Inspection on 02/12/05 for Ashlands

This inspection was carried out on 2nd December 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Ashlands 17/11/08

Ashlands 08/01/07

Ashlands 03/10/05

Ashlands 31/08/05

Ashlands 01/03/05

Ashlands 09/08/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Ashlands 152 Southwell Road East Rainworth Mansfield Nottinghamshire NG21 0EH Lead Inspector Jayne Hilton Unannounced Inspection 2nd December 2005 10:30 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 Ashlands DS0000060714.V268128.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. Ashlands DS0000060714.V268128.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ashlands Address 152 Southwell Road East Rainworth Mansfield Nottinghamshire NG21 0EH 01623 792711 01623 792711 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) Manonmany Wragg Manager post vacant Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Ashlands DS0000060714.V268128.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd October 2005 Brief Description of the Service: Ashlands is a two storey detached building converted and adapted to provide care for older people. There is sufficient space for dining and lounge for the number of people the home is registered for. The home is sufficiently adapted to meet the needs of service users with a physical disability. Adaptations/equipment include bath hoists, mobile hoists, handrails, grab rails and a passenger lift. The home has large pleasant gardens, which are secure and well maintained. The home is Registered for 21 beds, with bathrooms being located on both floors and some rooms having en-suite facilities. Ashlands DS0000060714.V268128.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The third unannounced inspection for the inspection year 2005/2006, was undertaken by, Regulation Inspector Jayne Hilton on 2nd December 2005 at 10.30am. The inspection concluded at 12.30pm. The methodology used included a part tour of the ground floor communal areas, the sampling of two care plans and associated records. Medication procedures were partly assessed, two staff files examined, Health and safety records, policies and procedures etc were all assessed. No staff or service users were interviewed at this inspection. The main focus of the inspection was to check whether the previous inspection requirements and recommendations had been met and to cover those standards not covered at the previous two inspections carried out for this inspection year. What the service does well: What has improved since the last inspection? Staff, are now being appropriately supervised. The health and safety training provision for mandatory training is either completed, ongoing or booked to be undertaken very shortly and a comprehensive fire risk assessment has been Ashlands DS0000060714.V268128.R01.S.doc Version 5.0 Page 6 carried out. Work has commenced to address the regulation and monitoring of water outlet temperatures and re-decoration of the laundry room. Improvement in the practices of administration of medicines is noted. Service users have opportunity to have a door key. Risk Assessments were in place for surface temperatures of radiators. Clearly the Registered Provider and Acting manager have worked hard to achieve the current status of no requirements at this 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. Ashlands DS0000060714.V268128.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 Ashlands DS0000060714.V268128.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): 3,4 Service users needs are assessed prior to moving in to the home and have their needs continually reviewed. Service users needs are well met. EVIDENCE: Two care plan files were examined. The care package documentation includes a pre assessment document, which is completed prior to admission. The owner or the manager goes out to undertake the pre assessment or sometimes they go together. A further assessment and care plans are implemented on the day of admission, which covers all issues as Required by St 3.3. Service users have locks on their doors, but there was no evidence of a key being offered or issued in the care assessment. A section for issuing of keys to bedroom doors and lockable facilities is included. The assessment documentation provides a personal history and medical profile, social and recreational needs profile, which included the likes and dislikes of service users. There was evidence of signature of service users or their representatives evident within care plans that service users are involved in their assessment and plan of care. Ashlands DS0000060714.V268128.R01.S.doc Version 5.0 Page 9 Service users were observed to be relaxed, happy, well dressed and autonomous. Ashlands DS0000060714.V268128.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): 7,8,9,11 Service users health, personal and social care needs are set out in a comprehensive care package. Medication administration is satisfactory; Information for dealing with dying and death still requires some minor updating. EVIDENCE: As reported in Standard 3 of this report the pre-assessment, care plans and reviews provide a total package, which meets the requirement of the standard. The inspectors overall assessment was that the care that was being provided was satisfactory. The manager writes detailed paragraphs of service users progress on a monthly basis and there was evidence of service user involvement within the care plan but no signature of agreement. Risk assessments were evident for mobility and the prevention of falls and stated if the service user had a history of falls recorded in the care plan. Daily records were observed to be neat and holistically written. Care plans were seen for specific issues such as challenging behaviour and medication issues. Ashlands DS0000060714.V268128.R01.S.doc Version 5.0 Page 11 The healthcare needs of service users appear to be well met with good detailed records of health checks, weight and nutritional screening. The manager reported that staff are undertaking courses in nutrition and health. Medication systems were assessed as satisfactory. A new system fro Boots has recently been installed Policies and procedures are in place for dealing with dying and death. The manager obtains information from service users/relatives where possible on their wishes for the end of life. The religious and cultural needs of service users are included in the documentation held in the files. The policy for palliative care now includes that the home is not registered to care for terminally ill service users and where medical/nursing input is required, that service users may wish to remain in the home, however a commitment from the GP will be needed that he will provide support from the primary Care services to support the staff in the home in caring for the dying individual. There should be an addition that care plans will be reviewed and that care charts will be implemented Ashlands DS0000060714.V268128.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): 13,14,15 Service users are generally helped to exercise choice and control over their lives, maintain contact with family/friends/representatives and the local community and enjoy a nutritional and balanced diet. Service users can chose from four meal options on a daily basis, including vegetarian and ethnic dishes. EVIDENCE: The documentation in the care package format does assess service users preferences and choices about their daily routines. The statement of purpose informs service users and relatives about the policy for maintaining contact with family friend sand representatives. Service users are assisted to venues in the community as required and the local school provided entertainment at Christmas time. The local church and age concern visit the home. One service user attends a day centre in a nearby village and enjoys flower arranging etc. Service users and care plans provided evidence that service users preferences and choice was respected, and the menu does now offer many alternative options for lunch and teatime Menu cards are provided on the dining tables and are clear and visible for those service users who may not see well. A Ashlands DS0000060714.V268128.R01.S.doc Version 5.0 Page 13 record is kept of what choices service users had made. A service user confirmed that menu cards were a success. The menus were devised over a 4 weekly cycle. The menu appeared to be nutritious and varied and provide a total of four meal options including vegetarian and ethnic dishes. Service users reported that the food was nice. Service users have always praised the quality of the meals at the home. The provision of menu cards and the diverse options exceed the standard Ashlands DS0000060714.V268128.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): 16,17,18 Service users right to participate in the civic process is being upheld. Policies are in place for protecting service users from abuse and staff have been provided with training in this area. Service users know how to make a complaint. EVIDENCE: A complaints procedure was displayed in the entrance and copies included in the service user guide. There were no complaints reported since the previous inspection. The acting manager reported that concerns raised are dealt with at the time and the topic was recently discussed in a resident/relative meeting. The complaints folder was no examined at this visit. There was evidence that the manager is working on care plans to enable service users were able to use their right to participate in the civic process. Relevant policies and procedures were noted to be in place. A copy of the Nottinghamshire Committee for Vulnerable Adults Procedures [NCVAP] guidance manual was observed in the office. Staff have now undertaken training in abuse awareness. Further training on reporting procedures for the acting manager and the provider are booked. A sample of service users personal monies and their financial records were examined at this inspection and covered in Standard 35 of the report. Policies for restraint and dealing with violence and aggression were seen in the policy file. Ashlands DS0000060714.V268128.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): 19,20,25,26 Overall the environment appears well maintained, safe, clean and comfortable, with service users needs being met by the facilities provided. Work has commenced for the regulation and monitoring of water outlet temperatures, re-decoration of the laundry room and provision of radiator covers to priority areas. EVIDENCE: The home appeared well furnished and comfortable on the day of inspection and the building appeared to be maintained to a satisfactory level. Communal areas comprise of a small lounge, large lounge and dining room, which appear to be adequate in meeting space requirements. The lounge areas have large windows almost ceiling to floor, which enable good views of the extensive and well - maintained gardens, from all seating areas. Dining tables were sufficient and were pleasantly adorned with pretty tablecloths and menu cards. Lighting is domestic in character. There was evidence that water storage temperatures were monitored for prevention of legionella and the records Ashlands DS0000060714.V268128.R01.S.doc Version 5.0 Page 16 showed that water outlets in the home were monitored at 43 degrees centigrade throughout. There was evidence that some radiators had been covered and evidence of risk assessments for surface temperatures. There were still areas in priority areas such as bathrooms without covers and this should be completed to ensure service users health and safety is safeguarded There is ongoing decorating work in the laundry to complete. Ashlands DS0000060714.V268128.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): 29,30 The training provision meets current standards and recruitment practices were satisfactory. EVIDENCE: A sample of two staff files were examined and evidence had been provided to the inspector that the completion of all staff files and satisfactory recruitment practices had now been achieved. Induction and foundation standards appear to be met and training programmes have been developed for staff to include regular updates of mandatory training and in meeting the needs of individual service users, such as diabetes, mental health issues and complex needs of older people. Staff reported that the manager, the owner and the deputy manager had attended training in dementia care and that all staff had undertook training in first aid. Further training in dementia care is to be provided for staff. A training programme for all staff has been devised for 2004/2005 and 2005/2006. Staff have now undertaken training in dealing with challenging behaviour. Ashlands DS0000060714.V268128.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): 31,32,35,36,37,38 Evidence regarding the management systems for the running of the home is satisfactory. Staff, are now being appropriately supervised. The homes record keeping and policies and procedures are assessed as satisfactory. The health, safety and welfare of service users and staff are promoted. Service users financial interests are safeguarded but improved policies and procedures would be beneficial to all. EVIDENCE: The acting manager has been working to meet the requirements set at the previous inspection and is committed to raising the standard of care provision in the home. The acting manager has submitted an application to be registered with the CSCI. The registered provider has now provided regulation 26 reports for the home. Ashlands DS0000060714.V268128.R01.S.doc Version 5.0 Page 19 The registered provider has been granted planning permission to extend the home to 30 beds and intends to submit a variation application to CSCI to register the beds and to include the service user category of Dementia. A sample of service users financial records were seen and found to be in order. A policy is in place for the safekeeping of service users personal and financial belongings. The registered provider is advised to review the system for safekeeping of service users small cash amounts and regarding receipting for valuables kept in safekeeping. The policy for service users finances needs to inform staff that they must not benefit from making purchases on service users behalf and give examples. Evidence was seen that formal supervision programme had been reinstated. A sample of records was examined as part of the inspection, including medication charts, staff personal files, fire safety records, care plans and associated records. The requirements of Regulation 37 have been met. Service users individual personal files were stored securely. Policies and procedures for health and safety were in place including infection control. Generic risk assessments were in place and a specialist consultant has undertaken a fire risk assessment. The accident records were examined and the manager has obtained the new tear out record type book, which complies with the Data Protection Act 1998. Training provision for staff is now arranged and ongoing to meet the needs of service users, in food safety, health and safety and infection control. Ashlands DS0000060714.V268128.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 X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 X X X X 3 3 STAFFING Standard No Score 27 X 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 X X 2 3 3 3 Ashlands DS0000060714.V268128.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 Refer to Standard OP11 OP19 OP25 OP25 OP35 Good Practice Recommendations Ensure that policy for dealing with dying includes the revising of care plans and implementation of care charts. Complete the repair damage in the laundry room Complete the work in relation to the fitting of regulation valves Complete the work in relation to the fitting of radiator covers Review the systems and policies for handling service users cash as specified in the report DS0000060714.V268128.R01.S.doc Version 5.0 Page 22 Ashlands Ashlands DS0000060714.V268128.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 Ashlands DS0000060714.V268128.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. 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