doc Version 5.2 Page 18 The training matrix confirmed that prevention of adult abuse training has been provided to all staff from the Oldham Metropolitan Borough Council training partnership. The member of staff who was interviewed was clear in understanding about behaviours and treatment that could be considered abuse, and was able to discuss, in general terms, the actions to be taken to deal with any suspicions; this included recording any incident and alerting the manager. This area could be improved further if staff had a clear flowchart of the things they must do according to their level of responsibility - and what to do if they feel dissatisfied with the outcome. However, there are posters and other information providing details about how to protect vulnerable adults posted in different parts of the home. Ashgrove House DS0000056308.V365557.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is excellent. This judgement has been made using available evidence, including a visit to this service. Ashgrove House provides clean, comfortable and accessible private and communal living areas. EVIDENCE: In the course of the inspection a tour of the Ashgrove House was completed. The majority of the bedrooms were inspected; these were clean and free from unpleasant odours. Bedrooms are decorated in subtle pastel shades and people were observed enjoying their rooms. Many rooms had been personalised with furniture, photographs and ornaments from their homes. All the radiators in the home have been covered and the temperature of hot water in the bedrooms and bathrooms was governed to maintain a safe temperature. The heating system in the home is new and under guarantee. Ashgrove House DS0000056308.V365557.R01.S.doc Version 5.2 Page 20 The corridors were clean and free from unpleasant odours. The lounge and dining areas were clean, nicely decorated and the furnishings were free from stains, clean and in good repair. People were observed accessing all areas of the home using aids and equipment provided. Hoists and other aids are available for use in the bathrooms and en-suite areas of the home. There are two assisted shower rooms and two assisted bathrooms. All these areas were clean and warm. The manager stated that kitchen hygiene continues to be assessed as satisfactory under the Safer Food Better Business initiative led by the local Environmental Health Agency. All parts of the home that were inspected were clean and free from unpleasant odours or stains. The corridors were inspected at different times of the day and they were odour free at all times. People said: ‘I love my room and the privacy, and I like the surroundings.’ Ashgrove House DS0000056308.V365557.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The current recruitment and selection process fully safeguards against employing unsuitable people, and staff are well trained and motivated. EVIDENCE: On the day of inspection there were 31 people living at Ashgrove House and the staffing ratio was five care staff plus the manager during the day and three staff wake and watch at night. A cook and domestic staff are also employed. The manager stated in the information provided that additional staff would be encouraged to become senior carers so that the number of people skilled to take on a senior role and demonstrate best practise could be increased. Residents felt that there were sufficient staff on duty. During the day it was noted that call bells were answered quickly and staff had time to spend with people, and went about their tasks calmly. The manager has stated in the AQAA that out of 26 care staff, 16 have attained the National Vocational Qualification in care level 2 award or above, and a further five were completing this training. Ashgrove House DS0000056308.V365557.R01.S.doc Version 5.2 Page 22 The training calendar and certificates confirmed that, since the previous inspection, staff have participated in the following training: health and safety awareness; infection control; fire safety; moving and handling; infection control; sensory impairment; first aid; care of ageing skin; medication 08; abuse; malnutrition universal screening tool (MUST); dementia care level 2 and tissue viability. Staff felt that they received sufficient training and support to carry out their work to a good standard. People who returned surveys were mostly confident that staff had the skills to meet the needs of service users. They commented ‘I find that the staff they employ are all friendly and particularly patient and caring with the elderly.’ Staff files were checked and the vetting documentation for six staff was examined. In each file was a sealed envelope labelled ‘CRB checks’, which held Criminal Record Bureau checks and letters were in place that confirmed that protection of vulnerable adults (POVA) checks had also been undertaken. Two references had also been obtained for newly employed staff. One person’s Criminal Record Bureau check had been completed by their previous place of work. The manager said that she had contacted the manager of the home who had applied for the CRB had been told that there had not been any problems regarding the carer. The manager also confirmed (during the completion of the this report) that she had approached the CRB organisation and been assured that the CRB was still valid. However, the manager needs to be aware that, at this moment in time, CRB’s are not portable, and must be taken up on each occasion by a new employer. Another CRB needs to be taken for this person. The staff member that was interviewed was enthusiastic about working at the home. She said: ‘I love working here, it’s great - you have the equipment you need and there are always enough staff - I have supervision about every three months and we have a staff meeting where we can speak freely’. She also said ‘The manager is good - we work as a good staff team and there are no bad feelings.’ Comments from relatives about the staff included: ‘Staff are good, I’ve never had any trouble’ and ‘Staff appear very caring.’ Ashgrove House DS0000056308.V365557.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The manager has developed systems that will ensure that Ashgrove House is run in the best interest of residents and which will promote the health and safety of those involved in the service. EVIDENCE: The manager has achieved NVQ level 4 in Management and certificates confirmed that she had attended courses to improve her practice. The courses included: care of ageing skin, tissue viability and a one-day moving and handling refresher course. Ashgrove House DS0000056308.V365557.R01.S.doc Version 5.2 Page 24 People using the service said that the manager is open to suggestions and listens to what is said. They commented: ‘The manager tries hard to keep everyone happy’ and ‘Denise (the registered manager) is approachable.’ Residents meetings occur and residents, their families and senior staff or the owners attend these. Notes indicated that topics discussed included: problems with the laundry system and requests for additions to the menu. The manager should be able to demonstrate how issues highlighted at residents meetings were responded to. The home’s quality assurance system seeks the opinion of relatives and health care professionals. An analysis of the process has not yet been completed and the advantages of producing a summary of the results of the home’s quality monitoring exercises was discussed. Particularly in respect of future plans for Ashgrove House. The manager stated that all residents, their families or the local authority now manage money and that invoices are sent when people make purchases. Receipts are kept and sent when a request for payment is made. Accounting books were maintained to record these transactions. Records and receipts confirmed that equipment used in the home is checked and maintained in accordance with the manufacturer’s recommendations. The accident and incident records were examined and it was assessed that those recorded had been dealt with in keeping with best practice guidance. Additional risk assessment and reduction plans had been completed and specialist advice and assistance gained when necessary. Examination of the records confirmed that a fire safety equipment check had been carried out within the last year and the recordings in the fire safety logbook confirmed that checks such as emergency lighting and the alarm system were completed regularly. All staff have received fire safety training. Certificates and the training records also confirmed that other health and safety related training included, food hygiene, first aid, moving and handling and infection control. The home has developed health and safety policies and guidelines concerning aspects of safe working practices, for example, dealing with dirty linen and wearing of overalls and gloves. Staff were observed adhering to these principles throughout the day. Appropriate posters promoting safe working practices and infection control were observed in the kitchen. Ashgrove House DS0000056308.V365557.R01.S.doc Version 5.2 Page 25 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 4 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 4 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 House DS0000056308.V365557.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action Ashgrove House DS0000056308.V365557.R01.S.doc Version 5.2 Page 27 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 4 5 6 Refer to Standard OP7 OP9 OP15 OP18 OP29 OP33 Good Practice Recommendations The registered person should ensure that daily records confirm that staff have carried out tasks in keeping with the care plans. The registered person should make sure that controlled medication is stored in full accordance with pharmacy guidelines. The registered person should make sure that it is easy to identify who has participated in or been offered the opportunity to participate in activities. The registered person should provide staff with clearer guidelines about the actions they should take when dealing with abuse. The manager needs to ensure that CRB’s are taken up for all employees regardless of when they last had one. CRB’s are not portable between employers. The manager should make sure that the quality monitoring is concluded so that people can see how their opinion has influenced the development of facilities. Ashgrove House DS0000056308.V365557.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Manchester Local Area Unit 1, 3rd Floor Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ashgrove House DS0000056308.V365557.R01.S.doc Version 5.2 Page 29 - 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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