Inspection on 09/05/08 for Ashley House

This inspection was carried out on 9th May 2008.

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 24/05/07

Ashley House 21/11/06

Ashley House 09/11/05

Ashley House 11/05/05

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 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Ashley House Ashley House Moulsham Street Chelmsford Essex CM2 9AQ Lead Inspector June Humphreys Unannounced Inspection 9th May 2008 09:00 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 DS0000017753.V363838.R01.S.doc Version 5.2 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 DS0000017753.V363838.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashley House Address Ashley House Moulsham Street Chelmsford Essex CM2 9AQ 01245 494674 01245 493254 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) Dr Kuldip Singh Dr Amrit Kaur Manager post vacant Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places Ashley House DS0000017753.V363838.R01.S.doc Version 5.2 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) 24th May 2007 Date of last inspection 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 en-suite toilets) and six double bedrooms (one with en-suite 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 residents with a diagnosis of dementia. A Service User Guide is available at the home from the manager’s office. The current range of fees is from £444.00 to £580.00 dependent on the level of care each resident requires. Residents pay for their own additional expenses such as hairdressing, chiropody, newspapers and personal toiletries. Ashley House DS0000017753.V363838.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that people who use this service experience adequate quality outcomes. This was a routine unannounced inspection, which included a visit to Ashley House on the 9th May 2008. The site visit lasted for eight and a half hours and was undertaken by one inspector. During the visit all of the key national minimum standards were addressed. Opportunity was taken to speak with residents and staff members. The Manager who was present at the last inspection in May 2007, left the service in October, and no further Manager has been appointed to date. The proprietor is currently managing the home, and was consulted throughout the inspection. Relevant records and documents were examined and observations of care practice formed part of the inspection, as did observation of staff and resident interaction. The Proprietor completed and returned the Annual Quality Assurance Assessment to the Commission, which is a self-assessment of how the service is doing; and information contained within this document will be reflected within the body of the report. Surveys were sent to residents, relatives, health care professionals and care managers. A limited number of surveys were returned on this occasion, but the information received will be included in the report. What the service does well: The residents spoken to on the day of inspection said they ‘liked their home’ and were very positive about the support they received from staff. Most service users were aware of how to make a complaint should they wish, but some would clearly not have the capacity to be able to do this easily and would require support. The staff spoken to say that they worked together to try to ensure residents needs were met, even at times when there was a shortage of staff. The proprietor was keen to address promptly any concerns raised by residents during the inspection. Ashley House DS0000017753.V363838.R01.S.doc Version 5.2 Page 6 The proprietor said she is keen to work with the staff team where ever possible, and attends health /medical appointments with residents. 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. Ashley House DS0000017753.V363838.R01.S.doc Version 5.2 Page 7 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ashley House DS0000017753.V363838.R01.S.doc Version 5.2 Page 8 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 DS0000017753.V363838.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with an opportunity to visit the home prior to admission, and the statement of purpose provides adequate information about the service being provided. EVIDENCE: The statement of purpose and service users guide was looked at as part of the inspection. It would benefit from being written in a more user-friendly format. It reflects the aims and objectives of the service, and the types of people that be admitted to the home. The documents on the day of inspection were not on display in the lounge, or entrance area as the proprietor had planned to do at the last inspection. The proprietor stated that most new residents are referred through social services, and that basic assessment information is provided at the point of referral. The annual quality assessment completed by the proprietor stated Ashley House DS0000017753.V363838.R01.S.doc Version 5.2 Page 10 that prospective residents are able to spend a day at the home prior to admission, and that family and friends are encouraged to visit and ask questions. “Getting to know you questionnaires are completed with service users and relatives, to gather insight and try to get to know about them”. Ashley House DS0000017753.V363838.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst residents have a plan of care, they cannot be assured that preventative measures are fully in place or that their privacy and dignity would always be protected. EVIDENCE: Four care plans were looked at as part of this inspection. Basic information was in place about the residents, but did not always advise on preventative care, for example what staff should look for when preventing a pressure sore. Care plans were not generally resident centred and did not provide sufficient evidence that staff were encouraging choices and independence, or identifying and preserving life skills. The care plans had been dated to show a review, but care, and care needs were generally not being evaluated on a regular basis with evidence to show changes and updates in the review notes. Ashley House DS0000017753.V363838.R01.S.doc Version 5.2 Page 12 Service users’ records show that in general health care needs are referred to appropriate health care professionals when necessary i.e. one resident was having an ulcerated leg dressed by the district nurse on the day of inspection. The district nurse was a locum, and had limited contact with the home, but advised that staff were not always at hand to provide feedback. The district nurses notes of each visit were updated by the nurse every time she visited, but daily recording notes used in the home were not clear in showing whether there had been improvement or not. The only recorded information seen was to record that the district nurse had visited. Two staff was asked about the care of the person, and both were aware that the person had regular visits from the district nurse service, and also sat on a pressure cushion. The care plan did not advise staff on any current practices with regard to the leg i.e. when assisting with personal care. It was also observed that many residents remain in their chairs throughout the day, this is of concern has this may increase the risk of pressure sores. Each resident had a cantilever table over their legs. All residents usually eat breakfast and tea whilst they are sitting in their armchairs. Some residents even eat the main meal of the day here instead of moving to the dining table. The proprietor advised that this was residents’ choice, and that new comfortable chairs had been purchased for the dining room. Whilst it is important to acknowledge the right for residents to choose, staying in one position all day has many disadvantages, and must be recorded in the care plan, with identifiable risks clearly recorded on the risk assessment. This must include details of preventive care that staff must follow i.e. regularly moving or turning the person in the chair, or even the person possibly being offered to lay on their bed for a short period of time during the day. The care plan should also detail activities offered that encourages movement and exercise, which was not observed on the day of inspection Most residents had jugs of water on the tables in front of them. Staff were seen to re fill residents glasses, but the intake of water/fluid was not monitored/recorded. Weight charts were on file, but not consistently completed. The proprietor referred to the annual quality assurance assessment where it has been stated that there is a need to purchase sit on weighing scales. This will be ordered in the near future. Medication practices have improved since the last inspection. A protocol for the administration of medication has now been written. Staff spoken to were aware of the protocol, and the changes the proprietor had made to improve the standards in storage and administration. Medication was observed being administered and was satisfactory. Medication was appropriately stored, and no gaps were found on the medication records. Ashley House DS0000017753.V363838.R01.S.doc Version 5.2 Page 13 The annual quality assurance assessment detailed a number of ways in which the service endeavours to provide respect and dignity to the residents. This includes residents choosing when they wish to get up, and go to bed. Residents are regularly spoken to and asked prior to any changes being made in routines, activities and menus. Surveys received from residents stated that staff did act on their wishes, and care was provided when they needed it, however it was observed that there was a delay in responding to residents’ requests due to the staff numbers available. The proprietor employs domestic staff to ensure that the premises remain clean, and this was the case except when the inspector initially entered the main lounge area where the smell of urine was quite unpleasant. The proprietor was made aware of this due to concerns previously expressed regarding a toileting programme within the home where residents had set times to go to the toilet. The proprietor confirmed that this was no longer in practice, and personal care was individualised. The smell was not present when re entering the room shortly afterwards. There are a high number of shared rooms that are separated by a curtain. Two curtains were not in place, and three were worn and creased. This not only looked shabby, but also again impacted on people’s dignity and privacy, particularly when being offered personal care. The proprietor stated that the bedrooms were in the process of being refurbished, and that the curtains that were missing were being replaced. Ashley House DS0000017753.V363838.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14, and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can expect activities to be offered by the staff working in the home, but overall opportunities, and the quality of what is offered is limited and can affect outcomes for residents. EVIDENCE: Both the relatives who responded to the surveys stated that residents would benefit from more entertainment. No activities were observed on the day of inspection. With the limited number of staff, and the amount of core tasks that staff needs to complete, it easy to see that time is limited to provide activities. Staff was seen to be talking to residents, and there was a nice rapport between staff and residents when care was being provided. Activities had not been regularly recorded, and the proprietor acknowledged this, in the annual quality assessment review stating” We could ensure that activities are made part of daily recordings, which does not always happen.” It maybe useful to consider if activities are best provided by in house staff or whether another outside source should be considered. The proprietor stated Ashley House DS0000017753.V363838.R01.S.doc Version 5.2 Page 15 that outings to the park, and occasional picnics are offered, but four residents spoken to say that they had not been out for a very long time and that the home had no transport. One person said that they were “taken into the garden by staff when the weather was nice, but that’s all staff could manage” Whilst residents are offered flexibility and autonomy about when to get up, if the majority of the time is spent sitting in the lounge as observed, then motivation to get up could be affected. The television in the lounge is up high on a stand, and out of view for many residents. One resident said, “I like to hear it, even if I can’t see it”. The proprietor stated in the Annual quality assurance assessment that the television was due to be changed. Maybe a larger T.V in a lower more central position may benefit more people. Residents’ family and friends are made welcome in the home, and are encouraged to visit. Two relatives were spoken to on the day of inspection. One felt the service provided was good, and that staff were “nice and caring, and available to help”. Another felt that staff shortages’ were worrying’. Please see complaints section re: further concerns raised. The main meal on the day looked appetising. The proprietor produced a list of what each resident had chosen earlier in the day. There was a range of fish to choose from which was streamed or fried and an alternative of an omelette. Residents who were spoken to were positive about the meals, but said that it did depend sometimes on who was allocated to cook. The proprietor confirmed that the cook had been off sick for approximately 10 weeks. The Manager had organised that she would cook today, but due to the inspection taking place another member of the care staff came in early to cook prior to completing her afternoon shift. Staff reported that this had been a regular occurrence. Looking at staff training records there was no record of staff having completed food handling training, or any form of training in relation to cooking. The proprietor stated that she was in the process of finding out when the cook was returning from sick leave. Ashley House DS0000017753.V363838.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents would be better protected if the home’s policies and procedures for dealing with complaints were adhered to. EVIDENCE: The complaints policy was seen displayed in the entrance hall. Feedback from questionnaires completed by several residents and family members confirmed that if they had a complaint, they would have no hesitation in speaking to the manager and felt that she would listen to them and try to resolve things. However this was a random sample, and one person did feel that since the Manager had left and the proprietor was managing the service, that the complaints procedure was not so robust, and often concerns were not properly responded to. There had been five complaints received since the last inspection in May 2007, the home’s complaints log referred to in the previous inspection, and given has a good practice example in the annual quality assurance assessment had not consistently been updated to show how and what the management had done i.e. an audit trail of actions taken. However the final outcome had been noted in the log. The Proprietor advised that regular residents and relative support groups were held and she would raise the area of ‘making complaints again’ at the next meeting. The use of outside advocacy would enable the complaints process to be more robust, as many residents are frail, and require support to make their views known. Ashley House DS0000017753.V363838.R01.S.doc Version 5.2 Page 17 A repeat requirement regarding staff training in relation to the protection of vulnerable adults/ safeguarding was made at the last inspection. All staff except two had now completed the training. The two staff who had not, had been in post for a short period of time, and confirmed that they would be completing the training in the near future. The training consisted of a DVD being shown, staff answering written questions and this then being sent away to be marked. There was a pass mark of 80 and staff had responded will to learning in this format. This also meant that training for new staff could be arranged quickly, and refreshers courses for updating existing staff could also be undertaken by the manager/proprietor at no extra cost. The proprietor had received a copy of the Essex County Council new guidance booklet and advised that she was already in the process of ensuring that staff understood any changes that have been made. Ashley House DS0000017753.V363838.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21,and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a comfortable environment, which is homely but in need of some improvements, which can sometimes impact on residents’ safety. EVIDENCE: The lounge is spacious and provides ample space for residents to be involved in a range of different activities. A smaller lounge is also available that was well decorated and cosy. This is used by visiting family and friends, and also if residents would prefer quiet time. The proprietor has begun to address some of the maintance issues raised at previous inspections, but this has generally been slow, with outstanding requirements being repeated i.e. in relation to the poor condition of bathroom 3 where requirements have been made, but the minimum has been undertaken to meet the necessary improvement. A further requirement has been made on this occasion, which implies that the management only act on requirements/recommendations when an inspection Ashley House DS0000017753.V363838.R01.S.doc Version 5.2 Page 19 has been undertaken. Regular house checks/audits are required by the proprietor to ensure the environment remains safe, comfortable, and well maintained at all times. There are currently six shared bedrooms in the home, which are divided by the use of a curtain to give privacy and personal space. Two curtains were not in place, and three were worn and creased. The proprietor advised that these had been purchased along with new bed linen, and were waiting to be put out. Beds, wardrobes and bedside cabinets with locking facility and bedroom chairs had also been replaced in most rooms. Rooms had been personalised and residents had been able to bring in personal items and small pieces of furniture. The toilet frame in bathroom 3 was seen to be corroded and flaking, and needed repairing to avoid presenting an infection control hazard. This was pointed out at the previous inspection in May 2007. The fire door of the same bathroom was also damaged due to general wear, and in need of repair/replacement. The carpet is worn and in need of replacement in bedroom four. The inside of the lift is also in need of cleaning, and the carpet is again worn and dirty. There are currently 19 residents living at Ashley House, and whilst there are three bathrooms available, only two are currently used. The proprietor advised that there were plans for the 3rd bathroom to be refurbished and have a walk in/seated shower. This would be a positive measure, as many residents do not use the wash hand basin facilities located in their rooms, due to their age and disability. Currently most resident are supported to bath weekly unless they request otherwise. There are concerns with regard to the current staff and managements awareness of current fire safety practices. An immediate requirement was made with regard to a wardrobe being placed in front of a fire exit, which was located in a bedroom. There was also a tumble drier cover located outside of the building partially blocking the fire ramp used for wheelchair escape in an emergency. The proprietor removed the cover immediately. The ramp also has two fire doors leading to a narrow ramp and the proprietor must risk assess that this provides an adequate means of escape. The fire safety unit are due to visit shortly in June 2008 and the proprietor will ensure that a record is made of the visit, as this was not the case when previous visits have been undertaken; therefore outcomes/recommendations were unavailable to view at this inspection. The kitchen has now been completely refurbished and was seen to provide, adequate food preparation space, which was clean and tidy. Staff commented on how better organised the new kitchen was and that is was easier to prepare food. Ashley House DS0000017753.V363838.R01.S.doc Version 5.2 Page 20 The laundry and sluice facilities are sufficient to meet the needs of the residents. A new commercial washing machine and tumble dryer have been purchased in the last 12 Months. Ashley House DS0000017753.V363838.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Recruitment procedures for staff have improved, and staff has now had the necessary checks prior to taking up employment, however residents cannot be assured that their needs will be always met by the current levels of staffing. EVIDENCE: The home is fortunate in being able to retain a small number of stable staff, which has worked at the home for many years. They know the residents well, and it is only because of this that current staffing levels, combined with staff’s general commitment, are sufficient to meet the basic care needs of residents. Time was spent observing staff, and current care practices are restrictive due the number of staff, and the high level of care the majority of residents require. They were seen to provide care and support to 17 residents on the day of inspection. Staff reported that sometimes there was only two staff on duty. The proprietor said this was rarely the case, as she often worked with and supported staff. The rota did evidence that three staff were working on most occasions, but sometimes staff were brought in to cover with limited notice, which is disruptive to the routines of the residents i.e. when a staff member is sick, another member of the late shift will be asked to come in and cover. The outcome is that there is two staff, but not for the whole shift. Ashley House DS0000017753.V363838.R01.S.doc Version 5.2 Page 22 The proprietor advised that agency staff is not employed within the home and that shifts are covered by existing staff, being offered extra hours. Whilst this is positive, as far as staff knowing residents, this can affect the quality of the care provided, if staff works long hours, and regularly work increased shifts. Several of the staff interviewed acknowledged that many staff were stressed, and had been off sick putting further pressure on the remaining staff. The proprietor stated that the needs of resident are always met by the dedication of her self, and the staff team. A number of staff had left, and yet to be replaced. Interviews were taking place shortly, and number of new staff had been employed but had not started work due to CRB checks not having been returned. There has been the current ratio of staff working at the home for a long time, and the needs of the residents have increased both those living at the home, but also new admissions. The proprietor should review the current levels of staffing, particularly at peak times of the day, and in relation to the dependency of residents. The records evidenced that staff are appropriately supervised every two to three months. Team meetings are currently held every three Months. Four staff was spoken to directly, and three staff questionnaires were received. Staff expressed a range of views, but the two points that were continually raised were low payment of salary, and lack of sufficient numbers of staff. The recruitment records for a recently appointed member of staff evidenced that the correct procedures and checks had been carried out and that the new staff member had not commenced duties until a clear CRB check had been received. This area of work has improved since the last inspection, along with the development of training relating to safeguarding. This provides confidence and reassurance to people living in the home that unsuitable staff will not be employed to care for them, and that staff know and understand how to protect residents by using appropriate polices and procedures. The annual quality assessment review demonstrates that an effort has been made for staff to complete mandatory training i.e. safeguarding. However the proprietor acknowledges, “we need to further improve on training”. It is not only about training it is important that staff clearly can demonstrate knowledge into practice, and as previously expressed knowledge with regard to fire safety is limited. Two staff members have started the NVQ 2, and three staff members have registered to enrol in level 3. The health and social care training is dependent on outside college funding which is dependent on staffs current levels of training. This can sometimes be limiting if care is a second career, and staff already have qualifications, as they will not be eligible for funding. Ashley House DS0000017753.V363838.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The lack of a registered manager has prevented the home from developing clear management processes, and being run in the best interests of residents. EVIDENCE: The home has been without a registered manager since 2005. The proprietor has appointed two managers within this period of time, but neither has registered with the C.S.C.I. It is is also noted that both managers appear to have been in post for a limited period of time. In an absence of a full time Manager the proprietor has acted as Manager. The proprietor stated as part of the Annual quality assurance review that she would be registering with the C.S.C.I within the next few months, and also enrolling in the N.V.Q 4 at Ashley House DS0000017753.V363838.R01.S.doc Version 5.2 Page 24 Braintree College. However at the inspection the management of the home was again discussed, and it would appear that the managers’ post had again been re- advertised but limited applications had been received. Hence the proprietors need to register as manager. Whilst it is important that the home has a registered Manager, the main issues are in relation to the lack of clear guidance in developing, and moving the service forward. The staff were unaware that the proprietor was intending to register as manager, and no one seem to know about why the previous manager left, as no notice period was given. This is unsettling for staff, and the proprietor should ensure that staff are aware of what is happening as far as is possible. The proprietor has a quality assurance survey form that has previously been used to seek residents’ views on the quality of care provided to them. It was noted that where residents are unable to complete this independently, relatives or staff members assist them: the inappropriateness of care staff helping residents to complete questionnaires about the care being received was discussed, and it was recommended that the proprietor consider other ways of providing residents with support with this task; hence the recommendation of advocacy support being offered to residents by an outside organisation such a Age Concern. A report on the outcomes of a survey was produced in early 2006, but no recent report was available. Residents’ meetings have been regularly held this year, and that relatives had also been invited. Minutes were available for the three meetings that had been held since the inspection in May 2007. There has been no progress in the management team developing an annual development plan, and there are no formal auditing tools in use in the home. This is particularly important in the process of developing a checklist for monitoring maintenance and health and safety issues around the home. Whilst medication administration has improved and a protocol is in place the Manager/proprietor is expected to monitor and audit medication practice. This is also important with regard to staff development and training. The system for recording residents’ monies within the home is clear and thorough. Two residents accounts were audited and in both instances the money remaining, tallied with the incomings and out goings. The Health and Safety policy could be improved, and the proprietor is currently reviewing a number of the current policies used within the home. The proprietor has improved levels of mandatory training offered to staff including moving and handling, safeguarding, and fire safety. However staff was observed working in the kitchen, cooking and preparing food without any food hygiene/ food handling training that is essential. The proprietor must act in the best interest of residents and organise a permanent cook or persons with relevant training to take on the everyday provision of food. The annual quality assurance assessment provided information in relation to regular servicing of equipment and utilities. Evidence was seen of regular internal checks on fire alarms, emergency lighting and extinguishers, and also Ashley House DS0000017753.V363838.R01.S.doc Version 5.2 Page 25 on hot water tap temperatures to ensure that hot water is maintained at a temperature that does not present a risk to residents of scalding. Hot water taps that did not have restricted temperatures (e.g. kitchen and laundry) were also checked to monitor that central hot water was maintained at a suitable temperature to reduce risk of Legionella. The proprietor said that she was aware of the new fire regulations, and confirmed that the home has a fire risk assessment. However a repeat requirement was made under the environment section, and also concerns relating to fire exits which implies lack of action being taken to safely protect residents. Ashley House DS0000017753.V363838.R01.S.doc Version 5.2 Page 26 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 2 X 2 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X 2 X X X X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 3 Ashley House DS0000017753.V363838.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP31 Regulation 8(1)(b)(i) Requirement A clear management structure within the home is required to lead, monitor and audit the safety of practice, and quality of service being offered to residents. (This relates to their being no registered manager, and no deputy manager) Fire safety arrangement in relation to the means of escape for residents must be in place. Immediate requirement notice left. (Relates to the removal of wardrobe in front of fire exit) Timescale for action 09/10/08 2. OP23 23 (4) (b) 10/05/08 3. OP19 23(2)(d) A maintenance programme must be developed that clearly shows what has been completed, and timescales for tasks that have not, to ensure residents live in a safe, and hazard free environment. This applies to the carpet being worn and in need of replacement in bedroom four. The inside of the lift is also in need of cleaning, and the carpet DS0000017753.V363838.R01.S.doc 09/09/08 Ashley House Version 5.2 Page 28 is again worn and dirty. 4. OP26 13(3) To ensure the health and safety of residents, the home must have suitable arrangements and facilities to prevent the spread of infection in the home. This in particular refers to the toilet frame in bathroom 3 that was seen to be corroded and flaking, and needed repair or replacement. 09/08/08 5. OP27 18 Having regard to the size of the 09/08/08 home, the statement of purpose and the number and needs of residents, that at all times suitable qualified, competent and experienced persons’ are working in the home in such numbers as are appropriate for the health and welfare of residents. (This is regard to the proprietor reviewing current staffing levels within the home, including a designated cook.) 6. OP8 15 To promote and protect residents’ health, care plans must clearly detail the preventative care that staff are expected to provide. The information must cross reference with the risk assessment. 09/07/08 Ashley House DS0000017753.V363838.R01.S.doc Version 5.2 Page 29 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. Refer to Standard OP1 OP13 Good Practice Recommendations Residents would benefit from the proprietor producing a service users guide in a more user- friendly format. The residents would benefit from outside advocacy, as the current practice of staff assisting residents with surveys etc is inappropriate. Continue to develop opportunities for activities, consulting with residents over this. The home should develop care plans relating to social and recreational needs, and explore ways of recording activities on individual records. 3. OP12 4. OP13 Staff are encouraged to explore and provide more opportunities for people to go out of the home, and for contact with the local community. This in relation to the need to access appropriate transport. The residents would benefit form the availability of extra bathing facilities (currently only 2 bathrooms in use) a shower facility is preferred by residents. The proprietor should continue to promote an ethos that encourages people to express any complaints and concerns, and responds to these positively. The recording of complaints should clearly show the stages and timescales of the process. All complaints should be recorded. All training should be provided by someone who has the knowledge and skills (including qualification, where applicable) to deliver training in each subject. It is recommended that the proprietor enrol on appropriate management training as soon as possible. To ensure that the home is run in the best interests of DS0000017753.V363838.R01.S.doc Version 5.2 Page 30 5. 6. OP21 OP16 7. OP30 8. 89. OP31 OP33 Ashley House residents, the home should establish and maintain a system for evaluating the quality of services provided at the care home. This must include systems for obtaining feedback from residents and their representatives about the quality of care in the home, but should also include other quality monitoring processes, including an annual development plan and internal auditing practices. 9. OP38 It is recommended that the manager review the home’s risk assessment on safe working practices to ensure that it covers all relevant work place risks and activities. This must include the fire exist at the rear of the building. Ashley House DS0000017753.V363838.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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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