Inspection on 21/09/05 for Ashley House

This inspection was carried out on 21st September 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Ashley House 08/05/07

Ashley House 02/06/05

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 Ashley House Christmas Hill Kings Road Shalford Nr Guildford Surrey GU4 8HN Lead Inspector Susan McBriarty Unannounced Inspection 21st September 2005 9.00am X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ashley House DS0000013558.V252519.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ashley House DS0000013558.V252519.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ashley House Address Ashley House Christmas Hill Kings Road Shalford Nr Guildford Surrey GU4 8HN 01483 561406 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Penelope May McKenna Mrs Christine Mary Back Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (27), Physical disability over 65 years of age (2) of places Ashley House DS0000013558.V252519.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd June 2005 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 DS0000013558.V252519.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, the second for 2005 – 2006. The focus of the inspection were the requirements made at the inspection of the 2nd June including the progress of the major works planned and a number of the remaining standards. During the course of the inspection a number of documents were sampled including staff supervision and training notes, resident files and some of the home’s policies and procedures. Observations were made by the Inspector of the interaction between staff and residents as well as their relationship with the manager and owners of the home. What the service does well: What has improved since the last inspection? What they could do better: This was a positive inspection with few requirements being made. The home has been required to revise the procedure for the protection of vulnerable to ensure they are in line with local guidelines. The current policy indicates that an investigation would take place to see if any allegation was correct prior to a referral being made. There are two radiators in the entrance hall of the home, both of which have furniture placed in front of them. A requirement has been made that the radiators be covered or replaced with low temperature surfaces. A requirement was also made for the home to forward a copy of their financial and business plan to the CSCI for information. In addition a recommendation has been made for the home to consider alternative options to ensure that confidential information held at the request of a resident is recorded. Ashley House DS0000013558.V252519.R01.S.doc Version 5.0 Page 6 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 DS0000013558.V252519.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ashley House DS0000013558.V252519.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,4,5 Standard 6 does not apply. Standards 1 and 2 were assessed during the inspection of the 2nd June 2005. Prospective residents are assessed prior to moving to the home to ensure the home is able to meet their assessed needs. EVIDENCE: The requirement made on the 2nd June 2005, that the home ensure that those residents needs are assessed by a suitable qualified professional and that the current registration be considered if necessary had been met. The home has made application to the Commission for Social Care Inspection (CSCI) to include older adults with dementia. The Inspector sampled resident files and evidence was seen of pre-admission assessments taking place. Residents are provided with a one month trial period to ensure the home is able to meet their needs. During this trial period further assessment takes place to enable the home to agree a care plan with the resident. The Inspector discussed with the manager and separately with the owners the need to consider how to record the request of a resident to hold confidential Ashley House DS0000013558.V252519.R01.S.doc Version 5.0 Page 9 information at the point of pre-admission. It is recommended that the home consider alternative ways to record information pertinent to the needs of the prospective resident and meets their wishes. Wherever possible the prospective resident and their family or representative visit the home to enable them to assess the home’s suitability. Ashley House DS0000013558.V252519.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,10 and 11 were assessed during the inspection of the 2nd June 2005. EVIDENCE: The requirement made at the inspection of the 2nd June to ensure that residents are risk assessed and that risk assessments are updated regularly had been met. Those files sampled by the inspector on the 21st September clearly identified risks to residents and actions required by staff. Ashley House DS0000013558.V252519.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14, and 15 were assessed during the inspection of the 2nd June 2005. EVIDENCE: Ashley House DS0000013558.V252519.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18 The home had policies and procedures in place to safeguard residents; further work is required to ensure that the home’s procedure for reporting concerns regarding the protection of adults is clarified in order to reduce any possible confusion for staff making a referral. The home’s complaint procedure meets the Standard. EVIDENCE: The home had not received any formal complaints in the preceding twelve months of the inspection of the 21st September 2005. A copy of the complaints procedure was placed on the notice board outside the manager’s office. A further copy was available in the home’s policy and procedure file. Residents were able to choose to use postal votes or attend the local polling station dependent on their choice. The majority of those who were able to choose or were able to vote preferred postal voting. The Inspector reviewed the home’s protection of vulnerable adults’ policy and found that further work is needed to clarify the procedure. The procedure indicated that the manager would investigate any concerns and refer on if there were felt to be a concern that a resident had been or was being abused. A requirement was made that the home revises the procedures to ensure they were in line with the local protection of vulnerable adult procedures. Ashley House DS0000013558.V252519.R01.S.doc Version 5.0 Page 13 Staff members are provided with training in the protection of vulnerable adults. The home is currently seeking a trainer to provide ongoing training within the home. Ashley House DS0000013558.V252519.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19,20,21,22,23,24,25 and 26 were assessed during the inspection of 2nd June 2005. EVIDENCE: A number of requirements were made at the inspection of the 2nd June 2005 and the home has been making good progress in completing the work required. The minor repairs required on the 2nd June had been completed including; reconnecting the water to the en-suite showers, moving the toilet roll holder in the specified bathroom, repairing the lock on the specified bathroom door and repairing the call bell in a particular room. The major works including the bathroom and flooring are in hand. The home has gained quotes for the work and has agreed contractors. All the bathrooms will be replaced with appropriate showers that the owners state meet the assessed needs of the residents’ and once this work has been completed Ashley House DS0000013558.V252519.R01.S.doc Version 5.0 Page 15 flooring will be replaced as required. As the work has been planned the requirement will not be repeated in this report. Three patio doors had been replaced since the inspection on the 2nd June and the remainder will be replaced as part of the work programme agreed with the Commission for Social Care Inspection. It is expected that given such a significant work programme being in place that the patio doors will all have been replaced by the end of 2007 at the latest. Although these standards were not assessed during the inspection it was noted, in discussion with the owner, that some of the radiators in the community areas were not covered. The radiators had furniture placed in front of them that lessened the risk to residents, however to further minimise any risk to residents a requirement was made. A requirement is made that the radiators in the community areas of the home be covered or replaced with low temperature surfaces. Ashley House DS0000013558.V252519.R01.S.doc Version 5.0 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,30 Standards 28 and 29 were assessed during the inspection of the 2nd June 2005. The home employs care staff and ancillary staff to meet the assessed needs of the residents. Staff members receive training appropriate to the needs of the home. EVIDENCE: The home had acquired a copy of the amended version of The Care Homes Regulations 2001 and had clear information regarding the recruitment of staff and the information required by the CSCI to be held by the home in respect of staff members. An arrangement with another home had enabled Ashley House to share training thereby opening up additional opportunities for their staff team for further training. Agency staff was used occasionally and the home manager ensured that the staff provided had been appropriately checked before they could begin work at the home. The staff team consisted of care staff, domestic staff and two cooks in order to ensure that the resident’s needs were met appropriately. Ashley House DS0000013558.V252519.R01.S.doc Version 5.0 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,34,36 Standards 32,35,37 and 38 were assessed during the inspection of the 2nd June 2005. The home provides a range of opportunities for staff and residents to inform the owners and manager of their views regarding the home. Appropriate levels of supervision are provided to staff members. Copies of the home’s finance and business have been required to be forwarded to the CSCI for information regarding financial viability. EVIDENCE: The manager is nurse qualified and is undertaking the Registered Managers Award and was considering additional training with regard to the National Vocational Qualification Assessors Award. The manager had worked at the home for some years having eventually being promoted to manager, most of her experience being with older people. Ashley House DS0000013558.V252519.R01.S.doc Version 5.0 Page 18 The owners of the home were in attendance most days and made themselves available for discussion with the manager and staff throughout the time they were there and were contactable by telephone at all other times. Throughout the inspection the Inspector observed residents coming into the office or approaching staff to ask questions and make requests indicating that they felt comfortable in doing so and have no concerns in seeking out staff members, the manager or the owners. A residents’ meeting is held several times a year at the home and is arranged and chaired by the relative of a previous resident. Minutes of the meeting are passed to the owners shortly after the meeting. Informal self monitoring by the owners takes place through discussion with staff members and residents. The Inspector has recommended that the home consider using the information gained to produce a survey that can be published and copies provided to prospective residents, their families and purchasers of the service. The owners have a financial and business plan and the CSCI have required that copies of these be forwarded to the local CSCI office for information. Insurance is in place and due for renewal at the end of September 2005 and the Inspector viewed the renewal document. The care staff members were supported with a range of supervision sessions with the manager. These included observed practice, a method that enables the manager to observe the member of staff working with residents and record the outcome, individual sessions where particular policies and procedures were discussed and sessions where those staff undertaking National Vocational Qualifications discuss the units they were undertaking. Ashley House DS0000013558.V252519.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 X X X X X X X X STAFFING Standard No Score 27 3 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 2 X 3 X X Ashley House DS0000013558.V252519.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? NO 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 18 Regulation 13(6) Requirement The registered person must ensure that the home’s procedure for the protection of vulnerable adults is revised in line with local guidelines. The registered person must ensure that all radiators in community areas are covered or replaced with low temperature surfaces. The registered person must ensure that a copy of their financial and business plan are forwarded to the CSCI. Timescale for action 28/10/05 2 25 13(4)(a) 30/11/05 3 34 25(1)(2) (3) 14/10/05 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 3 Good Practice Recommendations It is recommended that the registered person consider alternative ways of ensuring that confidential information is recorded regarding prospective service users. Ashley House DS0000013558.V252519.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Surrey Area Office 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. Extracts may not be used or reproduced without the express permission of CSCI Ashley House DS0000013558.V252519.R01.S.doc Version 5.0 Page 22 - 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. 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