Inspection on 27/04/05 for Ashlea Mews Residential Home

This inspection was carried out on 27th April 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Ashlea Mews Residential Home 09/08/07

Ashlea Mews Residential Home 23/08/06

Ashlea Mews Residential Home 12/12/05

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 Eileen Hulse Unannounced 27 April 2005 9:30am The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ashlea Mews Residential Home B52 B02 S34291 Ashlea Mews V219663 270405 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Ashlea Mews Residential Home Address Stanhope Parade South Shields Tyne and Wear NE33 4BA 0191 455 9051 0191 455 6251 none Winnie Care Limited Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Roslyn Ann Wright Care Home only 40 Category(ies) of OP Old age (40) registration, with number PD(E) Physical disability - over 65 (8) of places SI(E) Sensory Impair over 65 (6) MD(E) Mental Disorder -over 65 (1) Ashlea Mews Residential Home B52 B02 S34291 Ashlea Mews V219663 270405 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 21/1/05 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 B52 B02 S34291 Ashlea Mews V219663 270405 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and took 7hrs 30mins to complete, which included two hours to prepare for the inspection. A tour was made of the building with permission given by the service users to enter their bedrooms. Most of the time was spent inspecting records, discussing the requirements made in previous inspection reports, having lunch with the service users and spending a lot of the day talking to them about life in the home in general. Time was also spent talking with the Manager and members of staff who were on duty. 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 appear to have deteriorated since the last inspection. An activity coordinator has been employed to work in the home one day a week which does not allow enough time to arrange activities to ensure that service users can choose what they would like to do or if they prefer to go out. Ashlea Mews Residential Home B52 B02 S34291 Ashlea Mews V219663 270405 Stage 4.doc Version 1.30 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 B52 B02 S34291 Ashlea Mews V219663 270405 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Ashlea Mews Residential Home B52 B02 S34291 Ashlea Mews V219663 270405 Stage 4.doc Version 1.30 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 standard(s) 1 and 3 A statement of purpose is available to service users and their representatives that gives detailed information to give them the choice to decide if they would like to live in Ashlea Mews. The home’s pre-admission assessment document does not include sufficient information for the home to judge whether they can meet all the needs of a prospective service user. EVIDENCE: The statement of purpose sets out the aims and objectives of the home and includes the range and facilities the home aim to make available to service users. This ensures that service users are able to choose if they want to live in the home and if their needs can be met. Since the last inspection, the home has applied for and successfully updated their categories of registration to ensure they care only for people whose needs they can meet. Ashlea Mews Residential Home B52 B02 S34291 Ashlea Mews V219663 270405 Stage 4.doc Version 1.30 Page 9 The home ensures that care management assessments that are given to the home prior to the service user’s admission are used when formulating individual plans of care. However, when a prospective self-funding service user who does not have a care manager approaches the home for admission, there is no documentation available to ensure the home can meet their needs on a day to day basis. Ashlea Mews Residential Home B52 B02 S34291 Ashlea Mews V219663 270405 Stage 4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 and 9 Every service user has an individual plan of care in place. They are completed in minor detail and do not ensure that service users receive the care they need and that staff are guided in their every day practice. The medication arrangements in the home are good, staff who are responsible for the handling of medicines have received accredited training and this helps staff to ensure medication is handled safely. EVIDENCE: A sample of care plans examined have varying levels of information about personal care needs. The care plans inspected were noted to be signed by the service user where possible and a statement ensures service users are aware they have access to their personal records. Since the last inspection, staff who currently are responsible for administering medication to service users have completed accredited training. At the time of the inspection, the Inspector observed a medicine round. This was completed Ashlea Mews Residential Home B52 B02 S34291 Ashlea Mews V219663 270405 Stage 4.doc Version 1.30 Page 11 satisfactorily and the guidelines of The Royal Pharmaceutical Society were followed throughout. Ashlea Mews Residential Home B52 B02 S34291 Ashlea Mews V219663 270405 Stage 4.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 14 and 15 Service user meetings are held to include them in decision-making processes within the home. Leaflets and literature are on display in the foyer for service users and their families to help them if they have any concerns they require independent help with. The lunchtime meal was a pleasant relaxed occasion and staff offered help to service users in a discreet and dignified manner. EVIDENCE: On the day of the inspection, documentary evidence confirmed that service user meetings take place regularly and that issues raised are addressed prior to their next meeting. Discussions with service users confirmed this and their comments included: ‘I know who to speak to if I am worried about anything’ ‘Staff are always very helpful to me’ ‘It’s a lovely home and I wouldn’t like to live in another home’ Information on advocacy is also available and in the past, the Manager has involved advocates to help service users where this has been appropriate. Ashlea Mews Residential Home B52 B02 S34291 Ashlea Mews V219663 270405 Stage 4.doc Version 1.30 Page 13 The inspector shared a meal with the service users. The meal was hot, tasty and nicely presented and staff were observed to treat service users with dignity and respect at all times. Tea/coffee or a cold alternative of juice was served with the meal. Ashlea Mews Residential Home B52 B02 S34291 Ashlea Mews V219663 270405 Stage 4.doc Version 1.30 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 17 Records were inspected on the recording of compliments and complaints received in the home and were found to be well managed and maintained. Service users’ legal rights are protected at all times. EVIDENCE: Any complaints received by the home are responded to within the home’s permitted times. All complaints are recorded into a file and a system has been implemented to audit all complaints and concerns that are raised. One relative spoken to during the inspection stated that when she made a recent complaint to the Manager it was dealt with quickly and professionally and she was more than happy with the outcome. On the day of the inspection, service users who were able had been given the general election voting papers to complete. As they were postal votes, following completion they were then posted by a staff member. Ashlea Mews Residential Home B52 B02 S34291 Ashlea Mews V219663 270405 Stage 4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 24 and 26 The home is comfortable, well decorated and furnished and generally well maintained. Service users’ bedrooms are comfortable, homely and personalised to individual tastes with their personal possessions. Good policies and procedures are in place to guide staff in the control of infection in the home. staff have been given further practice guidance to minimise the risk of infection. EVIDENCE: The lighting in communal area and service users’ bedrooms on the first floor has been changed to increase lighting levels and this has enabled service users to be able to read in a better light in their bedrooms. The home was free from any unpleasant odours. All staff have received infection control training and the home has purchased an industrial washing machine that reaches the required temperatures to thoroughly clean laundry and thus controls the risk of infection. In all Ashlea Mews Residential Home B52 B02 S34291 Ashlea Mews V219663 270405 Stage 4.doc Version 1.30 Page 16 bathrooms and toilets antibacterial agents are available for staff which were used throughout the day. Ashlea Mews Residential Home B52 B02 S34291 Ashlea Mews V219663 270405 Stage 4.doc Version 1.30 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 28 Good staffing levels are maintained and these reflect the needs of the service users currently living in the home at this time. This allows for sufficient support to be provided to service users. Although staff training courses have increased since the last inspection, the home continue not to meet the numbers of staff needing to be qualified by 2005. EVIDENCE: Duty rotas checked show that the staffing levels are adequate and duty rotas are well maintained. Throughout the inspection, service users and visitors were very complimentary about the staff team. Service user and relatives’ comments included: ‘ You get well looked after in here and we can do anything we want’ ‘This is a lovely place to live with lovely girls’ ‘Lovely staff, there just never seems enough of them’ The home have 25 of staff qualified to NVQ Level 2 and therefore do not meet the standard. However, staff in the home who do not hold a qualification are all currently completing NVQ Level 2 and the 50 should then be achieved. Ashlea Mews Residential Home B52 B02 S34291 Ashlea Mews V219663 270405 Stage 4.doc Version 1.30 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 and 38 Records dealing with service users’ money held by the home for safe keeping are poor and therefore service users’ financial interests are not safeguarded at all times. The health and safety regarding staff practice was observed throughout the inspection and found to be good. EVIDENCE: All financial transactions on behalf of service users are recorded on loose leaf sheets of paper and held in one file. Receipts are not numbered to correspond with the entries on the sheets, therefore no cross-referencing or checking can be carried out. Following the guidelines of the Data Protection Act, all entries must be made into hard backed individual books with numbered pages and all receipts should be numbered to correspond with entries in the individual books. Throughout the day, staff were observed to follow health and safety guidelines in all practice procedures. Good moving and handling techniques were used Ashlea Mews Residential Home B52 B02 S34291 Ashlea Mews V219663 270405 Stage 4.doc Version 1.30 Page 19 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 B52 B02 S34291 Ashlea Mews V219663 270405 Stage 4.doc Version 1.30 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x x 3 x 3 STAFFING Standard No Score 27 3 28 2 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 x x x x x 2 x x 3 Ashlea Mews Residential Home B52 B02 S34291 Ashlea Mews V219663 270405 Stage 4.doc Version 1.30 Page 21 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 3 Regulation 14 Requirement All service users must have a care management assessment ( 1 April 05 ) Timescale for action 1/10/05 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 Good Practice Recommendations Ashlea Mews Residential Home B52 B02 S34291 Ashlea Mews V219663 270405 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection 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 B52 B02 S34291 Ashlea Mews V219663 270405 Stage 4.doc Version 1.30 Page 23 - 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. 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