Inspection on 31/10/06 for Ashleigh

This inspection was carried out on 31st October 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 09/08/07

Ashleigh 03/11/05

Ashleigh 26/01/05

Ashleigh 26/07/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Ashleigh 15 Gladstone Road Chesterfield Derbyshire S40 4TE Lead Inspector Unannounced Inspection 31st October 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 DS0000019927.V313804.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. Ashleigh DS0000019927.V313804.R01.S.doc Version 5.2 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 Ashleigh DS0000019927.V313804.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Plus Three (3) Day Care Places Date of last inspection 3rd November 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 are a total of 21 bedrooms with two double rooms. One bedroom has an en suite toilet and shower facility and there are also bathroom or shower facilities on both floors. On the ground floor there is a lounge/diner and a further two separate smaller lounge areas near the front entrance. Community support services are in available, 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. Fees for accommodation range from £318-50 to £350 per week. There are additional charges for such services as hairdressing and chiropody, and items such as toiletries and newspapers/magazines. Ashleigh DS0000019927.V313804.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 inspection covering all the key national minimum standards. The inspection visit took place over a period of approximately six and a half hours on the 31st October. The manager, Claire Doxey, was present for most of the visit and there was also the opportunity to meet with several of the staff on duty. A tour of the premises was undertaken and a variety of documentation was examined such as individual resident care files, staff files, training records, relevant policies and procedures together with health and safety records. Prior to the inspection a sample of residents were surveyed and the written comments have been taken into account for this report. On the day of the inspection there was the opportunity to talk with several of the residents directly, either individually or in small groups. What the service does well: What has improved since the last inspection? There were no significant areas for improvement detailed at the last inspection. Ashleigh DS0000019927.V313804.R01.S.doc Version 5.2 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 DS0000019927.V313804.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 Ashleigh DS0000019927.V313804.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 is not applicable to the Home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were generally suitable assessments obtained prior to admission so that resident needs could be appropriately met, though there was a recent example of the Home not receiving enough information in the case of an emergency admission. EVIDENCE: An examination of several care files showed that relevant information is obtained prior to admission from previous placements and from social services departments, which gave details of particular needs and a clear sense of the prospective individual’s capabilities and areas of vulnerability. Admission details and initial assessment information are subsequently developed. Ashleigh DS0000019927.V313804.R01.S.doc Version 5.2 Page 9 However, there was one care file relating to a recent emergency admission of a resident who has significant emotional needs, with little information on these needs and no assessments from relevant health professionals involved with the resident prior to admission. Ashleigh DS0000019927.V313804.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There was a degree of inconsistency in the maintenance of care plans, which meant that the needs of some residents were not always clearly defined, though their physical health needs were suitably promoted. Residents felt that they were treated with respect by staff. EVIDENCE: Each resident has an individual care plan, which is supplemented by information and records kept on computer. A sample of three individual care plan files was examined in detail. Two of these related to residents admitted to the Home in the past two months, one very recently. There was a lack of risk assessment information on these files and in the case of the resident admitted two months ago the assessment of daily living needs and routines was incomplete. The care file of the more established resident was in much better order with clear information on daily living, good details on preferences, social Ashleigh DS0000019927.V313804.R01.S.doc Version 5.2 Page 11 interests and assessments made with regard to mobility, hygiene, skin integrity and diet. Reviews of plans were undertaken and contacts with community health services such as G.P. district nurses, dentists, optician and chiropodist were recorded. There was also evidence of the use of specialist resources if necessary with referrals to the Community Psychiatric Nurse and also the ‘falls’ clinic. Updates on care plans were the responsibility of the individual resident. The ongoing monitoring of care plans was not always clearly evidenced. Residents spoken to were complimentary about staff attitudes and the support they received, one resident saying they couldn’t be looked after better. Residents also confirmed that they were spoken to in an appropriate manner by staff and they were observed interacting with residents in a warm and respectful way. Medication is kept secure and there are separate safe arrangements for the storage of any controlled drugs. Administration records were examined and were in order. There were clear systems in place for the ordering and disposal of medicines and the local community pharmacist undertakes regular audits and also provides training sessions for staff. Ashleigh DS0000019927.V313804.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Home had an organised approach to arranging social activities so that these were in line with residents’ expressed interests. The provision of meals also took into account the preferences of residents and the need for a varied and balanced diet. EVIDENCE: The Home arranges regular daily activities for residents in-house, such as painting, board games, dominoes, baking and flower arranging. Entertainers visit the Home on a monthly basis and small group outings are also arranged during the year. Some residents access local shops with staff and one resident regular goes out independently. Clergy visit the Home and two residents go out to a local church with their families. There were several visitors to the Home on the day of the inspection and residents confirmed that relatives are encouraged to visit. There were no residents with specific cultural needs. Resident meetings normally take place on a six weekly basis and residents’ views in such areas as catering and activities are sought and there was a Ashleigh DS0000019927.V313804.R01.S.doc Version 5.2 Page 13 system of questionnaires for residents and relatives regarding various aspects of the running of the Home. Residents spoken to were generally satisfied with the meals at the Home and confirmed that they could get alternatives to the meal of the day. Menus run on a four weekly cycle and were varied and nutritious. Special dietary needs were catered for and a list of individual preferences was kept. Ashleigh DS0000019927.V313804.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 inspected at least once during a 12 month period. 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 had clear information and systems for dealing with complaints so that they are dealt with effectively and in the interests of residents. Staff were made suitably aware of adult protection matters so that the safety of residents was enhanced. . EVIDENCE: The Home had a full complaints policy and procedure which is included in the resident handbook, though it is not displayed anywhere on the premises. Good recording systems are in place though no formal complaints have been received at the Home since the last inspection and none have been made direct to the Commission. It was noted that complimentary letters are put up on the Home’s notice board. Residents spoken to said that they found staff at the Home approachable and would feel comfortable in raising any concerns. The registered persons at the Home had undertaken relevant training in adult protection and were aware of the local multi agency procedures and protocols Ashleigh DS0000019927.V313804.R01.S.doc Version 5.2 Page 15 in this area. Staff confirmed that they had also received awareness training in the protection of vulnerable adults. Ashleigh DS0000019927.V313804.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The premises are maintained to a satisfactory standard so that residents have a safe and comfortable environment. EVIDENCE: The Home was generally well - maintained clean and hygienic, though somewhat cluttered in parts. There had been no changes to the environment since the last inspection and furnishing and décor were satisfactory throughout. There was a choice of lounge areas available to residents who moved around the Home as they wished. Handrails and grab rails were in place and the Home also had portable hoists available. There was also a loop system to assist those residents with a hearing impairment though this was not in use at the time of the inspection. The residents’ call system was functioning satisfactorily. Ashleigh DS0000019927.V313804.R01.S.doc Version 5.2 Page 17 Residents’ bedrooms were comfortable and personalised. Two residents had taken up the option of having their own bedroom door key. Bathroom and toilet facilities were appropriately maintained and decorated with adaptations available in the main bathroom on the first floor. The Home had its own small laundry on the ground floor, which was suitably equipped. A risk assessment on the premises has been completed. Ashleigh DS0000019927.V313804.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Home has an organised and active approach to staff recruitment and development, which enhances the quality of support given to residents. EVIDENCE: The Home maintains good staffing levels in line with the assessed needs of the resident group and there is little turnover of staff, though there is a current part time cook vacancy. Several staff files were examined and these were suitably organised showing that necessary recruitment procedures were followed and written references and criminal record checks were obtained. The Home’s training records were viewed and staff have a full range of relevant training opportunities available, including basic mandatory care courses such as moving and handling and food hygiene. Staff confirmed that they have induction training and have had some input on dementia awareness. The majority of staff have completed NVQ level 2 training and it was stated that most will go on to do Level 3. Regular supervision and appraisal systems are in place Ashleigh DS0000019927.V313804.R01.S.doc Version 5.2 Page 19 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 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Home is run in an effective and responsive manner so that residents benefit from an accessible management style that also promotes their health and safety in a responsible way. EVIDENCE: The registered manager has completed NVQ Level 4 training in care and management and together with the co owner of the Home provides substantial experience and continuity in the running of the Home. Both staff and residents commented that they found the management approachable, accessible and responsive. Ashleigh DS0000019927.V313804.R01.S.doc Version 5.2 Page 20 There are established systems at the Home for obtaining the views of residents and staff with regular meetings held. A system of questionnaires has been set up in order to gain the views of relatives and visiting professionals such as nurses and G.P.s, as well as residents and staff. The Home had a secure system for the holding of small amounts of money on residents’ behalf and records of transactions were kept for each resident. The Home has appropriate health and safety policies and procedures, which are available to staff. Servicing records for equipment and utilities were examined and were in good order and up to date. Records of fire safety were also appropriately maintained and a Fire Risk assessment had taken place in May 2003, though there was no evidence that this had been reviewed. Staff receive annual fire safety training, though night staff did not receive any extra input throughout the year. Accident records were suitably maintained. Ashleigh DS0000019927.V313804.R01.S.doc Version 5.2 Page 21 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Ashleigh DS0000019927.V313804.R01.S.doc Version 5.2 Page 22 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 OP3 Regulation 14 Requirement The manager must ensure that full assessment information is obtained on prospective residents prior to admission. The maintenance of individual care plans must be more consistent. Timescale for action 30/11/06 2. OP7 15 30/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard OP7 OP16 OP38 OP38 Good Practice Recommendations There should be clearer evidence that care plans are monitored on a regular basis. The Complaints policy and procedure should be displayed. Fire risk assessment reviews should be clearly noted. Night staff should receive additional fire safety training. Ashleigh DS0000019927.V313804.R01.S.doc Version 5.2 Page 23 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 © 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 DS0000019927.V313804.R01.S.doc Version 5.2 Page 24 - 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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