CARE HOMES FOR OLDER PEOPLE
Ashlea Court Church Lane Waltham Grimsby North East Lincs DN37 0ES Lead Inspector
Jane Lyons Unannounced 1st July 2005 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 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. Ashlea Court J54 57246 Ashlea Court V237009 1st July 2005 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Ashlea Court Address Church Lane Waltham Grimsby North East Lincs DN37 0ES 01472 825225 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Winnie Care (Ashlea Court Grimsby) Ltd Mrs Lesley Pearce Care Home 48 Category(ies) of OP registration, with number of places Ashlea Court J54 57246 Ashlea Court V237009 1st July 2005 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: The home has varied the registration to accomodate the placement of a service user younger than 65 yrs with progressive physical disabilities who requires significant nursing support. Date of last inspection 11th November 2004 Brief Description of the Service: Ashlea Court is located in a quiet residential area, close to all village amenities. The home provides care including nursing for up to 48 residents over the age of 65. The building is of a modern construction; purpose built in 1995 and in January 2002 had a 10 -bed extension registered. Furnishings and fittings are of a high standard. A passenger lift and stairs are provided to access both floors.All bedrooms are for single occupancy and meet the standard regarding minimum standards, 36 of the bedrooms have en- suite facilities and there is a range of assisted and non- assited bathing facilities within the home. There are four lounge areas and a tea room for residents and visitors to use. There are two coutyard areas, one of which is enclosed. Car parking spaces are available. Ashlea Court J54 57246 Ashlea Court V237009 1st July 2005 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over one day in July 2005. During the visit the inspector spoke to the manager, four staff, one visiting health care professional, ten residents and four visitors to find out how the home was run and if the people who lived there were satisfied with the care and facilities provided. The inspector looked at a number of bedrooms, bathrooms and communal rooms such as the dining room and lounge areas during the visit. Paper work relating to staff recruitment, staff training, activities, complaints, care plans and health / safety checks were looked at to make sure it was all in place and up to date. What the service does well:
The home has a friendly, relaxed and supportive atmosphere which helps the service user feel that the home is their own. The care support was seen to be of good standard, with service users looking well cared for. A district nurse said that she thought the standards of care were very good and that the staff were very helpful. Service users gave many positive comments during the inspection, for example one service user said:” I’m really happy, I have a lovely room, the food is excellent and the staff delightful”. One comment card received from a relative said” My mother has been at Ashlea Court for a year and it has proved very successful, it has reached the high standards we expected; the nursing care is excellent- stemming from confidence and care for the well- being of the whole person” Staff said when asked what was good about the home: “The care is good and the residents are the priority” The home provides very good facilities; the majority of all areas were decorated and maintained to a high standard. The home offers varying activities for the service users, and employs an activities co-ordinator. While the inspection was taking place service users were socialising with others, some had visitors and a number were sitting in the courtyard enjoying the warm weather. Towards the end of the visit a number of service users had gathered in the entrance hall and joined in with an informal sing a long session.
Ashlea Court J54 57246 Ashlea Court V237009 1st July 2005 Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better:
The management in the home must carry out the work asked of them, at this visit there was so much outstanding from the previous inspection. The manager must make sure that she has all the correct documents in place before new staff start working in the home to ensure the safety of all the residents. This was a requirement from the previous inspection. The staff do not have regular individual meetings with the senior staff which is important for them to talk about their work and the training they need. This was a requirement from the previous inspection. The manager has not fully put in place a quality assurance system, which would provide a better picture of all the checks and questionnaires that are carried out. This was a requirement from the previous inspection. Communal areas in the home needed to be kept tidier, which would improve the quality of the environment and also maintain the staff and resident’s safety. The staff did not always write down how care must be given to make sure that people living in the home are kept healthy, safe and comfortable. This is
Ashlea Court J54 57246 Ashlea Court V237009 1st July 2005 Stage 4.doc Version 1.40 Page 7 important to make sure that all the staff understand the care that everyone needs and can make sure that the care they are giving is working or not. This was a requirement from the previous inspection. All staff need to have regular fire safety and moving/ handling training. 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. Ashlea Court J54 57246 Ashlea Court V237009 1st July 2005 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Ashlea Court J54 57246 Ashlea Court V237009 1st July 2005 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2,3,4 and 5 Service users were informed of the home of their choice, were able to assess the suitability and facilities of the home to know it would meet their needs. EVIDENCE: The manager could provide evidence that she carried out pre- admission assessments however these needed to be formally documented and held in the service user files. Service users said that their families were included in the choice of their home; they visited the home before admission. Clear written contracts were provided to each resident, which detailed appropriate contractual arrangements and top up charges. Ashlea Court J54 57246 Ashlea Court V237009 1st July 2005 Stage 4.doc Version 1.40 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 standard(s) 7,8,9 and 10 Although care plans were not always adequately maintained or evaluated which could leave the service user at risk of inadequate care and unidentified health problems there was sufficient evidence that health and care needs of the service users were met. The systems for administering medication were good with clear and comprehensive arrangements in place. EVIDENCE: The service users stated that their care needs were met and described how care was provided in a way that respected their privacy and dignity. They stated that they were aware that records were kept. Staff were very knowledgeable about the care requirements of the service users. Case tracking of three service users was completed, which included examination of care records and discussions with service users and staff. The care plans were generally well developed and described well the care needs identified at assessment however there was evidence that the care plans had not been updated to reflect the current care needs, specifically when there had been multidisciplinary reviews and significant changes of need had occurred. There was evidence that the plans now contained nutritional risk assessments;
Ashlea Court J54 57246 Ashlea Court V237009 1st July 2005 Stage 4.doc Version 1.40 Page 11 however other risk assessments such as moving handling and tissue viability had not been updated. The medication policy was evidenced. Medication Administration Records evidenced were in order. All medication was stored correctly and C.D. medication recorded well. The clinic room temperature was better managed with the provision of a fan. All service users doors were closed during the inspection, staff were observed to knock on doors before entering. Service users were able to have visits from friends and family in private in their rooms and when health/ social care professionals visited they saw them in private. Staff were very polite and made visitors welcome. Ashlea Court J54 57246 Ashlea Court V237009 1st July 2005 Stage 4.doc Version 1.40 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 standard(s) 12,13,14 and 15 The service users were seen to experience a full life with opportunities to take part in varied activities. The meals in this home offered both choice and variety. EVIDENCE: Service users stated that they were able to exercise choice in relation to routines of daily living, leisure/ social activities and meals/ mealtimes. During the inspection it was pleasing to note service users were being offered varied activities; during the morning service users and their relatives enjoyed their morning coffee sat outside in the courtyard, whilst other service users enjoyed reading, watching T.V and in the afternoon participating in a game of bingo and then an impromptu sing a long session. There were numerous visitors to the home and evidence that service users regularly visited their families/ friends. One of the more dependent service users had been supported by the staff to attend a family wedding recently and was pleased to show the inspector a photograph of the event. A number of service users spoken to stated how they had been on visits to local places in the new minibus and how much they had enjoyed themselves. One service user reported that she walks up to the church each day. The activity co-ordinator has developed and maintained good social care plans; there was evidence that the co-ordinator provided a varied activity
Ashlea Court J54 57246 Ashlea Court V237009 1st July 2005 Stage 4.doc Version 1.40 Page 13 programme, one- to one sessions and specific exercise programmes for service users who have suffered strokes. The weekly menu evidenced that the meals were well balanced and varied. One service user said “The food is lovely” and another “if there is something I don’t care for- the chef is most helpful” Discussion about the menus was always on the agenda for the residents meetings. The dining room was well utilised during the visit; the atmosphere was noted to be lively with lots of conversation and positive interaction with the staff. Ashlea Court J54 57246 Ashlea Court V237009 1st July 2005 Stage 4.doc Version 1.40 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 standard(s) 16 and 18 The home had a satisfactory complaints system with some evidence that service users feel that their views are listened to and acted upon. Service users confirmed that they felt confident to raise issues with the staff and management. Recruitment and selection practices do not protect service users from abuse. EVIDENCE: A complaints procedure was displayed in the entrance hall. Service users and staff reported understanding of the procedure. Service users were very complimentary about the home and said that they had nothing to complain about. A procedure for responding to allegations of abuse was available and training records showed staff had been provided with adult abuse training. When asked about abuse, what it was and what they would do if they saw a service user being abused, the staff answered correctly. Recruitment and selection practices do not protect service users from the risk of abuse. Of the five staff records examined only one staff member had a CRB check in place. All CRB/ POVA First checks were managed by the staff at head office; it is vital this information must be in place at the home prior to employment commencing. Staff had been provided with adult abuse training and appropriate vulnerable adult procedures were in place. Ashlea Court J54 57246 Ashlea Court V237009 1st July 2005 Stage 4.doc Version 1.40 Page 15 Ashlea Court J54 57246 Ashlea Court V237009 1st July 2005 Stage 4.doc Version 1.40 Page 16 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 standard(s) 19 and 26 The standard of the environment in this home was high, providing service users with a very comfortable and homely place to live. The standard of cleaning throughout the home was very good however untidy areas in the home were putting staff and service user safety at risk. Untidy and overgrown garden areas detracted from the homes external appearance. EVIDENCE: The home was very comfortable with well decorated bedrooms and communal rooms. Service users rooms were personalised to the extent chosen by the individuals. The communal areas were all well utilised during the visit; a number of service users commented that they enjoyed sitting out in the garden during the good weather. The manager reported that the communal
Ashlea Court J54 57246 Ashlea Court V237009 1st July 2005 Stage 4.doc Version 1.40 Page 17 areas in the home had been included in this years redecoration programme; she also confirmed that the sitting room carpet was scheduled for replacement. Attention to tidiness in a number of communal areas was required; there were a number of electrical leads in the small lounge which needed to be secured and hidden to prevent risks of tripping also one of the fire escapes was compromised by furniture and equipment storage. The garden areas were noted to be overgrown in places and untidy with weeds growing through the block paving. The manager confirmed that the home was looking to recruit a new gardener for the home. It was evidenced that up to date risk assessments had been made of the home and a fire risk assessment was in place. Ashlea Court J54 57246 Ashlea Court V237009 1st July 2005 Stage 4.doc Version 1.40 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29 and 30 Service users are cared for by sufficient staff to meet their needs on the majority of occasions, however occasional shortfalls have occurred. The recruitment and training of staff is not as rigorous as required and may place service users at risk. EVIDENCE: The manager reported that the home had experienced problems in recent weeks with short notice sickness; advice was given to manage this more robustly. Staff turnover was reported to have increased since the previous inspection which staff reported had affected the skill mix on some shifts. The manager had recently completed a staff skills matrix to identify current training needs; courses in dementia, moving/ handling, adult abuse, basic food hygiene, fire safety and syringe drivers had been arranged. Given the significant gaps in fire safety training and moving/ handling it is important that further training in these areas was accessed to ensure this years statutory targets were met. A training co-ordinator was employed to specifically provide induction training for staff; there was evidence that a programme to meet NTO standard for induction and foundation was in place. Service users and relatives said that staff were very good, friendly and helpful. One relative commented that her mother enjoyed a joke and the staff were very good at communicating with her; she said that she visited daily and had noticed that sometimes there were staff shortages.
Ashlea Court J54 57246 Ashlea Court V237009 1st July 2005 Stage 4.doc Version 1.40 Page 19 Of the five staff files only one had all the necessary recruitment records in place. Although all files contained two written references; only one file had evidence of a CRB check and there were gaps with identification documents. The manager confirmed that the processing of CRB checks was managed through head office, it is vital that the Registered Provider reviews the system for confirming police checks to ensure that the written information is held in the home prior to new staff commencing work. Ashlea Court J54 57246 Ashlea Court V237009 1st July 2005 Stage 4.doc Version 1.40 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,33,36,38 The service users were satisfied that they lived in a home that was well managed and they were provided with appropriate opportunities however the poor administration is placing the service users at risk. The manager was proactive in ensuring that the health and safety of staff and service users was promoted and protected with regard to systems and equipment safety checks and risk management however the gaps in moving/ handling and fire safety checks and untidiness of the home provided a potential risk. EVIDENCE: Staff confirmed that moral was good. Staff and service user meetings were held regularly.
Ashlea Court J54 57246 Ashlea Court V237009 1st July 2005 Stage 4.doc Version 1.40 Page 21 No progress had been made since the previous inspection towards implementing a supervision and appraisal programme for all the staff. The manager has developed and implemented satisfaction questionnaires and audits however this now needs to be structured and supported by an annual development plan. Safety checks had been carried out on gas and electrical appliances, lifts, hoists, fire safety equipment and the nurse call system. Water temperatures at outlets accessible to service users were checked regularly. Fire drills took place monthly. Regular checks of the bed rails in use should be maintained in line with guidance from the MDA. The manager has completed 50 of the modules for the RMA; she has also embarked on another management course with the administrator in the home. It is hoped that specific areas such as prioritising workloads and time management skills will provide the manager with the skills required in these areas to be able to focus on further developing and implementing effective management systems in the home. Ashlea Court J54 57246 Ashlea Court V237009 1st July 2005 Stage 4.doc Version 1.40 Page 22 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 2 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 x 15 3
COMPLAINTS AND PROTECTION 2 x x x x x x 2 STAFFING Standard No Score 27 2 28 x 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 1 x 2 1 x x 1 x 2 Ashlea Court J54 57246 Ashlea Court V237009 1st July 2005 Stage 4.doc Version 1.40 Page 23 yes Are there any outstanding requirements from the last inspection? 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 OP3 Regulation 12,13 Requirement The registered person must ensure that the pre- admission assessment information for routine admissions is formally documented to ensure all staff have sufficient information to meed their needs. The registered person must ensure that a full audit of all the care plans (Including risk assessments) is carried out to ensure that all the service users current needs are fully identified. The Registered person must ensure care plan documentatuion is maintained appropriately and updated to reflect changes in need when these arise. The plans must be evaluated at least monthly.(Timescale- immediate effect- not met) The registered person must ensure that CRB checks and pova list checks are carried out and in place at the home prior to employment commencing.(Timescale immediate effect not met) The registered person must ensure that the appropriate staffing levels to meet the Timescale for action 15th September 2005 2. OP7 AND 8 12,15 and 13(4) 15thth September 2005 3. OP7 AND 8 12,15 AND 13(4) With immediate effect 4. OP 18 and 29 19 and 13(6) With immediate effect 5. OP27 18(1)a With immediate effect
Page 24 Ashlea Court J54 57246 Ashlea Court V237009 1st July 2005 Stage 4.doc Version 1.40 6. OP27 18 (1) a 7. OP29 19 and 13(6) 8. OP 30 18 (1)c , 13(5) and 23(4)d service users needs are in place at all times.(Timescaleimmediate effect- not met) The registered person must ensure that the management of sickness/ absence in the home is managed more robustly.(Timescale- with immediate effect- not met) The registered person must ensure that all the recruitment records to comply with Schedule 2 are in place for all staff members. The registered person must ensure that all staff receive annual mandatory training in fire safety and moving/ handling. The programme for mandatory training needs to be developed to identifiy all sessions to meet this target. The registered manager must ensure that she accesses appropriate support and prioritises her workload sufficiently to effect significant management change in the home.Develop an action plan to clearly identify the changes required and the timescales to implement the systems. The registered person must implement a formal structured quality assurance programme based on a systematic cycle of planning action and review; which is supported by an annual development plan. (Timescale of 28th February 2005- not met) The registered person must ensure that all staff receive regular documented supervision and that care staff receive at least six sessions per year.(Timescale of 30th January 2005 unmet) 15th September 2005 30th September 2005 Programme to be developed by the 15th September with all training sessions booked. Action plan to be developed by the 15th September 2005. 9. OP32 9 10. OP33 24 1st November 2005. 11. OP36 18(2) Programme to start by the 15th September Ashlea Court J54 57246 Ashlea Court V237009 1st July 2005 Stage 4.doc Version 1.40 Page 25 12. OP38 13(4) The registered person must With ensure that the home is kept tidy immediate with particular regard to keeping effect the fire escapes clear and electrical leads secured. 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. Refer to Standard OP28 OP31 OP38 Good Practice Recommendations The registered person should ensure that 50 of care staff hold NVQ level 2 or equivalent in care by 2005. The registered manager should hold NVQ level 4 or equivalent in Management and Care by 2005. The registered person should ensure regular checks on bed rails are carried out in line with guidance from the MDA. Ashlea Court J54 57246 Ashlea Court V237009 1st July 2005 Stage 4.doc Version 1.40 Page 26 Commission for Social Care Inspection Unit 3, Hesslewood Country Office Park Ferriby Road Hessle East Yorkshire HU13 0QF 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 Ashlea Court J54 57246 Ashlea Court V237009 1st July 2005 Stage 4.doc Version 1.40 Page 27 - 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!
