Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 14/07/05 for Ashley House

Also see our care home review for Ashley House for more information

This inspection was carried out on 14th July 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Ashley House provides a high standard of care to service users within a pleasant environment. Service users stated that staff were caring and considerate. Service users confirmed that the Manager and staff were approachable and that their individual choices were respected. The home is maintained to a high level of cleanliness and positive feedback was received regarding the meals provided at the home.

What has improved since the last inspection?

There is an ongoing program of staff training and development. Staff continue to receive regular updates in mandatory training, and study for NVQ qualifications in direct care. The home has continued to progress with re-decoration and re-furbishment within the property, and has recently purchased new furniture for some rooms.

What the care home could do better:

The home must continue with the maintenance and re-furbishment program. Some areas such as the communal bathrooms require upgrading. The home aims to complete work within the ground floor bathroom within the forthcoming year. The home must take further action to ensure that a satisfactory electrical hardwiring certificate is obtained, and that hot water temperatures do not exceed recommended levels.

CARE HOMES FOR OLDER PEOPLE Ashley House The Avenue Langport Somerset TA10 9SA Lead Inspector Sally Murphy Unannounced 14th July 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 D53 - D02 S16071 Ashley House V235901 050705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Ashley House Address The Avenue Langport Somerset TA10 9SA 01458 250386 01458 250386 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) South West Care Homes Ltd Susan Frances Timbrell Personal Care Home Only 25 Category(ies) of Old Age registration, with number Dementia - over 65 of places Ashley House D53 - D02 S16071 Ashley House V235901 050705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Registered for 25 persons in categories OP and DE(E) with a maximum of 6 DE(E). Date of last inspection 31st January 2005 Brief Description of the Service: Ashley House is situated in a residential area close to the centre of Langport. Service user accommodation is provided over two floors. There is a stair lift, assisted bathrooms and call system available at the home. Most rooms have en suite toilet facilities. Communal areas comprise of a lounge, dining room and large conservatory. The home has pleasant gardens that are accessible to service users. Ashley House is registered with the Commission for Social Care Inspection to provide care for up to 25 people over the age of 65 years who require assistance with personal care, including six service users who have a dementia. The Registered Manager is Mrs Susan Timbrell. The Registered Provider is South West Care Homes Ltd. Ashley House D53 - D02 S16071 Ashley House V235901 050705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out as part of the planned annual programme of inspection. The inspection was unannounced and carried out by one inspector over one day. The previous inspection was also unannounced and took place on 31st January 2005. On the day of the inspection there were nineteen service users residing at the home. During the course of the inspection service users, staff members and the Registered Manager were spoken with. Care practice was also observed, records examined and a tour of the premises was made. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ashley House D53 - D02 S16071 Ashley House V235901 050705 Stage 4.doc Version 1.40 Page 6 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 D53 - D02 S16071 Ashley House V235901 050705 Stage 4.doc Version 1.40 Page 7 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) 1,3,4 & 5 (Standard 6 does not apply) The home ensures that prospective service users are provided with appropriate information regarding the home. Service users and their families are invited to visit the home and assess the services provided. An assessment of need is completed prior to any service user moving in to ensure that the home will be able to fully meet their needs. EVIDENCE: The home has a Statement of Purpose and Service User Guide that provide details of the services and facilities offered at Ashley House. A copy of these documents is available in the entrance hall. Evidence of pre-admission assessments were seen within service user plans. Service users confirmed that they had been able to visit the home before moving in, and stated that staff had been helpful and welcoming whilst they were settling into the home. Ashley House D53 - D02 S16071 Ashley House V235901 050705 Stage 4.doc Version 1.40 Page 8 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) 7,8,9,10 &11 The home takes appropriate actions to meet service users health and personal care. Care plans are of a high standard and provide staff with the information required to fully meet service users needs. Staff are provided with appropriate medications training. Staff treat service users with dignity and respect. EVIDENCE: Care plans are maintained for each service user. These include details of individuals’ needs, daily routines and preferences. Care plans were thorough and included detailed directions to staff of the level and type of assistance to be provided to each person. A moving and handling assessment had been completed for each service user. Care plans had been regularly reviewed and updated as required. Staff are currently completing a distance-learning course on the safe handling of medications. The home has also received a visit from the Pharmacy Inspector from CSCI who has offered support and guidance the medication policies and practices within the home. All medications are stored securely. A record is maintained of all medications entering the home. Risk assessments had been completed in relation to Ashley House D53 - D02 S16071 Ashley House V235901 050705 Stage 4.doc Version 1.40 Page 9 service users who wish to self-medicate. The home must ensure that all hand transcribed entries are supported by two staff signatures. Appropriate records have been maintained in relation to medications being returned to the pharmacy. Service users are provided with assistance to undertake personal care tasks as required. Personal care is provided in private. The home works closely with the District Nursing Team and will aim to provide care to a service user until the end of their life whenever possible. Service users confirmed that staff treat them with dignity and respect. Ashley House D53 - D02 S16071 Ashley House V235901 050705 Stage 4.doc Version 1.40 Page 10 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) 12,13,14, &15 The home has taken appropriate action to meet individual service users’ social needs. Service users are encouraged to exercise choice over their lives. Meals are of a high standard and offer a well-balanced diet. EVIDENCE: Service users are encouraged to maintain interests and hobbies. There are staff available each day to provide assistance to service users in meeting their social needs. Service users are able to participate in a range of activities including: board games, nostalgia, bingo, quiz, armchair exercises, what’s in the news, manicures, favourite hymns, indoor sports, sherry evenings and arts and crafts. There has recently been a garden party at the home. The Manager also plans to assist service users in accessing the local library. Visitors are welcomed at the home. Holy Communion takes place at the home each month. Service users are able to spend time in communal areas or their own room, as they prefer. Individual choices are respected. Information has been displayed regarding Age Concern’s advocacy service and guidance for individuals who are privately funded. Meals are prepared at the home. Staff are aware of service users dietary needs and preferences. Service users spoke highly of the meals provided. Ashley House D53 - D02 S16071 Ashley House V235901 050705 Stage 4.doc Version 1.40 Page 11 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) 16 & 18 The home ensures that any complaints or issues raised are listened to, and appropriate action taken. The home has polices relating to the Protection of Vulnerable Adults and whistleblowing. EVIDENCE: The home has a complaints procedure, that includes details of external agencies that service users or their families may contact, including CSCI. There has been one written complaint received since the last inspection. The home has taken action to address the issues raised and responded within the appropriate timeframe. The home has appropriate policies relating to the Protection of Vulnerable Adults and whistleblowing. Ashley House D53 - D02 S16071 Ashley House V235901 050705 Stage 4.doc Version 1.40 Page 12 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) 19,20,21,22,23,24,25 & 26. There is an on-going program of re-decoration and re-furbishment throughout the home. Service user rooms have been decorated to a high standard. There is sufficient communal space to meet service users’ needs. Bathroom facilities require some upgrading. Hot water outlet temperatures exceed recommended levels and may pose a risk to service users. The home was found to have a high standard of cleanliness. EVIDENCE: Service user accommodation is provided over two floors. There are two assisted bathrooms, a stair lift and call system available. Automatic fire safety door closures have been fitted where required. All but two service user rooms have en suite toilet facilities. Two rooms on the first floor may be used as doubles by those wishing to share. Service user rooms have been decorated and furnished to a good standard. Communal areas comprise of a lounge, dining room and large conservatory. There are also well maintained gardens that are accessible to service users. Ashley House D53 - D02 S16071 Ashley House V235901 050705 Stage 4.doc Version 1.40 Page 13 The home plans to upgrade the assisted bathroom on the ground floor. The bath in the first floor bathroom is worn and also requires replacement. Hot water outlet temperatures for the bath and hand basin were tested. Both were found to exceed 50 C and may pose a risk of scalding to service users. Window openings on upper floors have been restricted and guards have been fitted to all radiators that are in use. The laundry areas were found to be clean and well organised. Red alginate bags are used as required. The home follows good practice in relation to infection control. Ashley House D53 - D02 S16071 Ashley House V235901 050705 Stage 4.doc Version 1.40 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 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 & 30 Staff are provided with appropriate training to undertake their role. There are sufficient staff on duty to meet service users’ personal care and social needs. The home operates a robust recruitment procedure. EVIDENCE: Duty rotas are maintained. On the day of the unannounced inspection, there was the Registered Manager, Team Leader, two Care Assistants, Cook and one Domestic Assistant on duty. The Registered Manager ensures that staffing levels are appropriate to meet service users’ needs and will cover shifts if required. Newly appointed staff are provided with a through Induction program. Staff are encouraged to undertake further training, including study for NVQs. By the end of 2005, 65 of staff at the home will have obtained the level 2 qualification or its equivalent. Staff have also recently attended training on infection control and dementia care, and are currently undertaking medications training. The Registered Manager completes a training needs assessment each year to ensure that appropriate courses are provided. Recruitment files were examined for the most recently employed members of staff. These were found to contain all of the documentation required under Schedule 2 of the Care Home Regulations 2001. Ashley House D53 - D02 S16071 Ashley House V235901 050705 Stage 4.doc Version 1.40 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 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) 31,32,33,34,35,36,37 & 38 The Manager provides strong leadership to the staff team. There are appropriate procedures in place to seek the views of service users. Records relating to service users are stored securely. The Registered Persons must take further action to promote the health and safety of staff and service users at home. EVIDENCE: The Registered Manager is Mrs Sue Timbrell. She is has many years experience of providing care to older people and has obtained the NVQ level 4 qualification in Management. Service users stated that the Manager and staff were approachable. A Residents Meeting is held every three months, and questionnaires have recently been provided to service users to obtain feedback on the service provided. Ashley House D53 - D02 S16071 Ashley House V235901 050705 Stage 4.doc Version 1.40 Page 16 Records relating to service users are stored securely. The home will keep money securely for any service user that wishes them to. Appropriate records are maintained of all transactions involving service user finances. Staff are provided with regular supervision. The home displays appropriate Employers Liability insurance. Fire safety equipment has been serviced and tested as required. Staff have been provided with regular fire safety training. Servicing records relating to the stair lift, heating system, portable appliances and wheelchairs have been appropriately maintained. The hoist was last examined on 7/9/04, and must be examined on a six monthly basis under the LOLER Regulations 1998. The home should advise the Inspector of actions being taken to address the recommendations of the gas engineer regarding the size of vents at the home. Further action is also required to ensure that the home has a satisfactory electrical hardwiring certificate. The cupboard housing the hot water tank was found to be accessible to service users, and poses a risk of scalding. Hazardous substances had been stored securely. Accidents have been recorded and reported as required. Ashley House D53 - D02 S16071 Ashley House V235901 050705 Stage 4.doc Version 1.40 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 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 3 x HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 2 3 3 3 2 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 3 3 3 3 3 2 Ashley House D53 - D02 S16071 Ashley House V235901 050705 Stage 4.doc Version 1.40 Page 18 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 OP9 Regulation 13(2) Requirement The Registered Manager must ensure that all hand transcribed entries are dated and supported by two staff signaures. (Previous timescale of 18.2.05 not met) The bath in the first floor bathroom requires replacement. The home must take appropriate action to ensure that the temperature of hot water discharged from the bath outlet does not exceed 44C. The hoist must be inspected on a six monthly basis under LOLER regulations 1998. (The Registered Manager has contacted CSCI shortly after the inspection to advise that this has been arranged). The home must obtain a satisfactory electrical hardwiring certificate. The cupboard housing the hot water tank and hot pipes, must not be accessible to service users and must be locked when not in use. Timescale for action 12.8.05 2. 3. OP21 OP25 23 (2j) 13(4c) 11.6.06 7.11.05 4. OP38 13(5) 9.9.05 5. 6. OP38 OP38 23(2b) 13(4a) 5.12.05 12.8.05 Ashley House D53 - D02 S16071 Ashley House V235901 050705 Stage 4.doc Version 1.40 Page 19 (The Registered Manager has contacted CSCI shortly after the inspection to advise that the hot water cupboard has been secured). 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 OP38 Good Practice Recommendations The home should advise the Inspector of actions being taken following recommendations from the gas engineer regarding the size of vents at the home. Ashley House D53 - D02 S16071 Ashley House V235901 050705 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection Riverside Chambers Castle Street Tangier Taunton TA1 4AL 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 D53 - D02 S16071 Ashley House V235901 050705 Stage 4.doc Version 1.40 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!