Inspection on 28/09/05 for Ashgrove House

This inspection was carried out on 28th September 2005.

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

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

Other inspections for this house

Ashgrove House 15/07/08

Ashgrove House 17/07/07

Ashgrove House 30/10/06

Ashgrove House 19/01/06

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 28th September 2005 7.15 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.V248954.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.V248954.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.V248954.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). 15/02/05 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.V248954.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken on 15/09/05 over an eight-hour period. The inspection process involved interviews with three service users and one service user representative. A group discussion was also conducted at lunchtime. One member of staff was also interviewed and in depth discussion with the manager and owners also occurred. Examination of the majority of care files was undertaken with detailed scrutiny of seven files and all records and reports pertaining to these service users. Other documents concerning the running of the home was 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. On the day of inspection the home was welcoming, clean and warm. Service users appeared well groomed. Although they made comments concerning the lack of activities away from the home, comments about the care and attitude of staff were very positive and included: ‘They are very good they’ll help you’ and ‘Couldn’t be any where better’. What the service does well: What has improved since the last inspection? Ashgrove House DS0000056308.V248954.R01.S.doc Version 5.0 Page 6 Routine health checks and other activities relevant to health are now recorded for each service user. The front garden has been landscaped. 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.V248954.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.V248954.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): 2,3, and 5 Service users are provided with appropriate terms and conditions of residency. The needs of service users are fully assessed prior to admission to the home. Prospective service users and their representatives are encouraged to visit the home prior to admission. EVIDENCE: During this inspection seven service user files where examined in detail. Each file contained a copy of the terms and conditions that included the cost of residency and the services and facilities provided by Ashgrove. Each file examined contained a comprehensive assessment completed by the referring agency or the manager prior to admission. The assessment provided information about the physical, psychological and social needs and interests of the service users. The care plans in response to the needs identified did not provide carers with sufficient information to meet the assessed needs. This is an ongoing issue concerning Ashgrove and was discussed with the manager and registered providers. Ashgrove House DS0000056308.V248954.R01.S.doc Version 5.0 Page 9 Three service users where interviewed, including a recent admission. This person confirmed that they and their representative had been provided with the opportunity to visit the home prior to admission. The manager also stated that it was policy for her to visit and assess service users needs prior to accepting an admission. Ashgrove House DS0000056308.V248954.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): 7,8,9 and 10. The social and psychological needs are not sufficiently set out and detailed in the care plans. The health needs of service users are met. Service users are treated appropriately in areas concerning privacy and respect. EVIDENCE: In the course of this inspection seven service users care files and other documents concerning the care, support and monitoring of service users were fully scrutinised. These records and reports consistently failed to demonstrate that the social and psychological support provided to service users had been fully identified and met. The home completes progress reports for service users on a weekly basis, however this frequency is not increased in line with any increase in the needs of service users. These issues where discussed at length with the manager and registered provider. Ashgrove House DS0000056308.V248954.R01.S.doc Version 5.0 Page 11 Discussion with service users and their representatives, however, indicated that health-monitoring checks took place and specialist care and advice was sought and provided for those residing at Ashgrove. The District Nurse attending the home during the inspection completed a Commission for Social care Inspection (CSCI) comment card and confirmed that she considered the management team to be caring and approachable, in addition it was her observation that the care staff always complied with her instructions. Service users and relatives stated that their health care needs were being met appropriately. It was noted that services users were wearing hearing aids and corrective glasses, demonstrating that these checks take place. Service users stated that all personal and health care was provided privately and with discretion. Actions observed on the day of inspection supported this ascertain, and reports where written respectfully. Ashgrove House DS0000056308.V248954.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): 12,13,14 and 15. Service users enjoy a flexible lifestyle and are helped to exercise choice over their lives. Service users are encouraged and enabled to maintain contact with friends and family. Service users are provided with wholesome and appealing meals at times that are convenient to them. EVIDENCE: Discussion with service users, their representatives and staff indicated that activities provided are varied and culturally appropriate. The home has recently designated one member of the care staff to co-ordinate activities for service users. Examination of the activities book detailed activities which included hairdressing each Friday, service users going shopping to a local supermarket, acknowledgement of significant events and celebrations such as VE day and Easter, attending a local bowling green to watch games, clothes parties, bingo and arts and crafts. During the course of the inspection it was noted that equipment and games were readily accessible. Ashgrove House DS0000056308.V248954.R01.S.doc Version 5.0 Page 13 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. In the course of interviewing service users and relatives, disappointment was expressed about the lack of trips out. Discussion with the manager indicated that this was been addressed. Services users and their representatives where keen to confirm that visits where unrestricted. The owners’ value involvement with the local community and recently the home took part in a local scheme involving school children. 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 a choice of soups and sandwiches are offered. The meal on the day of inspection was beef stew, potatoes, carrots and cabbage. This was sampled and found to be tasty and the vegetables where nicely prepared and cooked. The quality of the diabetic food options was in keeping with the quality of the main menu. The service user comments included: ‘we get very nice food here.’ The relative noted that staff where aware of the likes and dislikes of service users. The meals are well presented and the dining areas are clean and comfortable. Ashgrove House DS0000056308.V248954.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): 16 and 18 The home ensures that complaints are taken seriously and that service users are protected from abuse. EVIDENCE: The homes complaint procedure was examined in detail and found to provide sufficient information to enable service users or their representatives to make complaints. One person stated that they had made a complaint and the manager and owners had satisfactorily dealt it with. Certificates confirmed that staff had received training in the prevention and detection of adult abuse. Discussion with the care staff confirmed that this training was had been understood and, supervision notes indicated that their understanding of adult protection issues is monitored. Ashgrove House DS0000056308.V248954.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): 19,20,22,23,24,25 and 26 The environment at Ashgrove is safe, clean, well maintained and suitable to meet the needs of service users. Specialist equipment is provided as required. EVIDENCE: In the course of this unannounced inspection a tour of the entire building and external areas was undertaken. The corridors where 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.V248954.R01.S.doc Version 5.0 Page 16 The majority of bedrooms were inspected, and the majority of these where 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 radiators have been covered to reduce the risk of scalding to service users. The bedrooms were decorated in subtle pastel shades. Service users stated that Ashgrove was a comfortable place to live. The gardens have been redesigned increasing access to an appealing wellmaintained courtyard garden to the side of the property. The owners are keen to continue improving the facilities provided at Ashgrove and were eager, at the time of inspection, to discuss plans that are been developed. These plans include extension and refurbishment of the kitchen, enlarging one of the lounge areas, installation of en-suite facilities in all bedrooms that are large enough and replacement of the vanity units in all bedrooms. Ashgrove House DS0000056308.V248954.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): 27,29 and 30 Staff levels and staff training are sufficient to meet the needs of service users. The home recruitment and selection process provides satisfactory protection to service users. Staff receive sufficient training to enable them to do their jobs. EVIDENCE: On the day of this unannounced inspection the manager plus 3 care assistance were attending to the needs of 23 service users. Ancillary staff included a parttime cook and a housekeeper. Examination of the duty roster confirmed that was the usual ratio of staff. The owners also take an active role in the running of the home. Supervision records and certificates demonstrated that staff are well trained. In the past year they have had the opportunity to undertake training in the following areas: moving and handling, pressure area management, dementia and challenging behaviour, identifying abuse, health and safety, food hygiene, sensory impairment, infection control, and NVQ levels 2 and 3. Supervision notes also demonstrated that the responsibility to provide sensitive and constant palliative care is highlighted. Ashgrove House DS0000056308.V248954.R01.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,36,37 and 38 The home is well managed. Staff are provided with appropriate supervision. There are safeguards ensuring protection of the health safety and welfare of service users and staff. EVIDENCE: The manager has achieved NVQ level 4. Discussion with the manager confirmed that she was keen to continue improving her knowledge and practice concerning residential care, older people and management of staff. Service users, their representatives and the staff all confirmed that the management style and ethos of the home enabled frank discussion and innovation in relation to the running of the home. Ashgrove House DS0000056308.V248954.R01.S.doc Version 5.0 Page 19 Staff files indicated that supervision was provided to care staff on a regular basis. These records also demonstrated that training was offered as a means of improving the care provided by staff and reiterating the philosophy of care and support. In addition supervision was used to encourage staff in their areas of special interest concerning social care. The home encourages and supports safe working practice through staff training, this was particularly evident on the day of this unannounced inspection when staff attended fire safety training provided in the home by an outside agency. Specific health and safety training is provided for example moving and handing, first aid and food hygiene. Records and receipts confirmed that equipment used in the home is checked and maintained in accordance with the manufactures recommendations. A new fire alarm system has recently been installed. The home has developed health and safety policies and guidelines concerning aspects of safe working practices, for example dealing with dirty linen, the wearing of overalls and gloves. Appropriate posters appertaining to safe working practices were observed in the kitchen and the laundry room. Ashgrove House DS0000056308.V248954.R01.S.doc Version 5.0 Page 20 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 3 2 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 x 3 3 3 3 3 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X X 3 X 3 Ashgrove House DS0000056308.V248954.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement The registered person must undertake a review of the homes recording systems ensuring that care plans; reviews, risk assessments and daily reports reflect the assessed needs of the service users and the care delivered by staff. The registered person must ensure that details of the assessed needs of service users are transferred to and included in the service users’ care plan. Timescale for action 01/02/06 2 OP3 14 01/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP12 Good Practice Recommendations The registered person should review the provision of excursions activities provided away from the home. Ashgrove House DS0000056308.V248954.R01.S.doc Version 5.0 Page 22 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.V248954.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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