Inspection on 09/08/07 for Ashleigh

This inspection was carried out on 9th August 2007.

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 31/10/06

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 Ray Coonan Unannounced Inspection 9th August 2007 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.V340677.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.V340677.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 F/P 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.V340677.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Plus Three (3) Day Care Places Date of last inspection 31st October 2006 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 £352 to £362 per week. There are additional charges for such services as hairdressing and chiropody, and items such as toiletries and newspapers/magazines. Ashleigh DS0000019927.V340677.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection covered all the key national minimum standards and took place over a period of four and a half hours on the 9th August. The registered manager, Claire Doxey, was present throughout the visit, as was the other co – owner, Mrs Adele Doxey. There was the opportunity to interview several of the care staff on duty that day and also meet with many of the residents, either individually or in small groups. Some visiting relatives were also spoken with. A range of documentation was examined, including individual care plans, staff files and training records, staffing rotas, health and safety information and other relevant policies and procedures. A full tour of the premises was not undertaken, though communal areas and a small sample of bedrooms were seen. There was no staff or resident pre-inspection survey material available on this occasion. However, the Home had completed an Annual Quality Assurance Self Assessment document and this information was taken into account when planning the inspection. What the service does well: The Home has a relaxed atmosphere and residents were positive about the care they received and the warm and supportive manner of staff. One resident commented that this is not a ‘Home’ but a “big house” and there was a good understanding of individual preferences and needs, which helped to diminish any sense of ‘institutionalisation’. There is an experienced management team that run the Home in an effective and personable way. Staff are provided with clear expectations and good support. Residents have a generally comfortable environment with access to attractively maintained gardens. Ashleigh DS0000019927.V340677.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Ashleigh DS0000019927.V340677.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.V340677.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 was not covered as the Home does not provide an intermediate care service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Home obtained relevant pre –admission assessment information on prospective residents so that care plans could be developed to meet individual needs. EVIDENCE: A sample of three care plans was examined in detail. These showed that the Home obtains a range of relevant information on the health and social care needs of residents prior to any admission. There were examples of assessments from local social services and also nursing and discharge information on physical and emotional health needs when the resident came to Ashleigh DS0000019927.V340677.R01.S.doc Version 5.2 Page 9 the Home following hospitalisation. The Home carried out their own pre – admission assessment visits and there was the opportunity for prospective residents to visit the Home before any admission. Ashleigh DS0000019927.V340677.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual care plans were informative and well –developed so that the general health and social care needs of residents were actively promoted. However, the plans were not always consistently reviewed. EVIDENCE: Each resident had an individual care plan, which were computerised, well – organised and accessible to staff who would input daily notes. One of the senior care staff had responsibility for reviewing care plans. Information on the plans was based on daily routines and included notes on individual preferences such as times for getting up in the morning and in one instance specific dietary information and feeding routines. Risk assessments were also evident in such areas as mobility and skin care. The care information also included a social Ashleigh DS0000019927.V340677.R01.S.doc Version 5.2 Page 11 profile and notes on social care needs. There were systems in place for monitoring care plans on a regular basis though one plan had not been updated at all and another not since last year. The Health needs of residents were clearly documented and the Home kept records of contacts with community health services such as G.P.’s, district nurses, dentist, chiropodist and optician. One relative stated that that she thought the Home were very active in promoting health care needs and would ensure that residents were provided with any special equipment such as pressure relief aids. In general there was a great deal of positive feedback concerning the support and care provided at the Home from both residents and relatives, who saw staff as attentive and friendly. Staff were observed interacting in a warm and appropriate manner with residents and discussions with staff indicated that they had a good sense of the individual needs of the residents and were aware of their rights. Arrangements for the administration and storage of medication were viewed and were satisfactory. The Home is regularly audited and staff confirmed that they have received accredited training in this area. Ashleigh DS0000019927.V340677.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. 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 has an organised and active approach to promoting the recreational and social interests of residents so that they enjoy a lifestyle that is in line with their expressed preferences and interests. EVIDENCE: There was a generally relaxed atmosphere at the Home on the day of the visit with many residents using the sitting area outside in the rear garden. There were good verbal interactions between the resident group with visitors also electing to join them outside. Residents used the various parts of the Home as they wished, including bedrooms during the day, and there was no sense of any undue emphasis on routines. Residents confirmed that routines around getting up in the morning and going to bed were very much at times they had requested. Ashleigh DS0000019927.V340677.R01.S.doc Version 5.2 Page 13 Records of residents’ interests are kept on care plans. 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 system of questionnaires for residents and relatives regarding various aspects of the running of the Home. Residents spoken to were generally satisfied with their meals 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. The Home has a detailed recording system for monitoring residents’ meals intake. Ashleigh DS0000019927.V340677.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. 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. Residents benefit from an organised and responsive approach to their concerns and there is a satisfactory awareness of protection matters, so that there overall interests are suitably promoted. EVIDENCE: The Home had a full complaints policy and procedure, which is included in the resident handbook and is also displayed. The Home maintains clear records of complaints with details of any follow up actions. No complaints have been have been made direct to the Commission since the last inspection. 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 in this area. Staff confirmed that they had also received awareness training in the protection of vulnerable adults that is specifically organised by the Home, as well as having some input on NVQ training courses. Ashleigh DS0000019927.V340677.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have a safe and comfortable environment that is maintained and furnished to suit their needs. EVIDENCE: Although not all of the premises were viewed on this occasion, communal areas were seen to be light, clean, hygienic and pleasantly decorated. Since the last inspection the hall, stairs and lounge/dining dining area have had new carpeting fitted, and new chairs have been purchased for the lounge. The bedrooms that were seen were also comfortably furbished and personalised by Ashleigh DS0000019927.V340677.R01.S.doc Version 5.2 Page 16 residents. Garden areas were attractively maintained, accessible to residents who were using the sitting area on the day of the inspection. There is a choice of lounge areas available to residents and handrails and grab rails were in place to assist residents moving around the Home. There are also two portable hoists available and a loop system to assist residents with hearing impairment. Stair lifts and resident alarms were functioning satisfactorily. A risk assessment has been completed on the premises. The Home has a small laundry on the ground floor, which is appropriately equipped. Ashleigh DS0000019927.V340677.R01.S.doc Version 5.2 Page 17 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. 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 thorough approach to the recruitment and training of staff that enhances the support and protection given to residents. EVIDENCE: There has not been a great deal of staff turnover in the nine months since the last inspection. Staffing rotas showed that good staffing levels are maintained in line with the needs of the resident group. The manager stated that they are currently reviewing the deployment of care staff during the day and also considering appointing a member of staff to focus solely on the laundry service in the Home. The Home arranges a wide range of relevant training programmes and staff confirmed that they have attended courses in the basic mandatory courses such as manual handling and food hygiene. Some staff have had input regarding Bereavement, Dementia and Parkinson’s Disease. All staff interviewed had completed NVQ training. Discussions with residents and Ashleigh DS0000019927.V340677.R01.S.doc Version 5.2 Page 18 relatives indicated that they were satisfied with the competency and skills of staff. Three staff files were examined in detail. These were well – organised with clear records of induction training for new staff. The files also evidenced that full recruitment processes are followed through with written references and Criminal Record Bureau checks taken up. It was noted that staff appraisals were not up to date on two of the files. Ashleigh DS0000019927.V340677.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32. 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 a purposeful and effective manner so that the overall welfare, safety and interests of residents are clearly promoted. 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. Staff interviewed felt they were well supported at the Home, received good direction and information Ashleigh DS0000019927.V340677.R01.S.doc Version 5.2 Page 20 about residents’ needs and their responsibilities and could raise issues at any time with the managers. Senior Care staff were given some specific lead responsibilities in some areas such as fire safety checks and care plan monitoring. Residents and relatives commented that they found the management approachable, accessible and responsive. There Home has established and ongoing 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. A sample of these was viewed during this visit and was very positive about the standards of care provided. 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. Records of fire safety were appropriately maintained and a Fire Risk assessment had taken place in May 2003, though this still had not been reviewed. Ashleigh DS0000019927.V340677.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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 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 X X X X X X 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 3 3 X 3 X X 3 Ashleigh DS0000019927.V340677.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 OP7 Regulation 15 Requirement The monitoring and reviewing of care plans must be kept up to date. Timescale for action 30/09/07 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 OP30 OP38 Good Practice Recommendations Staff appraisals should be kept up to date Fire risk assessment reviews should be undertaken. Ashleigh DS0000019927.V340677.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V340677.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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