Inspection on 17/07/07 for Ashgrove House

This inspection was carried out on 17th July 2007.

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 House 15/07/08

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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Ashgrove House 72 Butterworth Lane Chadderton Oldham Lancashire OL9 8DX Lead Inspector Michelle Haller Unannounced Inspection 17th July 2007 07:15 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.V339715.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.V339715.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) Ash grove 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.V339715.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service 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). 30th October 2006 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 recently 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 includes 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 Ash grove House ranges from £353 - £375. A copy of the previous Commission for Social Care Inspection (CSCI) report was available in the foyer. Ashgrove House DS0000056308.V339715.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection included an unannounced site visit to the home on 16th July 2007 and was conducted over a period of eight and a half hours. The inspection process involved interviews with nine people using the service and four relatives. Two care assistants were also interviewed and in depth discussion with the manager took place. Examination of five care files and all records and reports pertaining to these people was completed, together with other documents concerned with the running of the home. A tour of the private and communal areas of the home was undertaken and during the course of the day the interactions between those at Ash grove House was observed. Two CSCI relatives’ surveys were returned and the CSCI received one anonymous complaint, this information was also used as part of the assessment process. The manager also returned a completed Annual Quality Assurance Assessment (AQAA). This is information we ask the management of the home to complete to tell us what they think they do well, what they have improved on, and what they need to do better. We use this information throughout our inspection process. What the service does well: The manager ensures a pleasant environment and Ashgrove is welcoming, clean and warm. People expressed a high level of satisfaction and feel able to make their views known directly to the manager and owners. In general, staff are provided with sufficient information for them to promote independence and physical well-being. Ashgrove provides comfortable and spacious communal and private accommodation. The staff are friendly and people feel that they are respected and listened to. The level of staff support available matches the needs of the people currently in the home. Ashgrove House DS0000056308.V339715.R01.S.doc Version 5.2 Page 6 Meals and food at Ashgrove are plentiful, good quality and fully satisfies the expectations of people in the home. People commented: ‘I am quite happy and comfortable here.’ ‘I have no worries what so ever.’ ‘The staff are excellent-never had any trouble with the staff.’ What has improved since the last inspection? What they could do better: The manager must make sure that staff do not wake people up too early and that if people are up early it can be demonstrated that this is their choice. If residents fall asleep soon after rising, the manager needs to look at why this happening and make any necessary changes in consultation with the resident. The manager must make sure that care plans fully reflect specific health needs and that staff receive sufficient training and information about these conditions to ensure that appropriate monitoring and health care is provided. The manager must make sure that all new employees are subject to the required vetting process so that people are safeguarded against unsuitable staff. The manager must ensure that new staff are provided with the appropriate induction training in line with the recommendations from the Skills for Care organisation. The manager must update the training calendar to include adult protection training. Ashgrove House DS0000056308.V339715.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ashgrove House DS0000056308.V339715.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.V339715.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 (NMS 6 is 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 receive a service that meets their needs as; the manager ensures that she has gathered sufficient information about them before they are admitted to the home. EVIDENCE: Each care file contained an assessment of needs that provided information about the health, social and psychological requirements of people. This information was clearly written and identified care that included personal and physical care, diet and weight, communication, falls and continence, medication and next of kin. Ashgrove House DS0000056308.V339715.R01.S.doc Version 5.2 Page 10 Staff had also completed a social history indicating the family involvement, social history including working life, current interests and hobbies and other life experiences was documented. Pre-admission assessments and information confirmed that people and their representatives were encouraged to visit the home prior to accepting a service. Information in these forms also illustrated that it was made clear that admission was on a trial basis. People said ‘I am happy with the information I received.’ Ashgrove House DS0000056308.V339715.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 adequate. This judgement has been made using available evidence including a visit to this service. People at Ashgrove benefit from the provision of health and personal care that is based for the most part on their individual needs, and which is provided in a respectful and dignified manner. EVIDENCE: Six 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 illustrated that people were encourage take control over when, where and how support was to be provided. Each plan had also been reviewed at least once a month. The progress records were read and these, though not completed daily, provided that information was detailed and described events in peoples lives and confirmed that medical and health care provided. Ashgrove House DS0000056308.V339715.R01.S.doc Version 5.2 Page 12 Information in care plans had improved further in that they gave more detailed instruction about the support required for routine activities such as moving and handling, oral hygiene, personal care and, in some cases, guidance concerned with specialist care for example following eye surgery for cataracts. Records also 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. To improve in the area the manager needs to demonstrate that additional risk assessments are developed in response to change in needs of people- for example where falls increase the manager must be able to demonstrate that action has been taken to both reassess the person’s needs and respond to any findings. The manager must also make sure that the risks associated with chronic health conditions such as diabetes are implemented and the results highlighted to all staff. Risk assessments and reduction protocols must be produced and staff receive appropriate training to equip them with the knowledge to recognise when extra intervention is required, and be able to identify symptoms that indicate that specialist intervention is required before the situation becomes an emergency. These issues were discussed with the manager. The medication round was observed and no particular problems were noted. Medication was stored and labelled correctly, the medication record sheets (MARS) were complete and medication was stored securely. Observation of the interactions during the day indicated that people were treated with respect and discretion. People were positive about the health and personal care provided in Ash grove House and reported that ‘Care is very good as a rule.’; ‘staff are respectful.’; ‘They are good with us.’; ‘I am happy with all the care my mother gets from staff.’ and ‘Each resident is treated as an individual, their independence maintained as much as possible and their dignity respected as well as their wishes by all the staff.’ Ashgrove House DS0000056308.V339715.R01.S.doc Version 5.2 Page 13 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 adequate. This judgement has been made using available evidence including a visit to this service. Meals and activities at Ashgrove meet the needs of the people and the manager provides opportunities for a varied lifestyle that matches expectations thereby, reducing boredom and promoting continued physical, social and psychological development. The routines within the home do not fully demonstrate that residents choices are fully listened to. EVIDENCE: Ashgrove employs two activities co-ordinators, and both have completed a training course about providing activities in a residential home. Discussion with people and their families, pictures and activities diary confirmed that activities provided are varied and culturally appropriate. The care plans identify ‘factors to maximise contentment’ for each person and this includes a description of interests and preferences. There is also information about the times when Ashgrove House DS0000056308.V339715.R01.S.doc Version 5.2 Page 14 people would prefer to go to bed and get up, although this could be improved if instead of ‘early’ a precise time was stated in all cases. Pastimes are changed weekly and includes and entertainer each month; birthday parties, outings to shows and local beauty spots; flower arranging, floral art, games and quiz sheets, word searches, books from the library; music and sing-a-longs, dominoes and other table top games, reminiscence talks, relaxation and arts and crafts. People can also have a weekly visit from the hairdresser. It was noted that staff asked people what they would like do, for example read the newspaper, listen to the radio or watch television. Staff also spend time talking with people discussing news events or the story lines in soap operas. Although one person felt that they would enjoy more activities in general people said ‘If they have something on we’ll join in- we’ve made banners, posters, cards, covered boxes and painted. The staff are excellent.’; and ‘we were invited to a local school for their concert, it was very very good.’ And ‘Residents are encouraged to participate in all activities if they so wish.’ During the course of the inspection equipment and games were readily accessible. People would like more excursions and the manager stated that she is hoping fund raise to purchase a minibus so that outings can arranged more spontaneously. People confirmed that visiting is unrestricted and visitors made welcome: ‘Visitors are welcomed’ and ‘There are no restrictions on visitors.’ The Commission for social Care inspection (CSCI) received a complaint highlighting a number of concerns one of which was that people had to get up very early in the morning. The manager responded to this complaint saying it did not happen. However this was also looked into as a part of the inspection process. The inspection commenced at 07.15 in the morning and at least 15 people were already up- some were asleep in their chairs. One member of staff on duty commented that they started getting people up early-stating ‘We start at 5am.’ A number of people already up were not able to say whether they had been given a choice about getting up, although one person commented that she had been woken up. ‘I’m tired because I wasn’t left sleeping- but they can’t do enough for you here though.’ Ashgrove House DS0000056308.V339715.R01.S.doc Version 5.2 Page 15 Everyone else spoken to, however, indicated that they had either got themselves up or was awake and summoned assistance to get up. One person was also uncertain about the time in that she said that she thought the time was 09.00am. People commented: ‘I get up at 5.30 and I get myself up- I don’t have to get up – I dress myself and wash myself ready for a cup of tea at 6.30.’; ‘It’s alright the hustle and bustle of the morning is a cue for me to get up.’; ‘I sleep well, go to bed about midnight, then I wake up refreshed- I’m a deep sleeper.’ ‘I always get up early and dressed.’ ‘I get up but then I dose off- they’re very good with us here through.’ This issue was discussed with the manager who stated that, the home was well staffed throughout the day so that they can provide a responsive and flexible service, and so there was no excuse if people were being got up before they were ready. It was also highlighted that peoples sleep patterns may have changed since admission and so instructions in care plans did not always reflect what they wanted or what actually happened. It was agreed that these would be updated, especially for people who are not able to tell staff what they want. Staff will need to consult with relatives if a resident is not able to indicate their wishes. Residents who are up but then fall asleep in the lounge chair quickly need to be reassessed as to waking times, as their behaviour would suggest they are still tired, and should be still in bed. The majority 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 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. The meal on the day of inspection was a choice of braised steak or beef-burgers and mash, both served with fresh vegetables. Followed by homemade cherry pie and custard. An option for diabetics was also provided. Two meals were observed breakfast was prepared as people came down to eat and so everything was fresh and nicely presented. Ashgrove House DS0000056308.V339715.R01.S.doc Version 5.2 Page 16 Lunch was a pleasant social event. Everyone who wanted to be was able to sit at a dining table and people were seen enjoying their meals and conversing over lunch. Since the last inspection the mealtime routine has been changed and this does appear to rush people because the dessert is placed on the table before people have finished eating the main course. This alteration was discussed with the manager who agreed to reconsider the change. Apart from this meals that were seen were well presented and the dining areas clean, comfortable and pleasant to use. 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 also been purchased and so accurate nutritional monitoring is now possible. People reported: ‘I’ve no complaints and I eat what is given.’ ; ‘the food is alright, it suits me and there’s enough variety- I’m not a big eater.’; ’The food is good.’; ‘I get more than I need.’; ‘They feed us very well- if anything we are overfed.’ And ‘The food is very good.’ Ashgrove House DS0000056308.V339715.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 adequate. 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 some systems are in place to protect people from abuse. EVIDENCE: Since the last inspection the manager has received a detailed written complaint about the home, which she investigated. Although the manager assessed that the complaints were unfounded, it must be noted that one of the issues did need to be addressed in more detail. People spoken to had made no complaints and all were confident if they talked to the manager or owner about any concerns they were certain that these would be taken seriously. People said ‘If I had any complaints I think they would see to it right away.’ ‘If I had any complaints I would talk to a relative and they would sort it out.’; ‘I’ve no complaints but if I did I would talk to Denise (the registered manager).’ Ashgrove House DS0000056308.V339715.R01.S.doc Version 5.2 Page 18 The manager stated that there had been no adult protection investigations in the home since the last inspection. Prevention of adult abuse training needs to be up-dated as according to the training records the rolling program of training that had been previously in place has not continued. Staff who were interviewed demonstrated a basic understanding about behaviours and treatment that could be considered abuse, and were able to discuss the actions to be taken to deal with any suspicions. The need to update this training was brought to the attention of the manager. The manager should also attend Oldham social services training as this links in with the adult protection protocol agreed by statutory services in the area. A copy of the Oldham Adult protection policy was readily available in the office, and the manager stated in the AQAA that the homes adult protection and whistle blowing (protected disclosure) policies had been reviewed in April 2006. Ashgrove House DS0000056308.V339715.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 provides clean, comfortable and accessible private and communal living areas. EVIDENCE: In the course of the inspection a tour of the Ash grove 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. Ashgrove House DS0000056308.V339715.R01.S.doc Version 5.2 Page 20 All the radiators in the home have been covered and the temperature of hot water in the bedrooms and bathrooms was governed to maintained a safe temperature. The heating system in the home is new and under guaranteed. 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 kitchen and laundry have both been modernised and the equipment in keeping with national minimum standards. The manager stated that kitchen hygiene had been 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. People said: ‘it’s lovely there are always flowers around the home and it’s clean.’ Ashgrove House DS0000056308.V339715.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): 27,28,28 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The current recruitment, selection and induction processes do not protect people at Ashgrove, however staff are provided with training opportunities and are motivated. EVIDENCE: On the day of inspection there were 32 people living at Ashgrove and the staffing ratio was 5 care staff plus the manager during the day and 3 staff wake and watch at night. A cook and domestic staff are also employed. The manager has stated in the AQAA 50 of the care staff have attained the NVQ level 2 in care award, and a further 25 have commenced this training. 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 and first aid. Staff also need to have their adult protection training updated and specialist training such diabetes care, dementia care and accredited moving and handling would also be beneficial. Ashgrove House DS0000056308.V339715.R01.S.doc Version 5.2 Page 22 Staff files were checked and the vetting documentation for all staff was examined. In each file was a sealed envelope that had been labelled ‘CRB checks’- however when these were opened it was found that a number of them contained blank sheets of paper and the manager was not able to demonstrate that either POVA firsts or CRB’s had been obtained for these people. Furthermore there were instances where the manager had not obtained two references for newly employed staff- and yet they were working in the home. The potential risks associated with this action were discussed with the manager. This finding makes judgement in this area ‘Poor’ because a continual repeat of this act could seriously jeopardise the safety of people living in Ashgrove. It was also noted that the most recent recruit had not undertaken the expected formalised induction process. The most recent recruit was interviewed; she stated that her induction involved close working with an experienced member of staff, she had not received any manual handling or adult protection training since taking up her post. There was no evidence available to confirm that this member of staff had been given information and her competency checked in respect of fire safety, health and safety, adult protection, infection control, manual handling, the principles of care or other important matters concerned with working at Ashgrove. Observations made about training however included: ‘I feel the staff are encouraged to gain appropriate qualifications and develop skills in elderly care. Nothing seems too much for them to do and they always are pleasant and cheerful to residents and visitors alike.’ Ashgrove House DS0000056308.V339715.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 adequate. This judgement has been made using available evidence including a visit to this service. The manager needs have additional systems in place to demonstrate that administration and management at Ashgrove is based on openness and respect. EVIDENCE: The manager has achieved NVQ level 4 in Management and certificates evidenced that she continued to improve and update her knowledge and practice concerning residential care, older people and management of staff Ashgrove House DS0000056308.V339715.R01.S.doc Version 5.2 Page 24 through attending conferences and courses, and is involved with prioritising improvements planned at Ash grove. People using the service say that the manager is open to suggestions and listens to what is said, they commented ‘the manager is very approachable.’ And staff reported that she ‘loved working in the home because there is a good atmosphere and good relationships between the residents and the owners.’ Residents meetings continue to take place and are chaired by the residents or care staff. And relatives are encouraged to be involved in the home through the development of the ‘Friends of Ash grove’ committee. Minutes and notes of staff meetings demonstrate that they are a listening team. The homes quality assurance system allows relatives and health care professionals the opportunity to comment about the service provided, these have been completed, the manager should finalise the process by analysing and correlating the results so that the information can be used effectively in future plans for the home. The Royal Bank of Scotland continues to manage the money for residents who have not made alternative arrangements. Money used for day-to-day expenditure is fully accounted for through the keeping of receipts and maintenance of accounting records. Records and receipts confirmed that equipment used in the home is checked and maintained in accordance with the manufactures recommendations. Examination of the records confirmed that a fire safety equipment check had been carried out within the last year. 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. And staff were observed adhering to these principles throughout the day. Appropriate posters promoting safe working practices and infection control were observed in the kitchen and the laundry room. The main area of concern in relation to management and administration is that CRB checks had not been carried and yet an attempt appeared to have been made to indicate that these were in place. This action does not demonstrate openness, full co-operation with the inspection process or a commitment to fully safeguard people from the risk of abuse through employing suitable people. In addition the training calendar does not demonstrate a commitment to adult protection, as this training need has not been made a priority. Ashgrove House DS0000056308.V339715.R01.S.doc Version 5.2 Page 25 Ashgrove House DS0000056308.V339715.R01.S.doc Version 5.2 Page 26 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 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 4 X X X X X X 4 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Ashgrove House DS0000056308.V339715.R01.S.doc Version 5.2 Page 27 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 OP18 Regulation 13(6) Requirement The registered person must ensure staff receive updated adult protection training to ensure that they know how protect vulnerable people from harm. The registered person ensure that risk assessments are developed and introduced to minimise risks associated with specific needs such as falls or diabetes. This is so that staff are alerted to any risks and the actions they can monitor the risk more effectively, and be alerted to the need for additional input before the situation becomes critical. The registered person must not employ people until they have completed CRB and POVA first checks and obtained two references, thereby safeguarding vulnerable people from harm. Timescale for action 01/10/07 2. OP8 13(4) 01/10/07 3. OP29 19(4) 01/10/07 Ashgrove House DS0000056308.V339715.R01.S.doc Version 5.2 Page 28 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 OP7 Good Practice Recommendations Care plans should be reviewed to reflect the choices people have made about important daily routines such as getting up and going to bed, with a view to maintaining their dignity and comfort. This will reduce the chance of people feeling that they have made to leave their rooms too early. Ashgrove House DS0000056308.V339715.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Manchester Local Office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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.V339715.R01.S.doc Version 5.2 Page 30 - 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!