CARE HOMES FOR OLDER PEOPLE
Ashleigh House Care Home 18-20 Devon Drive Sherwood Nottingham NG5 2EN Lead Inspector
Andrew Sales Unannounced Inspection 8th December 2005 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ashleigh House Care Home DS0000002188.V271540.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 Care Home DS0000002188.V271540.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Ashleigh House Care Home Address 18-20 Devon Drive Sherwood Nottingham NG5 2EN 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) 0115 969 1165 Mr William Scott Graham Moulds Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Ashleigh House Care Home DS0000002188.V271540.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 11th May 2005 Brief Description of the Service: Ashleigh House is a care home providing personal care and accommodation for 19 older people. The home provides short and long term care. The home is owned by William Scott, which is run as a family business. The home is located in a residential area of Sherwood close to shops, pubs, the post office and other amenities. The home was opened in 1987 and consists of 2 converted terraced houses with a purpose built extension.15 of the homes bedrooms are single, and none of the bedrooms have en-suite facilities. Bedrooms are located on 3 floors and there is a passenger lift. The home has a small, enclosed garden and a small car park. The home has recently appointed a new manager. Ashleigh House Care Home DS0000002188.V271540.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was unannounced and was conducted by A.J.Sales on 8 December 2005 at 10.00am. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for residents and their views of the service provided. This process considers the home’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provisions that need further development. The primary method of inspection used was ‘case tracking’ which involved selecting residents and tracking the care they receive through review of their records, discussion with them, the care staff and observation of care practices. An anonymous complaint had been raised with the commission, which was investigated as part of the inspection process. What the service does well: What has improved since the last inspection?
A number of the requirements set at the previous inspection have been addressed. The kitchen has been refurbished, window panels on resident’s bedroom doors have been blanked out and grab rails have been fitted where necessary. A number of care related issues have also been addressed. Ashleigh House Care Home DS0000002188.V271540.R01.S.doc Version 5.0 Page 6 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 Care Home DS0000002188.V271540.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 Care Home DS0000002188.V271540.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): 3 Residents are appropriately assessed prior to entering the home. EVIDENCE: The records of two resident’s, were checked as part of this inspection. The files contained assessments conducted by the manager and where appropriate local authority extended social care assessments. Both of the assessments were comprehensive and contained sufficient information to enable staff to ensure that they could meet the residents assessed needs. Detailed risk assessments were also present. Ashleigh House Care Home DS0000002188.V271540.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): 7,8,9,10. Residents receive a comprehensive assessment. Residents care plans are reviewed regularly. The home is able to meet the healthcare needs of it’s resident’s. Medication issues are managed appropriately. Residents are treated appropriately. EVIDENCE: All of the residents whose records were checked as part of this inspection had comprehensive care plans. The records show that the plans are being reviewed at least once each month and that residents, and where appropriate their representatives, are being involved in the review process. The resident’s plans also contained risk assessments, which are also reviewed each month. Resident’s care plans contain details of each resident’s individual health care needs, including a tissue viability and continence risk assessment. There is evidence that people have been appropriately referred to health care professionals. Care plans viewed, contained records of visits by district nurses, General Practitioners and other professionals. Staff said that they had recently had training in handling medicines from the pharmacist and were aware of correct practice for administering medicines.
Ashleigh House Care Home DS0000002188.V271540.R01.S.doc Version 5.0 Page 10 There were a number of references seen in care plans for promoting physical activity through encouraging mobility and there are weekly movement to music sessions. Staff were observed during the visit interacting professionally with residents. Two residents spoke with the Inspector and commented very positively on the conduct and attitude of the staff. They reported that staff provide a good standard of care and areas of concern would be discussed with the registered manager. Ashleigh House Care Home DS0000002188.V271540.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): 12,13,14,15. The daily routine is flexible to meet the preferences of residents and they are encouraged to exercise choice. Residents are generally happy with the food and choices provided. The kitchen has been renovated. EVIDENCE: Staff described flexibility over the daily routine and residents said that they are able to decide when they want to do things. Records showed that residents regularly go out. Residents spoken with felt they were happy with the level of activities within the home and outside. The staff reported that they encourage residents to participate in events and outings. Planned events are organised within the home. Ashleigh House Care Home DS0000002188.V271540.R01.S.doc Version 5.0 Page 12 One resident said she goes out regularly to town and enjoys collecting things on behalf of other residents. Another resident said he enjoyed reading and there were plenty of books available in the home. Residents said that visitors are welcome and can go to the residents’ room or one of the communal areas. Residents were observed briefly, eating lunch during the visit. The food appeared well presented. Resident’s spoken with commented positively on the standards and quality of food. Staff spoken with, were well aware of resident’s individual preferences. Ashleigh House Care Home DS0000002188.V271540.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): 16,18. The home has policies and procedures for dealing with complaints and adult protection issues. All staff must receive adult protection training. EVIDENCE: A complaint made anonymously to the Commission for Social Care Inspection and was investigated during this inspection (See standards 28,29,30,38). Complaints are being recorded and were observed. The Nottinghamshire Policy for the Protection Of Vulnerable Adults was observed, together with the homes polices on adult protection. After discussions with the manager and staff it was evident that a majority of staff require training in this area. Ashleigh House Care Home DS0000002188.V271540.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): 19,25,26. The home is domestic, clean and hygienic. Residents feel comfortable in this environment. A number of requirements have been addressed from the previous inspection. Attention needs to be paid to the control of Legionella and risk measures for scalding and adequate control of water temperature. EVIDENCE: The home was observed to be clean and tidy at the inspection. Residents spoken with, said they felt it provided a homely atmosphere. There is a sluice in the laundry and staff spoken with, were aware of infection control procedures and were seen using protective clothing. Records were observed for a number of safety tests for the fire system, emergency lighting and electrical equipment. Ashleigh House Care Home DS0000002188.V271540.R01.S.doc Version 5.0 Page 15 There was no evidence of the control of water temperatures, or measures for the control of legionella. The home will need to consult with the Environmental Health Officer for advice on legionella control measures, put in place risk assessments for all residents for potential scalding and record all water outlet temperatures on a regular basis. Ashleigh House Care Home DS0000002188.V271540.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): 27,28,29,30. Staff are being recruited to fill vacancies The manager is providing more care hours than is advisable. Residents are not being protected by suitable recruiting procedures. Staff receive training, but require updates and subjects specific to the care of older people. Staff have not had all the training they require to fully carry out their duties. EVIDENCE: On the day of inspection there was one care staff, one deputy manager, the acting manager, one cook and one domestic staff on duty. With a current occupancy of fifteen residents, from the staff rota provided, the staffing levels meet requirements. Staffing issues raised from the complaint were discussed, the acting manager confirmed that the two staff living on the premises do not conduct night duties any more. The home now has dedicated night staff. One staff file was sampled. This contained some evidence of applications, interviews, and only one reference. Other care staff records were not available and the manager stated they were kept at the proprietor’s other home. CRB checks were not available for the two staff living above the premises, who the manager stated only now conducted cleaning duties. However these are required and an immediate requirement is made in respect of this. Another care worker on duty that day did not have CRB clearance and an immediate requirement has been set to seek a 24 hour Adult Protection check and place the member of staff under close supervision.
Ashleigh House Care Home DS0000002188.V271540.R01.S.doc Version 5.0 Page 17 Training records observed are not up to date and need to be reviewed to identify which training, including updates, that staff require. Certificates were seen for a number of staff, but were out of date. A full review of training is required to address mandatory training and more specific training needs of staff. Ashleigh House Care Home DS0000002188.V271540.R01.S.doc Version 5.0 Page 18 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): 31,38. The home is generally well managed with residents interests put first. Health and safety management is well documented, in some areas, but requires improving. Some urgent Health and Safety measures are required. EVIDENCE: Residents said they felt the home was well run with improvements being made and the management team were on hand for support and advise. Staff spoken with confirmed that they felt supported by the acting manager and that they are approachable to discuss any issues. The acting manager stated that the staff have received some training updates in the last year on moving and handling, first aid, basic food hygiene, administration of medication and health and safety issues including hygiene control. But many staff were overdue for these.
Ashleigh House Care Home DS0000002188.V271540.R01.S.doc Version 5.0 Page 19 Records of fire system tests and other health and safety records were observed and were found to be carried out at the required intervals. There was no evidence of the control of water temperatures, or measures for the control of legionella. The home will need to consult with the Environmental Health Officer for advice on legionella control measures, put in place risk assessments for all residents for potential scalding and record all water outlet temperatures on a regular basis. The home also needs to determine whether the fire system requires servicing. Ashleigh House Care Home DS0000002188.V271540.R01.S.doc Version 5.0 Page 20 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 X HEALTH AND PERSONAL CARE Standard No Score 7 3 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 2 3 X X X X X 1 3 STAFFING Standard No Score 27 3 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X X X 2 Ashleigh House Care Home DS0000002188.V271540.R01.S.doc Version 5.0 Page 21 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 2 3 4 5 6 7 Standard 18 25.38 25,38 29 29 29 29.38 Regulation 13 (6) 13 (3)((4) 13 (4) 19 Schedule 2 19 (4)(5) Schedule 2 19 (4)(5) Schedule 2 19 (4)(5) Schedule 2 18 (1) (a) Timescale for action Ensure all staff receive formal 31/01/06 adult protection training. Ensure that the Environmental 31/01/06 Health Officer is consulted over Legionell control measures Ensure adequate measures are 26/12/05 put in place to prevent scalding from hot water temperatures. Ensure suitable records are 31/01/06 maintained in respect of staff and kept at the home. Ensure satisfactory pre- 08/12/05 employment checks are conducted for all staff. Ensure all staff are appointed 08/12/05 only after the satisfactory receipt of CRB disclosures. Ensure current members of staff 08/12/05 without CRB checks have immediate Protection Of Vulnerable Adults checks and are appropriately supervised. Ensure all staff receive induction 30/03/06 and training that complies with the National Training Organisation workforce training targets. …Schedule 2. Ensure the Safety 08/12/05 and well being of residents in
DS0000002188.V271540.R01.S.doc Version 5.0 Page 22 Requirement 8 30 9 38 13 (4). & 19 (4) Ashleigh House Care Home (5)… respect of the accommodation in premises occupied by staff without CRB checks and in respect of visitors to those occupants. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Ashleigh House Care Home DS0000002188.V271540.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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