CARE HOMES FOR OLDER PEOPLE
Ashleigh 15 Gladstone Road Chesterfield Derbyshire S40 4TE Lead Inspector
Andrew Bailey Unannounced Inspection 3 November 2005 10:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000019927.V261020.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000019927.V261020.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Ashleigh Address 15 Gladstone Road Chesterfield Derbyshire S40 4TE 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) (01246) 235162 (01246) 235162 Mrs Adele Doxey Miss Claire Helen Doxey Miss Claire Helen Doxey Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places DS0000019927.V261020.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Plus Three (3) Day Care Places Date of last inspection 26th May 2005 Brief Description of the Service: Ashleigh is situated near to the centre of Chesterfield. The accommodation is on two floors accessed by two stair lifts. There is a lounge/diner and a further two separate lounges. Community support services are in place, with a choice of General Practitioner, visiting Chiropodist, Dentist and Optician. The home offers in-house activities and trips out. A safe and well-kept garden is at the rear of the property. DS0000019927.V261020.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection and the duration of the inspection was approximately three hours. A partial tour of the building took place. Discussions were held with three residents and a visitor. A number of records were examined, including care plans (as part of the case tracking process, which is used to help determine how the home meets the needs of individual residents). Many of the key standards had been assessed at the last inspection of this service in May 2005. Therefore, the focus of this inspection was on the remaining key standards and on checking compliance with the one requirement made at the last inspection. This requirement, relating to glass safety, had been addressed. What the service does well: What has improved since the last inspection?
The one requirement from the last inspection, regarding a protective glass safety film on a window, had been addressed. An en-suite facility in one of the bedrooms had been completed. Fluorescent lighting in the lounge had been replaced with domestic style lighting, although some of the residents did not necessarily see this as a positive development. This action had been taken to comply with a National Minimum Standard, which states that lighting in communal rooms is domestic in character. New carpeting had been fitted in the lounge/dining area and many areas of the home had been redecorated as part of the on-going programme.
DS0000019927.V261020.R01.S.doc Version 5.0 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. DS0000019927.V261020.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000019927.V261020.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3&4 Assessments of need had been undertaken before and on admission, to ensure that the home could provide an appropriate service to new residents. EVIDENCE: Through the process of case tracking it was evident that residents had been assessed prior to and on admission to the home. The care planning process took information from other professionals into account, where appropriate. Residents spoken with felt that they had been sufficiently involved in the admission process. Staff training ensures that the home is able to provide a suitable placement for the range of needs that the residents present with. The home is also equipped with appropriate aids and equipment to meet the needs of residents accommodated at the home. DS0000019927.V261020.R01.S.doc Version 5.0 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Residents feel that the home meets their needs and there is detailed care planning to guide staff in meeting the needs of the residents. There are robust systems in place to provide safe medication administration for the residents. Residents feel that their privacy and dignity is respected. EVIDENCE: The computerised care planning system assists in the risk assessment process, with built in alerts that prompt staff to be aware of areas of risk to resident safety and welfare. The computer system is accessible to care staff and key workers play a leading role in documenting the assessments, daily progress and reviews of care of the residents. An appropriate range of risk assessment is undertaken, including tissue viability and nutrition. The community retail pharmacist had assessed the medication systems the day before this inspection. A report had been compiled and there were no serious shortfalls identified within the report. It was noted that maximum and minimum temperature records were not being kept and a recommendation has
DS0000019927.V261020.R01.S.doc Version 5.0 Page 10 been made to this effect so that temperatures are monitored to ensure that they do not fluctuate outside of the recommended range. Staff had undertaken competency-based training in the administration of medicines. Residents spoken with confirmed that staff respect their privacy and dignity, for example by knocking on bedroom doors before entering. DS0000019927.V261020.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 There is an on-going programme of activities and trips to provide stimulating opportunities for the residents. Residents feel that the home meets their expectations with regard to daily routines and social/recreational needs. EVIDENCE: There had been a recent trip to Skegness for the residents. On-going activities within the home include: flower arranging, bingo and colouring. Outside performers are invited to visit the home regularly to entertain the residents. One of the residents spoken with explained that residents are encouraged to maintain contact with the community, either by going out independently or accompanied from the home, and by inviting friends and relatives into the home to visit them. Other residents spoken with stated that they were satisfied with the social arrangements at the home. Residents’ preferences and routines are recorded as part of the care planning system. DS0000019927.V261020.R01.S.doc Version 5.0 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): 18 Staff have undertaken training to promote the protection of residents from abuse and neglect. EVIDENCE: The registered persons had undertaken training in adult protection, organised by the local authority. This ‘Adult Protection in a Multi-Disciplinary Setting’ training was of two-day duration. Care staff had attended one-day training in adult protection, with certificates issued on completion of the study. Staff had also received guidance on how to deal with verbal and physical aggression. DS0000019927.V261020.R01.S.doc Version 5.0 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, 20, 21, 24, 25 & 26 The home is maintained to a good standard and provides a safe and comfortable environment for the residents. EVIDENCE: New carpeting had been fitted in the lounge/dining area since the last inspection. Many areas had been redecorated as part of the on-going programme at the home. Lighting in the lounge/dining area was previously of the fluorescent type and had been replaced with domestic style lighting, to comply with National Minimum Standards. Some of the residents reportedly considered this to be a retrograde step. En-suite facilities had been completed in one of the bedrooms since the last inspection. There had not been any recent visits from Environmental Health, Fire Service or Health & Safety on which to report. There were no outstanding matters from previous inspections.
DS0000019927.V261020.R01.S.doc Version 5.0 Page 14 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28 & 29 Training is promoted and prepares staff to meet the needs of the residents. The recruitment processes in place promote the protection of the residents. EVIDENCE: Most of the care staff have either completed National Vocational Qualification (NVQ) training, or are in the process of completing this. Many of the staff have progressed to Level 3 of NVQ training. Residents spoken with felt that the staff were friendly, supportive and competent in meeting residents’ needs. A sample of recruitment documentation was examined at inspection. Appropriate pre-employment checks has been undertaken to protect the residents. DS0000019927.V261020.R01.S.doc Version 5.0 Page 15 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 There is effective management of the care home and management is accessible and responsive to residents. The safe working practices systems promote the health and safety of the residents. EVIDENCE: The registered manager recently completed recognised training in management and care, and demonstrates capability in the organisation and management of the care home. Residents commented that the home is well run and that management are responsive to the views and suggestions of the residents. They felt able to raise any issues of concern with the management. There are systems in place to seek the views of the residents, and staff and residents’ meetings are arranged on a frequent basis. It is recommended that a more formalised means of feedback of survey results be considered,
DS0000019927.V261020.R01.S.doc Version 5.0 Page 16 including arrangements to provide summarised published results for inclusion in the Service User Guide. The system for handling residents’ personal monies was examined and found to be satisfactory. Staff had received training in safe working practices such as infection control and fire safety. There was evidence that services had been regularly serviced/inspected (a sample of records was examined at this visit). The approach to safe working practices provides assurance that satisfactory efforts are being made to promote the health and safety of residents, staff and other persons visiting the premises. DS0000019927.V261020.R01.S.doc Version 5.0 Page 17 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 3 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 3 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 3 3 3 X X 3 3 3 STAFFING Standard No Score 27 X 28 3 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 DS0000019927.V261020.R01.S.doc Version 5.0 Page 18 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. 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. 1 2 Refer to Standard OP9 OP33 Good Practice Recommendations The maximum and minimum temperatures of the medication refrigerator should be recorded daily and lie between 2 degrees and 8 degrees Centigrade. Feedback to service users/prospective service users on the summary results of satisfaction surveys should include published findings for inclusion in the Service User Guide. DS0000019927.V261020.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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