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Inspection on 03/10/05 for Ashley House Care Home

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

This inspection was carried out on 3rd October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

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

What the care home does well

There is a complaints procedure in place and residents and relatives said they knew how to make a complaint if they needed to. Staff knew what to do if an instance of abuse occurred. The home is kept clean and residents were happy with the laundry service.

What has improved since the last inspection?

A record is kept of all medicines coming into the home and the controlled drugs register is being properly completed. Arrangements are being made for each resident to have an appointee bank account.

What the care home could do better:

Despite efforts made to do so, residents` social needs are not being properly planned and residents are not being involved in drawing up and reviewing their care plans. A record should be made of the wishes of residents in the event of terminal illness or their death so that these can be respected. The home is partly staffed by adaptation nurses who are recruited by an agency and do not have a Criminal Records Bureau check before they start to work. Other staff are recruited following the correct recruitment proceduresThe views of residents and relatives of the services provided have not been recently sought through a quality assurance survey, although relatives said that they are asked if everything is all right.

CARE HOMES FOR OLDER PEOPLE Ashley House Care Home Sunnyside Worksop Nottinghamshire S81 7LN Lead Inspector Stephen Benson Unannounced Inspection 3rd October 2005 09:30 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 Care Home DS0000024625.V255295.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 Care Home DS0000024625.V255295.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ashley House Care Home Address Sunnyside Worksop Nottinghamshire S81 7LN 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) 01909 500541 01909 500542 Mr L M Patil Vacant Care Home 40 Category(ies) of Dementia - over 65 years of age (40), Mental registration, with number disorder, excluding learning disability or of places dementia (10), Mental Disorder, excluding learning disability or dementia - over 65 years of age (40) Ashley House Care Home DS0000024625.V255295.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The 10 Places in category MD are available for people of 50 years of age and above 25/05/05 Date of last inspection Brief Description of the Service: Ashley House is a care home providing nursing and personal care for 40 residents / older people with special mental health needs. Within this 40, the registration allows admission for up to 10 service users over 50 years of age. It is privately owned by Mr. L.M. Patil.The home is located on the outskirts of Worksop, on a bus route into the town. The home was opened in 1988 and consists of a large converted old house, with a purpose built lounge and bedroom extension on the ground floor. The physical building does not meet National Minimum Standards and is need of refurbishment / modernisation. However, there are plans to re-build Ashley House, currently with Bassetlaw District Council. There are 17 single and 9 double rooms, 2 of the double rooms having ensuite facilities. There is a passenger lift. The homes grounds are well laid out and provide a secure environment for residents. Ashley House Care Home DS0000024625.V255295.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the second of two unannounced inspections carried out between April 2005 and March 2006. The inspection lasted for 4 hours and the main method of inspection used was called case tracking which involved selecting 3 residents and tracking the care they receive through the checking of their records and discussing this with them. Other residents were spoken with and additional records were seen. A discussion was had with the provider, care staff on duty and relatives. Care practices were observed. The premises were not inspected in detail but various areas of the home were visited as part of the inspection What the service does well: What has improved since the last inspection? What they could do better: Despite efforts made to do so, residents’ social needs are not being properly planned and residents are not being involved in drawing up and reviewing their care plans. A record should be made of the wishes of residents in the event of terminal illness or their death so that these can be respected. The home is partly staffed by adaptation nurses who are recruited by an agency and do not have a Criminal Records Bureau check before they start to work. Other staff are recruited following the correct recruitment procedures Ashley House Care Home DS0000024625.V255295.R01.S.doc Version 5.0 Page 6 The views of residents and relatives of the services provided have not been recently sought through a quality assurance survey, although relatives said that they are asked if everything is all right. 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 Care Home DS0000024625.V255295.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 Care Home DS0000024625.V255295.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): None EVIDENCE: Ashley House Care Home DS0000024625.V255295.R01.S.doc Version 5.0 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 the following standard(s): 7, 8 and 9 More forward planning is needed in meeting the social needs of residents. Improvements have been made in recording of medicines. EVIDENCE: A requirement was set at the last inspection that after consultation with residents a written plan should be provided detailing how their social needs are to be met by the home by 31st October 2005. Whilst some attempt had been made to comply with this, the requirement had not been fully understood. An activities coordinator is employed who arranges all activities, but does not at present have access to the care plans. A number of activities taking place were identified that have not been recorded. Ways of developing care plans to incorporate social needs were discussed and the timescale for this requirement is extended to allow for this to be taken in to account. At present there is no planning of activities in line with assesed needs of residents. A further requirement of involving residents or their relatives in drawing up their care plans has not occurred again due to uncertainty as to how this should be done and ways of doing this were also discussed. Residents spoke of playing games and relatives said they had seen activities taking place. A requirement to obtain wishes of residents with regard to terminal illness and death has partly been complied with as a form has been included in care plans, Ashley House Care Home DS0000024625.V255295.R01.S.doc Version 5.0 Page 10 however these have not all been completed and the provider requested more time to complete these as it can be a lengthy process. A record is made of all medicines coming into the home and the controlled drug register was correctly completed, both of which were requirements set at the last inspection and have been complied with. Ashley House Care Home DS0000024625.V255295.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): None EVIDENCE: Ashley House Care Home DS0000024625.V255295.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 and 18 Any complaint will be listened to and there are procedures in place to protect residents from abuse. EVIDENCE: The home has a complaints procedure, which is displayed in one of the lounges. A new log system has been put into place to record any future complaints. Residents and relatives said that would take anything they were not happy with to the senior. There has not been any incident of abuse reported. Staff spoken with knew the correct procedures to follow in the event of any incident occurring and were able to describe good practices to prevent incidents occurring between residents. Ashley House Care Home DS0000024625.V255295.R01.S.doc Version 5.0 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 the following standard(s): 26 The home is kept clean and the laundry service is satisfactory. EVIDENCE: Designated cleaning staff are employed and the home was clean and tidy at the time of the inspection. Residents said that the home is kept clean and they have their rooms tidied. Residents also said that they are happy with the laundry arrangements and their clothes are returned washed and ironed the following day. Ashley House Care Home DS0000024625.V255295.R01.S.doc Version 5.0 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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): 29 The required recruitment checks to safeguard residents are not being applied to staff recruited from overseas. EVIDENCE: The home is partly staffed by adaptation nurses who are recruited by an agency, which includes a police check from their country of origin and when they arrive at the home a Criminal Records Bureau (CRB) check is applied for. This practice must cease and all staff, including adaptation nurses, require a CRB prior to commencing work within the home, or a POVA first check providing the person is fully supervised until the CRB is obtained. Other staff are recruited following the correct procedures and there were two staff waiting for their CRB check to be returned before they can start. Ashley House Care Home DS0000024625.V255295.R01.S.doc Version 5.0 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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): 33, 35 and 38 Quality monitoring within the home has not been maintained. Good arrangements are being made for residents’ finances and the appropriate health and safety checks on the home are carried out. EVIDENCE: The home has been accredited to a quality assurance award (ISO 9000) and has carried out quality audits in the past, however one has not been carried out recently. Relatives have been asked if they are interested in forming a group and some have said they would. Information about monitoring services is included in the Statement of Purpose. Residents and relatives said that they are asked if they are happy with the services provided. Arrangements are being made to open each resident an appointee bank account. One resident was unhappy with the amount of money he receives each week. The arrangements were detailed in the care plan to help manage his daily needs. Ashley House Care Home DS0000024625.V255295.R01.S.doc Version 5.0 Page 16 All staff are provided with mandatory training and the appropriate checks and tests are carried out. Residents said they hear the fire alarm being tested. Unsafe practices were observed whilst vacuuming and the provider corrected this when bought to his attention. Ashley House Care Home DS0000024625.V255295.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 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 X 18 3 X X X X X X 3 X STAFFING Standard No Score 27 X 28 X 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 X X 3 Ashley House Care Home DS0000024625.V255295.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? YES (but still within the timescale) 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 OP7 Regulation 15 Requirement The Registered Person should after consultation with the resident provide a written plan of how their social needs are to be met by the home. The Registered Person must wherever possible involve the resident or their relatives in drawing up and signing the care plans. The Registered Person must obtain the wishes of the resident with regard to terminal illness and death, this should include the arrangements around the spiritual needs of the individual. Obtain a CRB or POVA first check on all staff prior to starting work within the home Undertake a quality assurance exercise Timescale for action 01/01/06 2 OP7 15 01/01/06 3 OP7 15 01/01/06 4 5 OP29 OP33 33 24 03/10/05 01/03/05 Ashley House Care Home DS0000024625.V255295.R01.S.doc Version 5.0 Page 19 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Ashley House Care Home DS0000024625.V255295.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 Care Home DS0000024625.V255295.R01.S.doc Version 5.0 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!