Inspection on 19/01/06 for Ashgrove House

This inspection was carried out on 19th January 2006.

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

The inspector 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 17/07/07

Ashgrove House 30/10/06

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 Announced Inspection 19th January 2006 09:00 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.V269483.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ashgrove House DS0000056308.V269483.R01.S.doc Version 5.0 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 25 Category(ies) of Dementia - over 65 years of age (8), Old age, registration, with number not falling within any other category (8), of places Physical disability over 65 years of age (8) Ashgrove House DS0000056308.V269483.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 25 OP, up to 8 PD (E) and up to 8 DE (E). 28th September 2005 Date of last inspection Brief Description of the Service: Ashgrove 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 to provide 19 single rooms, eight with en-suite and five shared rooms, and one with en-suite. 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 a shower. Easily accessible toilets are available on each floor. Communal areas include a large lounge and dining room and a smaller lounge that can be used by smokers. The home is fringed by pleasant landscaped gardens to the front a large courtyard style garden to one side. Ashgrove House DS0000056308.V269483.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was undertaken on 19th January 2006 over a period of six and a half hours. The proprietor, manager, staff, service users and their relatives were informed that the inspection was to take place, this is called an announced inspection. The inspection process involved interviews with three service users and one service user representative. One member of staff was also interviewed and in depth discussion with the manager and owners also occurred. Detailed scrutiny of three files and all records and reports pertaining to these service users was undertaken. Other documents concerning the running of the home were also examined. A tour of the private and communal areas of the home was also undertaken and during the course of the day the interactions between staff and service users was observed. At the time of writing this report four general practitioner, three relative and one health and social care, Commission for social care inspection (CSCI) comment cards had been returned. No service user comment cards had been returned. What the service does well: On the day of inspection the home was welcoming, clean and warm. Service users appeared well groomed. No negative comments were made about the home by anyone spoken to and written responses were overwhelmingly positive, with one minor objection acknowledged as been sensitively dealt with. Ashgrove provides comfortable and spacious communal and private accommodation. The staff are friendly and in general service user feel that they are respected and listened to. The level of staff support available is good and high standard of personal support and care is provided. The owners are keen to continue improving both the standard of care and the facilities made available to service users. The owners appear to have high personal standards and this is reflected in the quality of service provision for example, good quality food, furniture and fittings and training for staff from experts. Ashgrove House DS0000056308.V269483.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ashgrove House DS0000056308.V269483.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ashgrove House DS0000056308.V269483.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 4 The statement and purpose and service user guide provides detailed information about the facilities, services and routines of Ashgrove, enabling potential service users to make a judgement about whether the home will suit their needs. EVIDENCE: During the process of inspection the service user guide and statement of purpose were read and found to provide information about: admission to the home; meals and mealtimes; the rights of service users in respect of privacy and choice; access to medical attention, social aspects of living in the home, in addition to information about policies and procedures pertaining to adult protection and making complaints. The layout of the service user is particularly helpful as it is written as an alphabetical ‘questions and answers’ booklet. The service user guide will even more informative when it is updated to include the training and achievements, such as gaining the Investors in People Award, that have taken place between April 2005 and April 2006. Ashgrove House DS0000056308.V269483.R01.S.doc Version 5.0 Page 9 The outcomes for National Minimum Standards3 and 5 were inspected and assessed as reaching the expected targets at the inspection of September 2005. Ashgrove House DS0000056308.V269483.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 and 10 The health and social needs of service users is fully set out in detailed careplans, enabling staff to provide the support required and monitor the effect of all intervention. Health and social care is provided in a manner that fully promotes the dignity and rights of service users ensuring that they feel valued and respected. EVIDENCE: As a part of the inspection process, information including, correspondence records, reports, care-plans, and assessments in three service-user care-files were examined in full. The manager has recently introduced a new care plan and assessment recording system, which allow for more detail to be recorded pertaining to the support required by service users. The completed document identified the assessed needs, the required intervention and the expected outcomes related to these needs. Ashgrove House DS0000056308.V269483.R01.S.doc Version 5.0 Page 11 These new plans have assisted staff in improving the accuracy of monitoring the progress of service users and also assists in identify the need for further or reduced intervention. Through these care plans it was also possible to track the specialist and routine health care provided to service users. Staff who were interviewed stated that the new care plans helped them to be more confident in their approach to service users as they were informative and easy to complete. Two service users and two visitors were interviewed and all enthusiastic and positive in their praise of staff, who were said to be extremely kind and attentive when providing any kind of care in addition intimate and other personal care was always carried out in privacy and with respect. Comments included: ‘This is the nicest home I‘ve ever been in.’ and ‘cannot fault this place’. Observation of staff and service user interaction confirmed that service users were treated with respect and discretion at all times. Standards 8 and 9 concerned with health and personal care were assessed as reaching a good standard in September 2005. Ashgrove House DS0000056308.V269483.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 15 The home provides service users with the opportunity to experience a varied lifestyle that match their expectations in groups and as individuals thereby reducing boredom and promoting continued physical, social and psychological development. Dietary needs of service users are well catered for with a balanced and varied selection of food available that meets the needs of service users tastes and choice. EVIDENCE: Discussion with service users, their representatives and staff indicated that activities provided are varied and culturally appropriate. The home has designated one member of the care staff to co-ordinate activities for service users and she has recently attended a ‘Developing activities in residential care’ course run by Age Concern. Relatives also commented that staff sit and converse with services users, encouraging discussion and interaction. Activities calendar has been put on display and details daily activities including board games, arm chair exercises, service users also go shopping to a local supermarket, acknowledgement of significant events and celebrations such as VE day and Easter, clothes parties, bingo and arts and crafts. Ashgrove House DS0000056308.V269483.R01.S.doc Version 5.0 Page 13 During the course of the inspection it was noted that equipment and games were readily accessible. In addition to these activities the manager stated that they regularly booked a singer to entertain the service users. Service users stated that they enjoyed the activities provided and could choose whether or not to join in. Records indicated that the majority of vegetables and meat dishes are prepared from fresh ingredients. A delivery had taken place on the day of inspection. The purchases were of well-known good quality branded foods. The fresh fruit and vegetable order list was exemplary in its indication of the variety offered to service users. The menus at Ashgrove are rotated monthly and dishes included pea and ham soup, fish cakes, braised steak, pork-chop and apple and bacon and cabbage. At teatime is a choice of soups and sandwiches are offered. The meal on the day of inspection was rissoles or sausages with peas, carrots, Swedes, potatoes and gravy followed by homemade bakewell tart or egg custard tart for those on low sugar diets, demonstrating that the diabetic food option was in keeping with the quality of the main menu. The service user comments included: ‘we get very nice food here.’ Additional comments about food included: ‘They serve really good food here, and bring around cakes, biscuits and fruit every afternoon or what ever people want and in summer they also serve ice lollies and ice-cream as a snack in afternoon.’ Observations made while meals were being served confirmed that staff were aware of the likes and dislikes of service users. The meals are well presented and the dining areas are clean and comfortable. Standards 13 and 14 concerned with daily life and social activities were assessed as reaching a good standard in September 2005. Ashgrove House DS0000056308.V269483.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 17 The homes aim is to provide opportunity for service users involvement in the process of voting, however the process of involvement does not ensure that they are given sufficient support and encouragement to vote in local, national and European elections. EVIDENCE: The service user guide identifies that service users are able to registered to vote while living at Ashgrove and service users who are clearly able to make a decision are asked whether they would like to vote. Improvement in this process is necessary to ensure that all service users are registered to vote so that voting cards are issued at the time of an election. This is because it will assist the decision making of service users if, the question of whether to vote relates to an individual election, and not to voting in general. Standards 16 and 18 concerned with complaints and protection were assessed as reaching a good standard in September 2005. Ashgrove House DS0000056308.V269483.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 The home provides clean, comfortable and flexible private and communal living areas. Although for the most part the accommodation is safe, the home needs to prioritise some work as agreed at previous inspections, to minimising the risk of scalding to all service users. EVIDENCE: In the course of this announced inspection a tour of the internal building was undertaken. 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. Service users were observed accessing all areas of the home using aids and equipment provided. Hoists and other aids where observed in the bathrooms and en-suite areas of the home. Ashgrove House DS0000056308.V269483.R01.S.doc Version 5.0 Page 16 All bedrooms were inspected; these were clean and free from unpleasant odours. The en-suite areas were also clean. The bedrooms had been personalised either with the service users own belongings or a choice provided by the home. The majority of radiators have been covered, with two outstanding. This was a cause of disappointment because assurance had been given that this work would be completed as a matter of urgency. This was discussed with the owner who agreed to reprioritise this task. The bedrooms are decorated in subtle pastel shades, service users were observed enjoying both their bedrooms and the communal areas of the home. All equipment in the home was clean and free from stains and was therefore appealing to use. The owners are keen to continue improving the facilities provided at Ashgrove and plans including an extension and refurbishment of the kitchen, enlargement of one of the lounge areas, installation of en-suite facilities in all bedrooms, with the replacement of the vanity units in all bedrooms continues. Standards 20,21,22,23,24 and 25 concerned with the environment were assessed as reaching a good standard in September 2005. Ashgrove House DS0000056308.V269483.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28 Staff are well trained and well motivated ensuring that they provide up-to-date care and support to service users. EVIDENCE: Certificates provided evidence that staff have undertaken extensive training during 2005. Courses include Fire safety training, moving and handling, health and safety, infection control, sensory impairment awareness, safe handling of medication food and hygiene, dementia care and activities for people living in residential homes. Furthermore 12 of the 17 care assistants have attained the NVQ level 2 award in Care. The training calendar also identified future courses that included Level 2 in Dementia care, management of incontinent, NVQ level 2, and further certificated medication training. Discussion with staff indicated that the training they received modified and improved their confidence and their approach to the tasks they had to undertake. For example the staff who had completed the activities training were keen to confirm that they were well supported in implementing ideas that came out of the course. Observation of staff interaction with service users also indicated that they were able to put into practise training received relating to food and hygiene, moving and handling and working with service users with dementia. Ashgrove House DS0000056308.V269483.R01.S.doc Version 5.0 Page 18 Discussion with staff also indicated they felt well supported by the management team, and were able to work to the best of their ability, and kept motivated through the manager knowing their strengths and interests, and using these to the advantage of service users. Staff satisfaction in working in Ashgrove is very high demonstrated by the fact that 17 of the 21 staff have worked in the home for 2 or more years, and vacancies are rare. Staff consistently indicate that nothing was too much in respect of meeting the needs of the ‘residents’. Standards 27, 29 and 30 concerned with staffing were assessed as reaching a good standard in September 2005. Ashgrove House DS0000056308.V269483.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33 and 35 The home is run in a manner that enables service users to get the best out of residential care, however more consideration is necessary to ensure all service users are given the opportunity to participate in the quality assurance system. Service users money is accounted for in a manner that ensures the opportunity for fraud is minimised. EVIDENCE: Service users, staff family and friends all stated that the manager and proprietors of Ashgrove are very approachable and interested in their opinion. Minutes and notes of staff meetings demonstrate that they are a listening team. Ashgrove House DS0000056308.V269483.R01.S.doc Version 5.0 Page 20 Comments included: (From health care representatives) ‘an extremely well run home. All care staff helpful and friendly’; and the proprietor commented ‘Though it is a business you have to take pride in what you do.’ and this is reflected in the quality of food, snacks, activities, the training and support for staff, as well as in the refurbishment and extension plans for the home. The homes quality assurance system has been assessed as satisfactory, however more effort is required to ensure service users with memory loss are given the opportunity to comment, further more staff also need to participate in the process. Notwithstanding this, it must be reiterated that all observations made and comments received have been positive about the way in which all aspects of the home is run. Furthermore staff are encouraged to complete an exit form when they leave, thereby providing them with an opportunity to comment honestly on how the home is run. The Royal Bank of Scotland manages 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. Standards 31,36,37 and 38 concerning management and administration were assessed as reaching a good standard in September 2005. Ashgrove House DS0000056308.V269483.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x X 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 X 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 2 18 x 2 X X X X X X 3 STAFFING Standard No Score 27 X 28 4 29 X 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 2 X 3 X x x Ashgrove House DS0000056308.V269483.R01.S.doc Version 5.0 Page 22 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 OP19 Regulation 14(a) Requirement Timescale for action 01/04/06 2. OP33 35 The registered person must ensure all radiators in all bedrooms are covered so that the safety of service users is promoted. The registered person must 01/04/06 ensure that service users are fully involved in the quality assurance system that is used by the home. 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 OP17 Good Practice Recommendations The registered person should ensure service users are given informed choice about voting. Ashgrove House DS0000056308.V269483.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Ashton-under-Lyne Area Office 2nd Floor, Heritage Wharf Portland Place Ashton-u-Lyne Lancs OL7 0QD 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 House DS0000056308.V269483.R01.S.doc Version 5.0 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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