Inspection on 07/05/08 for Ashleigh Nursing Home

This inspection was carried out on 7th May 2008.

CSCI found this care home to be providing an Adequate service.

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 Nursing Home 15/08/07

Ashleigh Nursing Home 14/03/07

Ashleigh Nursing Home 13/06/06

Ashleigh Nursing Home 11/08/05

Ashleigh Nursing Home 10/05/05

Ashleigh Nursing Home 30/09/04

Ashleigh Nursing Home 21/06/04

Ashleigh Nursing Home 18/03/04

Similar services:

Hillside

Applegarth

Trevayler Residential Care Home

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Ashleigh Nursing Home 17 Ashleigh Road Off Narborough Road Leicester Leicestershire LE3 0FA Lead Inspector Debbie Williams Unannounced Inspection 7th May 2008 09:30 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 Nursing Home DS0000001885.V364083.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 Nursing Home DS0000001885.V364083.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashleigh Nursing Home Address 17 Ashleigh Road Off Narborough Road Leicester Leicestershire LE3 0FA 0116 2854576 0116 2854576 ash_ashleigh@btconnect.com 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) 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 DS0000001885.V364083.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia - Code DE Mental Disorder - Code MD A named person under Code LD (1) The maximum number of service users who can be accommodated is: 21 15th August 2007 2. Date of last inspection 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. Accommodation is available to both the ground floor and first floor, this being accessed by a passenger lift. Residents have their own private bedrooms or share in double bedrooms. All areas of the premises 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. The current range of fees charged fall between £291 and £475 per week. A copy of the last inspection report was available at the home. Ashleigh Nursing Home DS0000001885.V364083.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This inspection took place over three and a half hours on the 7th of May 2008. This inspection was positive, as the providers were able to demonstrate they were working hard to meet previous requirements made at the last key inspection and in many areas had achieved this. The main method of inspection was called ‘case tracking’ which meant selecting three residents and tracking the quality of their care by checking records, discussion with them and with staff and observation of care practices. Residents case tracked were unable to fully participate in discussion about the service due to communication difficulties. Two relatives and one staff member were spoken with and the manager and the owner of the home were also available for discussion and feedback throughout the inspection. Staff records were looked at to make sure staff get the training they need and checks are carried out on staff before they commence their employment. A partial tour of the premises also took place in order to assess environmental standards. What the service does well: The home has a friendly and homely atmosphere; relationships between residents and staff appeared very positive and respectful. Staffing levels were good and this enabled staff to spend time with residents. The management team were approachable and always available, this meant that relatives and staff felt able to raise concerns or make suggestions and they would be taken seriously. The providers and staff were flexible in their approach to care practice and knew resident’s needs and preferences well, therefore individual needs could be met and equality and diversity was promoted and respected. Staff consulted other healthcare professionals (such as psychiatrists and GP’s) for advice and guidance on a regular basis. Therefore people living at the home had good access to healthcare services and received the care they required. Ashleigh Nursing Home DS0000001885.V364083.R01.S.doc Version 5.2 Page 6 Assessment procedures were comprehensive and this ensured that people moving into the home would have their needs met. Staff demonstrated a good understanding and approach to the prevention and treatment of pressure sores. 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. The summary of this inspection report can be made available in other formats on request. Ashleigh Nursing Home DS0000001885.V364083.R01.S.doc Version 5.2 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 Nursing Home DS0000001885.V364083.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1,2,3 and 4. (Standard 6 is not applicable to this service) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are enabled to make an informed choice before moving into the home and only move into the home if their needs can be met. EVIDENCE: A service users guide is provided to all prospective residents and this sets out the range of facilities and services on offer and enables people to make an informed choice about whether to move into the home. A contract is then provided which sets out the terms and conditions of residency. A full needs assessment is carried out by a qualified nurse before admission to the home and this ensures that people only move into the home if their needs Ashleigh Nursing Home DS0000001885.V364083.R01.S.doc Version 5.2 Page 9 can be met. The assessment process is thorough and includes mental and physical health assessments. Individual preferences, cultural, social and recreational needs are also assessed and recorded. People living in the home have dementia or mental health needs. The provider employs one permanent Registered Mental Nurse and said they were currently recruiting more. A qualified nurse is on duty at all times. The specific social, cultural and religious needs of people from ethnic minority communities are catered for and understood. Social services and other relevant professional assessments are incorporated within the assessment process. Risk is also assessed before and at the point of moving into the home and the action staff must take to minimise risk is recorded. Ashleigh Nursing Home DS0000001885.V364083.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the home receive health and personal care that is based on individual need and adheres to safe policies and procedures. People living at the home are treated with dignity and respect EVIDENCE: People who live in the home had individual care plans which addressed their needs. Care plans provided instruction to staff on how to meet physical and psychological needs and how to communicate with individual residents. Care plans were reviewed at least monthly for the majority of the time. Staff were made aware of the importance of maintaining privacy and dignity for people living at the home. Ashleigh Nursing Home DS0000001885.V364083.R01.S.doc Version 5.2 Page 11 Care records seen and relatives spoken with confirmed that people had good access to healthcare services. Interaction observed between staff and residents appeared extremely positive and respectful. One relative said of the staff ‘they are all very kind and nothing is too much trouble’. Equipment for the prevention and treatment of pressure sores was provided and evidence of the successful treatment and healing of a pressure sore was seen. While care plans were in place for nutrition, a nutritional risk assessment was not being used, the providers said that this was being introduced and an example of the tool to be used was seen. Psychological assessment is ongoing within individual care plans. Safe medication management policies and procedures were being followed and this minimised risk for people living at the home. Ashleigh Nursing Home DS0000001885.V364083.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 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. Routines of daily living are made flexible in order to meet individual needs and expectations. Nutritional screening and menu planning would improve health and wellbeing for people living at the home by reducing the risk of malnutrition. EVIDENCE: Assessment and care planning records included the individual preferences, social and cultural needs of people living in the home. Examples of residents being enabled to exercise choice and meet their lifestyle preferences were seen during this inspection. Staff spoken with were able to describe how they ensured that people living in the home were enabled to make choices. Staff are instructed to facilitate activities for people living in the home each day. Entertainers occasionally come into the home. Ashleigh Nursing Home DS0000001885.V364083.R01.S.doc Version 5.2 Page 13 There were no restrictions on visiting and relatives said they were always made welcome at the home. The lunchtime meal served during this inspection was well presented and appeared appetising. Staff assisted residents with their meals in an appropriate and sensitive manner. There was not an actual menu in place, the provider said that catering staff were experimenting with new meals and assessing the reaction of residents, once this had been established then a menu would be developed, a recommendation was made regarding this. Information regarding the special therapeutic diet required by one resident was seen within care records and staff were following the instruction and guidance of the dietetic service for this Specific cultural/religious diets were being provided. Ashleigh Nursing Home DS0000001885.V364083.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Policies and procedures in place afford protection for people living in the home and minimise risk. EVIDENCE: The service has a complaints policy that is accessible to relatives and staff Care plans were in place for the management of challenging behaviour. Staff and residents spoken with felt that management were approachable and that complaints would be taken seriously. A thematic probe regarding safeguarding procedures was carried out during this inspection, this meant that specific questions were asked about recruitment and safeguarding procedures. We found that recruitment procedures ensured that all relevant employment checks were carried out before new staff commenced employment at the home. Although providers and staff had not received formal training regarding safeguarding, staff spoken with were aware of the correct procedures to follow in the event of suspected abuse. The providers said that safeguarding training was part of the training and development plan for managers and staff and that this training was forthcoming. Ashleigh Nursing Home DS0000001885.V364083.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Although a programme of refurbishment was underway, not all areas of the home were clean and well maintained. EVIDENCE: There was an ongoing programme of decoration and refurbishment and a maintenance person who also had responsibility for redecoration had recently been employed. New bedroom furniture had recently been provided and this included some electric profiling beds. Bedrooms seen appeared homely and were personalised. Ashleigh Nursing Home DS0000001885.V364083.R01.S.doc Version 5.2 Page 16 The provider said that new chairs for the lounges were on order. New floor covering, a new shower accessible for people with a disability and a new call bell system had also been fitted prior to this inspection. Redecoration was in progress during this inspection and the provider was aware of the areas that required attention, this included scratched paintwork in many of the corridor areas. A requirement was made at the last key inspection regarding the need for redecoration and refurbishment, this requirement remains unmet. There was an offensive odour in one bedroom and a requirement was made regarding this. All other areas of the home seen appeared clean and fresh. Ashleigh Nursing Home DS0000001885.V364083.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home are cared for by competent staff and are protected by recruitment policy and practices. EVIDENCE: An ongoing staff training and development programme was in place and this included induction training for when staff first commence employment. Induction training was in line with National Training Organisation specifications. A programme of National Vocational Qualifications in care was in place. Recruitment procedures were thorough and afforded protection for people living at the home. Staffing numbers and skill mix appeared to meet the needs of people living at the home. Ashleigh Nursing Home DS0000001885.V364083.R01.S.doc Version 5.2 Page 18 Staff spoken with felt they received the training they required to do their job and relatives spoken with felt that staff were competent. Ashleigh Nursing Home DS0000001885.V364083.R01.S.doc Version 5.2 Page 19 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): Standards 31,32,33,35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is run in the best interest of residents but improved risk assessment and quality assurance would ensure that a quality service was provided and health, safety and welfare protected. EVIDENCE: Risk assessment is part of the assessment and care planning procedure for individual residents. Ashleigh Nursing Home DS0000001885.V364083.R01.S.doc Version 5.2 Page 20 Risk assessments for the environment and premises were not being formally recorded, a requirement was made regarding this in order to ensure that people living in the home are kept safe. A quality assurance programme was in place to seek the views of residents and their relatives, a requirement was made that quality assurance systems be expanded to include systematic cycle of review and self monitoring, this is to ensure that people living in the home receive a quality service. Staff spoken with felt the management team were approachable. Staff meetings were regularly held. The provider said there had not been a resident/relative meeting for some time but that people could speak to staff or the management team at anytime, relatives spoken with agreed with this. Staff receive all mandatory health and safety training and were aware of health and safety policies and procedures. Policies and procedures were in place regarding the handling of residents money, this minimised the potential for financial abuse for people living in the home. Ashleigh Nursing Home DS0000001885.V364083.R01.S.doc Version 5.2 Page 21 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 3 x 3 3 x 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 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 1 x x x x x x 1 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 3 3 2 x 3 x 3 2 Ashleigh Nursing Home DS0000001885.V364083.R01.S.doc Version 5.2 Page 22 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 Requirement Ensure nutritional screening is carried out and kept under review for residents that have identified nutritional and dietary needs. This is to safeguard residents’ health and wellbeing. This was made a requirement at the last key inspection and remains unmet. 2. OP19 23 The programme of refurbishment 30/06/08 and redecoration must continue until all areas of the home are brought up to a reasonable standard and an attractive and comfortable environment is provided. This was made a requirement at the last key inspection and remains unmet. 3. OP26 23 The offensive odour identified during this inspection must be eradicated. 30/05/08 Timescale for action 30/05/08 Ashleigh Nursing Home DS0000001885.V364083.R01.S.doc Version 5.2 Page 23 4. OP38 23 Risk assessments should be carried out for the premises, environment and safe working practices. This should include the testing of hot water to ensure it is delivered at safe temperatures. 30/06/08 5. OP33 24 Quality assurance and quality 30/07/08 monitoring systems should be expanded to include a systematic cycle of review and selfmonitoring. This should cover all areas of care provided including the management of medication. 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 OP15 Good Practice Recommendations A menu should be in place (changed regularly), this should offer a choice of meals which are suitable for people living at the home and provide a nutritionally balanced diet. Ashleigh Nursing Home DS0000001885.V364083.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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. 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