Inspection on 11/05/05 for Ashley House

This inspection was carried out on 11th May 2005.

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

Ashley House 09/05/08

Ashley House 24/05/07

Ashley House 21/11/06

Ashley House 09/11/05

Ashley House 09/11/04

Ashley House 02/06/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Ashley House Moulsham Street Chelmsford Essex CM2 9AQ Lead Inspector Kathryn Moss Unannounced 11th May 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ashley House I56-I05 s17753 Ashley House v227006 110505 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Ashley House Address Moulsham Street, Chelmsford, CM2 9AQ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01245 494674 01245 493254 Dr Kuldip Singh Dr Amrit Kaur Care Home 22 Category(ies) of Old age, not falling within any other category 22 registration, with number of places Ashley House I56-I05 s17753 Ashley House v227006 110505 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, aged 65 years and over, only falling within the category of Old Age (not to exceed 22 persons) Date of last inspection 9/11/04 Brief Description of the Service: Ashley House is a large detached house, located in a residential area close to a park and a supermarket, and only a short distance from the centre of Chelmsford. The home has parking to the front, and a garden area to the rear. Accommodation is over two floors, with access via a through floor lift. There are ten single bedrooms (two with ensuite toilets) and six double bedrooms (one with ensuite toilet). The home has three bathrooms, several toilets, and two communal lounge areas (one with an integrated dining area). The home is registered to provide care and accommodation to 22 older people; it does not provide nursing care, and is not registered to admit service users with dementia. The home is currently being managed by one of the owners, Mrs Singh (Dr Kaur), but the assistant manager, Denise Starksfield, is due to make an application for registration as the manager. Ashley House I56-I05 s17753 Ashley House v227006 110505 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on the 11/5/05, lasting ten hours. This report represents evidence and information gathered as part of the inspection. The inspection process included: discussions with the owner, acting manager, three staff, six service users and five sets of visitors; premises observations on main communal areas and kitchen; and inspection of a sample of records. As there were a large number of requirements at the last inspection, part of the focus of this inspection was on reviewing the action taken to meet these. Any previous requirements not fully reviewed on this occasion will be inspected on the next inspection (e.g. medication records). Twenty-one standards were covered, and 8 requirements (including four repeat requirements) and 12 recommendations have been made. The owner of Ashley House had made significant progress towards meeting requirements identified at the last inspection. The home had a comfortable and friendly atmosphere, and service users spoken to were positive about living at Ashley House. What the service does well: What has improved since the last inspection? Although further action is still required, the home has made good progress with respect to a number of requirements identified at the last inspection, including implementing formal staff supervision, implementation of a formal induction programme, and the provision of more staff training. Since the last inspection, temperature control valves have been installed on all hot taps: this was a major task, and will protect residents from the risk of Ashley House I56-I05 s17753 Ashley House v227006 110505 stage 4.doc Version 1.30 Page 6 scalding. The home is progressing plans to install guards on radiators, in order to protect residents from any risk from these hot surfaces. There have also been some good training opportunities for staff over the last six months, with the home developing good contact with a lead nurse for care homes in the mid Essex area, who has provided staff and managers with training workshops on a number of relevant care issues. What they could do better: The home needs to progress some ongoing work on the property, including fitting radiator covers and refurbishing the kitchen. Some record keeping issues need further action, including the organisation of staff records, the maintenance of staff training and supervision records, the ongoing development of resident assessments and care plans, and the recording of activities. The home should also review its activities programme, especially with regard to how staff engage with residents who are not able to occupy their own time, or who have some level of cognitive impairment. Other requirements and recommendations are listed at the end of this report. 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. Ashley House I56-I05 s17753 Ashley House v227006 110505 stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Ashley House I56-I05 s17753 Ashley House v227006 110505 stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3 and 4 The home has information available to assist prospective residents find out about the home. There are systems in place to ensure that service users’ needs are assessed prior to admission. The home’s environment is suited to the needs it aims to meet, and staff have appropriate knowledge and skills. EVIDENCE: A revised statement of purpose and service user guide were submitted after the last inspection, and on this inspection it was noted that copies of these documents were available in the office, and the owner stated that the service user guide has been given to new residents. The files of two new residents were viewed. One contained a record of an assessment of needs carried out by the home, covering an appropriate range of issues. The second, for a person who had been admitted to the home the week before the inspection, only contained an assessment form from social services that contained insufficient information to inform the home about the person’s needs. The home owner stated that she and the acting manager had Ashley House I56-I05 s17753 Ashley House v227006 110505 stage 4.doc Version 1.30 Page 9 visited the person prior to admission to check that they could meet the person’s needs, but had not had time to write this assessment up. The residents and relatives spoken to during the inspection were happy with the care provided by staff at Ashley House, and were satisfied that staff had the skills to carry out their care. The home has appropriate facilities to meet the needs of the people it aims to accommodate (e.g. through floor lift, assisted baths, etc.). As individual training records were not available (see Staffing section) the level of overall staff training could not be demonstrated. However, there was evidence (e.g. certificates) that the managers and several staff had attended a variety of workshops over the last few months (e.g. falls prevention, infection control, skin and pressure area care, catheter care, and Parkinson’s Disease), all of which were very relevant to meeting the needs of individuals who would be admitted to Ashley House. This was good to see. Additionally, the assistant manager was due to attend a course to enable her to carry out moving and handling training, and one staff member had attended a two day dementia care course. It was noted that several residents had varying levels of confusion, and staff thought that some may have dementia; other staff have not currently attended dementia care training. Ashley House I56-I05 s17753 Ashley House v227006 110505 stage 4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, and 10. Health care needs were being appropriately met. Care plans generally described appropriate action to meet the health and personal care needs identified; however, they did not always identify and address all of a person’s needs. Staff observed during the inspection treated residents with dignity and respect. EVIDENCE: At last year’s inspection it had been highlighted that, apart from a brief preadmission assessment form, there were no other recorded assessments carried out by the home to identify individual’s needs, and from which care plans are generated. The home subsequently revised its assessment of needs form to incorporate more space to record information, providing space to record brief observations about all core care needs. This had been completed on two of the files inspected (for a new resident and an existing resident). However, there was still no evidence of any more detailed assessments of individuals’ needs: for example, there were no assessment forms being used where a resident had moving and handling needs, to monitor risk of pressure areas, or to monitor changing mental state, etc. There was a risk assessment form on several files inspected, used mainly for issues such as risk of falling. The need for more indepth assessments of certain needs was discussed with the home owner. Ashley House I56-I05 s17753 Ashley House v227006 110505 stage 4.doc Version 1.30 Page 11 Care plans were present on all files viewed, covering seven standard categories of ‘need’: mobility, moving and handling, continence, communication, personal care, diet and nutrition, and social/emotional needs. Most of those viewed contained good detail regarding the action required to meet each need, and there was evidence that these were generally being regularly reviewed (though not necessarily every month). However, there were no care plans to address more specific needs (e.g. pressure area care or preventative care, cognitive impairment or challenging behaviour, etc.). The home needs to ensure that care plans are not restricted to the seven standard categories of need covered by current care plans. There was no evidence to indicate if service users were directly involved in the development of their care plans. At the time of the inspection, staff reported that one resident had a pressure sore, and another had a recently healed sore that required ongoing preventative care. As noted above, there were no specific care plans to show the care required by staff: the latter person’s file did contain a risk assessment form that had been used to identify the risk of the person developing a sore bottom, and contained appropriate details of the preventative action being taken, including equipment in use; the other file did not contain any reference to the person’s pressure sore, the care required, or any equipment in use. Residents looked well cared for, and those spoken to were positive about the care and support given to them by staff. Care plans demonstrated the support or assistance given with personal care needs, including continence needs; daily notes reflected the general care given. Residents’ records showed when contact had been made with health care professionals. Weights were not being monitored and recorded within the home; nutrition records were not inspected on this occasion. Moving and handling needs were not discussed on this inspection. One staff member made some very good observations about the possible cause of disruptive behaviour from one resident: this showed good awareness and perception, and this sort of information should be recorded in the care plans. Staff were seen to treat residents respectfully, and to assist them in a dignified way. Residents and/or their relatives have all been asked whether they want lockable storage in their rooms, or locks on their bedrooms doors. This has been clearly recorded, and new residents will be asked the same. In due course the owner intends to ensure that lockable storage facilities are provided as part of the routine replacement of bedroom furniture. Several relatives commented that the residents are always dressed in clean clothes, and that clothes are laundered promptly and efficiently. One shared bedroom viewed was seen to have a curtain across the room to provide privacy to the residents. Ashley House I56-I05 s17753 Ashley House v227006 110505 stage 4.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 and 13 Routines in the home were flexible, and met residents’ preferred daily living preferences. Social and recreational interests and needs were not satisfactorily being met in all cases. Contact with family and friends was encouraged and supported. EVIDENCE: The home had flexible routines, with residents being able to choose when to get up or go to bed, where to have their meals, etc. It was noted in the early evening that many residents were still sitting relaxing in the lounge, and were under no pressure to start getting ready for bed; alternatively, one resident reported that they liked to get ready for bed after tea and then watch TV in their room, and that staff assisted them whenever they requested. Residents’ files contained a ‘Resident Profile’ showing hobbies and interests, and likes and dislikes; some files contained a completed ‘Getting to Know You’ form, showing preferred daily routines. Residents spoken to were very happy with the home, and made positive comments about the staff, the food, the laundry, etc. On the day of the inspection there were no specific activities observed taking place, although staff were seen to be regularly passing through the lounge, and interacted well with residents. The owner said that one staff member takes the lead on activities, and they were not working on that day. A few Ashley House I56-I05 s17753 Ashley House v227006 110505 stage 4.doc Version 1.30 Page 13 residents and some of the visitors commented that there is often ‘not much going on’. Several residents did say that they liked to read or do crosswords, and therefore occupied themselves; however, one visitor expressed concern about residents who were less mentally alert and were unable to stimulate themselves. Staff should look into developing more activities with these individuals. The acting manager acknowledged that activities were in ‘a bit of a lull’, saying that the home tends to have phases where certain activities are very popular (e.g. quizzes, as seen on a previous inspection), and then residents get bored with these. The activities programme therefore needs to be reviewed. Activities records were maintained, but these had lapsed a month previously, did not contain entries for each day, and did not always accurately represent who had joined in (e.g. often said ‘Everyone’, when this could not have been the case). It was good to see a large number of relatives and friends visiting the home on the day of the inspection, and the visitors’ book showed that this was a regular occurrence. One visitor particularly commented on the friendliness of staff, and the fact that they were always made welcome, could come at any time, and had been invited to stay for meals. A resident was seen being able to use the portable office phone to receive a phone call. Contact with the local community was not discussed on this occasion. Ashley House I56-I05 s17753 Ashley House v227006 110505 stage 4.doc Version 1.30 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 The owner has taken appropriate action to promote staff awareness of adult abuse issues, to ensure the protection of residents. EVIDENCE: Not all aspects of standard 18 were reviewed on this inspection. Following the last inspection, the owner had sent the CSCI a policy on the Protection of Vulnerable Adults (POVA) for Ashley House: this was quite brief, but referred to staff responsibilities, the need to report any abuse concerns, the chain of reporting, and the need to follow the procedure laid out in the Essex Guidelines. The owner had also submitted policies on Gifts (including staff not getting involved with residents’ wills), and on managing residents’ financial affairs. The owner and acting manager have now attended a POVA workshop run by social services, and the owner said that she had subsequently held sessions on this subject with all staff. Evidence to demonstrate that all staff had received this training was not available, but this was seen recorded on a couple of supervision records that were available for inspection. The owner intends to apply for places for other staff to attend any further POVA workshops available. Residents spoken to were happy with the care provided, and felt safe and well cared for. Ashley House I56-I05 s17753 Ashley House v227006 110505 stage 4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 25 and 26 The home generally provides a safe and well-maintained environment; however, some aspects of the environment still pose a risk to service users. The home was satisfactorily clean and hygienic on the day of inspection. EVIDENCE: Premises standards were not covered in detail on this visit. Communal areas of the home were warm and homely. The kitchen had still not been refurbished (noted to be in a poor condition at the last few inspections), but the owner confirmed that plans for this were in progress; it was acknowledged that action taken in relation to hot water taps and radiators had taken priority over the last 6 months (see below). One relative pointed out that some bedroom furniture was becoming worn and ‘elderly’, and would benefit from replacing. The owner reported that, since the last inspection, all residents had been asked whether they would like lockable storage facilities in their rooms and/or locks on their doors: their responses had been recorded, new residents Ashley House I56-I05 s17753 Ashley House v227006 110505 stage 4.doc Version 1.30 Page 16 will be offered these facilities, and lockable storage will be provided when furniture is next replaced. At the last inspection it had been noted that radiators had hot and unprotected surfaces that could present a hazard to residents. Although work to rectify this had not yet been completed, action was in progress: evidence was seen of risk assessments having been completed on all radiators, and quotes for fitting covers had been obtained. Since the last inspection, the owner had arranged for all hot taps in the home to be fitted with mixer valves to ensure that hot water remains close to 43°C. This is to be commended, and taps checked were within acceptable temperature ranges. There was no system in place to regularly monitor and record hot tap temperatures, but the valves had recently been checked by the plumber; the owner said that a system for monitoring temperatures would be implemented. The owner stated that the plumber had also made sure that the central boiler was set at 60°C: she was advised that there needs to be a system for checking that hot water continues to be stored at a minimum of 60°C. It was good to see on the day of the inspection that arrangements were in process to replace overhead lighting in the main lounge, to try to improve the brightness of lighting for activities. On the day of the inspection the home was reasonably clean, although there was a slight odour in one area, and some communal areas would have benefited from hoovering after lunch. Some relatives and a resident expressed concern about the general levels of cleanliness recently, and staff rotas did not provide evidence of consistent domestic cover (see Staffing section). It was noted that night staff do carry out some domestic duties (e.g. cleaning lounges and bathrooms, laundry, etc.) as part of their role, and also that a part-time domestic assistant had just been appointed. Residents and relatives were positive about the laundry service within the home, saying that clothes are regularly and efficiently laundered and returned to them. Laundry areas were not inspected on this occasion. Five staff (plus the owner and manager) had attended an infection control workshop this year; the owner stated that a staff member now has responsibility for ensuring liquid soap and paper towels are available in the laundry and in all bathrooms. Ashley House I56-I05 s17753 Ashley House v227006 110505 stage 4.doc Version 1.30 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30 Care staffing levels were being maintained at a level that met residents’ needs. Staff training provided the core skills required of staff; ongoing staff development (through NVQ training) was not yet satisfactory. The home lacked systems to evaluate and evidence staff competency and training. Recruitment practices included appropriate checks to protect residents. EVIDENCE: The rota for the week prior to the inspection was viewed, and agreed staffing levels appeared to have been well maintained, apart from on one day. The owner was confidant that cover would have also been arranged for that day, and should therefore ensure that any last minute cover arrangements are recorded on the rota. There were only occasional instances when staff were working double shifts, which is acceptable. Domestic cover was not clearly shown on the rotas: a range of rotas were seen, and some weeks seemed to have very little domestic cover recorded. The owner stated that care staff had previously volunteered to cover domestic work, and thought that this did not always get entered onto the rota. She was advised to ensure that this is always recorded. A dedicated domestic staff member has recently been appointed to work three days a week, which was good to hear; night staff also carry out domestic work as an established part of their job role. Ashley House I56-I05 s17753 Ashley House v227006 110505 stage 4.doc Version 1.30 Page 18 The files of two new staff members were inspected, to check whether appropriate recruitment practices had been followed. Both contained completed application forms, and two references (including the last employer) received before the person started work. The files contained either a copy of the person’s birth certificate or a copy of their passport, as evidence of ID; both contained CRB/POVA checks, one received before the person started work and the other a few days afterwards. The owner was reminded that a POVA or POVAfirst check must be received before someone starts work. The home had now obtained CRB checks for the majority of existing staff, with just two still in process; the owner had taken appropriate action in relation to someone who could not provide the evidence required to process a CRB application. This shows a significant improvement in recruitment practices since the last inspection. A number of training sessions had been arranged for staff already this year, including: falls prevention, pressure area and skin care, catheter care, infection control, and dementia care. Between one and four care staff had attended each session, and all staff had received some POVA training delivered by the owner. The assistant manager was due to attend a manual handling trainer’s course, and appointed first aider training. The owner stated that she is now carrying out a TOPSS induction programme with new staff: the staff member receives a workbook, and the owner goes through each of the TOPSS induction units with the carer. This represents a good improvement in training provided since the last inspection. Evidence of some of these training sessions were available in the form of certificates, but individual staff training records had still not been implemented. There is therefore no way of ascertaining what training each person has attended, or of identifying training needs. There was also no evidence of the TOPSS induction having been completed satisfactorily, as the carers retain the workbook. Of the thirteen care staff employed at the home, two are currently doing NVQ level 2 in care, and a further two have already achieved this qualification. However, further action is required to achieve the minimum standard of 50 staff trained to NVQ level 2. Ashley House I56-I05 s17753 Ashley House v227006 110505 stage 4.doc Version 1.30 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 36 and 37 There is currently no registered manager in the home. However, the home was being appropriately managed by the owner and acting manager. Staff and management roles were clear within the home, with suitable management support and direction. Feedback indicated that the home is generally run in the best interests of service users, but the home lacks formal evidence of quality assurance processes. Staff were being well supervised through day-today processes; formal staff supervision had not yet been sufficiently developed. Some of the home’s record keeping practices did not adequately safeguard staff and service users best interests. EVIDENCE: Mrs Singh (proprietor), as the registered person, has been managing the home in the absence of a registered manager; she is an NVQ assessor for care staff but does not have NVQ level 4 in care and management. However, the acting Ashley House I56-I05 s17753 Ashley House v227006 110505 stage 4.doc Version 1.30 Page 20 manager (Denise Starksfield) has now taken over much of the day-to-day management of the home, supported by Mrs Singh. She has just enrolled on the NVQ level in management and in care, and is due to be submitting an application for registration with the CSCI. She has recently been attending a wide range of training courses, and is due to attend a manual handling trainer’s course. Staff and residents reported finding Mrs Singh and Denise Starksfield supportive and approachable, with both of them being available to staff, residents and relatives. Staff meetings and residents/relatives meetings take place (evidence of these was not viewed on this occasion). Staff had clear roles, with rotas showing the person in charge of each shift; some staff had specific responsibilities within the home. There was a friendly atmosphere in the home on the day of the inspection: staff were seen to be helpful and caring towards residents, and to refer to the acting manager when necessary. Ashley House has a small staff team (13 care staff, plus the acting manager and owner). Both acting manager and owner work some shifts in the home, and are around in the home on a regular basis. There is therefore good dayto-day contact and informal supervision with the staff. The home has had an ongoing requirement to implement formal one-to-one supervision with staff, and it was noted on this inspection that this has now been started: a few samples of completed ‘supervision agreements’ or supervision notes were seen and the owner stated that all staff had now attended an initial supervision session, although records were not available in the home to evidence this. Whilst not yet meeting this standard in terms of frequency and evidence, it is good that formal one-to-one supervision has now been implemented; the owner was encouraged to ensure that this is maintained and that clear records are kept. The owner had obtained some information on supervision to use as guidance in developing skills in this area. Regarding quality assurance processes, the owner had carried out a survey of residents’ views, with questionnaires being completed by them independently, or with staff or a relative’s assistance. The questionnaire contained an appropriate range of questions about aspects of the home: the owner had read these, but had not yet analysed the responses as a whole, or produced a report on this review of care in the home. The home does not currently have an annual development plan; other aspects of quality assurance (e.g. internal systems for auditing and monitoring practices) were not discussed on this occasion. It was noted that record keeping systems in the home need urgent development: many records (e.g. staff recruitment records) were not organised in an organised or professional manner, some records were at the owner’s home, some records needed further development (e.g. individual training records, supervision records), and notices of deaths, injuries, etc., had not been submitted to the CSCI as required under Regulation 37 of the Care Homes Regulations. Ashley House I56-I05 s17753 Ashley House v227006 110505 stage 4.doc Version 1.30 Page 21 Ashley House I56-I05 s17753 Ashley House v227006 110505 stage 4.doc Version 1.30 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 x COMPLAINTS AND PROTECTION 2 x x x x x 2 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 2 3 2 x x 2 2 x Ashley House I56-I05 s17753 Ashley House v227006 110505 stage 4.doc Version 1.30 Page 23 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 7 Regulation 12, 13 and 15 Requirement Timescale for action 30/6/05 2. 8 12, 13 and 14 It is required that care plans cover all the assessed needs of each individual. This includes pressure area care/preventative care, behavioural needs, etc. It is required that the registered 30/6/05 person ensure that systems are in place to enable an appropriate assessment of specific healthcare needs (e.g. risk of pressure areas, moving and handling, nutrition, etc). This is a repeat requirement for the second time (last timescale 31/12/04). It is required that action to address the risk to service users from hot radiator surfaces is carried out as soon as possible. This is a repeat requirement (previous timescale 31/1/05). It is required that the registered person progress plans to ensure that 50 of staff are trained to NVQ level 2 or above. It is required that the registered person implement individual training and development profiles (records) for all staff, as 3. 25 13 31/7/05 4. 28 18 31/12/05 5. 30 18 30/6/05 Ashley House I56-I05 s17753 Ashley House v227006 110505 stage 4.doc Version 1.30 Page 24 evidence of their training and to identify training needs. This is a repeat requirement for the second time (last timescale 31/12/04). The registered person must establish a system for regularly reviewing the quality of care provided in the home. This should include the processes detailed in standard 33 (i.e. survey of service users views, feedback from relatives and other stakeholders, an annual development plan, and internal systems of self-audit). A report must be submitted to the CSCI regarding any review of the quality of care carried out in the home. This is a repeat requirement (previous timescale 31/12/04) The registered person must 30/6/05 establish appropriate systems for safe and orderly records maintenance, and ensure that records are available in home for inspection. This particularly relates to all staff records and to records relating to health and safety/premises and equipment. The registered person must 6/6/05 notify the CSCI in writing of any deaths, serious injuries or illnesses, misconduct or other serious incidents (etc.) occurring in relation to the home. 6. 33 24 31/8/05 7. 37 17 8. 37 37 9. Ashley House I56-I05 s17753 Ashley House v227006 110505 stage 4.doc Version 1.30 Page 25 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. Refer to Standard 3 7 8 12 Good Practice Recommendations The registered person should ensure that pre-admission assessments are always documented and available to staff prior to the service users admission to the home. It is recommended that service users, where able, are involved in the development of their care plans, and are asked to sign to show their agreement to them. It is recommended that service users are regularly weighed, and their weights recorded and monitored. It is recommended that the registered person review the current activities programme, to ensure that there is an appropriate and sufficient range of daily activities to meet the needs of all individuals (including those who are less able to initiate activity or interaction). It is recommended that the activities and interactions taking place with service users are recorded, and that records are sufficiently accurate to enable the manager to monitor the level and type of interaction taking place with each resident, and their response to this. It is strongly recommended that the registered person progresses plans to refurbish the kitchen. This is a repeat recommendation for the fourth time. It is recommended that the registered person establish a planned programme for replacing furniture that is becoming worn. This should include the provision of lockable storage facilities for service users. The registered person should implement a system for regularly monitoring and recording the temperature of water from all hot taps (to ensure these remain close to 43°C), and for monitoring that hot water is stored centrally at a minimum of 60°C (and distributed at at least 50°C). The registered person should ensure that staff rotas accurately reflect all domestic cover during each week (i.e. staff names and hours), and that there is sufficient domestic cover to maintain hygiene within the home. The registered person should ensure that an application for registration of the acting manager is submitted as soon as possible. Care staff should each receive six supervision sessions per year; it is recommended that the registered person I56-I05 s17753 Ashley House v227006 110505 stage 4.doc Version 1.30 Page 26 5. 12 6. 7. 19 19 and 24 8. 25 9. 27 10. 11. 31 36 Ashley House 12. 38 implement systems for monitoring that this is taking place. Fire drills should incorporate an actual practice drill for staff. Ashley House I56-I05 s17753 Ashley House v227006 110505 stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection Fairfax House Causton Road Colchester CO1 1RJ 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 Ashley House I56-I05 s17753 Ashley House v227006 110505 stage 4.doc Version 1.30 Page 28 - 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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