Inspection on 12/12/05 for Ashlea Mews Residential Home

This inspection was carried out on 12th December 2005.

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

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

Other inspections for this house

Ashlea Mews Residential Home 09/08/07

Ashlea Mews Residential Home 23/08/06

Ashlea Mews Residential Home 27/04/05

Ashlea Mews Residential Home 21/01/05

Ashlea Mews Residential Home 27/05/04

Similar services:

The Highlands

Turret Villa Retirement Home

Moor House

Blenheim House

1 Lanark Close

Mendip House

Beaconsfield Court Care Home

Ann Charlton Lodge

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

CARE HOMES FOR OLDER PEOPLE Ashlea Mews Residential Home Stanhope Parade South Shields Tyne And Wear NE33 4BA Lead Inspector Mrs Eileen Hulse Unannounced Inspection 12th December 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ashlea Mews Residential Home DS0000034291.V265714.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ashlea Mews Residential Home DS0000034291.V265714.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ashlea Mews Residential Home Address Stanhope Parade South Shields Tyne And Wear NE33 4BA 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) 0191 455 9051 0191 455 6251 Winnie Care Limited Mrs Roslyn Ann Wright Care Home 40 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (2), Old age, of places not falling within any other category (40), Physical disability over 65 years of age (8), Sensory Impairment over 65 years of age (6) Ashlea Mews Residential Home DS0000034291.V265714.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. One of the MD(E) places refers to current service user only. Date of last inspection 27th April 2005 Brief Description of the Service: Ashlea Mews is a purpose-built care home for older people in South Shields. It is registered to care for 40 people, 8 of whom may have physical disabilities. The home cannot provide nursing care. It is located near to local bus routes and the Metro Station is close by. A health centre and local shops are a short proximity and the beach is a short drive away. It has garden areas to the rear of the home which are accessible to all service users and an extensive car park to the front of the building. The building has level access into the home with wide corridors internally for ease of movement. It has a lift to take people to and from the first floor and adapted toilet and bathing facilities, and en-suite bedrooms throughout. The decoration, furnishings and fittings are of good standard and the home has a friendly comfortable environment. An emergency call system is in place. Ashlea Mews Residential Home DS0000034291.V265714.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the 12th December 2005 by one inspector (Eileen Hulse), it was un-announced and was carried out as part of the annual inspection programme. It took 9hrs 30mins to complete that included 1hr to prepare for the inspection. The focus of the inspection was to gain insight into the quality of life and services received by service users who live in the home. Time was spent chatting with service users, relatives and talking with the Manager and staff who were on duty, inspecting some records including care plans, health care records, risk assessments, medication and POVA policies and procedures. The Inspector had a lunchtime meal with service users in the dining room and a tour was made of the premises. What the service does well: What has improved since the last inspection? What they could do better: The good care delivered is not reflected in the service users’ care plans and they have not improved since the last inspection. It is strongly recommended that an activities co-ordinator is employed that will ensure that structured activities that are planned will be carried out on a regular basis. Ashlea Mews Residential Home DS0000034291.V265714.R01.S.doc Version 5.0 Page 6 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 Mews Residential Home DS0000034291.V265714.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ashlea Mews Residential Home DS0000034291.V265714.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 The home have a good admission procedure and that details all prospective service users must have an assessment carried out prior to admission that will ensure the care needs can be met by the home. The home does not provide intermediate care at this time. EVIDENCE: Of the sample of care plans inspected, records evidenced all service users have within their plans of care, an assessment that had been completed by a Care Manager prior to admission. Also within the records, there are good assessment documents that are completed by the Manager when she carries out a pre-admission assessment of potential new service users. This takes place in either the home of the service user or during a trial visit to the home. This ensures the home are able to meet all of the care needs and gives the service user choice if they would like to live in the home. Ashlea Mews Residential Home DS0000034291.V265714.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 10 Every service user has an individual plan of care in place. However, they are completed in minor detail and do not ensure that service users receive the care they are assessed as needing and they do not ensure that staff are guided in their every day practice. Service users have access to all services provided by the National Health Service and where possible they have been able to remain with their GP practice when moving into the home. In discussions with some service users they confirmed they are treat with dignity and respect from staff members at all times and made many positive comments about the home. EVIDENCE: Records evidenced that a range of information is maintained in service users personal files which confirms when service users have accessed health services and this includes the following services ie. chiropody, dentist and optician. The community nursing service also visits the home on a regular basis and currently the home have two district nurses attending some service users daily to administer treatment. Ashlea Mews Residential Home DS0000034291.V265714.R01.S.doc Version 5.0 Page 10 Risk assessments are in place which deal with pressure care and appropriate referrals are made to the community nursing services if it is identified that nursing intervention is required. When talking with service users they were very positive about the home and comments they made included: • • • ‘The staff are smashing’ ‘We always get asked what we want to eat’ ‘Couldn’t fault this place’ During the inspection, staff were observed to knock on bedroom doors before entering the bedrooms and service users confirmed that mail is delivered to them unopened. There is a public telephone which can be used in all bedrooms as the rooms are equipped with telephone sockets and six service users have had their own telephone installed. Service users are able to see GP’s and community nurses in the privacy of their own bedroom. Many of the service users choose to spend a lot of time in their bedrooms following their own pursuits and this is supported by staff. Ashlea Mews Residential Home DS0000034291.V265714.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 and 15 Daily living is flexible in the home and this ensures that service users can choose how to spend their days. However, although the home have activities in place, the home would benefit from having an activity co-ordinator employed who would organise structured activities leaving the care staff to carry out other roles. Good contact is maintained between service users, their relatives and friends and there are no restrictions on visiting the home, this enables service users to have visitors at a time that is suitable to them. Service users are offered and receive varied and nutritious meals that can contribute to their general well being and health. EVIDENCE: The home do carry out activities every day and this includes bingo three times a week, a weekly singing group run by the local college that service users can join in with, a pat-a-dog scheme and entertainment that is brought into the home. The activities programme was confirmed with an activity manual record that details what the activity is, the name of service users who have participated. However, there were no records to suggest that individual Ashlea Mews Residential Home DS0000034291.V265714.R01.S.doc Version 5.0 Page 12 activities take place or that the activities are planned in advance and not a lot of external activities take place. Service users can have visitors at anytime and where they choose either in the communal lounge or in the privacy of their bedrooms. Some service users choose to go out with their families or to go out shopping or to visit the local pub. The hairdresser visits the home every week but some service users stated that they choose to visit the hairdresser in the local vicinity. The inspector shared a lunchtime meal with service users. The arrangements in place were good, tables were well set with placemats, condiments, and serviettes. It was a two course meal comprising of a choice of either a mixed grill or shepherds pie with chips or mashed potato and mixed vegetables with apple crumble and custard or ice cream for sweet. The meal was hot, tasty and well cooked with good sized portions. Service users chatted with each other throughout the meal and were given sufficient time to sit and enjoy their meal without being hurried. Some service users spoke positively about the meals they receive and comments were as follows: • • • ‘The food is always very good’ ‘We get gorgeous breakfasts’ ‘The dinner is always swimming in gravy’ Some service users required help with their meal, this was given by staff in a sensitive and dignified way for the service user. Ashlea Mews Residential Home DS0000034291.V265714.R01.S.doc Version 5.0 Page 13 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): 18 Good systems are in place to help protect service users from abuse. Good policies and procedures and the Council’s manual are also available to staff to use as a reference guide should a situation arise. EVIDENCE: The home have policies and procedures from both the council and the providers of the home. The company policy covers the various types of abuse, how to recognise abuse and describes the indicators. Ten members of the staff team have recently received training on the Protection of Vulnerable Adults from South Tyneside Council to give them guidance on the various forms of abuse that can take place and what to do should they suspect any abusive practice. Their have been two incidents of abuse in a year and records show they were both dealt with in a professional manner. The Manager has now received lead officer abuse training over a period of two days and the remainder of the staff team will receive abuse training when dates have been arranged. Ashlea Mews Residential Home DS0000034291.V265714.R01.S.doc Version 5.0 Page 14 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 The home is comfortable, well decorated and furnished and well maintained. Service users bedrooms are comfortable, homely and personalised to individual tastes with their personal possessions. EVIDENCE: On a tour of the building lounges appeared comfortable and homely and during discussions with service users they stated: • • ‘This is a lovely home to live in’ ‘I have a lovely bedroom with all of my own things in’ However, the upstairs dining room requires decorating as the wallpaper is marked and peeling from the wall in some areas. Ashlea Mews Residential Home DS0000034291.V265714.R01.S.doc Version 5.0 Page 15 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): 28, 29 and 30 The numbers and skill mix of staff enable all the service users individual needs to be met. The home has a thorough recruitment of staff policy and procedure, which is followed when selecting prospective staff. However, staff files inspected showed not all staff have Criminal Records Bureau checks in place, therefore, service users are not protected at all times. Records showed that each member of staff has an individual training file and a training matrix is in place that shows when staff have received training. However, this matrix does not give any dates, therefore, annual mandatory training will not be identified. EVIDENCE: Thirteen members of the care staff team have achieved either an NVQ Level 2 or 3 qualification in care and another five staff have recently enrolled to commence NVQ training. The home have now achieved 50 of the care staff that are trained with a qualification. This ensures that the staff team have the skills and knowledge to meet the needs of service users on a daily basis. Following a completed application form, which matches the policy guidelines, prospective staff are invited to the home to attend for interview consisting of a panel of two senior members of staff. Following the interview, the necessary documentation is obtained and checked which includes two references and successful staff are given a job description and a three month contract which is followed up and reviewed by the Manager. A sample of staff files were Ashlea Mews Residential Home DS0000034291.V265714.R01.S.doc Version 5.0 Page 16 inspected, one member of staff was found to have no CRB check in place. All staff have copies of the General Social Care Council booklet Ashlea Mews Residential Home DS0000034291.V265714.R01.S.doc Version 5.0 Page 17 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): 35 and 38 Records dealing with service users’ money held by the home for safe keeping are good therefore, service users’ financial interests are safeguarded at all times. The health and safety regarding staff practice was observed throughout the inspection and found to be good, this helps to keep service users safe. EVIDENCE: All financial transactions on behalf of service users are recorded in hard backed individual books. Receipts are numbered to correspond with the entries within the books, therefore, cross-referencing or checking can be carried out. Throughout the day, staff were observed to follow health and safety guidelines in all practice procedures. Good moving and handling techniques were used when moving those service users requiring help from one area to another. Moving and handling equipment was used correctly at all times by staff. Ashlea Mews Residential Home DS0000034291.V265714.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 2 X X X X X X X STAFFING Standard No Score 27 X 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X 3 Ashlea Mews Residential Home DS0000034291.V265714.R01.S.doc Version 5.0 Page 19 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. 2. 3. Standard OP7 15 OP19 13 OP30 18 Regulation Requirement Care plans must include sufficient information to guide the practice of staff The dining room needs decorating The staff training manual needs to identify when training has taken place Timescale for action 01/03/06 01/03/06 01/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP12 Good Practice Recommendations An activities co-ordinator should be employed by the home. Ashlea Mews Residential Home DS0000034291.V265714.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection South of Tyne Area Office Baltic House Port of Tyne Tyne Dock South Shields NE34 9PT 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 Mews Residential Home DS0000034291.V265714.R01.S.doc Version 5.0 Page 21 - 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. 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