CARE HOMES FOR OLDER PEOPLE
Ashlea Court Ashlea Court Church Lane Waltham Grimsby North East Lincs DN37 0ES Lead Inspector
Mrs Jane Lyons Unannounced Inspection 16th December 2005 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 Ashlea Court DS0000057246.V274022.R01.S.doc Version 5.1 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. Ashlea Court DS0000057246.V274022.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Ashlea Court Address Ashlea Court Church Lane Waltham Grimsby North East Lincs DN37 0ES 01472 825225 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) Winnie Care (Ashlea Court Grimsby) Ltd Mrs Lesley Pearce Care Home 48 Category(ies) of Old age, not falling within any other category registration, with number (48) of places Ashlea Court DS0000057246.V274022.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. that the home can accept five persons under the age of 65 years (and no other under that age) until those persons reach the age of 65 years or terminate their contract with the home. 1st July 2005 Date of last inspection 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. Ample car parking spaces are available. Ashlea Court DS0000057246.V274022.R01.S.doc Version 5.1 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 December 2005. During the visit the inspector spoke to the manager, administrator, five staff, two visiting health care professionals, nine residents and four relatives 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, complaints, care plans and quality checks were looked at to make sure it was all in place and up to date. What the service does well:
The home provided very good facilities; all areas were decorated and maintained to a high standard. The home was very clean and tidy. There was a very relaxed and homely atmosphere in the home, residents were observed to be very settled and comfortable in their surroundings. One resident told the inspector that she was really pleased with her room and the staff were very kind and helpful; her relatives confirmed that she had resided in the home for ten years and was very settled and happy. The standard of care support remains very good with residents looking well groomed and cared for. A comment card completed by one of the District Nurses detailed “Patients I visit are very happy with the care provided” The home has a friendly, relaxed and supportive atmosphere which helps the service user feel that the home is their own. There was a good staff team, many of them have worked there for a long time and have built up good relations with the residents and their families. When the inspector spoke to them they said that they enjoyed working at Ashlea Court, the atmosphere was very friendly and the residents always came first. Although meals and activities in the home were not looked at in detail, from comments made by service users there was good evidence that the home has maintained good standards in these areas. One service user told the inspector that he had been a butcher and was very satisfied with the standard of the meals. Many service users told the inspector how much they had enjoyed the Ashlea Court DS0000057246.V274022.R01.S.doc Version 5.1 Page 6 homes’ 10th Anniversary party and were enjoying all the Christmas entertainments provided. What has improved since the last inspection? What they could do better:
All staff need to have regular fire safety and moving/ handling training. Ashlea Court DS0000057246.V274022.R01.S.doc Version 5.1 Page 7 The manager must ensure that records are clearly maintained of all complaints investigations, outcomes and contact with the complainant to demonstrate positive management systems are in place. The manager has improved the programme of audits which supports the quality assurance system; however now needs to complete the cycle of developing and implementing action plans to support the deficiencies identified and also to provide an annual development plan. This requirement has been outstanding since the introduction of the National Minimum Standards and efforts must be made to prioritise the full implementation of a formal programme. 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 DS0000057246.V274022.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ashlea Court DS0000057246.V274022.R01.S.doc Version 5.1 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 the following standard(s): 1,3 and 6 Good progress has been made to improve the admission procedure to ensure that there is a very detailed assessment prior to people moving into the service; residents are given enough information about the home and its facilities before admission, for them to be confident that their needs can be met by the service. EVIDENCE: The statement of purpose had been reviewed to detail the recent variance in registration which allows the home to provide care for five persons under the age of 65. The document remains in its original format, it is up to date and complies with Schedule 1 of the Care home regulations and NMS 1. Three case files were case tracked; thorough assessments were completed by the manager prior to admission and these were seen by the inspector. Further detailed assessments were completed on admission. All case files examined contained a copy of the local authority needs assessment and care plan.
Ashlea Court DS0000057246.V274022.R01.S.doc Version 5.1 Page 10 Staff at interview confirmed the admission process; there was clear evidence that they were well informed of service users needs on admission and all specialist equipment was in place if required. Service users confirmed that the manager had visited them prior to admission to the home; most said that their families or friends had visited the home to assess its suitability, which had been a satisfactory arrangement. The home does not provide intermediate care. Ashlea Court DS0000057246.V274022.R01.S.doc Version 5.1 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 and 8 Good progress has been made to improve care documentation to ensure that the health and personal care needs of residents are identified and met. EVIDENCE: Three case files were examined which evidenced that the care programmes were detailed, well organised and had been consistently maintained. All care needs had been identified from a detailed assessment. From case tracking the inspector was able to evidence that the documentation cross-referenced well and all problems had been updated to reflect current needs. All programmes were regularly evaluated. There were risk assessment tools for mobility, falls, tissue viability, bed rail provision and nutrition. Service users spoken to confirmed that they were aware of the care programmes but had no interest in reading them. There was evidence that service users needs had been formally reviewed; one service user with progressive dependent needs had been provided with new seating and sleeping systems which were reportedly working very well. Ashlea Court DS0000057246.V274022.R01.S.doc Version 5.1 Page 12 Staff demonstrated a good awareness of service user’s needs. The inspector spoke to two district nurses during the visit who confirmed that they were satisfied with the care provision at the home. Ashlea Court DS0000057246.V274022.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: Standards 12, 13, 14 and 15 were assessed and met/ exceeded at the previous inspection; there was good evidence that the service users were involved with and enjoying the various Christmas activities and entertainments provided. Ashlea Court DS0000057246.V274022.R01.S.doc Version 5.1 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 Although there was evidence that complaints are taken seriously and issues are investigated appropriately the manager needs to ensure that she documents all stages of complaint management to fully demonstrate this. Recruitment and selection practices have improved and now better protect service users from abuse. EVIDENCE: The home had received two complaints since the previous inspection; there was written evidence to support the investigation and outcome for one of the complaints. The manager confirmed that she had addressed the issues raised in the second complaint however there were no records to support this management. A complaints procedure was displayed in the entrance hall. Service users and staff reported understanding of the procedure. All service users and visitors spoken to confirmed that they felt confident in raising issues with the staff or manager. 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. The manager confirmed that head office had now reviewed the recruitment procedures and the manager was now able to access the POVA First checks to ensure all checks were in place prior to employment.
Ashlea Court DS0000057246.V274022.R01.S.doc Version 5.1 Page 15 The management had sought advice recently from the Commission regarding the re- employment of a staff member who had received convictions for an offence. The management were currently carrying out an investigation into the specific offences committed and had requested a current POVA check to support their decision to re- employ. Ashlea Court DS0000057246.V274022.R01.S.doc Version 5.1 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 the following standard(s): 19 and 26 The standard of the environment in this home remains high, providing service users with a very comfortable and homely place to live. The management have made progress in ensuring areas were tidier and safer. 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. New carpets for communal rooms and all corridors on the ground and first floors were scheduled to be fitted in the New Year. Areas throughout the home were observed to be much tidier; fire escape areas were clear and all electrical leads were safely secured behind furniture. A gardener had been employed and the grounds were now being regularly maintained.
Ashlea Court DS0000057246.V274022.R01.S.doc Version 5.1 Page 17 Up to date risk assessments for the environment and for fire safety in the home were in place and seen at the previous visit. The home was decorated very festively with Christmas trees and trimmings, many of the service users commented on how nice the home looked. Ashlea Court DS0000057246.V274022.R01.S.doc Version 5.1 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 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 The management have made good progress to ensure adequate staffing levels are better maintained. Improved recruitment practices now afford sufficient protection for service users. More fire prevention and moving/ handling training needs to be provided to staff to ensure the health and safety of staff and residents. EVIDENCE: There was evidence that staff sickness issues were being more robustly managed; return to work interviews and preliminary disciplinary action had been implemented by the manager. The home was currently providing care for sixteen service users with nursing care needs and thirty with residential care needs; twenty seven service users had identified low dependency care needs. From examination of the staff rosters levels of seven care staff in the a.m. and six care staff in the p.m. were being maintained on the majority of shifts, with a number of morning shifts eight staff were rostered. The inspector noted a shortfall of one care staff on one afternoon shift in the past month which the manager confirmed was due to late notice; there was good evidence that the home regularly employed agency care staff to cover shortfalls. The home operates a staff pay incentive for staff who do not take sick leave. All service users spoken to commented that they considered the staff had time to provide care in a timely fashion and did not feel they were unduly rushed or had to wait too long for their needs to be met. They also commented on how kind and supportive the staff were.
Ashlea Court DS0000057246.V274022.R01.S.doc Version 5.1 Page 19 Staff at interview considered the staffing arrangements and levels to be satisfactory. The manager and training co-ordinator have developed and implemented a skills assessment training programme which all the care staff are working through. The training co-ordinator is also responsible for the induction training programme which is based on NTO standards. At the last inspection deficiencies had been identified with the provision of moving/ handling and fire prevention training for staff; although there was evidence to support some improvements in the provision of moving/ handling training there remained significant shortfalls in staff who had accessed fire safety training. The general training programme continues with staff accessing courses on: adult protection, health/ safety, first aid, COSHH and infection control. The manager has completed an audit of all the staff files; the inspector reviewed three staff files, one for a staff member recruited three months previously and two records for staff currently being recruited. All files had a copy of the POVA First check in place. Two written references were in place for the staff member recruited in August and there was evidence that written references had been requested and were being provided for the staff currently being recruited. Identification documentation, completed application form, health declaration, job description and statements of terms and conditions documentation was in place. Ashlea Court DS0000057246.V274022.R01.S.doc Version 5.1 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 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, 35 and 38 The manager has improved her management of the administration systems in the home; the service users were satisfied that they lived in a home that was well managed and they were provided with appropriate opportunities. Some progress has been made towards fully implementing a staff supervision programme and formalising the quality assurance programme. EVIDENCE: Staff confirmed that moral was good and commented that there was a good team approach to the care delivery at the home. Staff and service user meetings were held regularly; there was evidence that requests and suggestions made at these meetings were discussed and actioned where possible. Ashlea Court DS0000057246.V274022.R01.S.doc Version 5.1 Page 21 There was good evidence that since the previous visit the manager has focused on improving the management systems in the home, specifically care documentation, recruitment practises, supervision and staffing levels. The manager was positive about the improvements and confirmed that she was better supported by the qualified staff. The manager has not yet finished all the units of her NVQ4 in management to gain the RMA. Significant improvements had been made towards implementing the staff appraisal and supervision programmes; almost all the staff had now received an appraisal. The manager had implemented a supervision programme which focused on clinical practice however did not follow any clear format; many of the staff were receiving frequent sessions and others had not yet accessed any. Advice was given to provide a supervision meeting every two months for all care staff which covered all areas of practice, ethos of the home, training needs and also gave the staff member an opportunity to discuss any issues arising. The manager had developed and implemented a more thorough programme of audits for the home which covered areas such as accidents, care programmes and facilities; action plans now need to be developed and implemented for all deficiencies identified and an annual development plan produced. The inspector advised the inclusion of staff supervision and complaint management in the audit process. Surveys were completed by service users and relatives these now need to be extended to cover other stakeholders to the home. The management of service users finances was examined; the system remains largely unchanged. There is a specific bank account which handles all the service users personal finances and the homes amenity fund; the account is non- interest paying. This account does not handle any of the service users fees. Two service users personal accounts were checked via the computer and receipts corresponded with payments. At the previous inspection it was evidenced that safety checks had been carried out on gas and electrical appliances, lifts, hoists, fire safety equipment and the nurse call system. The maintenance man regularly checks hot water temperatures at outlets accessible to service users and maintains records which evidenced effective management. The fire safety equipment and checks were all in place and up to date. Fire drills were carried out monthly. The maintenance man had commenced a programme of regularly checking the bed rails in use , however this had not been maintained. Risk assessments were undertaken for all safe working practices; individual risk assessments were better maintained. Accident reports were maintained, the manager audited the incidence monthly; advice was given to provide more detailed records of all further action taken especially with regard to falls.
Ashlea Court DS0000057246.V274022.R01.S.doc Version 5.1 Page 22 Ashlea Court DS0000057246.V274022.R01.S.doc Version 5.1 Page 23 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 4 X X X X X X 4 STAFFING Standard No Score 27 3 28 X 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 3 Ashlea Court DS0000057246.V274022.R01.S.doc Version 5.1 Page 24 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 OP30 Regulation 18 1c 13 5 23 4d Requirement 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. Timescale 15/09/05 not met. The registered person must fully 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 1/11/05 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 15/09/05 not met The registered person must ensure that records are clearly maintained of all complaints investigations, outcomes and contact with the complainant Timescale for action 15/02/06 2 OP33 24 31/03/06 3 OP36 18(2) 15/02/06 4 OP16 22 16/12/05 Ashlea Court DS0000057246.V274022.R01.S.doc Version 5.1 Page 25 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 OP38 Good Practice Recommendations The registered person should ensure that 50 of care staff hold NVQ level 2 or equivalent in care. The registered manager should hold NVQ level 4 or equivalent in Management and Care. The registered person should ensure regular checks on bed rails are carried out in line with guidance from the MDA. The registered manager should review the accident audit records to include details of staff action to further reduce risk, especially with regard to falls. Ashlea Court DS0000057246.V274022.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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