Inspection on 02/06/05 for Ashley House

This inspection was carried out on 2nd June 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

Ashley House 08/05/07

Ashley House 21/09/05

Ashley House 26/10/04

Ashley House 30/06/04

Similar services:

The Shelley

Thorndene

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Ashley House Christmas Hill Kings Road Shalford, Surrey GU4 8HN Lead Inspector Mrs Sue McBriarty Unannounced 2nd June 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 H58_s13558_Ashley House_v221249_020605_stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Ashley House Address 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) Christmas Hill Kings Road Shalford Guildford Surrey GU4 8HN 01483 561406 Mrs Penelope May McKenna Mrs Christine May Back Care Home 29 Category(ies) of OP - Old Age (27) registration, with number of places PD(E) - Physical Disability over 65 (2) Ashley House H58_s13558_Ashley House_v221249_020605_stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Old age not falling within any other category (27). Physical disability over 65 years of age (2 places). Date of last inspection 26th October 2004 Brief Description of the Service: Ashley House is a large detached property situated in a rural setting on the outskirts of Guildford. The home is set in spacious well maintained grounds, that are accessible to residents. The bedrooms situated on the ground floor have access to the garden. The local wildlife use the grounds including foxes, badgers and ducks. The home consists of ground floor and first floor accommodation. The majority of bedrooms are of a good size and have en-suite toilets. The home has seventeen (17) single bedrooms and six (6) double bedrooms. Car parking is available at the front of the premises. Ashley House H58_s13558_Ashley House_v221249_020605_stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, the first for 2005 – 2006. Eight (8) residents were spoken to and two (2) family members. The owners were present and made themselves available for discussion throughout the day. The cook was also met and spoken to during the day and one member of staff was available to assist with part of the tour of the building. A full tour of the building and grounds was carried out. The inspection took place over eight hours, much of this time was spent talking to residents. Documents sampled included daily notes, contracts, two residents’ files, one staff personnel file and the detailed induction notes in the same file. Lunch was sampled on the day. This home prefers to use the term residents and this has been reflected throughout the report. What the service does well: What has improved since the last inspection? The rooms on the second floor have been adjusted to ensure that residents no longer need to access other resident’s rooms in the event of a fire. The connecting doors have been closed off and alternative evacuation procedures had been put in place. Ashley House H58_s13558_Ashley House_v221249_020605_stage4.doc Version 1.30 Page 6 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 H58_s13558_Ashley House_v221249_020605_stage4.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 H58_s13558_Ashley House_v221249_020605_stage4.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, 2, The residents have the information they need to make a decision about moving to the home. Further work is required to take into account the changing needs of the residents. The home has written contracts. Standard six (6) does not apply, as this home does not provide intermediate care. EVIDENCE: The home has a statement of purpose that is available to prospective residents and is provided to new staff as part of their induction into the home. Written contracts are provided to each resident, the home is currently considering the content of their contracts. A number of the residents spoken to or met during this inspection were said to have memory problems. The home is not currently registered to support people with dementia. It is required that the home seek specialist assessments for particular residents and make an application to vary their conditions of registration if it is found that any person is diagnosed with dementia. Ashley House H58_s13558_Ashley House_v221249_020605_stage4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 10, 11 The residents social and health needs are adequately met. Further work is required to provide risk assessments. The home has a policy to support residents at the time of their death. EVIDENCE: The care plans sampled evidenced detailed information about the needs of the residents. The plans included personal histories, health needs and previous daily diary notes that showed how the person’s needs had been met. The care plans had been reviewed on a regular basis. However there were no documented risk assessments available, the home has been required to ensure that risk assessments are provided for each resident. The risk assessments to include smoking. A number of residents were spoken to during this inspection and all spoke highly of the staff and the service provided at the home. ‘They are very kind’ said one; another stated that ‘they always listen to me’. The last comment was made by a resident who found that the day after she had raised a slight issue about food the matter had been resolved. The resident’s files evidenced that people’s preferences following their death were documented clearly. Ashley House H58_s13558_Ashley House_v221249_020605_stage4.doc Version 1.30 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 Residents are able to exercise choice wherever possible. Family members and friends are able to visit the home when they wish. The menus were seen and were varied and nutritious. EVIDENCE: The home has a programme of activities that take place throughout the week. One of the residents had taken the responsibility of ensuring that everyone knew what was available during any one week. A copy of the programme for the week of the inspection had been put in a position where everyone could see it. One family member expressed concern about the activities and this was raised with the owners at the time of the inspection. All the residents spoken to during the inspection talked about friends and family visiting and whether they had been taken out or met and talked with the home. Friends and family can meet privately if they so wish. Several residents discussed the residents meetings that were taking place regularly and what type of issues they raised during the meetings. All the residents stated they were encouraged to have their say and given time to do so. Ashley House H58_s13558_Ashley House_v221249_020605_stage4.doc Version 1.30 Page 11 The home provides the residents with the menu each week and residents informed the inspector that they usually received the menu alongside the activities programme for the same week. Although residents informed the inspector they had no choice about the food they were given or the content of the menus, they later added that their personal preferences were considered and that another option would be available. The lunch was sampled and residents said ‘ we always get fresh vegetables here’. Food is generally eaten in the dining room however the residents can choose to eat elsewhere if they wish. The dining room was able to provide comfortable seating for all the residents and overlooks part of the garden. Ashley House H58_s13558_Ashley House_v221249_020605_stage4.doc Version 1.30 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 standard(s) These standards were not assessed during this inspection. EVIDENCE: Ashley House H58_s13558_Ashley House_v221249_020605_stage4.doc Version 1.30 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 standard(s) 19, 20 , 21, 22, 23, 24, 25, 26 Further work is required to meet standards 19, 21, 22, 25 and 26. The home provided adequate communal and personal space for the residents. EVIDENCE: The home has a number of areas where residents could choose to sit during the day. There were four areas on the ground floor that offered the opportunity to sit quietly and talk to friends, watch the television or to sit in the foyer watching the comings and goings of others. Those residents’ rooms seen had been personalised and were light airy and bright. One resident said ‘ I love my room’ another that she ‘did not think it would be so nice before I came here’. A number of the resident’s rooms have en-suite toilets and adequate communal toilets were available. However one communal bathroom with toilet required reviewing. The toilet paper holder had been attached to the wall away Ashley House H58_s13558_Ashley House_v221249_020605_stage4.doc Version 1.30 Page 14 from the toilet and residents and staff spoke of assistance being required by some to reach, this lessened the privacy available to some residents. Of the three bathrooms available only one was in use. It is the only bathroom provided with specialist equipment. The bathroom was small and difficult to move around in. The water had been turned off in those resident’s rooms that had been provided with showers. This decision had been made to lessen the risk of legionella as the residents preferred bathing. It is required that the use of the showers be reviewed as part of an overall review of the present provision. The full requirement is noted in this section of the report. The requirement had not been met from the last inspection. It is required that all the toilet and bathroom areas must be reviewed to ensure that liquid soap and paper towels are available for use. One toilet area seen had no soap available for use. Areas of the home required attention at the time of this inspection the work required is noted here. The flooring in the hallway requires work in some areas where it has split and is therefore difficult to keep clean. Further splitting may create a trip hazard. It is required that the flooring be risk assessed and repaired or replaced. The home had been working on providing covers for all the radiators; the work had not been completed at the time of this inspection. One radiator in particular was found to be extremely hot. Although care had been taken to place an obstacle in front of the radiator to reduce the risk of harm to the resident it is required that all radiators are covered. It is required that the provision of bathing facilities and the use of the showers be reviewed urgently and a proposal be forwarded to the CSCI regarding the work required to provide adequate bathing facilities. Reasonable timescales for the work required must be provided. The home has been replacing a number of patio doors. Some of the doors double-glazing seals had been breached and the windows were misted over. Two other doors had recently been broken and were awaiting replacement. It is required that the CSCI be provided with a plan including reasonable timescales for the repair or replacement of those patio doors. It is required that the toilet door lock that had been regularly repaired be reviewed for an alternative option and that the toilet paper holder be re-sited to maintain the privacy and dignity of the residents. Ashley House H58_s13558_Ashley House_v221249_020605_stage4.doc Version 1.30 Page 15 The call bell in one resident’s room is cracked and although it remains in working order requires replacement. In one residents room the lock to the wardrobe is small and coming away from the door. It is required that the lock is repaired and consideration be given to a larger lock or handle being provided to enable easier opening. It was noted by the inspector that part of the flooring under the sideboard was different to that of the remaining dining room. The flooring was lose and trapping dirt. The area under the sideboard in the dining room requires cleaning and the loose flooring must be repaired or replaced. The use of communal soaps and moisturising creams must cease. The owners took action on the day of the inspection. Each resident must have access to or if preferred purchase their own soaps and creams. The boiler room has loose floorboards and plaster was flaking away form the walls. The room is used by the cook to store a mop and bucket otherwise the area is only accessed by the owner. It is required that the area is made safe. Further reducing access and providing a notice to identify the risk is required. In one residents room the shower area had cracked tiles. It is required that these be replaced. During this inspection undated food was found in the fridge. It is required that all food must be dated on the day of opening. The kitchen was inspected and temperatures for the fridge, freezer, food storage and service were found to be kept on a regular basis. Evidence was also seen of regular deliveries of fresh meat. Ashley House H58_s13558_Ashley House_v221249_020605_stage4.doc Version 1.30 Page 16 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) 28, 29 Standard 28 was not assessed in full during this inspection. The home’s recruitment practice requires further Work. EVIDENCE: Staff members were provided with an induction programme the details were evidenced during this inspection. All staff were expected to sign and date that they had read and understood the policies and procedures within the home. One staff file was sampled during this inspection. The file did not meet the standard required and in discussion with the owners during the inspection it was found that they had been working to the un-amended version of The Care Homes Regulations 2001. The home must acquire the amended version of The Care Regulations 2001 and it is required that they meet the revised Regulations. Ashley House H58_s13558_Ashley House_v221249_020605_stage4.doc Version 1.30 Page 17 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) 32, 35, 37, 38 Further work is required in some areas. However the owners had an open and inclusive approach to managing the home. EVIDENCE: The owners were present during this inspection and were open about the issues raised and were able to discuss those areas where they had difficulties. These included the requirements raised regarding the current environment. They knew the residents well and were aware of the needs of those living at the home and had introduced new ways to involve the residents in the running of the home. One specified resident may be vulnerable due to their financial position, the issue was discussed and ways forward considered including contacting the local social services department for advice and assistance. Ashley House H58_s13558_Ashley House_v221249_020605_stage4.doc Version 1.30 Page 18 The records of the home were kept appropriately and in a lockable space. As noted earlier work is required with regard to risk assessments. It is also required that the current method of risk assessing but not documenting all the building requirements be addressed. The home had recently taken precautions regarding the possibility of the spread of a particular infection. The owners had taken prompt and appropriate action to ensure that the home including staff and residents were not compromised however they had not completed a Regulation 37 Notification. Given the circumstances it was recommended that any future such issues must be notified to the CSCI in writing. No other issues were raised regarding the provision of Regulation 37 Notifications during this inspection. The current registration certificate requires replacing as it states that it was supplied by The National Care Standards Commission. Ashley House H58_s13558_Ashley House_v221249_020605_stage4.doc Version 1.30 Page 19 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 2 x x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 3 3 2 3 3 2 2 STAFFING Standard No Score 27 x 28 3 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x 3 x x 3 x 2 2 Ashley House H58_s13558_Ashley House_v221249_020605_stage4.doc Version 1.30 Page 20 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 OP2 Regulation 14(1)(2) (a)(b) Requirement The registered person must ensure those specific users whose needs are changing are assessed by a suitably qualified professional and that the current registration be considered should this be necessary. The registered person must ensure that all service users are risk assessed for all aspects of daily living and that the risk assessments are documented and reviewed reguarly. The water needs to be conmnected to the showers in the en-suite bedrooms. (Timescale of 28/11/04 not met) The registered person must ensure that the toilet roll holder in the specified toilet be re-sited to enable service users to access without assistance. The registered person must ensure that the flooring in the hallway is repaired or replaced. The registered person must review those patio doors that are broken or have breached seals and provide the CSCI with a plan and reasonable timescales for the repair or replacement of Timescale for action 29th July 2005 2. OP7 13(4)(c ) 8th July 2005 3. OP19 23(c ) 22nd July 2005 30th June 2005 4. OP19 23 (2)(a) 5. 6. OP19 OP19 23(2)(b) 23(2)(b) 29th July 2005 8th August 2005 Ashley House H58_s13558_Ashley House_v221249_020605_stage4.doc Version 1.30 Page 21 those doors. 7. OP19 23 (2)(b) The registered person must ensure that the lock on the specified toilet door is repaired and if necessary replaced. The registered person must ensure that the call bell in the specified service users room is repaired or replaced. The registered person must ensure that the lock on the specified service users wardrobe door is repaired or replaced and a larger handle provided. The registered person must ensure that the flooring under the sideboard in the dining area is repaired and cleaned. The registered person must ensure that the boiler room floor is repaired and a safety notice is placed on the door. The registered person must ensure that the cracked tile in the specified service users room is replaced. The registered person must review the present provision of bathing and washing facilities and provide the CSCI with a written proposal of work required to be carried out in order to meet the needs of the service users and a reasonable timescale by which the work required will be completed. The registered person must ensure that all radiators are covered or have low temperature surfaces. The registered person must ensure that all bathrooms and toilets are supplied with liquid soap and paper towels. The registered person must ensure that all staff personnel files meet the requirements 24th June 2005 29th July 2005 30th June 2005 8. OP19 23(2)(b) 9. OP19 23(2)(b) 10. OP19 23(2)(b) (d) 23(2)(b) 30th June 2005 30th June 2005 30th June 2005 8th July 2005 11. OP19 12. OP19 23(2)(b) 13. OP22 23 (2)(a)(j) 14. OP25 13(4)(a) 12th August 2005 22nd July 2005 8th July 2005 Page 22 15. OP26 13(4) 16. OP29 19(1)(a) (b)(c) Ashley House H58_s13558_Ashley House_v221249_020605_stage4.doc Version 1.30 17. OP38 37 18. OP38 4(1) (Schedule 1 24(1)(a) (b) 19. OP29 made in The Care Homes Regulations (as amended) 2001. The registered person must ensure that any concerns regarding the spread of infection are notified to the CSCI. The registered person must ensure that the current registration certificate is replaced by one provided by the CSCI. It is required that the registered person acquire a copy of The Care Homes Regulations (as amended) 2001. immediate 2nd June 2005 30th June 2005 30th June 2005 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 Good Practice Recommendations Ashley House H58_s13558_Ashley House_v221249_020605_stage4.doc Version 1.30 Page 23 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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. 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