Inspection on 30/05/06 for Ashleigh Residential Home

This inspection was carried out on 30th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 14/10/05

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 30th May 2006 09:00 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.V298293.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 Residential Home DS0000060145.V298293.R01.S.doc Version 5.2 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 sarah.hirst@eldercare.org.uk 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.V298293.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21.02.06 Brief Description of the Service: Ashleigh is owned and operated by Eldercare (Halifax) Limited. 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 located approximately 2 miles from Huddersfield town centre and is accessible for public transport and local shops. It is a stone built detached property with a purpose built extension. There are gardens around the home and car parking at the front. There is ramped access to the home. Although not a secure unit, Ashleigh has a coded door lock for entry and exit. The home has one double and twenty-three single bedrooms with en-suite facilities (toilet and wash-hand basin) over two floors. There are three day/quiet rooms and a dining room on the ground floor. One of the day rooms has toilet facilities within and further toilet facilities are located near to the dining area and the two remaining day rooms. A passenger lift provides access to the first floor. Information about the home in the form of a statement of purpose, service user’s guide and the most recent CSCI inspection report are displayed in the home’s entrance area. Copies of these documents can also be requested from the home. On the 12.05.06 the registered person advised that home’s scale of charges were £340.87 to £395.00 per week. Additional charges are made for: hairdressing, chiropody, magazines, newspapers, personal clothing and toiletries. Ashleigh Residential Home DS0000060145.V298293.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors carried out an unannounced site visit at Ashleigh Residential Care Home on 30 May 2006. The inspection started at 9am and ended at 4.55pm. On the day of this visit there were 19 service users in residence. The last main inspection took place on 14 October 2005 and two additional visits were made to the home on 18 November 2005 and 21 February 2006 owing to concerns about poor care planning and care delivery at the home. There were also concerns about the home’s ability to meet the needs of some service users. Since then, some service users have had their needs reassessed and action taken to meet their needs. Progress has also been made with care planning and care delivery. During the site visit, the inspectors spoke with 10 service users some of whom, owing to their frailty, were unable to express their views about the service; a visiting relative, 3 members of care staff, the home’s administrator and the registered manager, Mrs Sarah Hirst. Prior to this visit, questionnaires were sent out to obtain the views of service users, relatives, GPs and health and social care professionals. Surveys were sent to a sample of 10 service users at the home, 3 were returned; their next of kin; four were returned; GPs, two were returned; and social and health care professionals, three were returned. The registered manager also completed and returned the Commission’s pre-inspection questionnaire. The inspection findings are also based on a range of accumulated evidence received by CSCI since the last inspection, including, for example, notifiable incident reports when service users are involved in an accident or incident and monthly management reports from the provider. The care records of four service users were inspected, including care plans, risk assessments, medication, any monies and accounting records held by the home. Other records inspected included the food menu, complaints log, staffing rota, staff recruitment and training records and some policies and procedures. A partial tour of the building was made, including the bedrooms of four service users whose care was case-tracked as part of the inspection. The inspectors would like to thank all those who contributed to the inspection process. Ashleigh Residential Home DS0000060145.V298293.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Improvements must continue with care planning and associated documentation so that assessment, monitoring and specialist information is included and so that service users’ needs are not overlooked by omission. Care plans should contain more detail so that staff have full information to enable them to meet service users’ care and support needs in a consistent manner. Where relatives express a desire to be involved in care planning, arrangements should be made to allow this to happen and their involvement should be recorded. It’s evident from GP surveys that one GP is not satisfied with the service provided at the home. It may be beneficial for the home’s management to consult with GPs who visit the home, so that any issues can be addressed. Service users have a range of diverse needs, some of which are being met, but not all service users feel their needs are being met fully. Improvements need Ashleigh Residential Home DS0000060145.V298293.R01.S.doc Version 5.2 Page 7 to be made to some areas of care related to sensory impairment, so that staff are able to support service users in their daily lives and so that service users do not become socially isolated owing to their disability. Further action needs to be taken to ensure that the home provides activities that meet service users’ needs and capabilities and that this includes religious activities so that service users are stimulated and their daily lives enhanced. More variety should be introduced with regard to food provided and this should include more fresh fruit and vegetables so that service users receive a wellbalanced and varied diet. The dining environment should be improved to create a more pleasing dining experience. Domestic arrangements should be reviewed so that care staff are available to service users over mealtime rather than engaged in domestic duties. Where staffing is needed to cover vacant shifts, appropriate arrangements should be made, so that the home’s manager does not work an excessive number of shifts and so that her hours can be supernumery to allow her to focus on managing the home and to addressing those areas which do not meet minimum standards. The home’s management need to ensure that records are fully completed and up-to-date. And, where appropriate, the Commission should be informed of all incidents, which adversely affect service users, as required by legislation. 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.V298293.R01.S.doc Version 5.2 Page 8 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.V298293.R01.S.doc Version 5.2 Page 9 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): 3, 6 Service users’ needs are assessed before they move into the home and they are assured that these will be met. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Ashleigh does not provide intermediate care. From records, surveys and discussion it’s clear that service users’ needs are assessed before they move into the home. Service users also receive confirmation that the home can meet their needs. Service users and their relatives are welcome to visit the home before making a decision to live there. Two service users confirmed that they had visited the home before deciding to move there; one of whom had also been visited in their own home before admission. One service user commented that the manager showed the service user and family around Ashleigh and that all their questions were answered. Two of the three service user surveys returned noted that a contract had been received; one person wasn’t sure. Ashleigh Residential Home DS0000060145.V298293.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Individual care plans do not identify all service users’ health and social care needs. Not all service users are protected by the home’s medication policies and procedures. Service users are treated with respect and their right to privacy upheld. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Care plans and associated records for four service users were inspected. There have been clear improvements in record keeping and care plans have been reviewed with the service user or relatives’ involvement. Service users or their relative had signed care plans. According to records, one relative indicated a wish to be involved in care planning, but there had been no recorded involvement since May 2005. Five relatives reported that the home kept them informed about important matters. Two service users said that they always receive the care and support they need; one said they usually do. There was a good level of detail in some areas of the care plans, but other areas such as social care, finances and eating and drinking were not Ashleigh Residential Home DS0000060145.V298293.R01.S.doc Version 5.2 Page 11 completed, or sufficiently detailed, in all cases. Issues pertinent to individual service users, such as physical and mental health, did not have a plan of care, even though issues had been noted on the pre-admission assessment and in the daily records. A requirement has been made about this. It’s important when producing care plans, that pre-admission assessment information is included, as well as information from the monthly evaluation and daily records, so that all the service user’s identified needs have an up-to-date plan of care and so that care staff are fully informed. There was insufficient information and instruction for staff in some areas of care so that they would know what action they needed to take to support service users. A healthcare professional advised staff to monitor a service user’s condition, but a monitoring record had not been put in place. A GP survey noted that specialist advice is not always incorporated into the service user plan. A monthly management report by the service provider also noted that further work is necessary with regard to care planning. It was evident, however, from discussion with staff on duty that they were aware of service users’ care and support needs, although one was not sure that anything was being done to meet one aspect of a service user’s assessed needs. Service users’ appearance was clean and tidy and movement and handling by staff was in line with the care plan. One service user said that they always received the care and support needed and that “staff always make time for me”. All four relative surveys noted satisfaction with the overall care provided by the home and one relative said “I am satisfied with the care (my relative) gets in the home”. From records, observation, discussion and surveys, it was evident that service users have access to healthcare professionals such as dietician, optician, dentist, district nurses, chiropodist, community psychiatric nurses and GPs. A GP survey noted that specialist advice is incorporated into care plans and that care at the home “currently seems to be noticeably improved”. However, another GP expressed dissatisfaction with the service noting poor communication and a failure to understand service users’ needs. One out of the three surveys returned from health and social care professionals, noted similar concerns. One survey also noted that the home’s management “seems, at times, reluctant to review placements”. This had also been identified during a follow up visit to the home earlier in the year, following which two service users’ needs were reassessed. The home’s management needs to be mindful of changes to service users’ care and dependency needs, so that appropriate care Ashleigh Residential Home DS0000060145.V298293.R01.S.doc Version 5.2 Page 12 and support is provided to them whether it be in this or an alternative care setting. Service users who have been risk assessed as being safe to do so, may self medicate. But, in most cases, owing to service users’ frailty, care staff administer medications. One service user who self-medicates some medications did not have a risk assessment on file. This must be addressed. Any risk must be clearly documented to support decision-making and risks must be reviewed monthly. A requirement is made regarding this. Staff were observed to safely administer medication, which was stored securely, and samples checked were easily reconciled with records held. Where appropriate, service users were offered pain relieving medication and a service user said it was regularly offered and that it helped. Staff receive medication training and a medication policy and procedure is available to them. Service users confirmed that staff respect their privacy and dignity. And reference to this was made in care plans. From observation staff promote privacy and dignity when supporting service users. Also, door locks are in place on toilets, bathrooms and bedrooms. All five GP, health and social care professional surveys returned, noted that visits took place in private. Ashleigh Residential Home DS0000060145.V298293.R01.S.doc Version 5.2 Page 13 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 Activities provided do not fully meet service users’ expectations. Service users maintain contact with family and friends, but contact with the local community is limited. Generally, service users like the food provided. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: There were references in service users’ records about their likes and dislikes; their religion, cultural background and recreational interests. But some information was limited and care plans lacked sufficient detail about how these needs were to be met. The manager said there were no plans to recruit an activities person, following the recent departure of the activities organiser, but to ensure that service users have access to activities, a member of the care team had been made available for four hours a day, Monday to Friday. Music centres and large print books were on display, but during this site visit, although two service users played dominoes, the majority of service users were sat in lounges with the television on for most of the time. A relative felt there was a lack of activities at the home and a service user expressed boredom and that “nothing is done” about this. Ashleigh Residential Home DS0000060145.V298293.R01.S.doc Version 5.2 Page 14 The minutes of service user meetings also noted that service users would like more activities and outings. One service user reported that the home usually arranges activities and that “There is no pressure to join in. Sometimes I just like to watch”. Although records show that some activities such as dominoes, music, walks and visits to the town centre do take place, these are irregular. There was little recorded evidence of activities having taken place which support service users’ interests and hobbies or that service users’ spiritual needs are addressed. The manager reported difficulty in getting ministers of religion to visit the home and that no service users visit a place of worship in the community. A requirement is made in this report about recreational, social and religious opportunities. Service users confirmed that they are able to maintain contact with relatives and friends and that visits can be held in private. A relative was observed to visit a service user in private during the inspection. This was also supported by comments made in surveys. All four relative surveys noted that visitors are welcomed into the home at any time. Service users confirmed that they could decide what time they got up and go to bed and where they liked to sit during the day. Service users were seen to come down for breakfast at different times throughout the morning and some, who were able, were seen to move freely around the home. One service user enjoys clearing the dining tables after meal times. An experienced cook, who is new to post, has been employed to work over 5 days; a member of care staff or the manager, both of whom have received food hygiene training, cover the remaining two days. There is a vacant cook’s post, which has yet to be recruited to. On the day of the inspection, service users were offered a choice of two main dishes for the mid-day meal – pasta bake or meat balls - served with oven chips and frozen peas. Followed by fruit cheesecake or tinned fruit and cream. A choice of cold cordial drinks was also served. Service users were offered hot drinks and biscuits mid-morning and afternoon. Service users who commented on the mid-day meal said they had enjoyed it. Two service users said they always liked the food; one said that they usually like the meals at the home. The manager explained that fresh vegetables are purchased once a week and when these run out frozen vegetable are used. The menu for the week of the inspection shows that sandwiches were to be served for tea on five days, with fish, cheese or meat salads on two days. One relative said that food choices were available and that their relative “eats well and has gained weight”. Another relative felt that food was an area that could be improved. The inspectors are of the view that an increased range of fresh fruit and vegetables Ashleigh Residential Home DS0000060145.V298293.R01.S.doc Version 5.2 Page 15 be made available to service users and that consultation takes place with them about the food provided at the home, taking into account service users’ likes, dislikes and any cultural preferences. A recommendation is made. Paper napkins, salt, pepper and silk flower decorations were on each dining table. However, the Formica topped tables were without table-cloths or place mats and plastic pudding bowls and beakers were also in use. This did not contribute to a pleasing dining environment. Where plastic crockery is used, this should be based on the needs, preferences and capabilities of the service users, not for the convenience of staff or the registered provider. A recommendation is made regarding the dining area. Service users’ independence with eating was promoted with the provision of adapted cutlery. And where service users required assistance to eat, staff supported them in a caring and dignified manner. When the cook was on duty, sufficient staff were available to support service users over the mid-day meal, but the cook is not available during the evening meal when care staff are responsible. This effectively reduces the level of supervision and support available to service users. Consideration should be given to domestic arrangements during this period, so that care staff time is not taken up with domestic activities. A recommendation is made about this within this report. Ashleigh Residential Home DS0000060145.V298293.R01.S.doc Version 5.2 Page 16 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): 16, 18 The service listens to and acts on complaints, but not all service users and their relatives are aware of the home’s complaints procedure. Action is taken to protect service users from abuse. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Not all relatives and service users contacted were aware of the home’s complaints procedure. The procedure is displayed in the home’s entrance area and included in the home’s statement of purpose and service user’s guide. However, it would be useful to discuss the procedure at service user/relatives’ meetings on a regular basis, so that those involved become familiar with the procedure. A recommendation is made about this in this report. Records show that three complaints/concerns were made over the last 12 months relating to health and personal care, one of which was looked into by the Commission. One complaint/concern was substantiated and two were partially substantiated. All were addressed within the 28-day timescale. The manager should maintain a log of complaints/concerns which notes the nature of the complaint/concern, the outcome of any investigation and the action taken, where appropriate, to put things right. A recommendation is made about this within this report. It was evident from staff records and discussion with them that POVAFirst (Protection of Vulnerable Adults) and Criminal Record Bureau (CRB) checks are Ashleigh Residential Home DS0000060145.V298293.R01.S.doc Version 5.2 Page 17 completed, so that those employed to work at the care home are suitable to work with vulnerable adults. Staff spoken with had a good understanding of adult protection and they confirmed, as did training records, that adult protection training is provided. The home’s adult protection policy and procedure was updated in April 2006 and is available to staff. However, the document should be amended, as discussed with the manager, so that it makes clear who is responsible for making referrals to the POVA list, where appropriate. A recommendation is made about this in this report. It is positive to note improvements in the making of referrals to the local authority adult protection team where there are suspicions or allegations of abuse. It was evident from discussion with staff, management, observation and records that action is being taken to promote service user safety. Ashleigh Residential Home DS0000060145.V298293.R01.S.doc Version 5.2 Page 18 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, 26 Generally a safe, well-maintained environment is provided for service users. The home is generally clean, pleasant and hygienic. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Ashleigh is generally well maintained. One of the bedrooms seen had been recently redecorated and a new carpet had been laid. Where redecoration has taken place this is to a good standard. The communal lounges receive plenty natural light. A service user who said “I like living here” was satisfied with her bedroom accommodation. Bedrooms seen were clean and odour-free. It’s evident that service users are able to bring personal possessions with them when they move into the home. Equipment suited to service users’ needs is provided, for example, pressure relieving and movement and handling equipment. Bedrooms, which have door locks fitted are accessible to staff in an emergency, but, in the inspectors’ view, the locks on the inside of the door are Ashleigh Residential Home DS0000060145.V298293.R01.S.doc Version 5.2 Page 19 not really appropriate for older people, some of whom are physically and mentally frail. The locking device is small and not easy to manipulate. Door locks should be suited to service users’ capabilities. A recommendation is made for the service provider to assess the suitability of the existing locks and replace them as appropriate. The home’s manager explained that action necessary to maintain fire safety, agreed with West Yorkshire Fire & Rescue Authority, was in hand with a planned completion date of 14 June 2006. Until written confirmation has been received from the service provider that the work has been completed, a requirement is made in this report. A previous recommendation regarding the cleaning of bath hoists has been addressed. However, a first floor bathroom, which a carer said was not used, and the ground floor shower room had a stale odour. It is recommended that the cause of the odour be investigated and appropriate action taken. Of the three service user surveys returned, one said that the home is always fresh and clean; two said it usually was. On arrival at the home on the day of the visit, the entrance area did have an unpleasant odour, but the odour disappeared as the morning progressed. This is an area where service users like to sit. Staff explained that linen from the first floor is brought down in the lift and transported through this area to the laundry. This could be a cause of the odour. It’s recommended that the home’s management check that the systems in place to control offensive odours are working effectively. A service user and a relative reported that there are some problems with laundry getting mixed up, which means that service users’ clothing is not always returned to them. Also that, on one occasion, a service user was found to be wearing items of clothing belonging to another service. A member of staff explained that clothing is labelled, but that laundry mix-ups do sometimes occur. It’s important that staff preserve and promote service users’ dignity and identity, so staff must ensure that service users’ clothing is returned to them and that service users, or their relatives, do not find that service users are dressed in clothing belonging to other people. A recommendation is made about this in this report. Ashleigh Residential Home DS0000060145.V298293.R01.S.doc Version 5.2 Page 20 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, 28, 29, 30 Recruitment policy and practices support and protect service users. Staff receive relevant training to ensure they are competent to do their jobs. Pressures on the staffing rota have a potential to negatively impact on the ability of the service to fully meet service users’ needs. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Staffing rotas for the period 01.05.06 to 11.06.06 were looked at. Staffing levels were adequate for the number of service users in residence, with three carers in the morning and evening and, on most occasions, four carers on duty for a few hours during the afternoon. Staff felt that staffing levels were sufficient. The rotas show that between the 1st and 21st May, the manager worked 16 days in a row covering care and cook shifts and was supernumery on only two of those days. The manager explained that she did not like to use agency staff and that she was covering staff holidays and the vacant cook post. However, working 16 consecutive days without a day off is not good practice and appropriate arrangements should be made to cover vacant shifts. Because the manager’s hours should be supernumery so that she can focus on managing the home, a requirement is made in this report. Ashleigh Residential Home DS0000060145.V298293.R01.S.doc Version 5.2 Page 21 Two relatives felt that sufficient staff were on duty, but one said “they could do with more staff”. One relative noted: “the care staff work very hard and are very caring”. During the inspection staff were observed to respond to service users in a caring, helpful and patient manner. One service user spoke fondly about staff and another said that they are “alright”. Two service users said that staff were always available and that they received the care and support they needed; one said this was usually the case. From discussion with staff, management and records, it is clear that staff receive a range of relevant training and this is ongoing. For example, NVQ (National Vocational Qualification) level 2 and 3, movement and handling, food hygiene, health and safety, infection control, tissue viability, first aid, dementia, continence, adult protection and induction. Such training means that staff have the appropriate knowledge and skills necessary when providing care to older people. Twenty-three per cent of staff hold an NVQ level 2 qualification and 38 of staff are working towards the qualification. However, until 50 of staff have achieved an NVQ, as recommended in the National Minimum Standards for Older People, a recommendation is made within this report. One member of staff holds an NVQ Level 3 qualification and another member of staff is working towards the award. The recruitment records of four staff were inspected and contained the required information. This helps to ensure that only people who are suitable to work with vulnerable adults are employed. The recruitment process was confirmed in discussion with staff. Ashleigh Residential Home DS0000060145.V298293.R01.S.doc Version 5.2 Page 22 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, 33, 35, 38 The home’s manager is developing her management skills and making progress towards improved service provision for service users. Action is taken to obtain service user views regarding the running of the home but their views are not always addressed effectively. Service users’ financial interest are safeguarded. Health and safety is promoted within the home. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Sarah Hirst, who is experienced in working with older people, is registered with the Commission as being fit to manage the home. She is currently working towards the NVQ level 4 in care and management. Mrs Hirst explained there was a difficulty with having her work checked by an NVQ assessor but that this was being dealt with. A recommendation is made for the manager to complete the NVQ, as this will support her to develop her management skills. Ashleigh Residential Home DS0000060145.V298293.R01.S.doc Version 5.2 Page 23 It was clear from discussion with a relative and staff that Mrs Hirst is approachable and any issues can be raised with her. One member of staff said that Mrs Hirst has an “open door policy” and another felt that she worked “as part of the team” and that staff morale had improved. It’s also clear from evidence seen during the inspection process that the manager has made some progress towards improving standards of care at the home and to record keeping. However, progress needs to continue so that the lifestyle experienced by those living at Ashleigh meets their needs and expectations. Documentary evidence and discussion with the home’s manager indicates that the views of service users, relatives and staff are sought about the running of the home. A quality assurance questionnaire is distributed annually and service user meetings are held on a 3-monthly basis to which relatives are invited to attend. However, a copy of any report has not been supplied to the Commission and a requirement is made within this report. Staff meetings are held monthly. Minutes of service user meetings show that service users have expressed satisfaction with the home. Some resident and key worker care plan review questionnaires were seen which seek service users’ views about personal care, meals and daily activities. It’s important, however, that action is taken to address issues raised by service users, particularly in relation to social and leisure activities, as noted above under the section Daily Life and Social Activities. Service users, where able, manage their own finances. Some have the support of their family or a representative, who send money to the home to hold on behalf of the service user or the home invoices the family where expenses are incurred. Three samples of service users’ monies, securely held by the home, were checked and reconciled with records held, which indicates that service users’ monies are safeguarded. From the pre-inspection questionnaire and records, discussion with the manager and observation it’s clear that action is taken to maintain the health, safety and welfare of service users and staff. However, even though accidents to service users are recorded, not all have been reported to the Commission where appropriate. A requirement is made for the Commission to be notified of all relevant incidents. Ashleigh Residential Home DS0000060145.V298293.R01.S.doc Version 5.2 Page 24 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x 3 x x 2 Ashleigh Residential Home DS0000060145.V298293.R01.S.doc Version 5.2 Page 25 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 Timescale for action A. Service users’ care plans must 29/06/06 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, 10.08.05, 18.11.05 and 12.04.06 not fully met). B. Where issues are identified on assessment, at evaluation and in daily records, this information must form part of the service users’ plan of care. C. Advice from healthcare professionals must be actioned, therefore, monitoring records must be part of the service user’s plan and completed by staff. Any service user who self29/06/06 medicates must have a risk assessment in place, which indicates they are safe to do so. And the findings must be included in their plan of care. A range of activities that reflect 17/07/06 service users’ interests, hobbies, preferences and capacities must be provided. DS0000060145.V298293.R01.S.doc Version 5.2 Page 26 Requirement 2. OP9 13(4)(c) 3. OP12 16(2)(n) Ashleigh Residential Home 4. 5. OP12 OP19 16(3) 23(4)(a) 6. OP27 18(1)(a) 7. OP33 24(2) Opportunities must be provided for service users to attend religious services of their choice. The service provider must provide the Commission with written confirmation that the actions agreed in the fire officer’s report dated 14.03.06 have been completed. Appropriate staffing arrangements must be made to cover vacant hours so that no member of staff works an excessive number of days in one stretch. Following a quality audit of the services provided at the home, a copy of any report must be supplied to the Commission. Timescales of 15.10.03, 21.07.04, 30.11.04 and 21.02.06 not met). Accidents to service users requiring treatment must be reported to the Commission as required under Regulation 37 of The Care Homes Regulations 2001. (Timescale of 14.11.05 and 17.03.06 not fully met). 17/07/06 20/06/06 17/07/06 20/06/06 8. OP38 37 20/06/06 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 The cook should consult with service users about the food menu. And the food provided should be reviewed so that it includes a choice of five portions of fresh fruit and vegetables per day. DS0000060145.V298293.R01.S.doc Version 5.2 Page 27 Ashleigh Residential Home 2 OP15 3 4 5 OP15 OP16 OP16 6 7 OP18 OP24 8 9 10 11 12 13 OP26 OP26 OP26 OP27 OP28 OP31 The dining environment should be enhanced so plastic crockery should not be used unless it meets the assessed needs of individual service users. The use of table cloths or place mats should be considered. Domestic arrangements should be reviewed so that care staff are not engaged in domestic activities over the time of the evening meal. Action should be taken to raise service users’ and relatives’ awareness of the home’s complaints procedure. A log of complaints/concerns should be kept which notes the nature of the complaint/concern, the outcome of any investigation and the action taken, where appropriate, to put things right. The home’s adult protection policy and procedure should be amended so that it makes clear who is responsible for making referrals to the POVA list, where appropriate. Bedroom door locks should be suited to service users’ capabilities, therefore, the service provider should assess the suitability of the existing locks and replace them as appropriate. The cause of the stale odour in the first floor bathroom and the ground floor shower room should be investigated and appropriate action taken to eliminate the odour. Checks should be made to ensure that systems in place to control offensive odours in the home’s entrance area are working effectively. The laundry system should be reviewed so that individual service user’s clothing is returned to them and not to other service users. The registered manager’s working hours should be supernumery so that she can focus on managing the care home. A minimum of 50 of staff should hold an NVQ level 2 qualification, or an equivalent. The registered manager should complete the NVQ level 4 qualification in care and management to support her in developing her management skills. Ashleigh Residential Home DS0000060145.V298293.R01.S.doc Version 5.2 Page 28 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.V298293.R01.S.doc Version 5.2 Page 29 - 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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