Inspection on 11/10/05 for Ashleigh House

This inspection was carried out on 11th October 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Ashleigh House 02/07/07

Ashleigh House 20/04/05

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Ashleigh House 2 Stonehouse Road Boldmere Sutton Coldfield West Midlands B73 6LR Lead Inspector Amanda Lyndon Unannounced Inspection 11th October 2005 09:55 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 House DS0000063255.V258665.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 House DS0000063255.V258665.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ashleigh House Address 2 Stonehouse Road Boldmere Sutton Coldfield West Midlands B73 6LR 0121 354 1409 0121 308 8091 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) Senex Ltd Mrs Suzanne Hammond Care Home 13 Category(ies) of Old age, not falling within any other category registration, with number (13) of places Ashleigh House DS0000063255.V258665.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home is registered to provide personal care for 13 people for reasons of old age (13 OP) The home must provide a minimum of three members of staff on duty during peak hours when the home is at full occupancy (this may include the manager). This can be reduced pro-rata for reduced occupancy to no less than 2 members of staff, however, the staffing levels must be determined by the dependencies of the service users in the Home at that time. 20th April 2005 Date of last inspection Brief Description of the Service: Ashleigh house, formerly a large family home has been extended to provide accommodation for thirteen older people on two floors. It is situated in a residential area of Sutton Coldfield, within easy walking distance of local amenities and public transport. The homes category of registration is for older people excluding people in need of care for reasons of dementia, learning disability or other reasons. The home has adaptations including a stair lift to assist residents’ access to the first floor however access to the first floor for wheelchair users is restricted. All bedrooms are for single occupancy and each have an en suite toilet and a wash hand basin. Decoration in the home is of a high standard. There is a spacious lounge and dining room with doors and ramp access opening out onto a small patio area and garden. Ample parking is provided to the rear of the Home and there is a non smoking policy throughout. Ashleigh House DS0000063255.V258665.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was undertaken by one Inspector during a morning when there were twelve residents living there and was assisted by the Registered Person. Information was gathered from speaking with the residents, staff and visitors, examining care and health and safety records and observing the staff perform their duties. A short tour was undertaken. This is the second inspection of this service in the 2005/2006 inspection year and linked to the Commission’s focus on outcomes for residents and proportionate inspections, we would recommend that you read this report in conjunction with the last inspection of this service on 20th April 2005. What the service does well: Residents are well supported by the care staff to meet their ongoing health, welfare and personal care needs using comprehensive care plans. The care staff monitor any treatments prescribed by the Doctors to ensure that the residents’ health problems are improving. Residents are cared for in a respectful manner by staff working at the Home and this ensures that residents’ self esteem and dignity are maintained. The Home has an open visiting policy and residents are supported by the staff working at the Home to maintain contact with their friends and families. One visitor met during the inspection said “ I visit here twice a week and I am happy with the care here”. Residents are able to exercise choice over their daily lives and the activities that they choose to participate in which promotes their individuality and independence. Any complaints made about the service provided at the Home are investigated by senior staff in an appropriate and timely manner. Ashleigh House provides a homely, comfortable, clean and safe environment for residents to live in. The Home has a stable work force and do not use agency staff and this ensures that continuity of care is maintained. One resident said “ I find the staff to be very helpful”. Ashleigh House DS0000063255.V258665.R01.S.doc Version 5.0 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 House DS0000063255.V258665.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 House DS0000063255.V258665.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): 1, 3, 4 & 5 The assessment and admission processes are comprehensive which ensures that prospective residents have all relevant information about Ashleigh House and are aware that their individual care needs can be met there. Residents are reassessed should their care needs change to ensure that the Home could continue to meet their needs. EVIDENCE: A comprehensive service user guide had been produced and this required further development to include residents’ views. This was also available in large print. Prior to admission to the Home, prospective residents are assessed by senior staff, using a comprehensive pre admission assessment document. Residents are reassessed prior to returning to the Home following a stay in hospital to ensure that the Home could continue to meet the resident’s holistic care needs. Residents come to live at Ashleigh House for a trial period of four weeks however this time scale is flexible. Ashleigh House DS0000063255.V258665.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 & 10 Residents are well supported by the care staff to meet their ongoing health, welfare and personal care needs using comprehensive care plans that ensure that resident’s preferred routines and continuity of care are maintained. Residents are cared for in a respectful manner by staff working at the Home and this ensures that residents’ self esteem and dignity are maintained. EVIDENCE: Since the previous inspection, improvements had been made in respect of the care planning system and residents’ care files were found to be organised, structured and contained all relevant information. On admission to the Home, comprehensive assessments are undertaken of residents’ care needs, including good detail of their individual preferences and life histories and care plans are derived from this information. Separate care plans are written for each care need, including health care needs and these included good detail of the specific support required by the staff to meet each individual need and were reviewed each month. Ashleigh House DS0000063255.V258665.R01.S.doc Version 5.0 Page 10 Residents and their relatives had been involved in the writing and agreeing of care plans. Daily reports were recorded in good detail and included information about the activities that the resident had engaged in during that day. Comprehensive risk assessments of residents’ personal needs had been undertaken including moving and handling needs, pressure area monitoring and the risk of falls. Residents have access to visiting Health and Social Care Professionals, including General Practitioners, Nurse Specialists, Social Workers, Opticians and Community Physiotherapists and a record of these visits was maintained. Staff request prompt medical advice as necessary and monitor the physical and mental health of residents following the advice of the Health Care Professionals as required. Appropriate pressure relieving equipment was available as required following individual assessments of residents’ needs. Residents appeared to be well supported by the care staff to meet their personal care needs and the female residents were wearing make up and had their hair styled to suit their preferences. The system for the management of medication had met the required standard at the last inspection. A record of the reasons why residents may not be able to hold the keys for their bedroom doors was kept and a lockable storage facility was available in each residents’ bedroom. Staff were interacting with residents in an appropriate and respectful manner. Ashleigh House DS0000063255.V258665.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 & 14 The activities on offer meet the needs and expectations of residents living at the Home. Residents are encouraged to maintain contact with their family and friends with support from the home’s staff. Residents are able to exercise choice over their daily lives and the activities that they choose to participate in which promotes their independence and individuality. EVIDENCE: There was a variety of activities on offer that residents could participate in if they chose, including arm chair exercises, painting, board games and sing a longs. The care staff had the responsibility for organising activities and one hour each day is set aside for this. A hairdresser visits the Home every fortnight and Holy Communion is available. Each resident had been consulted about the type of activities that they are interested in participating in and a record of this was maintained. A number of residents chose to go outside of the Home with their friends and families and attended day centres and clubs. One resident said “ I enjoy going out with my family”. The Home has an open visiting policy. One visitor met during the inspection said “ I visit here twice a week and I am happy with the care here”. Ashleigh House DS0000063255.V258665.R01.S.doc Version 5.0 Page 12 Residents can choose the time that they rise out of bed in the morning and the time they retire to bed in the evening and have a choice of food at mealtimes. Ashleigh House DS0000063255.V258665.R01.S.doc Version 5.0 Page 13 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 Any complaints are investigated by senior staff in an appropriate and timely manner and the complaints procedure is comprehensive and is accessible to residents and their visitors. EVIDENCE: A comprehensive complaints procedure had been produced and this was on display. Since the previous inspection, the Home had received one informal complaint and this was in respect of the cleanliness of a resident’s bedroom. This issue was addressed in an appropriate and timely manner and measures were implemented to rectify the concerns raised. Ashleigh House DS0000063255.V258665.R01.S.doc Version 5.0 Page 14 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, 21, 25 & 26 Residents are provided with a homely, comfortable, clean and safe environment to live in, however the shower facility available limits some residents’ choice to use this facility independently. Remedial action of some health and safety issues in respect of the premises had been undertaken to ensure that the health and safety of residents is maintained. EVIDENCE: The internal environment of the Home was decorated to a high standard and furniture and fittings were of a good quality. Since the previous inspection, the kitchen had been refurbished to a high standard and a number of residents’ bedrooms had been redecorated. One resident said “ My bedroom is really beautiful”. Plans were in place to make the garden area to the rear of the Home secure and a ramp had been built for residents to access this safely from the dining room. Risk assessments are to be undertaken to assess the need for ramps to be built from individual residents’ bedrooms patio doors into the garden area. Ashleigh House DS0000063255.V258665.R01.S.doc Version 5.0 Page 15 A new shower chair had been purchased recently, however, the shower facility is not suitable for all residents to use independently as they would have to negotiate a step up into the shower. A risk assessment must be undertaken in respect of this. The internal temperature of the Home was comfortable on the day of the inspection. Attractive radiator covers had been fitted in residents’ bedrooms, however the radiators in the hallway were not covered and a risk assessment must be undertaken in respect of this. Hot water outlet temperatures did not exceed safe limits. The Home was found to be clean and fresh on the day of the inspection and there were hygienic hand washing facilities appropriately located throughout the Home including a new hand washing facility in the laundry. The washing machine was in good working order, however it did not have a sluice cycle facility. A comprehensive cleaning schedule in respect of the kitchen was in place. Ashleigh House DS0000063255.V258665.R01.S.doc Version 5.0 Page 16 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 The Home do not use agency staff and this ensures continuity of care. EVIDENCE: A stable workforce has been established at Ashleigh House. A domestic/kitchen staff member provides ancillary support to the care staff on duty, there were currently no staff vacancies and agency staff had not been used. The current staffing rota and staff personnel files were not available at the Home on the day of the inspection and as a consequence of this staff recruitment, induction and training records were not available for examination. These standards were, however, assessed during the last inspection. The previous week’s rota was available at the Home and this did not identify the person in charge of each shift. One resident said “ I find the staff to be very helpful”. One staff member met during the inspection stated that she had undertaken a comprehensive induction programme after commencing employment at the Home. Ashleigh House DS0000063255.V258665.R01.S.doc Version 5.0 Page 17 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, 36, 37 & 38 Staff working at the Home are supported to ensure that they work competently within their job roles and this ensures that good staff morale is maintained. The health, safety and welfare of residents is protected through regular maintenance checks of equipment used at the Home. EVIDENCE: Resident service satisfaction questionnaires had been distributed, however a report based on the findings of these had not been written. A system for formal staff supervision and appraisal had been implemented. The system for the management of residents’ personal allowances had met the required standard during the last inspection. Policies and procedures had not been reviewed and updated as necessary for a period of time. Ashleigh House DS0000063255.V258665.R01.S.doc Version 5.0 Page 18 The Commission For Social Care Inspection are informed of any accidents or incidents involving residents living at the Home and regular audits of accidents occurring at the Home are undertaken. Health and safety checks of equipment used at the Home are undertaken regularly including the fire alarm system, emergency lighting and the nurse call system. A fire drill had been undertaken and the fire risk assessments had been reviewed recently. Ashleigh House DS0000063255.V258665.R01.S.doc Version 5.0 Page 19 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 2 x 3 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 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 x 2 x 2 x x x 2 3 STAFFING Standard No Score 27 2 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 2 x x 3 2 3 Ashleigh House DS0000063255.V258665.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? yes 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 OP1 Regulation 5 Requirement Residents views must be incorporated in to the service user guide. (timescale of 20 September 2005 not met) Remedial action must be undertaken to restrict residents’ access to the main road from the rear garden. An action plan of how this is to be achieved must be submitted to CSCI. (previous timescales of 28 September 2004 and 01 June 2005 not met) Risk assessments must be undertaken to assess the need for ramps to be built from individual residents’ bedroom patio doors into the garden area. A risk assessment must be undertaken in respect of the suitability of the existing shower facility for the residents’ use. (timescale of 30 June 2005 not Ashleigh House DS0000063255.V258665.R01.S.doc Version 5.0 Page 21 Timescale for action 01/02/06 2. OP19 13(4) 30/11/05 3. OP19 13(4) 30/11/05 4. OP21 13(4) 30/11/05 5. OP25 13(4) 6. OP27 17(2) met) A risk assessment must be undertaken in respect of the need for covers to be fitted to the radiators in the hallway of the Home. The current staffing rota must be available on display in the Home at all times. The Registered Person received this in the form of an immediate requirement. The staffing rotas must identify the identity of the person in charge of each shift. (timescale of 20 April 2005 not met) All staff files must be available at the Home. (timescale of 20 April 2005 not met) The Registered Person received this in the form of an immediate requirement The Registered Person must operate a thorough recruitment procedure ensuring the protection of residents. The Registered Person must not employ a person to work at the care home unless the information and documents detailed in Schedule 2 have been obtained. (previous timescale of 14 September 2004 and 20 April 2005 not met) The Registered Person received this in the form of an immediate requirement 30/11/05 11/10/05 7. OP27 17(2) 01/11/05 8. OP29 17, 19 11/10/05 9. OP29 19(1) 01/11/05 Ashleigh House DS0000063255.V258665.R01.S.doc Version 5.0 Page 22 10. OP30 18(1) This requirement was not assessed on this occasion as the staff personnel files were not available at the Home. All employees must receive a basic health and safety induction prior to commencing employment at the Home. The Registered Person received this in the form of an immediate requirement. (timescale of 20 April 2005 not met) This requirement was not assessed on this occasion as the staff personnel files were not available at the Home. All staff must undertake an induction programme within six weeks of commencing employment at the Home and a record of this must be maintained. (timescales of 14 December 2004 and 31 May 2005 not met) This requirement was not assessed on this occasion as the staff personnel files were not available at the Home. An annual report based on the findings of the residents’ service satisfaction questionnaires must be produced and made available to residents. (timescale of 01 September 2005 not met) Policies must be reviewed to ensure that they meet current guidelines and include both an issue and review date. (timescales of 14 January 2005 01/11/05 11. OP30 18(1) 30/11/05 12. OP33 24 01/02/05 13. OP37 17 15/12/05 Ashleigh House DS0000063255.V258665.R01.S.doc Version 5.0 Page 23 and 01 July 2005 not met) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 3. 4. Refer to Standard OP26 OP30 Good Practice Recommendations It is recommended that the washing machine is replaced with a sluice cycle model when the current machine fails, or residents needs change. It is recommended that an individual training matrix is developed for all staff and that the training records include the content and duration of each training session, together with an indication of when updated training will be necessary. This recommendation was not assessed on this occasion as the staff training records were not available at the Home. Ashleigh House DS0000063255.V258665.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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. 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