CARE HOMES FOR OLDER PEOPLE
Ashleigh Manor 1 & 3 Vicarage Road Plympton Plymouth PL7 4JU Lead Inspector
Jane Gurnell Announced 10/06/05 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ashleigh Manor D52-D04 S3570 Ashleigh Manor V214585 100605 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION
Name of service Ashleigh Manor Address 1 & 3 Vicarage Road, Plympton, Plymouth, Devon, PL7 4JU Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01752 346662 01752 336233 Mrs Maureen Lawley Miss Loretta Maher-Lawley Mrs Maureen Lawley Care Home 38 Category(ies) of Dementia (38), Old age, not falling within any registration, with number other category (38), Physical disability (38) of places Ashleigh Manor D52-D04 S3570 Ashleigh Manor V214585 100605 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Five residents Category PD 50yrs Date of last inspection 15/12/04 Brief Description of the Service: Ashleigh Manor is a large detatched house set within its own grounds in a residential area of Plympton. The home is registered to provide accommodation with personal care for 38 service users, who may or may not have physical disabilities or mental health problems associated with age. The home does not intend to provide this service for people who have a functional mental health disorder or whose behaviour due to personality or illness causes them to display challenging behaviour or aggression.The home does not provide intermediate care services but does accept a small number of residents who require short term respite care.The majority of rooms are single and en suite, and many are purpose built. The home naturally separates into two units linked at the rear of the building by a large conservatory and covered walkway.The home has access for wheelchair users including a passenger lift and stair lifts and ramps to the garden. The home has good parking to the front. Ashleigh Manor D52-D04 S3570 Ashleigh Manor V214585 100605 Stage 4.doc Version 1.20 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was announced and took place on 10th June 2005 over a period of 6 hours. The focus of the inspection was to consult with the residents and to review the care planning process. Miss Maher-Lawley, the Registered Provider, was present and she and her staff team assisted the inspector throughout the inspection. The inspector spoke to 21 residents, toured the building and examined the care plans and documentation relating to the management of the care home. What the service does well: 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 full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office.
Ashleigh Manor D52-D04 S3570 Ashleigh Manor V214585 100605 Stage 4.doc Version 1.20 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Ashleigh Manor D52-D04 S3570 Ashleigh Manor V214585 100605 Stage 4.doc Version 1.20 Page 7 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 4 and 5 The assessment process ensures that residents can be confident that care staff are aware of their needs prior to their admission and are able to meet those needs. Documentation provides clear information regarding the services provided. EVIDENCE: The Statement of Purpose and Service User Guide provide a clear and easy to read description of the services provided by Ashleigh Manor. A further book entitled “About Ashleigh Manor” is in the main entrance and provides further information for residents and families and tries to answer the more common questions raised when moving into a care home: this book also documents Miss Maher-Lawley’s future plans for the home and the development of new services, such as a meditation room and complementary therapies. Miss Maher-Lawley or an assistant manager undertake pre-admission assessments: these were evident for 2 newly admitted residents. Residents said that they had been able to visit Ashleigh Manor prior to making a decision to move in. Staff confirmed that they had recently received training relating to the care needs of residents with dementia.
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The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 10 Residents’ health, personal and social care needs are being met and residents are treated respectfully. The home’s practices relating to medication administration protect the residents from risk. EVIDENCE: Those residents able to comment said that they were very well looked after and the inspector observed those residents with confusion being treated respectfully by the care staff. An assessment is made of each resident upon admission to identify immediate health care needs and allows consultation with other health care professionals as quickly as possible. Those care plans sampled detailed care needs and had been reviewed and updated regularly. Risk assessments for activities both in and out of the home were documented. Specialist advice is sought when necessary from Community Mental Health Nurses, District Nurses and the continence advisor. Records of accidents were well maintained and reviewed by the Registered Provider: there did not appear to be a pattern of accidents or evidence that any residents were repeatedly falling.
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The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 15 Social activities are managed well and provide daily interest for the residents. Meals are nutritious and varied. EVIDENCE: Residents commented how much they enjoy the daily activities organised by the care staff. A programme of the month’s activities was on the notice board and included in-house activities and trips to local places of interest and musical concerts. Many of the residents had significant memory loss and information relating to advocacy services for them and their families was provided in the main entrance. Residents said that the food was plentiful and very good. Drinks and snacks were available at all times. Ashleigh Manor D52-D04 S3570 Ashleigh Manor V214585 100605 Stage 4.doc Version 1.20 Page 10 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 17 and 18 Complaints and suggestions from residents, relatives or other visitors to the home, are treated seriously. Residents are listened to and issues resolved promptly. EVIDENCE: The Statement of Purpose and Service User Guide stress the willingness of the Registered Providers and staff to receive comments about home and to resolve any concerns raised. Those residents able to comment said that they had confidence in the Registered Providers and the staff and felt safe and well cared for. No complaints had been received since the last inspection. Care staff had received training relating to the protection of vulnerable adults. Ashleigh Manor D52-D04 S3570 Ashleigh Manor V214585 100605 Stage 4.doc Version 1.20 Page 11 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 23, 24, 25 and 26 The residents live in a pleasant home that is comfortable and warm and which provides sufficient facilities to meet their needs. EVIDENCE: Residents said that they found the home warm, spacious and comfortable. In addition to four lounge and dining rooms provided there is a library, a conservatory and a quite area and these give a feeling of living in a much smaller home and assists residents with memory loss to become more familiar with the layout of the home. The home was found to be clean and free from offensive odours and infection control practices protect residents and staff from cross infection. Bedrooms are of a good size and are nicely decorated: many provide en suite facilities. Lockable storage facilities are provided. The garden is large and provides a pleasant, safe environment of residents. Maintenance staff ensure that repairs and re-decorating tasks are undertaken promptly. A number of radiators are still to be covered to protect the residents from the risk of burns.
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The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30 Residents are cared for by trained and motivated staff in sufficient numbers to meet the needs of those currently living in the home. Recruitment practices protect vulnerable residents. EVIDENCE: Residents described the staff as very kind and caring and confirmed they responded promptly to requests for assistance. Care staff are supported by catering and domestic staff. The Registered Provider recently undertook a review of residents’ care needs to ensure that staff are employed in sufficient numbers to meet the needs of the residents currently living in the home: records of this review were available. All staff either had a NVQ qualification or were in training. All care staff received dementia care training in April 2005 and a further more in-depth course has been arranged for the Registered Provider and an assistant manager in June and September 2005. Those staff files examined contained the required documentation. Ashleigh Manor D52-D04 S3570 Ashleigh Manor V214585 100605 Stage 4.doc Version 1.20 Page 13 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 36, 37 and 38 Residents live in a well managed home. The Registered Providers and the staff team strive to provide a stimulating, safe environment that respects and protects residents’ rights. EVIDENCE: Residents said that they feel safe and secure in their home and that the home was well managed. Staff supervision is provided formally and informally and includes teaching sessions that address the changing needs of the residents: these should be recorded to provide evidence of the home’s good practice. A quality assurance survey is sent 6-monthly to residents and their families and annually to visiting health care professionals to ensure that the home continues to meet residents’ needs and allows comment upon any areas for improvement. The assistant manager meets formally with the residents every 3 months to discuss all aspects of the day-to-day management of the home and the services provided. The registered provider undertakes unannounced visits to the home and reviews and samples the National Minimum Standards
Ashleigh Manor D52-D04 S3570 Ashleigh Manor V214585 100605 Stage 4.doc Version 1.20 Page 14 with those care staff on duty. Senior care staff meetings are held every week to ensure consistency with residents’ care. Inspection of the fire logbook indicated that the required weekly and monthly testing of the fire alarm system was being undertaken. Staff had received fire safety training. Regular unannounced fire drills are undertaken to ensure both the care staff and the residents and visitors are ware of the procedure should a fire be discovered. The kitchen was found to be clean and tidy and records of fridge and freezer temperatures were recorded daily indicating that regular cleaning and monitoring were being undertaken. Ashleigh Manor D52-D04 S3570 Ashleigh Manor V214585 100605 Stage 4.doc Version 1.20 Page 15 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. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 4 3 3 3 3 N/A 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 3 3 3 x 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 x 3 3 x x 3 3 3 Ashleigh Manor D52-D04 S3570 Ashleigh Manor V214585 100605 Stage 4.doc Version 1.20 Page 16 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP25 Regulation 13 Requirement Radiators must be covered or have guaranteed low temperaute surfaces to protect residents from the risk of burns. Portable electrical appliances must be safety tested. Timescale for action 31.7.05 2. OP38 13 31.12.05 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. Refer to Standard OP36 Good Practice Recommendations Teaching sessions relating to the changing needs of the residents should be recorded. Ashleigh Manor D52-D04 S3570 Ashleigh Manor V214585 100605 Stage 4.doc Version 1.20 Page 17 Commission for Social Care Inspection Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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