Inspection on 07/06/05 for Ashleigh

This inspection was carried out on 7th June 2005.

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 19/01/06

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 HU5 1LT Lead Inspector Malcolm Stannard Unannounced 7 June 2005 10:00 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 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 J54_s834_Ashleigh_v232084_080605_stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Ashleigh Address 27-33 Ash Grove Beverley Road Hull HU5 1LT 01482 346959 01482 346959 Telephone number Fax number Email 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 OP Old age 37 registration, with number DE(E) Dementia - over 65 37 of places Ashleigh J54_s834_Ashleigh_v232084_080605_stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 14 September 2004 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 accesible by a chair lift and a passenger lift. Part of the first floor is not accesible by either of these been situated on a different level. The home has 19 single and 9 double bedrooms, of which offer ensuite accomadation. 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 J54_s834_Ashleigh_v232084_080605_stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 5 hours. Some parts of the building were looked around and a few of the records were inspected. Ten of the Thirty Four residents were spoken with, five of these for some time. One visitor was spoken with as well as chats with staff members as they worked. The manager and deputy manager were available during the inspection. What the service does well: Residents and visitors spoken to all said that the management and staff at the home look after them well. One resident said “staff treat us well” and another “I wouldn’t change a thing”. Staff members put a lot of effort into providing afternoon activities meaning that there is always something going on for residents to join in with if they want. There is a very good assessment of peoples needs carried out before they come to the home and a written offer of care is made to people who the home thinks can be cared for. Meals are nicely presented and healthy and residents can choose from a number of things what they would like to eat. The home had a welcoming atmosphere, was clean and felt very homely. Residents are able to personalise their bedrooms. Staff at the home take time to sit and chat to residents and do their work with a smile on their face. Ashleigh J54_s834_Ashleigh_v232084_080605_stage 4.doc Version 1.30 Page 6 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. Ashleigh J54_s834_Ashleigh_v232084_080605_stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Ashleigh J54_s834_Ashleigh_v232084_080605_stage 4.doc Version 1.30 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 standard(s) 3,4 and 5 The admission procedure ensures that a proper assessment is carried out prior to people moving into the service. This process means that a resident and their representatives can be sure the home will meet their needs. EVIDENCE: An assessment of care needs is carried out on all residents before admission to the service. This is completed either in the resident’s own home or hospital. Two staff members are involved, usually the deputy manager and a senior staff member. Each prospective resident is given an offer of care document, which tells him or her if the home can meet their needs. After entering the home a reception record is completed and the residents needs assessment is reviewed every 4 weeks. Each of the residents has an individual file, which contains a copy of the assessment. The information in the assessment is used to make up the plan of care for each resident. Staff members knew about each residents needs. The home does not offer intermediate care. A relative spoken with, who was visiting her mother said that she had been able to visit the home for an afternoon prior to admission. Ashleigh J54_s834_Ashleigh_v232084_080605_stage 4.doc Version 1.30 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 standard(s) 7,8 and 10 Health care needs of residents are identified and met. Residents are able to live in the home experiencing respect and privacy. EVIDENCE: Each resident has an individual plan of care, which contains details of their health, personal and social care needs. The plans looked at were reviewed on a four weekly basis and discussed in key worker meetings where any changes been made to the care given are recorded. Recording of information takes place on a daily basis, with all health aspects of care recorded separately. Evidence seen on resident’s files matched descriptions by residents of what had happened to them. Residents who were spoken with said that their privacy was always respected, one expressed the view that “staff always knock on the door” and another stated, “the staff treat us well”. All the residents spoken with stated that they were able to access health services easily; one said, “You only have to ask” another stated, “Staff have contacted a Doctor on my behalf when requested”. Ashleigh J54_s834_Ashleigh_v232084_080605_stage 4.doc Version 1.30 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 standard(s) 12,13,14 and 15 A range of recreational activities is provided in the home and resident’s preferences are accommodated. Daily choice for residents is enabled and contact with friends, family and within the local community is encouraged where appropriate. Residents have choice, diversity and experience good quality in the meals provided. EVIDENCE: Of the five residents spoken to at length, all stated that the food provided was enjoyable. One resident said;” The food is lovely, always is” and another “The quality has remained the same for the 13 years I have been here”. Whilst few residents were able to state what food they were expecting at lunchtime, the three weekly menu was displayed prominently in the home and in each individual bedroom. A choice is offered at every mealtime, the lunch seen during the inspection been either toad in the hole or pork chops. The home holds the heartbeat award in recognition of the healthy food provided. All care staff take part in the provision of internal activities each afternoon, residents been able to choose whether to partake or not. One resident spoken with also told of her choice over bedtimes, stating “ I get up and go to bed when I want”. During the visit, activities taking place were some board/matching games and a game of dominoes using equipment suitable for those with diminished eyesight. Ashleigh J54_s834_Ashleigh_v232084_080605_stage 4.doc Version 1.30 Page 11 Residents spoke fondly of a recent painting session they had taken part in, along with memories of a visiting artist and bingo sessions. The manager stated that no resident had expressed a wish to partake in attendance at religious worship, however two residents had voted in the recent general election. Visitors are encouraged where appropriate and one lady said, “ They can come anytime they want”. Ashleigh J54_s834_Ashleigh_v232084_080605_stage 4.doc Version 1.30 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 standard(s) 16 and 18 The home has a complaints procedure, which meets the needs of residents, and relatives who feel their views are listened to. A vulnerable adults procedure and policy is available and staff are formally supervised and trained in order to protect residents from abuse. EVIDENCE: A written complaints procedure is available and displayed prominently in the home. Forms are displayed in the front entrance hall should anyone wish to make a written complaint. Residents and the visitor spoken to were aware of what to do if they were not happy with something, one resident said,” I would speak to Ian or Chris if I had any concerns”, another stated, “I have no problems”. A complaints record is available which showed that complaints made had been dealt with immediately they were made known, Outcomes were also recorded in this record. Many of the entries related to requests for improved lighting or individual toiletries, these requests had been dealt with immediately. An appropriate adult protection procedure is available and staff members undergo two monthly supervision. All staff are checked via the Criminal Records Bureau including a POVA 1st check. Many staff members have now attended training on undertaking protection of vulnerable adults risk assessments. Cascaded training is given to staff in order for them to be aware of how to deal with any concerns raised. No one at the home assumes responsibility for any resident’s finances; these are dealt with by families or solicitors where necessary. Ashleigh J54_s834_Ashleigh_v232084_080605_stage 4.doc Version 1.30 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 standard(s) 19,23,24,25 and 26 The home provides a safe, comfortable and clean environment for residents, which is pleasant and homely. Rooms available meet the needs of individual residents. EVIDENCE: The home is well presented in all areas and hygienic with no malodours detected. On the day of visit a hallway and a small lounge carpet had been cleaned. The deputy manager stated that this was a regular occurrence in order to avoid smells developing. All carpeting seen throughout the home was clean and in good condition. Three domestic staff members are employed to ensure the home is kept clean. There were some areas in the corridors where superficial damage had been caused to the lower part of some doors and walls, most probably by contact with wheelchairs. The manager explained that redecoration of these areas was planned shortly as part of the ongoing maintenance programme for the home. A handyman who is shared with two other homes is available. During the visit he was attending to the architrave of the door to the kitchen. Ashleigh J54_s834_Ashleigh_v232084_080605_stage 4.doc Version 1.30 Page 14 Resident’s rooms seen during the visit were suitable for individual needs, where furniture is not required; this is recorded on resident’s files. All rooms are capable of been locked unless a risk assessment dictates otherwise for safety reasons. One resident spoken with was in his own room during discussions and he confirmed that he was happy with the provision in the room. He had been able to have sky TV facilities fitted, many residents had personalised their rooms. Ashleigh J54_s834_Ashleigh_v232084_080605_stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 28,29 and 30 Procedures for the recruitment of staff are satisfactory and offer protection for the residents in the home. Staff training and checking of their competence enables good quality care to be offered. EVIDENCE: Turnover of staff within the home has been minimal since the last inspection and many staff members have worked at the home for a lengthy period of time. Two staff member’s files were looked at, these contained the required information, including evidence of a CRB check having been carried out, written references sought and copies of relevant qualifications. A training programme for 2005 was available; this identified which staff members required training on which subject. Areas intended to be addressed include Stroke care, First Aid, Moving and Handling and Medication administration. Most of the care staff in the home have undertaken Basic food hygiene training. Staff member’s competence is discussed in two monthly supervision sessions along with ongoing live supervision. Five staff members hold an NVQ level 2 qualification, two hold an NVQ level 3 and four further staff are undertaking the qualification, there was no evidence that the required level of 50 of care staff holding a relevant qualification will fail to be achieved soon. No volunteers are used in the home. During the visit staff members were observed to have time to talk with residents, which they did with a smile on their faces. All staff wear identification badges whilst in the home. Ashleigh J54_s834_Ashleigh_v232084_080605_stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32, 33,35 and 38. The management of the home is carried out with leadership and appropriate guidance; ensuring residents receive a quality of care, which is consistent. A resident centred ethos is promoted within the home. Resident’s financial affairs are safeguarded by the homes policy. Health and safety provision within the home is addressed positively. EVIDENCE: The manager of the home is registered with the Commission for Social Care Inspection and has recently completed the registered managers award. The home is resident centred and time is taken to ensure that no resident is isolated from the decision making process within the home. 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. Ashleigh J54_s834_Ashleigh_v232084_080605_stage 4.doc Version 1.30 Page 17 The management of the home encourage residents to deal with their own financial arrangements where able, families and solicitors would be used where needed. The small amount of money, which the home does hold for residents, is robustly recorded. Health and safety of residents is protected by the management ensuring safety certificates are up to date and appropriate risk assessments are carried out. Accident records were completed appropriately, a recommendation that the home take account of the requirements of data protection legislation was made. Ashleigh J54_s834_Ashleigh_v232084_080605_stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 4 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x 3 3 3 3 STAFFING Standard No Score 27 x 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 3 x 3 x x 3 Ashleigh J54_s834_Ashleigh_v232084_080605_stage 4.doc Version 1.30 Page 19 NO 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. 1. 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 38 28 Good Practice Recommendations The management of the home should take account of data protection legislation whilst completing accident recording. 50 of care staff should be qualified to NVQ level 2 or equivilent Ashleigh J54_s834_Ashleigh_v232084_080605_stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection First Floor Unit 3 Hesslewood Country Office Park Ferriby Road Hessle East Yorkshire 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 J54_s834_Ashleigh_v232084_080605_stage 4.doc Version 1.30 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. 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