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Inspection on 12/10/09 for Ashlea Grange Residential Home

Also see our care home review for Ashlea Grange Residential Home for more information

This inspection was carried out on 12th October 2009.

CQC found this care home to be providing an Adequate service.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Housekeeping standards are high and the home is kept clean and tidy and free of any hazards. Any repairs or maintenance issues are dealt with promptly ensuring that the residents live in a safe comfortable environment. A good range of social activities continues to be provided and residents are offered the option to take part in them or to opt out if they wish. The activities coordinator has built up a good understanding of the types of activities that the residents like to take part in. A good range of well cooked meals are provided and served in pleasant surroundings. The home demonstrates that they deal with complaints promptly and to the satisfaction of the person making the complaint.Ashlea Grange Residential HomeDS0000034293.V378093.R01.S.docVersion 5.2

What has improved since the last inspection?

A new decked walkway and seating area with raised flower beds has been created at the rear of the building. Good access to this area has been established with the installation of doors directly from the lounge. And the provision of fencing ensures that the residents have a pleasant and safe area to sit in during the warmer weather. A new acting manager has been appointed in order to ensure that the staff receives regular management support and supervision. Staffing levels have been increased in order to offer a better ratio of carers on each shift. And at the time of our visit staff morale appeared to be good. The registered owner and regional manager carry out more frequent and regular visits to the service to carry out quality audits. And from this are identifying what improvements need to be made. Families of residents have confirmed that they are satisfied with the services being offered in the home.

What the care home could do better:

The written plans of care must continue to be developed and included detailed actions that demonstrate how people are being supported in a consistent way with their assessed needs. Assessment charts and other records that are used as part of the care process must be kept up to date and signed by staff when carrying out evaluations. And care plans should be evaluated at least monthly or if there is a change in needs. Staff must receive training that is appropriate to their work and comprehensive records must be kept to demonstrate what training has taken place. Staff must not potentially compromise the fire safety within the home by wedging fire doors open. And records must be available to confirm that staff is receiving regular fire instruction and fire drill training.Ashlea Grange Residential HomeDS0000034293.V378093.R01.S.doc Version 5.2 All staff should have the opportunity to take part in regular staff meetings as well as receiving formal supervision. The registered owner must write to the commission to formally advise us of the management arrangements that are in place within the home.

Key inspection report CARE HOMES FOR OLDER PEOPLE Ashlea Grange Residential Home Philadelphia Lane Newbottle Houghton-le-spring Tyne And Wear DH4 4ES Lead Inspector Clifford Renwick Key Unannounced Inspection 12th October 2009 09:00 DS0000034293.V378093.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Ashlea Grange Residential Home DS0000034293.V378093.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Ashlea Grange Residential Home DS0000034293.V378093.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashlea Grange Residential Home Address Philadelphia Lane Newbottle Houghton-le-spring Tyne And Wear DH4 4ES 0191 584 8159 0191 512 0089 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 Limited Position vacant Care Home 40 Category(ies) of Dementia - over 65 years of age (12), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (1), Old age, not falling within any other category (40), Physical disability over 65 years of age (8), Sensory Impairment over 65 years of age (3) Ashlea Grange Residential Home DS0000034293.V378093.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The SI(E) and MD(E) service user categories relate to current service users only. The service may from time to time admit person(s) who are under the age of 65, but who fall within the currently registered service user categories. 21st November 2008 Date of last inspection Brief Description of the Service: Ashlea Grange is a large modern, purpose built care home that provides 40 places for older people some of whom may have dementia care needs, physical or sensory disabilities. The accommodation is within 40 single rooms, all with en-suite facilities. There is a good range of sitting areas and sufficient bathrooms, some with specialist lifting equipment, to meet the needs of the people who live here. There is level access into the home, and wide corridors allow easy access by people who use a wheelchair. The accommodation is over 2 floors, which are served by a passenger lift. The home has good links with the local community. It is close to local amenities such as shops, pubs and churches and is on a direct bus route to Sunderland. The Provider, Winnie Care Limited, operates a number of other homes for older people in Sunderland and the North East region. The fees charged at the home range from £414 to £440 per week. Ashlea Grange Residential Home DS0000034293.V378093.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations – but only when it is considered that people who use services are not being put at significant risk of harm. In future if a requirement is repeated, it is likely that enforcement action will be taken. The quality rating for this service is 1 star. This means that the people who use this service experience adequate quality outcomes. Before the visit: We looked at: • • • Information we have received since the last visits in November 2008 and June 2009. How the service dealt with any complaints & concerns since the last visit. Any changes to how the service is run. The Visit: An unannounced visit was made on the 12th October 2009. During the visit we: • • • • • • • • Talked with a number of the people who live in the home and also staff who were on duty. Held discussion with the acting manager and also the registered owner who was present during part of our visit. Observed staff working practices. Looked at information about the people who live in the home & how well their needs are met. Looked at other records, which must be kept in relation to health and safety and staffing. Checked that staff had the knowledge, skills & training to meet the needs of the people they care for. Looked around the home to make sure it was well maintained, safe and free of any hazards. We also gathered information from looking at care records to assess how staff supports the residents with their assessed needs. Ashlea Grange Residential Home DS0000034293.V378093.R01.S.doc Version 5.2 Page 6 • We also focused upon looking at care files for 3 residents as a part of the inspection we refer to this as “case tracking”. And this involves looking at all records of the care for a named individual. The people who live in this home prefer to be known as residents therefore this term of reference is used throughout the report. At the time of our visit there were 22 people living in the home. The person who is currently managing the service is referred to in the report as the acting manager. What the service does well: Housekeeping standards are high and the home is kept clean and tidy and free of any hazards. Any repairs or maintenance issues are dealt with promptly ensuring that the residents live in a safe comfortable environment. A good range of social activities continues to be provided and residents are offered the option to take part in them or to opt out if they wish. The activities coordinator has built up a good understanding of the types of activities that the residents like to take part in. A good range of well cooked meals are provided and served in pleasant surroundings. The home demonstrates that they deal with complaints promptly and to the satisfaction of the person making the complaint. Ashlea Grange Residential Home DS0000034293.V378093.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: The written plans of care must continue to be developed and included detailed actions that demonstrate how people are being supported in a consistent way with their assessed needs. Assessment charts and other records that are used as part of the care process must be kept up to date and signed by staff when carrying out evaluations. And care plans should be evaluated at least monthly or if there is a change in needs. Staff must receive training that is appropriate to their work and comprehensive records must be kept to demonstrate what training has taken place. Staff must not potentially compromise the fire safety within the home by wedging fire doors open. And records must be available to confirm that staff is receiving regular fire instruction and fire drill training. Ashlea Grange Residential Home DS0000034293.V378093.R01.S.doc Version 5.2 Page 8 All staff should have the opportunity to take part in regular staff meetings as well as receiving formal supervision. The registered owner must write to the commission to formally advise us of the management arrangements that are in place within the home. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Ashlea Grange Residential Home DS0000034293.V378093.R01.S.doc Version 5.3 Page 9 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 Grange Residential Home DS0000034293.V378093.R01.S.doc Version 5.3 Page 10 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are suitable arrangements for making sure that peoples needs are assessed before they are admitted into the home. This means that people using the service can be confident that staff will know how to meet their needs. EVIDENCE: There have been no new admissions since the last random inspection visit to this service that took place on 10th June 2009. Previous visits have confirmed that prior to anyone being offered a place in the home a full assessment of needs is always carried out. Ashlea Grange Residential Home DS0000034293.V378093.R01.S.doc Version 5.3 Page 11 In discussion with staff they confirmed that once the initial assessment is completed this process continues once someone moves into the home. Care files that we have looked at previously confirmed that an assessment of need was carried out prior to admission. And previous discussions held with residents relatives confirmed that people did have the opportunity to visit the home before deciding to move in. Ashlea Grange Residential Home DS0000034293.V378093.R01.S.doc Version 5.3 Page 12 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples health, personal and social needs are met by care practices in the home, in a manner that promotes their privacy and dignity. However the written care plans do not include sufficient information to ensure that care practices are consistent. Medication administration follows good practice to ensure that residents’ general health and wellbeing are safeguarded and promoted. EVIDENCE: Each resident has an individual written care plan that has been developed from the assessment document. Staff is involved in the care plans and this process that is used to demonstrate how staff will assist residents with their assessed needs. Ashlea Grange Residential Home DS0000034293.V378093.R01.S.doc Version 5.3 Page 13 We looked at the care files for three people and we refer to this process as “case tracking”. And this involves us looking at all records that are held about an individual person. Though the care plans contain a range of information about a persons assessed needs they do not always contain sufficient or clear detail about how a person is to be supported. In addition to this the quality of the information varied in different files. For example it is an expectation that people will have their weight checked on a monthly basis especially where there are concerns about a person’s nutritional needs. And for one person this had not occurred for 3 months and the nutritional risk assessment had not been evaluated or updated since January. For another person, records of weights taken for the last 4 months showed significant weight loss but no record of what staff did about this. In further discussion it was established that the weight records may not have been accurate due to how staff were using the scales. In one care plan it states that someone requires assistance to go to the toilet every 2 hours but there is no evidence to confirm how this has been assessed. And there is insufficient information to confirm if staff is following the correct procedures. The care plans are not always being evaluated on a monthly basis for everyone as they should be. And some documents such as risk assessments are not being reviewed when there is a change in needs. There are some good records being kept by staff but they lack consistency in all of the files that we looked at. For example for one person there is an in depth risk assessment that clearly identifies some risk areas related to mobility and how staff is to support this person. Observations made confirmed that staff offers consistent and positive support. However there is no reference to these positive practices in the persons care plan. Where staff have completed the document “A day in the life of” good information has been collated by staff to help with the care process. In discussion with the deputy manager it was confirmed that senior staff are responsible for administering prescribed medicines. And it was confirmed that these staff have received training in the safe handling of medicines. Ashlea Grange Residential Home DS0000034293.V378093.R01.S.doc Version 5.3 Page 14 It was positive to note that as part of the assessment process one resident was being supported to manage their own medicines thereby retaining independence in this area. An appropriate risk assessment had been completed by staff and this was kept under review to ensure that the person continued to receive the necessary support. The records of receipt, administration and disposal of medicines were looked at. And to support the staff there is a list for each resident of what side effects/allergies they may have attached to their medicines administration sheet. Discussion was held with the deputy manager about the completion of the administration records as for two people there were two gaps on the chart where it could not be established if medicines had been offered. Apart from this the records were being completed correctly and are much improved. We also looked at records that relate to health care and these confirmed that residents are able to access all community health services. Records are kept of when people see the doctor, community nurse and other professionals. And when it has been necessary for residents to attend hospital appointments families have been involved. In discussion with families who were present during the visit they confirmed that staff keep them up to date with all matters about their relative’s health. Ashlea Grange Residential Home DS0000034293.V378093.R01.S.doc Version 5.3 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents lead fulfilling lifestyles through exercising choice and control over how they spend their day. People’s lifestyle is good with regular contact being maintained with relatives and friends and the residents receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. EVIDENCE: There are notices in home of the activities that is planned for the coming months for the residents. And this includes the forthcoming Halloween party. In discussion with the activities coordinator it was explained that other activities that had been planned were a trip to the Empire to see the Sound of Music. There was also a singer who was visiting the home to carry out a musical show. A range of other activities take place in the home and this range from board games to craft sessions and records are kept of who has been involved. Ashlea Grange Residential Home DS0000034293.V378093.R01.S.doc Version 5.3 Page 16 The residents stated that they are free to join in social activities if they wish and that they are not made to join in activities if they do not want to. Activities are carried out in the lounge and though everyone may not wish to take an active part they also receive some stimulation by seeing what is going on around them. One person prefers to spend time in their room watching the football and as has previously been reported has their own stock of refreshments in the room. In discussion with this person they said that they still enjoy living here and staff is very supportive. The routines in the home are flexible and revolve around the residents. Due to the home not been fully occupied the eight people who reside on the first floor now spend their day on the ground floor with other residents who live in the home. In discussion with families they said they were not consulted about this and had mixed views about these changes. As a result of these changes better opportunities to take part in stimulating activities have been made available to the residents. There are no restrictions on families or friends visiting the home and in discussion with some of the relatives they raised a number of points with the inspector. They stated that due to the many changes the home had undergone they wanted more meetings with the owner so that they could be kept up to date with things. One person said that the last meeting had been held in June. Some of the families also commented on how at times the home had made use of agency staff on the nightshift and they felt that by using agency staff. These staff would not know the residents sufficiently well enough to offer consistent care. Though this was the views expressed by families there was no evidence to suggest that people had not been cared for correctly when agency staff had been used. Ashlea Grange Residential Home DS0000034293.V378093.R01.S.doc Version 5.3 Page 17 In further discussion with families they did confirm that they were happy with the care that was provided in the home despite the changes that had been made. Lunch was taken with the residents and this offered a good opportunity to chat with people during the meal as well as observe the staff practices. It was good to see that for those people who provided assistance to eat their meal that this was provided by staff. The meal was unhurried and people received the necessary support at a pace that suited them. And whilst offering support the staff offered gentle encouragement to people while they were eating. Discussion with the cook confirmed that a range of meals are provided that reflect resident’s choices and also incorporate meals for people who have diabetes. The cook is relatively new in post having first worked in the home as an agency worker. He is now employed full time by the home. Tables were nicely set with tablecloths, serviettes and place mats and glasses for drinking. There were a selection of hot and cold drinks throughout the meal and people were asked if they wanted additional drinks while eating. There were two choices for the main meal. And the meals that were served were hot, well presented and very tasty. For dessert there were three choices. We also had the opportunity to have breakfast with the residents and this consisted of a range of cereals as well as well as a cooked breakfast. One person particularly likes bacon sandwiches with the crusts cut off the bread and this was provided. In discussion with this person they confirmed that staff always served their breakfast the way they liked it. Ashlea Grange Residential Home DS0000034293.V378093.R01.S.doc Version 5.3 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Robust policies and procedures are in place that ensures residents are protected from abuse and an effective complaints procedure ensures that any complaints are resolved. However there is insufficient evidence to confirm that staff has received updated training in safeguarding adults in order to demonstrate that they are kept up to date with best practice. EVIDENCE: Information is on display that informs families what to do and whom to contact if they have any concerns. Should they wish to contact the area manager a telephone number is on display in the main lobby. In addition to this the home policies and procedures that demonstrate how any complaints will be addressed. Three complaints were received by the commission prior to the inspection. And due to the nature of the complaints families were advised to formally complain to the registered provider. Ashlea Grange Residential Home DS0000034293.V378093.R01.S.doc Version 5.3 Page 19 These complaints related to changes in the home, insufficient staffing and for one person care practices. It was confirmed by the complainants that following discussion with the registered provider that the matters were rectified. Policies and procedures are in place that deals with safeguarding adults and in discussion with staff it was clear that staff is aware of the guidelines they must follow. In our last visit in June the person who was managing the service at the time had stated were to undergo updated training in safeguarding adults. However it could not be established from the records available if staff had received this updated training. And in discussion with staff they were unclear as to what training they had undertaken as some training that had been arranged by the previous manager had been cancelled. There are currently no safeguarding issues being dealt with in the home. Ashlea Grange Residential Home DS0000034293.V378093.R01.S.doc Version 5.3 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a homely, well maintained environment, which promotes their privacy, independence and comfort during their stay at the home. And the home is clean, pleasant and hygienic which supports the health and lifestyles of people living there. However the practice of wedging bedroom doors open potentially compromises the fire safety of people who live and work in the home. EVIDENCE: The home continues to provide good standard of accommodation that meets the needs of the residents. Ashlea Grange Residential Home DS0000034293.V378093.R01.S.doc Version 5.3 Page 21 Bedrooms are individually decorated and residents are encouraged to furnish their rooms with personal items, making it pleasant and familiar environment for the occupants. One person has satellite television installed and they stated that this makes the place fell like “home from home”. They also went on to say that the “girls” work very hard and that their room was always cleaned to a high standard. Most of the residents have their own televisions and DVD players and some residents have their own telephone. The home has their own maintenance person who shares their time between this home and other homes owned by the company. And this ensures that any repairs are dealt with quickly. We only looked at the facilities on the ground floor during this visit and it was noted that good housekeeping standards are in place. There were no unpleasant odours and housekeeping staff were kept busy during the day to maintain these standards. During our visit we saw that a number of the bedroom doors were wedged open whilst the rooms were unoccupied. And this has been noted on previous visits to the service. This practice of wedging doors open potentially compromises health and safety as fire and smoke could not be contained within an area. Thereby allowing the spread of smoke or fire which potentially prevents people from being able to evacuate to a safe area. This was discussed with the person in charge who was advised to seek advice from the fire authority. Ashlea Grange Residential Home DS0000034293.V378093.R01.S.doc Version 5.3 Page 22 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is enough staff on duty to meet the needs of the residents and this ensures that safety and welfare is promoted. However it is unclear if staff receives training appropriate to their work due to the absence of appropriate training records. Robust recruitment procedures are in place to prevent unsuitable people being employed, and this ensures residents are protected and their welfare is promoted. EVIDENCE: Due to the timing of our visit which commenced early morning we were able to spend some brief time talking with staff that had been working nightshift and also take part in the staff handover. There were three staff who had been working on nightshift and the day staff consisted of 3 care workers and 1 senior care worker with a new manager due to commence shift that day. Ashlea Grange Residential Home DS0000034293.V378093.R01.S.doc Version 5.3 Page 23 Three care staff and one senior member of staff were rostered to work the late shift 3 – 10pm. In addition to the care staff working through the day there were other staff on duty that were responsible for catering and housekeeping as well as the activities coordinator. The staffing levels in place ensured that were sufficient staff to meet the needs of service users. At the time of our visit the person employed as a part time cook had recently ceased to work in the home. It was confirmed by the cook that the home were advertising this post. Until this position was filled other staff was temporarily assisting in the kitchen on a rota basis. The manager was advised to ensure that any staff that was assisting in the kitchen were up to date with their basic food hygiene practices. During our last visit in June the person who was then in post as manager confirmed that a range of training courses were being arranged for staff. Some information about what training had taken place was kept in individual staff files as well as certificates of attendance. However the training record/matrix that was in place was difficult to understand. In conjunction with the new manager who had commenced work on the day of our visit we looked at the training file. However we could not establish from these records what training had taken place and for whom. And what training was arranged for the rest of the year. In discussion with the person who has been recruited as the acting manager we were informed that they would be looking at and reviewing the training records. And if it was identified that staff required updated training this would be arranged. We also looked at staff personnel files for the two new people who had recently been appointed in the home. And this confirmed that robust procedures are in place when recruiting people to work in the home. References are obtained, previous employment history and also the necessary criminal record bureau checks. This ensures that unsuitable people are not employed. Ashlea Grange Residential Home DS0000034293.V378093.R01.S.doc Version 5.3 Page 24 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is managed by an experienced and qualified person. However the procedures that is in place to ensure the health, safety and welfare of People who live and work in the home must be more robust. EVIDENCE: At the time of our visit we were informed that the person who was employed as manager in January 2009 was currently on long term sick leave. Ashlea Grange Residential Home DS0000034293.V378093.R01.S.doc Version 5.3 Page 25 A person had been appointed as acting manager and commenced work on the day we were carrying out our visit to the home. We were informed by the acting manager that her appointment was to be reviewed in 6 months. The acting manager is working in the home 40 hours per week Monday to Friday. This person has worked in social care since 1997 and is in receipt of the registered manager’s award as well as NVQ Level 3 in care. This person has worked in a management role for 3 years. Time was spent in discussion with the manager and also the registered provider who was present during part of our visit and who had came to the home to meet the new acting manager. And introduce them to the staff team. We advised the owner that in light of these recent management changes the commission would need to receive written notification confirming the management arrangements that are in place in the home. In our discussions we were informed that the registered provider and also the regional manager are visiting the home unannounced on a weekly basis. This is to give support to the new manager. As part of these visits the registered provider stated that they carry out audits of the service and this ensures that developments continue to be made where any shortfalls are identified. It was confirmed that part of these developments will include the regional manager carrying out training with staff. And this training will cover complaints and safeguarding adults. We looked at the accident book and this confirmed that staff is following appropriate first aid procedures when dealing with accidents in the home. The records indicated that when necessary the home also contacted the emergency medical services to ensure people received appropriate medical care. The evacuation and fire procedure was available and this instructs staff what to do in the event of the alarm sounding. However we could not confirm whether staff were receiving appropriate fire instruction training or taking part in fire drills. The fire log book could not be located at the time of our visit though it was confirmed by the deputy manager emergency lights and the alarm system are tested monthly. And records were available to confirm this. Ashlea Grange Residential Home DS0000034293.V378093.R01.S.doc Version 5.3 Page 26 In further discussion the deputy manager was able to locate a piece of paper that confirmed the most recent fire drill had taken place in May and this listed the staff who had taken part. It was noted that when staff enter the building they no longer sign in as they now have a computer log in system. Any visitors to the home always sign the visitor’s book. As staff are no longer singing into the building there is no immediate record to confirm who is in the building and which could be used if there were a reason to evacuate the building in an emergency. This was discussed with the acting manager who was advised of what steps should be taken to rectify this. During our visit we did not look at any records that relate to monies held on behalf of the residents. As previous visits have demonstrated that the records systems in place are now more robust and are audited on a regular basis by the regional manager. In discussion with staff it was stated that staff did not have the opportunity to attend meetings with the previous manager. And they had not received formal supervision since January of this year. In discussion with the acting manager it was confirmed that they would be meeting with staff once they had settled into their role. And from this dates would also be identified to carry out staff supervisions. It was evident from discussion with the deputy manager that at some stage when the previous manager had been in post that changes had been made to records systems. Particularly in relation to care plans, training records and records that related to fire safety. And as a result of this the deputy manager was unsure as to where certain records were or why they had not been available during our visit. It would appear that the shortfalls with the records systems are not being picked up on as part of the regular visits and quality audits by the registered owner and regional manager. In addition to this it was noted that the insurance cover certificate that was on display for the home had expired the previous month. Confirmation was received following the inspection that appropriate insurance cover was in place and we saw the new certificate of cover. Ashlea Grange Residential Home DS0000034293.V378093.R01.S.doc Version 5.3 Page 27 In discussion with families they stated that there was very little consultation held with the owners and that this needed to be improved. They went onto say that they were only aware of changes once they had been made. They stated that they wanted to be involved and consulted with if any further changes were to be made. And they also said that they were unaware of what was happening in the home in relation to the management of the service. And would welcome some discussion with the owner about this. The previous inspections of this service indicated that a number of improvements were being made. However the absence of a permanent registered manager would appear to be a main contributing factor as to why a number of areas still require development. Ashlea Grange Residential Home DS0000034293.V378093.R01.S.doc Version 5.3 Page 28 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X 2 X 2 2 2 Ashlea Grange Residential Home DS0000034293.V378093.R01.S.doc Version 5.3 Page 29 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement Each resident must have a written plan of care that clearly sets out in detail how their assessed needs are to be met. All staff must receive training that is appropriate to their work. And records must be available to confirm what training they have undertaken. The staff practice of wedging fire doors open must stop. And advice should be sought from the fire officer on the best way to maintain fire safety within the home. A written record must be maintained that shows every fire drill and fire practice that staff has taken part in. And which also confirms that drills and training are being carried out in accordance with the guidance issued by the Fire Authority. The registered owner must confirm in writing to the commission the current management arrangements that are in place. Timescale for action 31/01/10 2. OP30 17(2) & 18 31/01/10 3. OP19 23 12/10/09 4. OP38 17 (2) Schedule 4 31/10/09 5. OP38 39 30/11/09 Ashlea Grange Residential Home DS0000034293.V378093.R01.S.doc Version 5.3 Page 30 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 OP7 Good Practice Recommendations All documents that are used as part of the care process should be evaluated at least monthly. Staff should sign and date these documents when the evaluation has taken place. All staff should have the opportunity to meet with the manager on a regular basis. And also receive formal supervision at least 6 times per year. The manager should ensure that all records that are required to be kept by regulation are in place and also updated. The registered owner should consider consulting with residents and their relatives on a regular basis so that they have the opportunity to discuss any changes that are being made in the home. 2. OP36 3. 4. OP38 OP38 Ashlea Grange Residential Home DS0000034293.V378093.R01.S.doc Version 5.3 Page 31 Care Quality Commission Care Quality Commission Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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