Inspection on 14/10/05 for Ashleigh Residential Home

This inspection was carried out on 14th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 Residential Home 19/01/07

Ashleigh Residential Home 30/05/06

Ashleigh Residential Home 09/05/05

Ashleigh Residential Home 19/10/04

Ashleigh Residential Home 21/07/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Ashleigh Residential Home Ashleigh Residential Home 60 Stile Common Road Primrose Hill Huddersfield HD4 6DE Lead Inspector Jacinta Lockwood Unannounced Inspection 14th October 2005 11.30 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 Residential Home DS0000060145.V258934.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ashleigh Residential Home DS0000060145.V258934.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ashleigh Residential Home Address Ashleigh Residential Home 60 Stile Common Road Primrose Hill Huddersfield HD4 6DE 01484 514291 01484 515532 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) Eldercare (Halifax) Ltd Mrs Sarah Rose Hirst Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Ashleigh Residential Home DS0000060145.V258934.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th May 2005 Brief Description of the Service: Ashleigh was purchased by Eldercare (Halifax) Limited, a small local company, in May 2004. The home was originally registered to provide personal care and accommodation for up to 33 older people, but at the providers request the registration was reduced to 25 in May 2005. Ashleigh is a stone built detached property with a purpose built extension. There are gardens around the home and car parking at the front. The home offers accommodation on two floors with several lounge/dining areas. A passenger lift provides access to the first floor. The home is located approximately 2 miles from Huddersfield town centre and is accessible for public transport and local shops. Ashleigh Residential Home DS0000060145.V258934.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this inspection on 14 October 2005. It started at 11:30 and ended at 18:45. The following inspection methods were used: discussion with service users, staff and management. Five comment cards were received from healthcare professionals. A sample of records were inspected, including care plans, risk assessments, accident log, medication, staffing rota, staff training, staff meeting minutes and some policies and procedures. A limited tour was made of the building. A follow up visit was made to the home on 30 August to check progress with meeting requirements made in the report dated 9 May regarding care planning, medication, hygiene, staffing and call bell leads. Little action has been taken to address the shortfalls in care planning for identified service users. The registered manager said staffing difficulties have been an issue. A meeting has been held with the responsible individual and the assistant group care manager to discuss issues of concern regarding the home. The Commission will monitor action taken to address the requirements and recommendations made in this report. What the service does well: What has improved since the last inspection? Some requirements and recommendations have been addressed. There has been some improvement to the operation of the medication system. Call leads are now available to all points in the ground floor lounge areas. Ashleigh Residential Home DS0000060145.V258934.R01.S.doc Version 5.0 Page 6 The manager has recently arranged for a member of the care team to engage service users in activities on an afternoon pending recruitment of an activities organiser. 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 Residential Home DS0000060145.V258934.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ashleigh Residential Home DS0000060145.V258934.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were assessed on this inspection. EVIDENCE: Ashleigh Residential Home DS0000060145.V258934.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Limited progress has been made on improving arrangements to ensure that the welfare and health care needs of service users are identified and met. These shortfalls have a potential to place service users at risk. EVIDENCE: Individual plans of care were available, but little progress has been made on the requirement to ensure that all aspects of health, personal and social care needs are identified and planned for. Plans lack specific detail as to how the service user’s needs are to be met. They are not up-to-date and are not being reviewed on a regular, monthly basis. There are significant gaps in daily recording and available entries gave little indication of how well the care plan is working and the actual care given. Some risk assessments were available, but not all identified risks had been assessed. Action had also not been taken to assess and plan for a risk, identified during the follow up visit on 30 August 2005, regarding an aspect of a service user’s behaviour and the potential risk of this behaviour to other service users. Ashleigh Residential Home DS0000060145.V258934.R01.S.doc Version 5.0 Page 10 Record keeping is poor. Monitoring records, for example, regarding fluid input and output are not completed on a consistent basis. The daily report for one service user on a fluid chart raised a concern but there was no indication that any follow up action was taken to address this. Where records were maintained, action was not being taken in response to the findings. For example, weight records for a service user previously identified as being at risk from weight loss, show a further recent loss of weight but there was no evidence that action was being taken to manage this risk and so secure the service user’s health and welfare. There were mixed responses from healthcare professionals as to whether staff demonstrated a clear understanding of service users’ care needs and whether the home communicates clearly with and works in partnership with them. Discussion with staff suggested that some needs were being addressed even though there was a lack of clear plans and guidance. Verbal communication systems are insufficient. A member of staff was not aware of a recent visit by a healthcare professional and the advice given. Previous concerns have been raised about the management of the home’s medication system. New supplies of service users’ medication had been started and records were satisfactory. However, the drugs returns book had not been completed since April 2005 although, according to the registered manager, drugs had been returned to the chemist for destruction. Although staff responsible for drug administration receive relevant training, the stock balance in the controlled drugs register had been altered in a manner that is not consistent with good record keeping practices. Ashleigh Residential Home DS0000060145.V258934.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 More work needs to be done to ensure that the lifestyle experienced by service users meets their social and recreational interests and needs. Service users are helped to exercise choice and to maintain contact with family, friends and the local community. EVIDENCE: At the time of the last inspection it was reported that an activities organiser was due to start working at the home. However, the post is now vacant. In the meantime care staff provide activities. An activities programme is displayed on the notice board. A service user spoke excitedly about a recent trip to the local coal-mining museum and said she’d “loved it” while showing the inspector photographs of the visit displayed on the notice board. A clothes party has been arranged for 20 October. Some service users were seen reading magazines and the local paper, which is delivered daily to the home, and it was positive to see service users discussing news items. A small library of large print books is also available. At the time of this inspection, staff encouraged service users to join in the singing of old time songs, which they clearly enjoyed. This activity had a positive and settling effect on a service user, who up until the activity started was unsettled and whose behaviour was causing other service users to become Ashleigh Residential Home DS0000060145.V258934.R01.S.doc Version 5.0 Page 12 agitated. Another service user expressed boredom, saying, “There was nothing to do”. A service user spoke of going to the shops and for a coffee in the town centre with staff. A minister of religion visits the home on a regular basis and a parish magazine was available to service users. Service user social care plans need development to ensure that their individual preferences are identified and met. Entries on the record of activities engaged in by service users were sparse. One service user’s care plan notes that he should have one to one contact time with staff to ensure that he does not become isolated but there was little evidence that this was happening. Service users confirmed that there was choice and flexibility with regard to times of rising and retiring and service users who were able, moved freely around the home. Service users were offered a choice of food and drinks by staff. Service users confirmed that they are able to maintain links with the local community, family and friends and that visits can be held in private. The majority of healthcare professionals indicated that they are able to see their patients in private when they visit the home but that a senior member of staff was not always available for them to confer with about the care of service users. Standard 15 was only assessed to follow up a previous requirement regarding the kitchen area of the home. However, service users did make positive comments about the food provided at the home. A satisfactory report has recently been received from an Environmental Health Officer. The registered manager explained that, following the visit, the kitchen floor was water damaged and that action was being taken to address this. Ashleigh Residential Home DS0000060145.V258934.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Some systems are in place to ensure that service users are protected from potential abuse, but a lack of staff awareness and training means that service users are not fully protected from the potential risk of abuse. EVIDENCE: The majority of staff have now received adult protection awareness training. Further training is being arranged. Staff gave examples of what they would see as abuse and the action they would take. It was evident from discussion with staff and records that there have been adult protection incidents of aggression or inappropriate sexual behaviour by some service users. A member of staff explained that a service user had to be restrained on one occasion. This is a cause for concern. It was also evident from discussion with another member of staff that being hit by service users is seen as ‘part of the job’. It would appear that staff are doing what they can to manage these behaviours, but staff need to receive appropriate training, support and guidance when caring for service users, some of whom are exhibiting challenging behaviours. Authorities such as the Commission for Social Care Inspection and the local authority adult protection team must also be notified of incidents and allegations involving service users, as appropriate. This is not happening in all cases. A policy on abuse is available to staff. However, the policy should be amended to include the up-to-date contact telephone number for reporting incidents or Ashleigh Residential Home DS0000060145.V258934.R01.S.doc Version 5.0 Page 14 allegations of abuse. The policy should also be reviewed to incorporate the possibility that there may be incidents of service user on service user abuse. Ashleigh Residential Home DS0000060145.V258934.R01.S.doc Version 5.0 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 the following standard(s): 19, 22, 25, 26 Service users live in a generally safe, well maintained environment, which is clean, pleasant and generally odour free. EVIDENCE: The home is generally well maintained. Redecoration is ongoing and is of a good standard. Service users expressed satisfaction with the accommodation provided. The fire detection system has been checked by a competent person and is compliant. However, evidence should be provided to the Commission that the completed fire safety works identified in the fire officer’s report dated 16.10.03 meets the requirements of the fire authority. Standard 22 was only assessed in relation to the availability of call leads in the lounge areas. Call leads were in place on the day of the inspection. Ashleigh Residential Home DS0000060145.V258934.R01.S.doc Version 5.0 Page 16 Standard 25 was only assessed to determine precautions against the prevention of risks from Legionella. Arrangements have been assessed by a competent person and found to be satisfactory. Water temperature checks are carried out and records show that these are within safe limits. The home was clean, tidy and generally odour free throughout. However, there was an odour of urine in one of the lounge areas. The registered manager explained that they were having difficulty managing the continence of a service user. Where continence is an issue, management arrangements should be reviewed so that service user and the area in which service users sit do not smell of urine. The bath hoist on the ground floor, the coating of which needs repairing or replacing, has been swopped with the hoist from the first floor. Cleaning arrangements should be reviewed, as the design of the bath seat now in the ground floor bathroom makes cleaning the inside of the seat support difficult and prevents the promotion of good hygiene. Ashleigh Residential Home DS0000060145.V258934.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 Staffing levels were adequate, but not all the needs of service users were being adequately met. The provision and completion of relevant staff training together with support and guidance to staff should provide them with the skills and knowledge necessary to meet the needs of current service users. EVIDENCE: There were 21 service users in residence at the time of the inspection. Staffing levels were adequate with three carers on the morning and afternoon shift and two wakeful night staff. An on-call system is also in operation. Staff vacancies are being recruited to. The manager’s hours are supernumery although she has been covering care shifts owing to current staff vacancies. Staff interviews were taking place on the day of the inspection. Although staffing levels were adequate for the number of service users in residence and staff training is ongoing, there is evidence to suggest that not all the needs of current service users are being adequately met. It was noted at the time of the follow up visit on 30 August and during this inspection that service users were not being adequately supervised by staff and were being left for lengthy periods of time without staff being available to provide support. Ashleigh Residential Home DS0000060145.V258934.R01.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 The manager is experiencing difficulty in managing the home so that it meets the requirements of The Care Homes Regulations 2001 and the National Minimum Standards for Older People. EVIDENCE: Mrs Sarah Hirst is the registered manager. Mrs Hirst has experience of working in a senior position with older people in a residential setting. It is evident from the findings of this and previous inspections that Mrs Hirst is finding it difficult to fully discharge her responsibilities. Mrs Hirst explained that she is receiving support from her line manager to help her to develop in her management role. This support, together with completion of the NVQ 4 in management and care and the Registered Manager’s Award should assist Mrs Hirst in developing her management skills and knowledge. Ashleigh Residential Home DS0000060145.V258934.R01.S.doc Version 5.0 Page 19 Standard 38 was not assessed during this inspection. However, it was evident from the home’s accident log that accidents sustained by service users and requiring treatment were not being reported to the Commission as required. Ashleigh Residential Home DS0000060145.V258934.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 1 2 X X 3 X X 3 2 STAFFING Standard No Score 27 1 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X X X X X X X Ashleigh Residential Home DS0000060145.V258934.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement The registered person shall prepare a written plan as to how service users assessed needs are to be met. The plan must be in sufficient detail to provide clear guidance to staff on the actions to be taken by them to meet service users health, welfare and social care needs. (Timescales of 21.07.04, 01.11.04, and 10.08.05 not met) Risk assessments must be undertaken for all service users where there is an identified risk and, as far as possible, the risk eliminated. Timely advice must be sought from relevant healthcare professionals where appropriate, for example, when a service user is experiencing continued weight loss or concerns are noted. The kitchen floor covering must be repaired or replaced. Those staff who have not yet done so, must receive training in the protection of vulnerable adults. (Timescale of 15.10.03, 21.07.04 and 10.08.05 not fully DS0000060145.V258934.R01.S.doc Timescale for action 18/11/05 2. OP7 13(4)(c) 18/11/05 3. OP8 13(1)(b) 18/11/05 4. 5. OP15 OP18 16(2)(j) 13(6) 18/11/05 18/11/05 Ashleigh Residential Home Version 5.0 Page 22 6. 7. 8. OP18 OP18 OP26 13(6) 37(1) 17(1)(a) Sch3(3) (p) 16(2)(c) 9. OP27 18(1)(c) (i) 10. OP31 9(2)(b)(i) 11. OP33 24 12. OP38 37 met). All adult protection incidents must be reported to the relevant authorities. A record must be kept of any physical restraint used on a service user. Bath hoists must be thoroughly cleaned and maintained. (Timescale of 21.07.04, 15.11.04 and 10.06.05 not fully met). Current staff who have not yet done so, must receive all mandatory training. (Timescale of 15.11.04 and 15.09.05 not met). The registered manager must manage the home so that the health, safety and welfare of service users is promoted and maintained. The quality of care provided at the home must be reviewed and any report made available to service users and a copy supplied to the Commission (Timescales of 15.10.03, 21.07.04 and 30.11.04 not fully met). Standard not assessed on this occasion. Accidents to service users requiring treatment must be reported to the Commission as required under Regulation 37 of The Care Homes Regulations 2001. 14/11/05 14/11/05 14/11/05 14/01/06 14/11/05 10/08/05 14/11/05 Ashleigh Residential Home DS0000060145.V258934.R01.S.doc Version 5.0 Page 23 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. 2. 3. 4. 5. 6. Refer to Standard OP7 OP7 OP7 OP9 OP9 OP12 Good Practice Recommendations Care plans should be signed by service users or their representatives to evidence their involvement. Care plans, including risk assessments, should be reviewed on a monthly basis. To ensure that service users’ needs are met, staff should implement care plans. Medication records should be maintained in accordance with good record keeping principles. Medication returned to the supplying pharmacist for destruction should be recorded in the drugs returns book. A varied activities programme should be implemented which meets service users expectations, choices and preferences. (Recommendation carried forward from 21.07.04, 19.10.04 and 09.05.05). Urine odours should be eliminated. The homes recruitment policy and procedure should be followed regarding gaps in employment history. Standard not assessed on this occasion. 7. 8. OP26 OP29 Ashleigh Residential Home DS0000060145.V258934.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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 Residential Home DS0000060145.V258934.R01.S.doc Version 5.0 Page 25 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!