Inspection on 09/08/07 for Ashlea Mews Residential Home

This inspection was carried out on 9th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 23/08/06

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

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 Key Unannounced Inspection 9th August 2007 09:15 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.V347919.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.V347919.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.V347919.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 23rd August 2006 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 distance away and the beach is a short drive away. It has garden areas to the rear of the home that 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 weekly fees are £395:00 to £400:00 per week depending upon care needs. Additional charges are made for hairdressing, personal items and newspapers. Ashlea Mews Residential Home DS0000034291.V347919.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection that took 7hrs to complete over a one day visit to the home and was carried out as part of the annual inspection programme. The Registered Manager was present throughout the visit and some time was spent with her looking at systems they have in the home such as staffing levels, staff training, medication systems and spending time in communal areas of the home. Time was also spent talking with service users and their visitors to get their views about the home. How care staff help and support service users was observed throughout the visit and a lunchtime meal was taken with the service users. Information about the quality of life and care received by service users was collected using a system called ‘case tracking’. This involves following the care and experience of a group of service users by looking at care plans, talking with people, sampling records such as assessment records, complaint records, medication taken by service users and their records. Issues that we asked the home to put right in previous inspection reports were discussed with the Manager. Discussions also took place with other staff members who were on duty at various times throughout the visit. The judgements made are based on the evidence made available during the visit to the home and from details obtained from the home before the visit was made. This gave up to date information about the home to include within the report. During the visit comments from service users and their families gave some insight on what it is like to live in the home and included: ‘I decided I wanted to come into a home and get looked after and this is the one’ ‘I cannot fault this home in anyway, my (relative) is well looked after’ ‘I visited this home before my (relative) came in and was very impressed with it’ ‘The girls are very very good’ ‘It’s a great home and very welcoming’. What the service does well: Ashlea Mews is a well managed home and it provides a good quality of care. The staff team are respectful and caring to service users whilst making sure they are involved in making decisions about their lives. Good healthcare arrangements are available that makes sure the health care needs of service users are met at all times. Ashlea Mews Residential Home DS0000034291.V347919.R01.S.doc Version 5.2 Page 6 Staff are well trained with good training programmes made available and all staff hold a care qualification. The recruitment and selection process for prospective staff help to make sure that the right staff are employed by the home. Service users and families are very positive about the service that Ashlea Mews provides and other comments they made included: ‘It’s a great place to be when you need caring for’ ‘I never go away from the home worrying about how my (relative) will be’ ‘It always has a very homely atmosphere’. All service users spoken stated they knew how to make a complaint should they ever felt they needed to and the complaints information is made available in various formats that include large print and audiocassettes. 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. The summary of this inspection report can be made available in other formats on request. Ashlea Mews Residential Home DS0000034291.V347919.R01.S.doc Version 5.2 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.V347919.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home uses a good assessment and admission process that ensures the needs of people can be met prior to their admission. The home does not provide intermediate care but can provide respite care when they have vacancies. EVIDENCE: The homes admission and pre admission assessment procedure ensures that service users have an informed choice about moving into the home. They are given information before visiting the home that informs them how their care needs are to be met. Ashlea Mews Residential Home DS0000034291.V347919.R01.S.doc Version 5.2 Page 9 A care Manager is involved with the process and provides the home with a care plan prior to admission. Several visits are then arranged between the service user and the home before admission to give people the choice if they would like to live there. Ashlea Mews Residential Home DS0000034291.V347919.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have regular access to healthcare professionals and the care plans are organised and detailed and this helps to promote the welfare of service users and know that the care needs are being met. EVIDENCE: The care plans sampled are detailed with sufficient information for staff to give the care and support to meet the care needs of service users. They are well organised into sections so that information is easily accessible and the contents include the terms and conditions of residency, pre admission completed assessment, admission information, the care managers assessment and completed risk assessments for each individual plan of care. Ashlea Mews Residential Home DS0000034291.V347919.R01.S.doc Version 5.2 Page 11 The home has a safe and effective policy that is followed when staff administer medication and all staff with responsibility for administering medication have completed the ‘Safer Handling of Medication training. The recording of the MAR (medicine administration record) sheets and an audit trail of the medicines showed that the medicines held in the home were correct and the records were signed appropriately. A member of staff was observed giving out medication to service users following their midday meal, this was completed following the medication procedure. Throughout the visit, staff were observed to be respectful to service users knocking on bedroom doors and calling them by their preferred name. Service users made positive comments about the home and the staff and they included: ‘The staff are a grand set of girls, they do everything for you that you ask’ ‘It’s been excellent here from day one, they are lovely staff’ ‘It’s a lovely home this and I am really pleased I came here’. Ashlea Mews Residential Home DS0000034291.V347919.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. A good range of social activities are provided that enable service users to make positive choices about how they spend their time and they are able to follow their own daily routines which satisfy their social, cultural and religious needs. EVIDENCE: The home employs an activity co-ordinator to plan and organise a range of activities that are carried out on a daily basis. Service users are notified of events taking place and there are posters on the walls throughout the home and through a newsletter that is distributed to service users and their visitors every two months. A Church service takes place every month and everyone regardless of their religious beliefs is asked if they would like to take part. Other churches visit to offer service users Holy Communion and service users are also invited to the local church events. Ashlea Mews Residential Home DS0000034291.V347919.R01.S.doc Version 5.2 Page 13 One activity very popular with service users is the pat dogs that regularly visit the home. Comments made by service users regarding the activities offered included: ‘I like to take part in the activities, I do enjoy the bingo’ ‘I read a lot and I like to go out walking’ ‘I still enjoy my Art group two days a week’ ‘The home does well always organising something for us to do’. Service users use the facilities of the local community, many trips to the nearby seafront are arranged and visits to the local customs house to see shows are also organised. In discussions with service users they talked about the recent summer fete that had taken place and how they had enjoyed the day. All activities are well recorded and show that service users are given the choice if they wish to take part. During the visit, a meal was taken with the service users. Tables were well set and the meal was hot, tasty and wholesome. Throughout the meal, service users stated: ‘The meals are good and you get a choice’ another service user said ‘The portion sizes are just right and not massive portions that puts you off’. One service user likes tripe and this is purchased once a week. Many service users choose to have breakfast in bed, this was evidenced during the visit and others can choose to have breakfast when they prefer it between 8.30 am11.00 am. Ashlea Mews Residential Home DS0000034291.V347919.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home have a detailed complaints procedure that is made available to each service user and their representative. This ensures service users have the information they need to make a complaint should they be dissatisfied with the service and they have good adult protection procedures that help to protect service users should an abuse situation arise or be suspected. EVIDENCE: An easy to understand complaints procedure is made available in a variety of formats such as audio, large print and if requested in different languages from Head office. All service users are given this information following admission and further copies are placed in the entrance to the home so that the information is always made available. The complaints procedure includes the name, address and phone numbers of the company head office and the Commission for Social Care Inspection. No persons currently living in the home are using advocacy services but the information is available should they need to access this service. Ashlea Mews Residential Home DS0000034291.V347919.R01.S.doc Version 5.2 Page 15 Suggestions and complaints made about the service are documented including who the complaint was made by, time and date of concern or complaint, who it was passed to, to be dealt with and following the investigation if the complainant was happy with the outcome. All complaints received are documented and a yearly audit takes place to ensure that all complaints made have been finalised to the complainant’s satisfaction. The POVA (Protection of Vulnerable Adults) procedures are in the home and accessible to the staff and all of the staff team apart from two recently recruited staff have received protection of vulnerable adults training from the Local Authority that also includes a trainee currently based in the home, the company training department and an outside training company Care Alliance, all staff regardless of their role in the home receive POVA training. The home have received no POVA issues to date and they complete protection issues forms on a monthly basis that are then sent to company headquarters monitor this information. Discussions with service users highlighted should they have a concern or a complaint they were confident it would be dealt with and comments included: ‘If I had a complaint I would go to the Manager, she is marvellous, she treats everybody the same’ ‘There is never anything to complain about in here but I would tell the office if I wasn’t happy’ ‘I haven’t got anything to complain about but I know who I would talk to about it, the staff really care in this home’ ‘I have never needed to complain but the home have told me how to should I need to’. Ashlea Mews Residential Home DS0000034291.V347919.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This home is clean and generally well maintained and a number of improvements have been made since the last inspection. This ensures service users live in a comfortable and homely environment. All staff have received infection control training and this helps to protect the well being of service users. EVIDENCE: Recent refurbishment of the bedrooms has included new bedroom furniture and all communal areas such as the lounges and corridors have been recently redecorated and lounge chairs have been replaced. Wheelchairs are now stored within the service users bedrooms and the hoist has been moved into the basement rooms when not in use. Ashlea Mews Residential Home DS0000034291.V347919.R01.S.doc Version 5.2 Page 17 Service users bedrooms are homely with personal possessions making the rooms comfortable. Ashlea Mews Residential Home DS0000034291.V347919.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Well-trained, caring and committed staff are in post with good staffing levels and this ensures staff have the knowledge and skills to care and support people. Service users are protected by the home’s good recruitment procedures. EVIDENCE: All staff regardless of their position has three personal files that are held in the office and they each cover personal recruitment information, staff training that holds certificates and information on courses that have been attended and supervision records. A detailed up to date training matrix is up on the office wall and accessible to the staff team showing all staff training and all staff have completed level 2 NVQ and some staff have achieved level 3. Applications have been made for the kitchen and domestic staff to commence an NVQ qualification. On the day of the visit the home had sufficient numbers of staff on duty, there were four care staff, a senior care assistant, activity co-ordinator two domestic staff, a cook and assistant cook and a springboard trainee and the rota confirmed that the staffing levels are maintained at this level at all times. Ashlea Mews Residential Home DS0000034291.V347919.R01.S.doc Version 5.2 Page 19 The home has a policy and procedure that is followed when recruiting prospective staff, the Manager was able to explain in detail how the procedure is carried out. A sample of staff files showed that all the checks, which must be carried out prior to employment, were in place. Ashlea Mews Residential Home DS0000034291.V347919.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33, 35 and 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The service is well managed by a person who is experienced and shows good leadership skills and this helps to ensure the service is run in the best interests of the service users and the risks to the health and safety of service users, visitors and staff are minimised. EVIDENCE: The Manager has 10 years experience of working in a care setting and has completed the Registered Managers Award and NVQ levels 3 and 4 in care. She has completed recent training to update her knowledge and skills in Nutrition, health and safety in fire prevention and Protection of vulnerable adults. Ashlea Mews Residential Home DS0000034291.V347919.R01.S.doc Version 5.2 Page 21 In discussions with service users, relatives and staff they all confirmed the ‘Manager was approachable’ and ‘always ready to listen to them’. All staff receives supervision every two months and all issues discussed are recorded and placed in individual staff files. Service user meetings are also held every two months and minutes recorded, at the last meeting service users expressed they did not like the last entertainer and did not want them back, this was recorded and minuted. As part of the homes quality assurance programme, questionnaires are given to service users, families and staff and this information is used to progress the service, the last survey carried out was in July 2007. The questionnaires are anonymous but there is an area where people can include their name and address should they want to. The questionnaires are given to everybody regardless of their abilities and plans are currently in place to produce this form in picture format. An audit of money held by the home for safekeeping was correct and the records kept were up to date and well maintained. Money is stored safely and securely and records showed there are two signatures entered whenever a financial transaction takes place and records follow the guidelines of the Data Protection Act. The fire records have recently been changed, they are detailed and up to date and show that fire tests are carried out at the stated times. Ashlea Mews Residential Home DS0000034291.V347919.R01.S.doc Version 5.2 Page 22 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 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 4 3 X X X X X X 3 STAFFING Standard No Score 27 4 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 x 4 X 4 X X 4 Ashlea Mews Residential Home DS0000034291.V347919.R01.S.doc Version 5.2 Page 23 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Ashlea Mews Residential Home DS0000034291.V347919.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection South Shields Area Office 4th Floor St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V347919.R01.S.doc Version 5.2 Page 25 - 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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