Inspection on 19/01/06 for Ashleigh

This inspection was carried out on 19th January 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

Ashleigh 29/05/07

Ashleigh 07/06/05

Ashleigh 14/09/04

Ashleigh 18/05/04

Ashleigh 04/02/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Ashleigh 27 - 33 Ash Grove Beverley Road Hull East Yorkshire HU5 1LT Lead Inspector Malcolm Stannard Unannounced Inspection 19th January 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 Ashleigh DS0000000834.V274283.R01.S.doc Version 5.1 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. Ashleigh DS0000000834.V274283.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Ashleigh Address 27 - 33 Ash Grove Beverley Road Hull East Yorkshire HU5 1LT 01482 346959 01482 346959 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) Hestan Court Limited Mr Ian Crowther Care Home 37 Category(ies) of Dementia - over 65 years of age (37), Old age, registration, with number not falling within any other category (37) of places Ashleigh DS0000000834.V274283.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th June 2005 Brief Description of the Service: Ashleigh is a privately owned care home operated by Hestan Court Ltd and managed by Mr Ian Crowther, one of the company directors. Ashleigh is registered to provide care for up to 37 older people who may also suffer from dementia. The home has two floors with the first floor being accessible by a chair lift and a passenger lift. Part of the first floor is not accessible by either of these been situated on a different level. The home has 19 single and 9 double bedrooms, of which offer ensuite accommodation. Space available for the use of all residents includes a lounge, quiet lounge, smoking lounge and dining area. There is a garden/patio area to the rear of the home. The home is on a street, which runs off the busy Beverley Road, with easy access to local bus services. Shops, churches and public houses are all near to the home. Ashleigh DS0000000834.V274283.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on an unannounced basis. Some records were looked at, the medication system was examined and time was spent talking to residents in the lounge and dining room areas. The manager and deputy were available during the inspection. What the service does well: What has improved since the last inspection? Work has been carried out to the fabric of the building to ensure it remains in a clean and presentable condition. Mandatory staff training has continued to be offered for all, ensuring their personal development. Accident records have been addressed to ensure they meet with the requirements of the Data protection act. Ashleigh DS0000000834.V274283.R01.S.doc Version 5.1 Page 6 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. Ashleigh DS0000000834.V274283.R01.S.doc Version 5.1 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 Ashleigh DS0000000834.V274283.R01.S.doc Version 5.1 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): 2 & 6. A statement of terms and conditions sets out the terms of residence at the home for all residents. EVIDENCE: Each resident is provided with a statement of terms and conditions. This contains all required information, including the fees to be paid, what is included in the fees, the room to be occupied and the service that the resident can expect from the home. Advocates would be used where the resident is not able to understand the terms of the statement. The home does not offer intermediate care. Ashleigh DS0000000834.V274283.R01.S.doc Version 5.1 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): 8 & 9. Health care needs are met proactively. The medication system in place provides protection for residents. EVIDENCE: Policies and procedures are available in relation to medication receipt, storage and administration in the home. The home utilises the Nomad system of medication dispensing, which is provided by a local pharmacy. The medication is receipted into the home by one of the two team leaders, both of whom have been trained in medication receipt. Supplies are received on a weekly basis. Nine staff members administer medication, all of whom are senior staff members and who have received training via the pharmacy and local authority. The medication system is situated in a dedicated locked room, with supplies been held in a locked trolley. Controlled drugs are held in a double locked cabinet and recorded in a controlled drugs register. The record is double signed by staff. The system was checked and found to be in order. The Nomad system was also checked and all entries were found to tally with the drugs present. There were no gaps in the records and it was possible to ascertain who had administered medication via use of the signature sheet. Ashleigh DS0000000834.V274283.R01.S.doc Version 5.1 Page 10 Health care at the home is dealt with on a proactive basis, with dentist and GP appointments made for residents. Residents are also able to access health care provision following a request. One gentleman was waiting to attend an appointment during the visit. Staff made sure that he was suitably dressed, knew where he was going and ensured he had a cup of tea and biscuits prior to leaving as he would not be there for lunch. The resident was escorted to the appointment by two members of staff from the home. Ashleigh DS0000000834.V274283.R01.S.doc Version 5.1 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 & 15. A range of recreational activities is provided in the home and resident’s preferences are accommodated. Residents have choice, diversity and experience good quality in the meals provided. EVIDENCE: All residents spoken with stated that the food provided was of a good standard. One resident said;” There aren’t many meals that I don’t like”. A three weekly menu was displayed prominently in the home and in each individual bedroom, although most residents were not sure what they were to have for dinner. A choice is offered at every mealtime, the lunch seen during the inspection was meat pie and vegetables. The sweet was a sponge pudding with custard with alternatives of fruit or yoghurt been offered where required. The home holds the heartbeat award in recognition of the healthy food provided. The dining facilities are ample and suitable for the needs of the residents; staff members were able to take time to sit with residents at periods throughout the meal. Those residents who required assistance with their meal were given this help individually by staff in a private and dignified manner. Ashleigh DS0000000834.V274283.R01.S.doc Version 5.1 Page 12 An activities programme continues to take place most afternoons, with residents been able to choose whether they take part or not. Independence is encouraged wherever appropriate, one male resident returned from a walk to the shops in time for his lunch. The serving of lunch was observed and all needs of residents were met in a dignified manner, staff explaining procedures to some of the newer residents who may have been a little confused. The front lounge area of the home is equipped with a TV, music facility and a karaoke machine. Visitors to the home are encouraged at all reasonable times, however none were present during the visit. Ashleigh DS0000000834.V274283.R01.S.doc Version 5.1 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): None of the above standards were assessed during this visit. All were met at the previous inspection. EVIDENCE: Ashleigh DS0000000834.V274283.R01.S.doc Version 5.1 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 & 26. The home provides a safe, comfortable and clean environment for residents, which is pleasant and homely. EVIDENCE: The home continues to be well maintained and presented. The cleanliness of the home was good with no malodours detected. Walls and doors showed little of the damage caused by wheelchairs to lower areas. These areas had been redecorated as part of the ongoing maintenance programme. A handyman who has responsibility for three homes is available to deal with day-to-day issues, enabling any problems to be dealt with prior to them becoming unsightly or dangerous. Domestic staff are employed to ensure hygiene matters in the home are addressed. Carpets throughout the home continue to be cleaned on a regular basis in order to prevent any formation of odours. Suitable furnishings are available throughout the home. Ashleigh DS0000000834.V274283.R01.S.doc Version 5.1 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 & 30. The mix of the staff team ensures residents needs can be met. Staff members are trained and supported by the home management. EVIDENCE: Staff turnover at the home remains minimal, with many experienced staff continuing employment at the home. The training programme for staff remains in place, with all areas of mandatory training been addressed. Staff members continue to have two monthly supervision sessions as well as ongoing live supervision. All areas of competence and development are covered in these sessions. Leadership of the shift observed was good, with all staff aware of their individual roles and responsibilities and guidance been given in a positive manner. The number of staff holding NVQ qualifications has increased since the last inspection, however still remains just short of the requirement for at least 50 of care staff to hold a qualification equivalent to an NVQ level 2. There is no evidence however that this requirement will fail to be achieved shortly. Presently four staff hold an NVQ level 3, five hold an NVQ level 2 and five are undertaking the qualification at level 2. There are 21 care staff employed and 43 of those hold a qualification. The staff team is generally experienced, with a mixture of backgrounds and skills been apparent, there are two male care staff employed. No volunteers are used in the home. All staff wear identification badges whilst in the home. Ashleigh DS0000000834.V274283.R01.S.doc Version 5.1 Page 16 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 & 38. Management of the home is carried out in a fit and proper manner. Residents interests are considered in all decisions taken in regard to the running of the home. Health and safety provision is addressed appropriately. EVIDENCE: The manager of the home is registered with the Commission for Social Care Inspection and holds the registered managers award. Residents are encouraged to contribute to the decision making process in the home and regular residents meetings are held. The home operates an internal quality assurance system, which includes the use of audits, questionnaires and assessments. A local authority quality development provision is also held. Health and safety issues are dealt with by the management in order to protect residents and staff. All equipment is serviced under maintenance agreements and appropriate risk assessments are carried out. Ashleigh DS0000000834.V274283.R01.S.doc Version 5.1 Page 17 Accident records are now held on a loose leaf basis allowing these to be held as individual records, meeting the requirements of the Data Protection Act. Evidence from the records shows that they can be cross referenced to other entries and notifications made to the Commission for Social Care Inspection. Ashleigh DS0000000834.V274283.R01.S.doc Version 5.1 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 3 X X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X X 3 Ashleigh DS0000000834.V274283.R01.S.doc Version 5.1 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. Standard OP28 Regulation 17 Requirement 50 of care staff must be qualified to NVQ level 2 or equivalent. Timescale for action 19/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Ashleigh DS0000000834.V274283.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Ashleigh DS0000000834.V274283.R01.S.doc Version 5.1 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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