Inspection on 23/08/06 for Ashlea Mews Residential Home

This inspection was carried out on 23rd August 2006.

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 12/12/05

Ashlea Mews Residential Home 27/04/05

Ashlea Mews Residential Home 21/01/05

Ashlea Mews Residential Home 27/05/04

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The Highlands

Turret Villa Retirement Home

Moor House

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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 Mr Allan Helmrich Unannounced Inspection 23rd August 2006 10:00 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 Mews Residential Home DS0000034291.V305962.R01.S.doc Version 5.2 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.V305962.R01.S.doc Version 5.2 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.V305962.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One of the MD(E) places refers to current service user only. Date of last inspection 12th December 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 and 6 may have sensory impairment. 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. The home’s weekly charge is £345. Ashlea Mews Residential Home DS0000034291.V305962.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the home’s annual unannounced key inspection. It was conducted over two days and lasted approximately nine hours. Time was spent talking to the company’s area manager, the home manager, staff, residents and their visitors. Information provided by them is used in the production of this report. A selection of the home’s records was reviewed together with systems to ensure residents are safe and well looked after. The living conditions were looked at which included some resident’s bedrooms and all of the communal living areas. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ashlea Mews Residential Home DS0000034291.V305962.R01.S.doc Version 5.2 Page 6 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.V305962.R01.S.doc Version 5.2 Page 7 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, 6. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Admission processes reduce the likelihood of unsuitable placements being accepted. This home does not provide intermediate care. EVIDENCE: Four care plans were looked at. Each contained an appropriate assessment conducted before admission into the home. The information obtained was sufficient to make an informed decision that the person’s needs could be met. The manager confirmed that she is involved in all admissions to the home. The daughter of a resident recently admitted to the home stated that she was given good information. It was an emergency admission and the staff provided good support to her and her mother. The manager also confirmed that referrals for intermediate care to rehabilitate people to return home are not accepted. Respite is provided when the home is not full. Ashlea Mews Residential Home DS0000034291.V305962.R01.S.doc Version 5.2 Page 8 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Residents’ health and personal care needs are met, although medication procedures could be improved. Residents’ privacy and dignity is respected. EVIDENCE: Four care plans reviewed had recently been updated. Each contained details of how the individual personal and healthcare needs are met. Details of healthcare appointments are recorded. The records demonstrated that dental and optical health checks occur regularly. Residents were observed to be in good health and two visitors spoken with stated their relatives health had improved since they can into the home. The system for storing, recording and administering medicines was checked and found to be reasonably satisfactory. The systems in use could be improved; a procedure was not in place to ensure ‘alerts’ sent by the Medical Devices Agency are actioned, hand written entries on medical administration records were not signed by the writer and some prescribed barrier creams Ashlea Mews Residential Home DS0000034291.V305962.R01.S.doc Version 5.2 Page 9 were on view in communal bathrooms. Staff dealing with medicines have all received training and good secure medication storage is available on each floor. Three staff spoken with were aware of their responsibilities in relation to privacy and dignity and instances of good practice were observed during the inspection. Several residents spoken with confirmed that staff respect their privacy and dignity and that keys are available for bedroom doors if they desire them. Bathroom, toilet and bedroom doors all lock and with the exception of one lock (attended to by the handyman during the inspection) they operated smoothly and efficiently. Ashlea Mews Residential Home DS0000034291.V305962.R01.S.doc Version 5.2 Page 10 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, 14, 15. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home’s routines are flexible and visiting is encouraged. Residents choose what to do and have staff support if required. Meals are well presented and nutritious. EVIDENCE: Residents’ preferences in daily living are recorded. During the inspection the hairdresser was available for residents and staff were supporting two residents who choose to visit a local hairdresser. Following a recommendation at the last inspection the home now employs activities co-ordinators to work alongside staff in providing a range of activities. One resident spoken to stated the home is lively which suits her tastes and others were content reading and talking in quiet areas. Two visitors stated they felt the level of activity in the home was good. Visitors and residents confirmed they could meet in private or use one of the home’s lounges. Visitors confirmed they are made welcome. The manager stated that residents are encouraged to handle their own finances, however, a system is maintained for residents who choose to have Ashlea Mews Residential Home DS0000034291.V305962.R01.S.doc Version 5.2 Page 11 the home hold some monies for them. This system was checked, transactions are detailed and two signatures record the transaction. The company regularly audits these records. A triplicate book records all monies brought into the home by residents families. Menus on the wall of each dining room showed that appropriate varied balanced meals are provided. All residents spoken to were happy with the meals. The lunchtime meal in one dining room was unhurried with sufficient staff on duty to attend appropriately to everyone’s needs. The kitchen was clean and food stores contained appropriate quantities of food. Ashlea Mews Residential Home DS0000034291.V305962.R01.S.doc Version 5.2 Page 12 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, 18. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Complaints are taken seriously and a well-trained staff team protects residents. EVIDENCE: A complaints procedure is provided in the home’s Service User Guide which is given to each resident on admission. The manager takes complaints seriously and records all issues of dissatisfaction with the service. Three complaints were received since the last inspection. The issues were recorded in a log along with how they were resolved. Several letters and cards of compliment received by the home were posted on the home’s notice board. The majority of staff have received training related to abuse awareness and further training is planned. The manager has attended an advanced course. Appropriate procedures and Department of Health guidance are available in the home for staff. Staff spoken to during the inspection were aware of their responsibilities regarding protecting vulnerable people. Ashlea Mews Residential Home DS0000034291.V305962.R01.S.doc Version 5.2 Page 13 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, 26. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Residents live in a clean, comfortable, well-maintained home. Some practices to improve safety could be made. EVIDENCE: The home that was purpose built in 2001 is near to shops, bus and metro services. Following a requirement at the last inspection the dining room was redecorated. Other decorations in communal areas are in progress. This is part of a refurbishment programme. The grounds are kept safe and tidy and the car park is capable of meeting the needs of visitors to the home. Ashlea Mews Residential Home DS0000034291.V305962.R01.S.doc Version 5.2 Page 14 The home is clean and well maintained with no odours detected. Suitable measures are taken, like liquid soap and towel dispensers being provided at communal washing points to promote good hygiene and infection control. The home’s laundry is fitted with equipment appropriate to the size of the home. Floors and walls are easily cleanable and good storage for clothing is provided. The laundry did not contain washing instructions for staff. Although systems are in place to promote the home’s safety for residents and visitors, several issues that may affect residents safety were observed: One bathroom did not contain a thermometer to assist staff in determining safe bathing temperatures, however each of the other bathrooms did have one. A wheelchair and hoist were stored in a bathroom; a bathroom contained open shampoo and a prescribed skin cream; several storerooms were unlocked and a shower room that was having the floor re-laid. Ashlea Mews Residential Home DS0000034291.V305962.R01.S.doc Version 5.2 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): 27, 28, 29, 30. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Residents are supported by trained staff, employed in sufficient numbers to meet their needs. Staff recruitment limits the possibility of employing unsuitable staff, therefore promoting the safety and wellbeing of residents. EVIDENCE: Staff on duty appeared to be able to meet the needs of the residents. A staffing rota demonstrated that the home employs sufficient staff. The manager, two senior care staff, four care staff and an activities organiser were on duty during the inspection. Of 22 care staff employed in the home, 13 have a National Vocational Qualification (NVQ) in care at level 2 or 3. A training plan is in place for all staff and as required at the last inspection the dates of training completed have been added. 20 staff are enrolled on a 12 week dementia awareness course that should benefit residents. Other future training is planned in fire awareness and the Protection of Vulnerable Adults. The home does not employ any staff under 18 years old. Four staff files reviewed, showed the home have a suitable recruitment process that ensures the safety of residents. Each file contained two references, a Criminal Record Bureau check and details of an induction into the home. Each Ashlea Mews Residential Home DS0000034291.V305962.R01.S.doc Version 5.2 Page 16 new employee is provided with a copy of the home’s handbook to read and a copy is retained in the staff room. Staff confirmed they receive a good standard of training and that any requests made for additional training are considered. Compliments on the quality of the staff team were received from residents and visitors to the home. Ashlea Mews Residential Home DS0000034291.V305962.R01.S.doc Version 5.2 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): 31, 33, 35, 38. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. A competent manager runs the home. The quality of care provided to residents is monitored. A system to safeguard residents monies is in place. Safe working practices could improve for the benefit of residents. EVIDENCE: The manager is a competent person who has recently completed the Registered Managers award and is awaiting the certificate. Residents and visitors praised her during the inspection. Although only recently returned to work she was aware of the residents needs and has regular meetings with residents and staff. The manager is aware of her responsibilities in the home. The home has a quality assessment process in place and during the inspection an area manager of the company visited to conduct a regular assessment of Ashlea Mews Residential Home DS0000034291.V305962.R01.S.doc Version 5.2 Page 18 care provided. A programme of renewals is in place and evidence of recent improvement was noted. Questionnaires are provided to residents and their visitors to comment on the service. Details of future inspections and previous reports are available to all on notice boards and tables near the entrance. A notice board holds cards of compliment from grateful families and there are many photograph albums of recent social events. Residents and their families are encouraged to control their own monies, however, the home will hold some monies for residents. A system of recording is in place that requires two signatures for each transaction. Monies are securely maintained separately for each resident and are regularly audited by staff from head office. No one currently uses an advocate but contact details are provided by the home. Systems are in place in the home for auditing safe working practices but these are not consistently maintained for the safety of residents. In addition to the issues identified previously during a tour of the home, not all staff have received regular fire instruction. The periodic fire safety checks are carried out and a risk assessment for fire safety is in place. Maintenance certificates are in place to demonstrate the home’s lift, water, gas and electrical systems are satisfactory. Hoisting equipment was recently checked and staff have received recent health and safety training. Ashlea Mews Residential Home DS0000034291.V305962.R01.S.doc Version 5.2 Page 19 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 3 8 3 9 2 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 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Ashlea Mews Residential Home DS0000034291.V305962.R01.S.doc Version 5.2 Page 20 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 OP9 Regulation 13(2) Requirement The manager must improve medication processes by producing a procedure for staff on receipt of notifications from the Medical Devices Agency. Ensure hand written entries on medical administration records are signed by the transcriber. Ensure prescribed medicines are kept safe. The manager must attend to the following health and welfare issues; Kept storage cupboards and rooms where building works are ongoing, locked. Remove creams and toiletries from bathrooms after use. Do not use bathrooms for storage of hoists and wheelchairs. The manager must ensure staff receive fire instruction at the appropriate intervals. A system should be introduced to confirm this occurs. Timescale for action 30/09/06 2. OP19 12(1)(a) 30/09/06 3. OP38 23(4)(e) 30/09/06 Ashlea Mews Residential Home DS0000034291.V305962.R01.S.doc Version 5.2 Page 21 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 OP26 Good Practice Recommendations Display washing instructions for staff in the home’s laundry. Ashlea Mews Residential Home DS0000034291.V305962.R01.S.doc Version 5.2 Page 22 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. 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