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Inspection on 11/08/05 for Ashleigh Nursing Home

Also see our care home review for Ashleigh Nursing Home for more information

This inspection was carried out on 11th August 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home has a friendly and relaxed atmosphere. Staff employed at the home have a good understanding of the residents individual care needs and they offer support in a professional and dignified manner. Staff have a good understanding of adult protection and are aware of what to do should they suspect anything untoward. Professional input is sought on a regular basis ensuring the residents get the appropriate care that they need. All staff stated that they were well supported by management and both the residents and staff benefit from the family ethos that was evident throughout the home.

What has improved since the last inspection?

Appraisals and supervision sessions have now commenced and these are to be offered to all staff on a regular basis. A number of residents rooms have been decorated and an on going decoration programme is in place.New perimeter gates have been installed and further work to install trellising along the side and back wall at the rear of the home is planned. A number of pressure relieving mattresses have been purchased.

What the care home could do better:

If all appropriate risk assessments were completed and reviewed possible risks to resident`s health and welfare could be identified, monitored and acted upon. Ensure that creams/preparations prescribed for residents are not given to other residents to use. All records held in the home must be up to date and accurate to ensure that the health and safety of the residents is maintained at all times. Notify the Commission for Social Care Inspection of any incidents or injuries that affect a residents` well being as reqiured under Regulation 37 of the Care Standards Act 2000.

CARE HOMES FOR OLDER PEOPLE Ashleigh Nursing Home 17 Ashleigh Road off Narborough Road Leicester LE3 0FA Lead Inspector Diane Butler Unannounced 11 August 2005 9:30 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 Nursing Home C51 C01 S1885 Ashleigh NH V243049 110805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Ashleigh Nursing Home Address 17 Ashleigh Road off Narborough Road Leicester LE3 0FA 0116 2854576 01162854576 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) Mr Ashley Cox Mrs Zarina Cox Mrs Zarina Cox Care Home 21 Category(ies) of Dementia - over 65 years of age (21), Learning registration, with number disability (1), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (21) Ashleigh Nursing Home C51 C01 S1885 Ashleigh NH V243049 110805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. To admit a named person of category LD(55 ) named in variation application No. 1847 dated 12 january 2004. 2. To be able to admit the named person of category DE/LD and under 65 years of age named in variation application No. 20242 date 10 May 2005. Date of last inspection 10/05/05 Brief Description of the Service: Ashleigh Nursing and Residential Home is registered to admit up to 21 people over 65 years of age who have dementia or mental health care needs. The home is situated near to the centre of Leicester and is a short walk away from main bus routes. Accomodation is available on the ground floor and the first floor. Residents have their own private bedrooms or share in double bedrooms. All areas of the premsies are accessible for people with mobility impairments. The rear of the building offers a small garden area with a patio.The laundry facilities are situated in a separate building. All external doors are alarmed. Ashleigh Nursing Home C51 C01 S1885 Ashleigh NH V243049 110805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over four hours and commenced at 9.30am on 11th August 2005. The main method of inspection used was ‘case tracking’ which involved selecting four service users and tracking the care they receive through the checking of their records, discussion with them, the care staff and observation of care practices. The Commission for Social Care Inspection is inspecting Ashleigh Nursing Home for the eighth time and is in its third year of inspections being inspected against the Care Standards Act 2000. A tour of the premises took place and residents were observed in the communal lounges and the dining room. Some residents were not able to express their opinions directly to the inspector due to their dementia care and mental health needs. The registered owner was most helpful during the inspection process. What the service does well: What has improved since the last inspection? Appraisals and supervision sessions have now commenced and these are to be offered to all staff on a regular basis. A number of residents rooms have been decorated and an on going decoration programme is in place. Ashleigh Nursing Home C51 C01 S1885 Ashleigh NH V243049 110805 Stage 4.doc Version 1.40 Page 6 New perimeter gates have been installed and further work to install trellising along the side and back wall at the rear of the home is planned. A number of pressure relieving mattresses have been purchased. 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 Nursing Home C51 C01 S1885 Ashleigh NH V243049 110805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Ashleigh Nursing Home C51 C01 S1885 Ashleigh NH V243049 110805 Stage 4.doc Version 1.40 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 standard(s) 1,2,3,5, Standard 6 was not applicable at the time of the inspection. Prospective residents are given detailed information about the home and its services enabling them to make an informed decision about admission to the home. The admission process in place ensures that the residents identified care needs are met. EVIDENCE: • A statement of purpose/Service User Guide is displayed in the homes reception area. This document includes information about the facilities in the home and the services that can be provided. Four residents files were checked during the inspection. All included an initial needs assessment and the necessary contracts were in place. On speaking with relatives of one the service users case tracked, the inspector was informed that they had had the opportunity to look around the home before deciding whether or not their relative should move in. C51 C01 S1885 Ashleigh NH V243049 110805 Stage 4.doc Version 1.40 Page 9 • • Ashleigh Nursing Home Ashleigh Nursing Home C51 C01 S1885 Ashleigh NH V243049 110805 Stage 4.doc Version 1.40 Page 10 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) 7,8,9,10 Residents are currently looked after well in respect of their health and personal care however lack of risk assessments and risk assessment reviews for some residents could potentially put their health and welfare at risk. EVIDENCE: • • Four residents care files were checked. All included a care plan and all four care plans had recently been reviewed. Evidence was seen of the manager involving a number of professionals in the residents care. These included the Tissue Viability nurse, Speech and Language Therapy team, Occupational Therapist and the Learning Disability service. This is seen as good practice. On checking the risk assessments completed for the four residents case tracked it was noted that not all the relevant risks had been identified. These included the use of cot sides and the use of a wheelchair with out its footplates. It was also noted that some risk assessments had not been reviewed since July 2004. C51 C01 S1885 Ashleigh NH V243049 110805 Stage 4.doc Version 1.40 Page 11 • Ashleigh Nursing Home • The Procedures for the administration of medication were in order with all paperwork completed appropriately. On checking the room belonging to one of the resident’s case tracked it was noted that E45 cream and Irriclens solution prescribed for other residents were being used. Discussion with relatives and staff and observations during the inspection showed that the staff had a good awareness of how to ensure residents privacy and dignity is maintained. • Ashleigh Nursing Home C51 C01 S1885 Ashleigh NH V243049 110805 Stage 4.doc Version 1.40 Page 12 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) 12,13,14,15 Visiting is encouraged to enable residents to maintain contact with family and friends and residents are helped to exercise choices on a daily basis. EVIDENCE: • Family and friends are encouraged to visit the residents. Comments made by a visitor during the inspection included: “The care is excellent, I’m very pleased” “I can come any time and am always made welcome” • Choices are offered to residents on a daily basis including what to wear, when to retire to bed, what and where to eat lunch and whether to join in activities. A musical entertainer arrived to entertain the residents during the inspection. The meal seen on the day of the inspection was well presented and appealing in appearance. • Ashleigh Nursing Home C51 C01 S1885 Ashleigh NH V243049 110805 Stage 4.doc Version 1.40 Page 13 Ashleigh Nursing Home C51 C01 S1885 Ashleigh NH V243049 110805 Stage 4.doc Version 1.40 Page 14 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) 16,18 Arrangements for the receiving and responding to complaints are sound resulting in satisfactory protection of resident’s rights. Staff awareness of actions to take should any form of abuse be suspected ensures protection of the residents in their care. EVIDENCE: • There is a complaints procedure in place. A copy of this can be found in the homes reception area and a copy is also included in the homes Statement of Purpose/Service User Guide document. Staff spoken with during the inspection were all aware of what to do should they suspect any act of abuse and the registered owner was aware of the procedure to follow with regard to adult protection. • Ashleigh Nursing Home C51 C01 S1885 Ashleigh NH V243049 110805 Stage 4.doc Version 1.40 Page 15 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) 19,22,23,24,26 The standard of the environment within this home is on the whole good providing residents with a comfortable and homely place to live. EVIDENCE: • The home is appropriately maintained and suited to the residents needs. The communal areas are decorated and furnished to a standard that creates a comfortable and homely environment. It was noted whilst walking around the home that there were a number of areas in need of decoration. This included an area on the 2nd floor of the home next to the bathroom, a number of doorways and the room belonging to one of the resident’s case tracked. The registered owner explained that an ongoing decoration programme was in place to address these decoration issues. A double bedroom on the ground floor was being redecorated on the day of the inspection. C51 C01 S1885 Ashleigh NH V243049 110805 Stage 4.doc Version 1.40 Page 16 • Ashleigh Nursing Home • The floor covering in the ground floor bathroom has been replaced and the registered owner stated that it was his intention to replace the flooring in the downstairs corridor currently taped with black and yellow tape in the near future. Personal possessions were evident in the rooms that were checked and specialist equipment including a hospital bed and pressure mattress were in place. On checking the laundry facilities it was noted that there were no hand washing facilities. The laundry assistant explained that she would always wear protective gloves when dealing with the laundry to prevent any infection. • • Ashleigh Nursing Home C51 C01 S1885 Ashleigh NH V243049 110805 Stage 4.doc Version 1.40 Page 17 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) 27,28,29 Staff are employed in sufficient numbers to meet the current needs of the residents. EVIDENCE: • There were sufficient numbers of staff on duty on the day of the inspection to meet the current needs of the residents. Staff spoken with confirmed this and felt they were able to care for the residents without feeling rushed. All the staff on duty were aware of the care needs of the residents and had the appropriate training to look after those residents in their care. Access to staff files was not available on the day of the inspection though the registered owner confirmed that the appropriate checks had taken place for all staff working at the home. These include the collection of two references and a suitable Criminal Records Bureau check. Staff spoken with confirmed that these checks had been carried out. • • Ashleigh Nursing Home C51 C01 S1885 Ashleigh NH V243049 110805 Stage 4.doc Version 1.40 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 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) 31,32,33,35,37,38 The home is managed efficiently and appropriate policies and procedures are in place to ensure the continued safety of the residents. EVIDENCE: • • All staff spoken with felt extremely well supported by the registered owner, the registered manager and the care manager. It was evident during the inspection that the residents benefit from the ethos, leadership and management that the registered owners and care manager provides. The necessary policies and procedures are in place and staff are aware of how to access them. C51 C01 S1885 Ashleigh NH V243049 110805 Stage 4.doc Version 1.40 Page 19 • Ashleigh Nursing Home • The registered owner explained that appraisals and supervisions have now commenced. This was confirmed on discussion with staff on duty during the inspection. On inspection of the accident book it was noted that one resident had had three falls in a short period of time, with one of these falls resulting in the home calling for an ambulance. On inspection of the daily records it was noted that only one of these falls had been recorded. It was also noted that the home had not notified The Commission for Social Care Inspection as required under Regulation 37 of the Care Standards Act 2000 regarding this resident being taken to hospital or with regard to another resident who was also taken to hospital. • • Ashleigh Nursing Home C51 C01 S1885 Ashleigh NH V243049 110805 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x 3 3 3 x 3 STAFFING Standard No Score 27 3 28 3 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 3 x 3 x 2 2 Ashleigh Nursing Home C51 C01 S1885 Ashleigh NH V243049 110805 Stage 4.doc Version 1.40 Page 21 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 8 Regulation 13 Requirement 1)The Registered Person must ensure that all the necessary risk assessments are completed to ensure the safety of the resident and act on the findings. Timescale for action 12/09/05 2. 9 13 3. 37 17 4. 38 37 2)The Registered Person must ensure that all risk assessments are appropriately reviewed. The registered Person must 20/08/05 ensure that all creams/preparations etc are only used by the residents they are prescribed for. The registered Person must 20/08/05 ensure that records held with regard to residents in their care are maintained, up to date and accurate The registered person must 20/08/05 notify the Commission for Social Care Inspection of any incidents or injuries that affect a residents well being. Ashleigh Nursing Home C51 C01 S1885 Ashleigh NH V243049 110805 Stage 4.doc Version 1.40 Page 22 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 7 Good Practice Recommendations The Registered person should clear any irrelevant information from the resident care plans to allow the reader a clearer understanding of the current needs of the residents. Ashleigh Nursing Home C51 C01 S1885 Ashleigh NH V243049 110805 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection 5 Smith Way Grove Park Enderby Leicestershire LE19 1SX 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 Nursing Home C51 C01 S1885 Ashleigh NH V243049 110805 Stage 4.doc Version 1.40 Page 24 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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