CARE HOMES FOR OLDER PEOPLE
Ashleigh 17 Beech Grove Ashton Preston Lancashire PR2 1DX Lead Inspector
Mrs Felicity Lacey Announced Inspection 6th December 2005 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 DS0000009838.V252578.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. Ashleigh DS0000009838.V252578.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Ashleigh Address 17 Beech Grove Ashton Preston Lancashire PR2 1DX 01772 723380 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) Mrs Gillian Wilcock Care Home 11 Category(ies) of Dementia (11) registration, with number of places Ashleigh DS0000009838.V252578.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 10th May 2005 Brief Description of the Service: Ashleigh is a care home, registered with the Commission for Social Care Inspection that specialises in providing personal care services for older people with dementia. The home is registered for eleven persons of either sex. The proprietor of the home is involved in daily management activities and is supported in her duties by a manager and two deputies. Ashleigh is situated on a quiet road, within easy reach of all local services and amenities. The home is arranged over two floors and is served by a passenger lift. Accommodation comprises of eleven single rooms, two lounge areas and a dining area. There is a pleasant enclosed garden at the side and rear of the premises and a car parking area for visitors. The proprietor and staff are committed to providing a standard of care that is responsive and reflective of the individual needs and preferences of residents. The home has established links with health support and social services. The proprietor and staff are experienced and skilled in providing specialist care for older people with dementia, and are committed to involving the residents and their representatives in the planning and delivery of care. Ashleigh DS0000009838.V252578.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an announced inspection. The inspector was able to examine various documents as well as talk to residents, staff and a relative. Comment cards were provided prior to the inspection from 2 relatives or friends. What the service does well: What has improved since the last inspection?
The owner and manager have introduced a new induction pack and staff handbook. Window restrictors have be fitted to all opening first floor windows. There is an ongoing maintenance programme for refurbishment and replacement of furniture in individual bedrooms. A new record for medical visits and contacts has been established. This system is working well. All staff members at the home have the opportunity to study for National Vocational Qualifications, which provide grounding in good care practices,
Ashleigh DS0000009838.V252578.R01.S.doc Version 5.0 Page 6 specialist training in Dementia Awareness is planned in the New Year for all staff. A number of senior staff have completed an advanced medication course. All staff have had Moving and Handling training since the last inspection. The Investors in People award for the home has been successfully renewed, this is a quality assurance award. The owner has produced a new induction pack and staff handbook. 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 DS0000009838.V252578.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 Ashleigh DS0000009838.V252578.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): Standard 6 does not apply. Standard 3 was assessed at the last inspection. EVIDENCE: Ashleigh DS0000009838.V252578.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): 9 The medication procedures at the home ensure that medication is administered safely. EVIDENCE: The policies and procedures of the home ensure that medication is safely administered and stored. 3 senior staff members have recently completed an advanced medication course; all members of staff receive general training. The records kept were completed accurately and provide an audit trial of medications at the home. Ashleigh DS0000009838.V252578.R01.S.doc Version 5.0 Page 10 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): These standards were assessed at the last inspection. EVIDENCE: Ashleigh DS0000009838.V252578.R01.S.doc Version 5.0 Page 11 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): 16,18 The home has a complaints procedure and residents are encouraged to make their concerns known, service users and their supporters are confident that any complaint they may have will be treated with importance. The residents are protected by robust procedures for the protection of adults. EVIDENCE: The home has a complaints procedure. A relative spoken with and those who returned comment cards indicated they were aware of the policy, but had not had cause to use it. Relatives felt able to raise concerns and were confident that they would be dealt with appropriately. The home has an adult protection policy, and this is also covered through training. Ashleigh DS0000009838.V252578.R01.S.doc Version 5.0 Page 12 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): 24 Residents own rooms are arranged to suit their needs, which provides a safe and homely environment. EVIDENCE: Following the last inspection the furniture in some bedrooms has been renewed. There is an ongoing plan for decoration and refurbishment. Ashleigh DS0000009838.V252578.R01.S.doc Version 5.0 Page 13 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): 29,30 The recruitment procedures at the home are sound and this safeguards the welfare of residents. Staff receive regular training opportunities to ensure their practice is based on understanding and the values of good quality care. EVIDENCE: The recruitment procedures of the home ensure that all appropriate checks are carried out. Vacancies are advertised locally. The turnover of staff is low, one relative commented how nice it was to see the same faces. The owner and manager have introduced a new induction programme to ensure that all new staff are aware of their role and responsibilities. Ashleigh DS0000009838.V252578.R01.S.doc Version 5.0 Page 14 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): 33,35,28 Residents and staff benefit from living and working in a well run home. All aspects of health and safety are monitored and this provides a safe environment in which to live and work. EVIDENCE: Ashleigh holds Investors in People quality assurance award, this has recently been renewed. Planning for development of the home takes place on an informal level, between the owner and senior staff. Policies and procedures are regularly reviewed and updated. There are financial procedures in place and records are kept of all transactions. Individual records are maintained of resident’s personal allowance and the staff member who is recording transactions made should sign these. Staff receive health and safety training as part of their induction and ongoing training courses, for example First Aid, Moving and Handling and Basic Food Hygiene. The manager ensures that the health, safety and welfare of service users and staff are promoted as is reasonably practicable. The home has
Ashleigh DS0000009838.V252578.R01.S.doc Version 5.0 Page 15 appropriate Health and Safety policies and a qualified contractor services the boilers and electrical systems. Windows on the first floor are fitted with restrictors. An accident book is maintained and monitored to ensure any hazards or patterns of falls are identified and acted upon. Ashleigh DS0000009838.V252578.R01.S.doc Version 5.0 Page 16 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X 3 X X STAFFING Standard No Score 27 X 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 2 X X 3 Ashleigh DS0000009838.V252578.R01.S.doc Version 5.0 Page 17 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 Refer to Standard OP35 Good Practice Recommendations Records of financial transactions undertaken on behalf of residents should be signed. Ashleigh DS0000009838.V252578.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Chorley Local Office Levens House Ackhurst Business Park Foxhole Road Chorley PR7 1NW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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