Inspection on 16/11/05 for Ashlett Dale Rest Home

This inspection was carried out on 16th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Ashlett Dale Rest Home 05/11/09

Ashlett Dale Rest Home 31/03/08

Ashlett Dale Rest Home 21/08/06

Ashlett Dale Rest Home 04/11/04

Ashlett Dale Rest Home 03/06/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Ashlett Dale Rest Home Stonehills Fawley Southampton Hampshire SO45 1DU Lead Inspector Mrs Michelle Presdee Unannounced Inspection 16th November 2005 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 Ashlett Dale Rest Home DS0000011884.V266729.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. Ashlett Dale Rest Home DS0000011884.V266729.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ashlett Dale Rest Home Address Stonehills Fawley Southampton Hampshire SO45 1DU 023 8089 2075 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 Frederick William Liddington Mrs Maureen Mary Liddington Mrs Collette Willis Care Home 14 Category(ies) of Dementia (3), Dementia - over 65 years of age registration, with number (14), Learning disability over 65 years of age of places (14), Mental Disorder, excluding learning disability or dementia - over 65 years of age (14), Old age, not falling within any other category (14), Physical disability over 65 years of age (14) Ashlett Dale Rest Home DS0000011884.V266729.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Three named service users in the DE category may be admitted at the age of 63. Date of last inspection Brief Description of the Service: Ashlett Dale provides care and support to 14 service users with dementia, Learning disabilities, mental illness and physical disabilities, over the age of 65 years. The Home is situated in a semi rural area in Fawley on the outskirts of the New Forest. There is a public house within a short walking distance and a number of other amenities and leisure activities a short car journey away. The Home is a two-storey building having a reasonable sized garden of which service users spend time in during the warmer months. Ashlett Dale Rest Home DS0000011884.V266729.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second inspection, with the aim of ensuring all core standards had been addressed over the two inspections and to see what progress had been made on the requirements made at the last inspection. Fourteen service users were being accommodated, nine women and five men. The manager of the home was unavailable, but Mr Liddington the registered provider came into the home to assist the inspector. During the inspection the inspector spoke to the majority of service users and two visitors to the home. Some records were looked at, but it was not possible to view all records as these were locked away and access could not be gained. Mr Liddington accepted records should be available at all times. What the service does well: What has improved since the last inspection? What they could do better: Ashlett Dale Rest Home DS0000011884.V266729.R01.S.doc Version 5.0 Page 6 Statutory records that are required must be kept in the home and be available at all times. Pre-admission assessments could be expanded to give a clear picture of why a service user is moving into the home and record service users needs at that time. Assessments and care plans must include all up-to-date information. Supervision must be started in the home and records should be available to evidence this. 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. Ashlett Dale Rest Home DS0000011884.V266729.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 Ashlett Dale Rest Home DS0000011884.V266729.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): 3 All service users have a pre-admission assessment completed, which identifies some needs, but they could be improved to give details of all service user needs, including the reasons why the service user moved into the home. EVIDENCE: The assessments of two service users were viewed. One service user had been in the home for six months and the other had been in the home six weeks. Both service users had files, which contained all the necessary basic information, including date of birth, the date they moved into the home and the next of kin details. One file did not have a photograph but it was agreed this would be put on the file. Pre admission assessments had been completed, but these were in the form of a tick box assessment. Assessment and care plans were also completed, which were signed and dated. Moving and handling assessments had been completed and risk assessments were in the file. It was noted these had not been completed for one service user and now need to be completed. Information was recorded on all medical visits, a bathing record and weight chart were available. Ashlett Dale Rest Home DS0000011884.V266729.R01.S.doc Version 5.0 Page 9 From discussions with one service user and their visitor, it was clear the home was meeting the service users needs. They felt their had been good communication with the home. However it was clear from these discussions a lot of information was not recorded on the serviced users file. It was agreed this information was important and should be recorded. Ashlett Dale Rest Home DS0000011884.V266729.R01.S.doc Version 5.0 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 Care plans have been completed for each service user and identity some of the service users needs. However these could be improved to record a service users overall needs. EVIDENCE: Two service users care plans were looked at. Both had care plans, which set out their social, health and personal needs. Care plans gave sufficient information for carers to meet service users identified needs. However there is still a need to ensure all details are recorded and up-to-date. From discussions with a service user and their relative it was clear not all relevant information had been recorded on the care plan. This information related to personal care issues and social issues. The service user and relative felt the home had communicated well over these issues, but they were not recorded on the care plan. From evidence seen care plans were being reviewed and signed and dated every two months, these should be every month. Ashlett Dale Rest Home DS0000011884.V266729.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): 14 Practices in the home ensure that service users do have where possible choice and control over their lives to meet specific needs. EVIDENCE: It was clear from discussions with staff, service users, relatives and visitors to the home, efforts are made to ensure service users have choice and control over their lives. One service user wished to have more than one bath a week the home have managed to offer him a bath twice a week, which he reports is better than once. Service users are always given a choice at meal times. Service users have freedom of movement around the home, with some service users spending time in their own rooms whilst others prefer to spend time in the lounge. One service user expressed a desire to go out of the home alone, however it was explained there were concerns over the risks involved but staff and family members would try and accompany him where possible. The service user felt this was difficult to accept, but he also had difficulty accepting his medical diagnosis. Ashlett Dale Rest Home DS0000011884.V266729.R01.S.doc Version 5.0 Page 12 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): EVIDENCE: These standards were not assessed on this occasion. Ashlett Dale Rest Home DS0000011884.V266729.R01.S.doc Version 5.0 Page 13 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 The home provides a clean comfortable and homely environment for service users. EVIDENCE: The home is clean and provides a homely environment. Cleaner works in the home five mornings a week. A new bathroom suite has been fitted to the main bathroom. No unpleasant odours were detected and one visitor commented one of the reasons they had chosen the home was because there was no unpleasant odours only the smell of home cooking to greet them. Control of substances Hazardous to Health (Coshh) assessments have been completed and all cleaning materials were locked away. Ashlett Dale Rest Home DS0000011884.V266729.R01.S.doc Version 5.0 Page 14 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): 27,29 The home has good staffing levels, which ensures service users needs are met. Staffing records must be available to ensure service users are safe and protected from staff. EVIDENCE: The home has a written duty rota, which is displayed in the home. Staff explained they try to keep to the same shifts each week. Staff spoken to felt the home had a good staff group who all worked together as a team and supported each other. Staff felt there were adequate staff on duty to meet service users needs. The duty rota demonstrated there were adequate staff on duty to meet service users needs. Two new members of staff have been employed in the home. Staffing records were unavailable so it was not possible to establish if all necessary checks had been undertaken. The two new members of staff were not on duty. Ashlett Dale Rest Home DS0000011884.V266729.R01.S.doc Version 5.0 Page 15 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): 31,33,36,38 The manager is approachable and has an open style of management, ensuring the home is run in the best interests of service users. It was not possible to demonstrate supervision have been undertaken in the home ensuring service users safety is promoted in the home. EVIDENCE: Care staff and visitors to the home reported they felt the registered manager was able to communicate well and ran the home with an open style of management. All felt they would be able to go to the manager and discuss any concerns they had. The home makes efforts to ensure the home is run in the best interests of serviced users. The majority of service users in the home have limited communication skills so the home has found service users meeting not workable. However each service user is consulted individually to see if they Ashlett Dale Rest Home DS0000011884.V266729.R01.S.doc Version 5.0 Page 16 have any concerns or anything they would like to be changed. The home also takes on board the views of visitors to the home. It was unclear if formal supervision had been started in the home. Staff did feel they had discussions with the manager on care practice issues but non were aware of records being maintained of signing a supervision record. Records were unavailable. The fire logbook was available and it was possible to establish the majority of the necessary tests were being carried out within the agreed timescales. The weekly fire check had not being carried out for two weeks. It was not possible to establish if staff had had adequate fire training, as the records were not available. It was also not possible to see evidence if the fire alarm and fire fighting equipment had been serviced, as records were not available. Fire extinguishers had been checked in March 05. Ashlett Dale Rest Home DS0000011884.V266729.R01.S.doc Version 5.0 Page 17 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 3 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X 2 X 2 Ashlett Dale Rest Home DS0000011884.V266729.R01.S.doc Version 5.0 Page 18 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 (1) (2) (b) Requirement Care plans and assessments must be up-to-date with all information recorded. Care plans should be reviewed monthly. Previous timescale of 01/08/05 not met. All staff must receive a minimum of six formal sessions of supervision a year. Previous timescale of 1.4.05 has not been met. Records as identified in Schedule 3 and 4 must be available at all times for inspection. Timescale for action 01/02/06 2. OP36 18 (2) 01/02/06 3 OP29 17 01/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Ashlett Dale Rest Home DS0000011884.V266729.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Ashlett Dale Rest Home DS0000011884.V266729.R01.S.doc Version 5.0 Page 20 - 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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