Inspection on 19/10/05 for Ashleigh Manor

This inspection was carried out on 19th 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 Manor 05/10/09

Ashleigh Manor 08/04/09

Ashleigh Manor 13/10/08

Ashleigh Manor 20/11/07

Ashleigh Manor 19/04/07

Ashleigh Manor 19/05/06

Ashleigh Manor 10/06/05

Ashleigh Manor 15/12/04

Ashleigh Manor 18/06/04

Ashleigh Manor 03/02/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE Ashleigh Manor 1 & 3 Vicarage Road Plympton Plymouth PL7 4JU Lead Inspector Jane Gurnell Unannounced 19th October 2005 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 V241948 181005 Stage 4.doc Version 1.40 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 Old age, not falling within any other category registration, with number (38), Dementia (38), Physical Disability (38) of places Ashleigh Manor D52-D04 S3570 Ashleigh Manor V241948 181005 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Five residents Category PD 50yrs Date of last inspection 10.6.05 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 V241948 181005 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place on 19th October 2005. The focus of the inspection was to consult with the residents and to review the care planning process. Mrs Carol Mills, the Assistant Manager, was present and she and her staff team assisted the inspector throughout the inspection. The inspector spoke to 17 residents and 4 visitors, toured the building and examined the care plans and documentation relating to the management of the care home. Residents and visitors praised the staff for their care and attention. 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 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 V241948 181005 Stage 4.doc Version 1.40 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 V241948 181005 Stage 4.doc Version 1.40 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) 3, 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. EVIDENCE: One newly admitted resident and her family said they were very pleased with the care and support provided at Ashleigh Manor. A pre-admission assessment was documented and the resident confirmed that they had been able to visit the home prior to making a decision to move in. Ashleigh Manor D52-D04 S3570 Ashleigh Manor V241948 181005 Stage 4.doc Version 1.40 Page 8 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 standard(s) 7, 8, 10 Residents’ health, personal and social care needs are being met and residents are treated respectfully. 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 sought for residents from the Community Mental Health Team, District Nurse and Continence Advisor, and this was evident in 2 of the care plans sampled. Records of accidents were well maintained and reviewed by the Registered Provider: there did not appear to be a pattern of accidents. Ashleigh Manor D52-D04 S3570 Ashleigh Manor V241948 181005 Stage 4.doc Version 1.40 Page 9 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 standard(s) 13, 15 Relatives and friends can be confident that they are welcome at Ashleigh Manor and that their relationships with the residents will be supported. Meals are nutritious and varied. EVIDENCE: Those visitors spoken to by the inspector said that the Registered Providers and the staff made them very welcome. Family members said they were kept fully informed of their relative’s care needs. Residents said that the meals were very good; at the time of the inspection residents were enjoying a roast pork meal with fresh vegetables and a selection of desserts. Four dining rooms ensure that residents can take their meals in a pleasant and homely environment rather than a room large enough to accommodate 38 residents. Ashleigh Manor D52-D04 S3570 Ashleigh Manor V241948 181005 Stage 4.doc Version 1.40 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 Complaints and suggestions from residents, relatives or other visitors to the home, are treated seriously. Residents are listened to and issues resolved promptly. EVIDENCE: Residents and visitors said that the Registered Providers and the care staff are very approachable and they were confident that any issues of concern would be dealt with promptly. There have been no complaints since the last inspection. Ashleigh Manor D52-D04 S3570 Ashleigh Manor V241948 181005 Stage 4.doc Version 1.40 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, 24, 25, 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. The laundry room was found to be clean and tidy, however several baskets of wet, clean washing were waiting to be dried: consideration should be given to providing a further tumble drier. 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. The remainder of radiators identified a posing a risk of burns to residents have been covered. Ashleigh Manor D52-D04 S3570 Ashleigh Manor V241948 181005 Stage 4.doc Version 1.40 Page 12 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 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, 29, 30 Residents are cared for by 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 indicating that there are sufficient staff to meet the needs of those currently living in the home. Care staff are supported by catering, laundry and domestic staff. The file of a newly appointed member of staff was examined: an application form and 2 written references were evident. Mrs Lawley, the administrator, confirmed that a Criminal Bureau Records disclosure had been applied for, although there was no evidence of this or the accompanying ID checks on the file. The member of staff confirmed that they remained working under supervision. An in-house induction-training programme for new staff was provided and the Registered Providers should consult with their training provider to ensure that it meets the National Training Organisation’s specifications. Ashleigh Manor D52-D04 S3570 Ashleigh Manor V241948 181005 Stage 4.doc Version 1.40 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) 31, 32, 35, 38 Residents live in a well managed home. The Registered Providers and the staff team strive to provide a 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. Ashleigh Manor is owned by Mrs Lawley and her daughter, Mrs Mayer-Lawley, both of whom have many years experience in managing the care home: Mrs Maher-Lawley has achieved the Registered Manager’s Award. Mrs Lawley is the Department of Works and Pension appointee for one resident and these financial arrangements are kept separate from those of the care home. The kitchen was found to be clean and tidy indicating that regular cleaning takes place. It was, however, very hot while the midday meal was being prepared. The chef explained that the extractor fans were not working but the repair work was in hand: an additional fan had been provided. Records of Ashleigh Manor D52-D04 S3570 Ashleigh Manor V241948 181005 Stage 4.doc Version 1.40 Page 14 fridge, freezer and cooked food temperatures were recorded daily indicating that regular monitoring was being undertaken. The carpet in the extension hallway was found to be ill-fitting causing a trip hazard. 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 aware of the procedure should a fire be discovered. Mrs Mills, the Assistant manager, confirmed that although the equipment had been purchased the portable appliance testing had not yet been undertaken. Those windows above ground level identified as posing a risk to residents had been fitted with opening restrictors: a discussion was held regarding fitting restrictors to all windows above ground level. Ashleigh Manor D52-D04 S3570 Ashleigh Manor V241948 181005 Stage 4.doc Version 1.40 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. 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 x x 3 x 3 x 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 x 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 x x x 3 3 3 STAFFING Standard No Score 27 3 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 3 3 x x 3 x x 2 Ashleigh Manor D52-D04 S3570 Ashleigh Manor V241948 181005 Stage 4.doc Version 1.40 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. 2. 3. 4. 5. Standard OP29 OP38 OP38 OP38 Regulation 19 16 13 13 Requirement Timescale for action 19.10.05 Documentation relating employment must be available at all times. The extractor fans in the kitchen 31.10.05 must be repaired. The hallway carpet in the 31.10.05 extension must be made safe. Portable electrical appliances 31.12.05 must be safety tested. 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 OP30 Good Practice Recommendations Registered Providers should consult with their training provider to ensure that the induction programme for new staff meets the National Training Organisation’s specifications. Ashleigh Manor D52-D04 S3570 Ashleigh Manor V241948 181005 Stage 4.doc Version 1.40 Page 17 Commission for Social Care Inspection Unit D1 Linhay Business Park Ashburton Devon, TQ13 7UP 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. Extracts may not be used or reproduced without the express permission of CSCI Ashleigh Manor D52-D04 S3570 Ashleigh Manor V241948 181005 Stage 4.doc Version 1.40 Page 18 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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