Inspection on 02/07/07 for Ashleigh House

This inspection was carried out on 2nd July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 11/10/05

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 Kulwant Ghuman Key Unannounced Inspection 2nd July 2007 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 Ashleigh House DS0000063255.V338522.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 House DS0000063255.V338522.R01.S.doc Version 5.2 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.V338522.R01.S.doc Version 5.2 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. 19th September 2006 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 people to access 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. The fees at the home range from £400 - £425. Ashleigh House DS0000063255.V338522.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was carried out by one inspector over two days during July 2007. Prior to the inspection the home had completed and returned the annual quality assurance assessment that provided the commission with information about the home. During the inspection the inspector was able to speak with 9 of the 13 people living in the home, two visitors and three staff as well as the manager. The inspector looked at detail on the files of one member of staff and one person living in the home and other files for specific issues. Several other documents were also sampled. A tour of the communal areas of the home and 6 bedrooms was carried out. There had been no complaints or issues of adult protection that had been raised with the Commission since the last inspection. What the service does well: The home provides a comfortable homely environment for the individuals to live in. Bedrooms were individualised with personal belongings and comfortable. Individuals moving into the home were assessed and had the opportunity to visit the home before deciding whether to move in. Friends and relatives were able to visit at all reasonable times. The people living in the home were able to go bed and get up at a time of their choosing. They were free to sit in their bedrooms or the lounge. They could choose where to eat their meals. The majority of the people living in the home were able to undertake a lot of their own personal care tasks and required only some support from the staff. There had been little staff turnover since the last inspection. Ashleigh House DS0000063255.V338522.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The registered person needed to ensure that the people living and working in the home and those visiting the home felt that they could raise issues that were concerning them and that they would be listened to. There needed to be closer liaison with individuals regarding the provision of meals and activities in the home so that the people living in the home felt that their lives were fulfilled and happy. The manager needed to be more visible in the home, carrying out a monitoring and developing role so that the service continued to evolve in line with current standards and requirements. The manager needed to ensure that staff were confident about the policies and procedures in the home and that the people living in the home received the help that they needed. Medication procedures needed to be improved to ensure that the people living in the home received their medication as prescribed. Ashleigh House DS0000063255.V338522.R01.S.doc Version 5.2 Page 7 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 House DS0000063255.V338522.R01.S.doc Version 5.2 Page 8 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.V338522.R01.S.doc Version 5.2 Page 9 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): 1,2,3,and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People were admitted to the home following a visit to the home and an assessment was carried out to ensure their needs could be met at the home. EVIDENCE: There was no service user guide available at the home for inspection but one was sent to the inspector following the inspection. The manager needed to ensure that copies of these were readily accessible for visitors and people who may wish to move into the home. The pre-admission assessment for one person living in the home was sampled. The individual was mostly self-caring and the level of detail in the assessment was acceptable. There was evidence on the file that the individual had visited the home prior to admission. The individual was also able to tell the inspector about the visit to the home. Ashleigh House DS0000063255.V338522.R01.S.doc Version 5.2 Page 10 If more dependent individuals are admitted to the home then the level of detail in the pre-admission assessment would need to be greater to enable the home to make a decision about whether their individual needs could be met. The inspector was shown a sheet that would be added to the pre-admission assessment that would record the individuals daily choices of living and would record information such as the time they would like to get up, whether they would like a cup of tea before breakfast and at what time, where they would like breakfast and so on. The contract or terms of residence for the individuals living in the home were not available for inspection. The inspector was told that they were held at the offices in the sister home. A blank contract showed that the room to be occupied by the individual was identified and there was space to show what the weekly fee would be. It identified that a trial period of residence was used to determine whether the home was suited to the individuals needs. The home had a no smoking policy and no pets were allowed. Individuals were able to bring in small items of furniture. Ashleigh House DS0000063255.V338522.R01.S.doc Version 5.2 Page 11 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 adequate. This judgement has been made using available evidence including a visit to this service. The care plan included some good information about the individuals but some areas needed more detail to ensure all their needs were met. Health care needs were generally met but there were incidents where this could be improved ensuring that individuals received help as and when required. The management of medicines was generally good. EVIDENCE: The care plan for one individual who lived in the home was sampled. Aspects of care for three others were also looked at. On the day of admission a care plan was drawn up using the information gained during the pre-admission assessment. The care plan covered areas such as general health, medication, mobility, relationships, financial matters, community links, dietary requirements and likes and dislikes. There was also a ‘preferences for daily choices of living’ sheet. This indicated that the individual got up in her own time, was self-caring and able to choose the Ashleigh House DS0000063255.V338522.R01.S.doc Version 5.2 Page 12 clothes she wore on a daily basis. The preferred activities were going for a walk, playing bingo, listening to music, sing-a-longs, exercising and having her hair done. There was evidence that the home had got information from other agencies involved in the person’s care. There was some good information regarding the individual’s mental health and other medical needs. There was a care plan that indicated that the individual had diabetes, that she should have 5 fruit and vegetables a day and that her blood sugar levels would be monitored. The plan did not indicate the frequency of the testing and who would carry out the tests. This would enable the staff to follow up the tests if they did not happen at the required frequency. The plan also did not record what the normal blood sugar levels for the individual should be. From the food records sampled it was not possible to determine whether the individual was receiving five portions of fruit and vegetables a day. A review had been carried out that indicated that the individual was happy and that she had shown the staff how to cook some of the foods she liked. There was evidence on the files of visits from medical professionals including GP, chiropodist, CPN and dentist when required. The file of another person in the home indicated that some parts of their file, for example, the care plan for their mobility had been updated as this had deteriorated but areas such as personal care had not been. The inspector was told that this was because the individual had only been in the home for a few days and this would be updated as more information about the individual’s ability to self care was gathered. The daily records for the individual did not give substantial evidence of what they could do and what assistance was being given by staff. The daily records indicated that ‘full assistance’ was being given. One of the files sampled indicated that the individual concerned had not received medical care as quickly as would have been expected following a fall. It was unclear as to why the member of staff had not called for paramedic assistance immediately. The inspector was told that an individual had used the emergency call system for assistance but when no-one attended they had gone to the bedroom of another individual who also activated the system but as assistance had still not arrived she went to get a member of staff. This is not acceptable behaviour and could have had serious consequences. Ashleigh House DS0000063255.V338522.R01.S.doc Version 5.2 Page 13 It could not be confidently stated that the weight of all the people living in the home was being monitored. The weight record for one person was not available, the weight of two others was stable. The home was using a monthly monitored dosage system for the majority of medicines in the home. The inspector was told that there were no controlled medicines in use at the home but the record for controlled medicines was not available for auditing as it had been archived with the individual’s records at the sister home. The home must obtain a controlled medicines register that must be kept on the premises at all times. The home had been using a lockable tin for storing controlled medicines in however the tin could be removed from the medicine cabinet. The home did have in its possession a cupboard that needed to be attached to the wall inside another cabinet. A limited, random audit of the blistered medicines for two of the people living in the home showed that there were some discrepancies in the record keeping. For one person one of the medicines had been signed as given but the capsule remained in the blister pack. In another instance 6 capsules had been taken out of the blister pack but there were only 4 signatures to say that the medicine had been given. For another person the records showed that the individual had been given a food supplement drink on three occasions however there had only been two taken from the cupboard. Where people living in the home were self-administering medicines there needed to be a risk assessment of their ability to look after the medicines and also compliance checks carried out to ensure they have been taking or using the medicines as prescribed. A protocol for the use of ‘as and when required’ medicines had not been written up as required at the last inspection. A random audit of three boxed medicines in the home was found to be accurate. The medicines were being appropriately booked in and records of medicines returned to the pharmacist kept. There was a list of signatures indicating who was able to administer medicines and the inspector was told that they had all undertaken training in the safe handling of medicines. Bedrooms and bathrooms had appropriate locks in place. There were en-suite facilities in all the bedrooms sampled and this promoted privacy and dignity in the home. There were no shared bedrooms. The communal phone was placed in the entrance hall and did not really afford privacy to anyone using it. There was nowhere else that the telephone could be located to improve privacy but the home could consider a portable phone that could be wheeled to individual bedrooms. Ashleigh House DS0000063255.V338522.R01.S.doc Version 5.2 Page 14 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 adequate. This judgement has been made using available evidence including a visit to this service. There was flexibility in the daily routines for the people living in the home but recreation and activities were limited for some of them. Not all cultural needs were being met at the home. People living in the home were not satisfied with the meals provided at the home. EVIDENCE: Some of the people living in the home had the ability to go out with friends and relatives and occasionally some went out with the staff to the knit and natter club or the Carpenters Arms pub – although this had been closed for the last six weeks. The inspector was told by some of the people living in the home that there had been an entertainer in the home the previous week and the manager said an entertainer had been in the home in February and April this year also. The manager told the inspector that all the people living in the home had been registered with ring and ride and one person had gone out on it once escorted by a member of staff. Ashleigh House DS0000063255.V338522.R01.S.doc Version 5.2 Page 15 It was difficult to determine the level of activity in the home as records were only kept in the daily records. Therefore it was difficult to know if the same people were going out regularly or if it was only the more able ones. Several of the people living in the home told the inspector that they did not get out very much. It was only if the relatives took them out. Staff indicated that they could take residents out but this was dependent on staffing levels. When there were two staff on duty they couldn’t take them out as this left only one staff member in the home. The manager told the inspector that there was an activities programme on display but that this was not always followed because the people living in the home were not interested. She stated that they did play card games and bingo. There were observed to be visitors in the home during the inspection. There was no evidence to suggest that people living in the home could not have visitors when they wanted. One visitor was able to join the people living in the home for lunch. There was a priest who visited the home. The inspector was told by several people who lived in the home that the quality of the food was not good. This comment was also made in one of the questionnaires completed by the people living in the home. There were some people in the home who said they had bought their own teabags because they did not like the tea bought in by the home. They commented that most of the meals were processed things such as pies and that this was not the fault of the staff as they were ‘carers and not cooks’. One person commented that the gammon they had had was tough and another said that there was never any lamb on the menu because it was too expensive. The files sampled did not evidence that the dietary needs of people were being adequately assessed and planned for. The manager stated, and showed the inspector a list of food that one person had asked to be bought for them however, the records sampled did not evidence that these needs had been met. There was an indication that one of the people living in the home had shown staff how to cook some foods she liked but the menus and food records did not evidence that this food had been provided. People commented to the inspector that cooked breakfasts were never provided and when they had asked for an egg there had been none available. The manager did show the inspector records that indicated that occasionally some of the people living in the home had had eggs or bacon sandwiches. Ashleigh House DS0000063255.V338522.R01.S.doc Version 5.2 Page 16 The menu sheets provided indicated that there was some choice in the food available at lunch and tea. One the first day of the inspection the inspector was able to join the people living in the home for lunch. The choice available at lunch time was roast chicken breast lattice or southern fried chicken. The home needed to ensure that there was a real choice available. The menu stated that green beans and carrots were the vegetables however, mixed vegetables were served on the day. The dessert was due to be apple strudel and custard or sugar free jelly, however chocolate cake was served with tinned fruit for those on a diabetic diet. The food was well presented and cooked well on the day of the inspection. The inspector observed that no-one was offered any extra portions and no-one was offered choices of creamed or roast potatoes, vegetables, gravy or pudding. The meals came plated up from the kitchen. One of the individuals asked for fruit instead of the chocolate cake she had been given and this was provided. Drinks were ready poured out before people sat down for lunch. This was an area where more choice could be introduced into their lives. At the time of the inspection the records of food eaten did not allow for an assessment to be made as to whether a varied and nutritious diet was being provided. The records provided only ticks and did not say what the meal was for example, the sheet said meat, vegetables, potatoes and so on but not what the meat was, what the vegetables were, what type of potato and so on. The inspector was shown some records of meetings with the people who lived in the home where food was discussed. There was no evidence of how the information gathered at these meetings had been used in the home to meet the individuals’ wishes. The aspect of meals and mealtimes are a very important part of the lives of the people living in the home and it is important that the home liaises both on an individual level to meet their needs and also in a group to improve the satisfaction in this area. On the second day of the inspection one of the individuals living in the home had been asked to ask the others to indicate their preference for the carpet for the communal areas from a sample board. People in the home were able to go to bed and get up when they wanted although at least one person said they had to wait because they needed assistance. They were able to go their bedrooms or stay in the lounge for as long as they wished. Their bedrooms were personalised to their likings with some personal belongings. There was evidence that they were being asked whether they wanted a key to their bedroom door. Ashleigh House DS0000063255.V338522.R01.S.doc Version 5.2 Page 17 There did not appear to be any involvement of the individuals living in the home or their representatives in reviewing their care plans after the initial 28 day review. Ashleigh House DS0000063255.V338522.R01.S.doc Version 5.2 Page 18 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 adequate. This judgement has been made using available evidence including a visit to this service. Systems were in place to safeguard the people living in the home. The home needed to ensure all expressions of dissatisfaction about the service were recorded. EVIDENCE: No complaints about the home that had been lodged with the commission and no complaints had been logged at the home. It was important that the home recorded any issues raised by the staff, people living in the home and relatives and visitors to show that they took seriously any issues raised about the service and how they responded to expressions of dissatisfaction. Some of the people spoken with during the day said that they would raise issues whilst others commented that they did not want to be seen as trouble makers and would tend not to raise things. Along with the majority of older people they were concerned about complaining about small things, not wanting to get anyone in trouble and not facing reprisals for raising issues. The recruitment procedures were satisfactory and the management of any monies held on behalf of the people living in the home safeguarded them from abuse. Ashleigh House DS0000063255.V338522.R01.S.doc Version 5.2 Page 19 No issues of adult protection had been raised concerning the home however, two issues of staff not responding to the emergency call system and not requesting assistance following a fall were of concern. Ashleigh House DS0000063255.V338522.R01.S.doc Version 5.2 Page 20 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, 20, 21, 22, 23 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The premises were homely in character and met the needs of the people living in the home. EVIDENCE: A tour of the communal areas of the home and six bedrooms was carried out. The home remained much the same as at the last inspection. There was a communal lounge and dining room for the people living in the home to sit in. They had access to a rear garden. As at the last inspection the garden was not enclosed. The manager stated that any of the people living in the home could leave the home via the front door if they wanted so that the garden was no additional risk. She had undertaken individual risk assessments for them. Ashleigh House DS0000063255.V338522.R01.S.doc Version 5.2 Page 21 The home had some adaptations in place including an emergency call system throughout the home, a stair lift and electric bath seats. The inspector was told that the shower in the bathroom on the ground floor was due to be made into a floor level, walk-in shower. This would be of benefit to those people who found it difficult to step into the shower tray. The bedrooms seen during the inspection appeared to meet the needs of the occupants. There were no offensive odours in the home. A comment was made to the inspector about the level of cleaning in the home. It was stated that although staff went around with a vacuum cleaner there was a lack of dusting throughout the home. It was also stated that staff did not always have the appropriate cleaning materials to clean items such as commodes. Staff stated they did have cleaning materials. The bottom of the chair in the bath on the ground floor needed to be cleaned, cotton towels needed to be removed from bathrooms and paper towels needed to be available in all the dispensers. The chairs on the first floor landing needed to be removed as they did not show that they were made of fire retardant materials. Ashleigh House DS0000063255.V338522.R01.S.doc Version 5.2 Page 22 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 adequate. This judgement has been made using available evidence including a visit to this service. The manager needed to ensure that there were sufficient staff on duty, with the appropriate skills, to enable the people in the home to live fulfilled lives. Staff were provided with mandatory training. EVIDENCE: The staffing levels were generally two members of staff on duty. One of whom was allocated to cooking and the other to caring. There was one member of staff on duty during the night. The staff stated that they could undertake the everyday tasks but they were not able to take anyone out when there were only two staff on duty as that left only one person in the home. The manager needed to consider having a qualified chef on duty and someone allocated to cleaning as the current domestic was going over to a caring role. One person living in the home told the inspector that sometimes staff rushed her and were abrupt in their manner. The inspector was told by several people that the manager popped into the home but did not stay all the time. This was discussed with the manager who stated that she was sometimes doing the shopping; at the sister home where there was a photocopier and the documents were archived, and, that she had Ashleigh House DS0000063255.V338522.R01.S.doc Version 5.2 Page 23 had a period of time when she had been on holiday and was then off sick and had hurt her ankle. The information provided to the Commission prior to the inspection stated that 10 of the 13 care staff had achieved NVQ level 2 or equivalent and that the staff received induction training, and that 12 staff had undertaken safe handling in food and infection control training. There was evidence on the files that induction training had taken place for some of the staff but for the member of staff whose file was checked there was only a brief induction checklist that had been completed. The manager stated that this was because the individual had worked elsewhere and was currently undertaking some studies also. The manager needed to gain evidence from the previous place of employment if a ‘skills for care’ induction had been undertaken or from the place where the individual was currently studying to check which standards would be covered in this training. The recruitment procedure was satisfactory in that the references, medical declaration and CRB checks were available, however, examination of one application form showed that a full employment history was not available. There was a note on the application that a CV was available however one was not available for inspection. It could not be determined from the paperwork what date the individual actually started work. The paperwork showed that the induction checklist and some of the training had been undertaken before both the references had been received. The individual had had training in fire prevention, moving and handling, first aid and incontinence. The second file sampled indicated that the employee had not started work before the CRB and references had been received. The home was carrying out a quarterly review with the staff and at the end of this there was a discussion about the future development of the individual. The manager said that she had not done a training matrix. Ashleigh House DS0000063255.V338522.R01.S.doc Version 5.2 Page 24 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): 31,33,35,37 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Health and safety in the home was generally well managed ensuring staff and people living in the home were safe. The management of the home needed to be more robust to ensure that the people living in the home were satisfied with the service provided. EVIDENCE: The manager, who was also the owner of the home, had managed the home for several years. She had recently been on some training regarding the Mental Capacity Act and seemed to have taken on board the need for all records in the home to show how the people living in the home were being given opportunities to make choices. Ashleigh House DS0000063255.V338522.R01.S.doc Version 5.2 Page 25 The inspector had noted an overall decline in the level of satisfaction of the service being provided at the home since the last inspection. The inspector was left with the impression that the manager was not spending as much time monitoring the service in the home as was required. From the discussions with staff, people living in the home and visitors to the home it was clear the they did not think that the home was being run with the needs of the people living in the home in mind. Comments were made such as ‘the home was run on a shoe string’ , ‘ the quality of tea in the home is poor’, ‘Suzanne pops in most days but doesn’t stay’ and ‘don’t want to be seen as a trouble maker and asked to leave’. The manager stated that there had been a period of time when she had been on holiday and had hurt her ankle so was not in the home the usual amount however she said that she came to the home most days and if she didn’t it was because she was working elsewhere on paperwork or carrying out assessments. The views of the relatives and people living in the home were not being gathered on a regular basis so that the service could be developed along those lines. The records for the management of monies held on behalf of the people living in the home were well organised, showed receipts were available for all expenditures and there were double signatures. There had recently been a raffle in the home, the proceeds of which had gone towards providing entertainment in the home. The records for this were not available for inspection as the member of staff holding them was on leave. There had been some changes to the way in some of the information was recorded in the home, for example, the food and activity records. The new formats did not enable anyone to look at them and determine whether all the people living in the home had been offered suitable recreational activities or whether they were receiving a balanced and nutritious diet. On several occasions during the inspection records could either not be located or they were said to be at home or in the office in the sister home. These included accident records, records of fund raising and records of investigations of incidents. The health and safety in the home was generally well managed with equipment being serviced and maintained on a regular basis however, the fire training for staff was not being undertaken every six months and the Loler tests for the bath chairs were not being undertaken six monthly. Ashleigh House DS0000063255.V338522.R01.S.doc Version 5.2 Page 26 Some aspects of the management of medicines in the home needed to be improved and it needed to be ensured that calls for assistance were attended to promptly. The management of fire procedures was not sampled during this inspection. The inspector was informed that the radiators that had not been guarded had been risk assessed and did not pose a risk to the people living in the home. The radiator in the bathroom was to be guarded when the alterations were made to the shower. Ashleigh House DS0000063255.V338522.R01.S.doc Version 5.2 Page 27 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 2 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 2 2 3 X X 3 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X 2 2 Ashleigh House DS0000063255.V338522.R01.S.doc Version 5.2 Page 28 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 OP8 Regulation 13(4)(c) Requirement The registered person must ensure that staff respond to the emergency call system as soon as possible. This will ensure that the people living in the home will get the help they need. The registered person must ensure that staff are confident about what to do in the event of a fall. This will ensure that the people living in the home will get medical assistance in a timely manner when required. A risk assessment must be in place for individuals who self administer medicines and there must systems in place to test their compliance. This will ensure that their medical needs are met. A protocol must be in place for medicines used on a ‘when required’ basis. This will ensure that staff know when this medication is to be given. Ashleigh House DS0000063255.V338522.R01.S.doc Version 5.2 Page 29 Timescale for action 01/08/07 2. OP9 13(2) 01/09/07 Previous timescale of 01/11/06 not met. The registered person must ensure that people living in the home receive their medicines as prescribed. The registered person must ensure that staff medication audits are carried out. This will ensure that the people living in the home receive their medicines as prescribed. The registered person must ensure that facilities are provided to store and administer controlled medicines in accordance with the Misuse of Drugs Act 1971 and regulations. Records of the food provided must be in sufficient detail to enable anyone inspecting them to determine whether the diet is nutritious and varied. This will ensure that people living in the home receive a suitable diet. The bottom of the bath chair must be cleaned. This will ensure that the risk of cross infections is minimised. There must be sufficient staff on duty to meet the needs of the people living in the home. The registered person must ensure that new staff have the appropriate skills as identified by the Skills for Care competences before they are able to work unsupervised. An annual report based on the findings of the residents’ service satisfaction questionnaires must be produced and made available DS0000063255.V338522.R01.S.doc 3. OP15 17(2) Sch 4(13) 01/09/07 4. OP26 13(3) 01/09/07 5. 6. OP27 OP30 19 Sch 2 18(1)(a) 01/08/07 01/08/07 7. OP33 24 01/10/07 Ashleigh House Version 5.2 Page 30 to residents. (Previous timescales of 01/09/05 and 01/02/05 not met.) 8. OP38 13(4)(c) The chairs on the first floor landing must be removed unless their fire retardancy can be determined. The registered person must ensure that weight bearing equipment in the home is serviced at the required time intervals. (Evidence that this had been done was received on 24/07/07) Fire training for staff must be carried out every 6 months. 01/08/07 9. OP38 23(2)(c)) 01/08/07 10. OP38 23(4)(d) 01/09/07 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 OP2 OP7 Good Practice Recommendations Contracts and terms of residence should be available in the home for inspection. The care plan should include details of all aspects of care so that the staff can chase up if any aspect of care is not being met. Care plans should be updated as soon as possible after the changes in need occur. Daily records should show the care being provided and what care tasks could be undertaken by the individual so that care plans could be updated as required on at least a monthly basis. Weight records for all the people living in the home must be accessible so that the person in charge of the home can monitor their health. The registered person should ensure that the social and recreational needs of the people living in the home are DS0000063255.V338522.R01.S.doc Version 5.2 Page 31 3 4 OP8 OP12 Ashleigh House 5 OP14 6 OP15 met on both a one to one level and in a group setting. The registered person should involve the people receiving a service and any representatives they want to involve in reviewing their care plans so that they can receive the care in the way they want. The individual cultural and dietary needs and preferences of the people living in the home should be catered for. The registered person should liaise with the people living in the home to discuss their perceptions of the quality of the food provided and how any improvements could be made. The registered person should ensure that all expressions of dissatisfaction with the service are recorded and records kept of how they have been addressed to show that the views of the people living in the home have been listened to. It is recommended that the washing machine is replaced with a sluice cycle model when the current machine fails, or residents’ needs change. Cotton towels should be removed from communal areas and all communal hand washing facilities should have paper towels available to reduce the risks of cross infection. The registered person should ensure that the staff undertaking cooking and cleaning in the home have the appropriate skills. The registered person should ensure that there is a full employment history for all new applicants and staff records show a start date for the individuals. 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. 7 OP16 8 OP26 9 10 11 OP27 OP29 OP30 Ashleigh House DS0000063255.V338522.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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