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Inspection on 26/01/06 for Ashley House Nursing Home

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

This inspection was carried out on 26th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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.

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

The Home offers both personal care and nursing care to residents that have a wide selection of needs, but at the same time actively encourages individual choice. It offers comfortable and attractive accommodation, which is well maintained. Staff are well trained and well managed and there is a healthy culture of wanting to improve on the services provided. There is a good selection of food, which accommodates many dietary needs.

What has improved since the last inspection?

Training and maintenance records continue to be organised and updated. Refurbishment of the reception area has been completed and the lounge has subsequently also been decorated and fitted with new soft furnishings. The dining room has also had the same treatment. The turn over in staff has slowed down and there are some signs of continuity within the staff team.

CARE HOMES FOR OLDER PEOPLE Ashley House Nursing Home 118 Trafalgar Road Cirencester Glos GL7 2EN Lead Inspector Mrs Janice Patrick Unannounced Inspection 26th January 2006 2:15pm 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 Nursing Home DS0000016370.V278275.R01.S.doc Version 5.1 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 Nursing Home DS0000016370.V278275.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Ashley House Nursing Home Address 118 Trafalgar Road Cirencester Glos GL7 2EN 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) 01285 650671 01285 650672 BUPA Care Homes (BNH) Limited Mrs Ann Lilian Alden Care Home 47 Category(ies) of Old age, not falling within any other category registration, with number (47) of places Ashley House Nursing Home DS0000016370.V278275.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Temporary variation to client categories DE(E) for 1 (one) named service user. The home will revert to the original client category when this service user no longer resides at the home. Date of last inspection 9th June 2005 Brief Description of the Service: Ashley House is situated on the outskirts of Cirencester Town and is within walking distance of a main bus route. This Care Home is well known within the local community and offers nursing care to the older person. The Home is predominantly private fee paying, but will consider Social Service or Health funded care on an individual basis. Private accommodation is provided in single bedrooms with ensuite facilities, some larger bedrooms are available for those who wish to share. A few bedrooms overlook the courtyard garden and have their own patio area. Spacious communal rooms also have a view of the courtyard where the flowers and water feature can be enjoyed in the summer months. The Home is staffed with qualified nurses, 24 hours of the day. Ashley House Nursing Home DS0000016370.V278275.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out by one inspector between the hours of 2.15pm and 6.15pm. The Registered Manager and her Deputy were on duty including a full compliment of other staff. Relevant information and views of the service were gathered from both residents and staff. Some of the building was seen during this process, but a full tour of the premises was not carried out on this occasion. A selection of records and documentation were inspected, these were pertaining to staff recruitment and training, complaints, maintenance and quality assurance. The medication system was inspected. What the service does well: What has improved since the last inspection? What they could do better: Some minor shortfalls were identified within the medication system inspection. Please contact the provider for advice of actions taken in response to this Ashley House Nursing Home DS0000016370.V278275.R01.S.doc Version 5.1 Page 6 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ashley House Nursing Home DS0000016370.V278275.R01.S.doc Version 5.1 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 Nursing Home DS0000016370.V278275.R01.S.doc Version 5.1 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 of the above standards were inspected on this occasion. N/A EVIDENCE: N/A Ashley House Nursing Home DS0000016370.V278275.R01.S.doc Version 5.1 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): 9 The medication system is generally safe with arrangements in place to ensure this remains as such, although a few shortfalls were identified, these were not at a level that would endanger residents. EVIDENCE: The medication storage and administration records were inspected. Storage is organised and appropriate records are generally well maintained. The Deputy Manager had carried out an internal audit on 04/01/06. This identified relatively minor things that required action and reminded individual nurses that they are accountable for their own practice, such as ensuring they sign for any drug administrations they make (some gaps in the administration records were identified). A photograph of each resident accompanies his or her administration record to aid identification. Medication stock coincided with records kept and the disposal of medication is being carried out correctly. A few minor shortfalls were present at the time of this inspection and were passed on to the Manager and her Deputy to action. These included: • Two open tubes of a medicated ointment in the fridge with no names attached (these were discarded during the inspection). Ashley House Nursing Home DS0000016370.V278275.R01.S.doc Version 5.1 Page 10 • • • Medication fridge had a broken catch and was not locking. Sign on the clinic door was not appropriate for the type of gases stored within. Instructions on one particular medication box did not correspond with those on the printed administration sheet (a change in medication dose had obviously occurred at some point, but the label had not changed). Ashley House Nursing Home DS0000016370.V278275.R01.S.doc Version 5.1 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 of the above standards were inspected on this occasion. N/A EVIDENCE: Although none of the above standards were specifically inspected the Inspector did observe the more frail residents receiving a very thick, homemade soup for supper and an extensive sweet trolley being provided. Ashley House Nursing Home DS0000016370.V278275.R01.S.doc Version 5.1 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 A robust corporate complaints policy is in place with procedures that are followed by the Home to ensure that any concerns and complaints are investigated appropriately. EVIDENCE: Information pertaining to ‘how to make a complaint’ and who to make this to is found in the reception area. It is also within the information given to each resident/representative on admission. The Registered Manager has to report to BUPA any concerns raised or complaints made and the Home’s operation manager thereafter monitors the process closely. A record is kept in the Home of the complaint itself, any action taken and correspondence that takes place. The Home had received two complaints since the last inspection in June 2005. One related to food at suppertime and another was received over the period of time the lift broke down. Both were responded to in appropriate time scales. Ashley House Nursing Home DS0000016370.V278275.R01.S.doc Version 5.1 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): None of the above standards were inspected on this occasion. N/A EVIDENCE: N/A Ashley House Nursing Home DS0000016370.V278275.R01.S.doc Version 5.1 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 Home’s recruitment practices are good and help to protect residents from poor practice or abuse. EVIDENCE: The recruitment documentation pertaining to 3 members of staff were inspected. One had not commenced in post at the time of this inspection. All contained the relevant criteria as laid down in the Care Home Regulations 2001. Criminal Record Bureau (CRB) clearances and a check against the Protection of Vulnerable Adults (POVA) list were present for all staff except for the new recruit who had not yet commenced in post. A record of the interview process is also maintained as good practice. Ashley House Nursing Home DS0000016370.V278275.R01.S.doc Version 5.1 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): 31, 33, 35 & 38 The Manager has a clear vision for the Home, which she effectively communicates to her staff and a continuous process of audit helps to ensure that the quality of care and services provided, are maintained at a high level and are delivered in a safe manner. Arrangements are in place to protect residents from financial abuse and to allow them to maintain their independence in this area if they are able to do so. EVIDENCE: The Manager has managed the Home for the past 10 years. She is a registered nurse and holds qualifications in management. She also keeps updated in basic mandatory trainings and is due to update in moving and handling soon. Ashley House Nursing Home DS0000016370.V278275.R01.S.doc Version 5.1 Page 16 The Home adheres to BUPA’s robust quality assurance systems and carries out regular internal audits, one of which was carried out recently on the medication system and seen at this inspection. Another initiative called ‘personal best’, runs alongside this and asks staff to reflect on and improve their individual practice and service they are involved in providing. A resident and relatives questionnaire was circulated in December 2005 asking for general views on the services provided in the Home, the results of this have yet to be collated. The Inspector was unable to inspect the records pertaining to residents’ personal monies during this inspection, but she is aware that these are regularly monitored. The Inspector did speak with two residents who manage their monies independently. Both confirmed they were able to do this without interference. One resident explained that he was a ward of court and that he received a set amount of money, which he was free to spend how he chose. Health and safety checks are carried out on all major systems and equipment in the Home, both internally and by contractors. Records confirming these were seen during this inspection. Staff receive fire training twice yearly. Records were seen demonstrating that staff are receiving this. One bank member of staff and another who has been on long-term sick leave were identified as requiring updates as soon as possible. There are 5 members of staff currently updated in First Aid and 4 others that now require an update. The Home has recently had its training systems audited by the University of York in relation to adaptation training for overseas nurses and its National Vocational Qualification in Care (NVQ), the results of which were good. Ashley House Nursing Home DS0000016370.V278275.R01.S.doc Version 5.1 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 X 8 X 9 2 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 X X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Ashley House Nursing Home DS0000016370.V278275.R01.S.doc Version 5.1 Page 18 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 OP9 Regulation 13(2) Requirement The Registered Manager must ensure that the medicine system is running safely, therefore the following must be corrected. • All medication in use must be labelled with the name of the individual it was prescribed for. • The medication fridge lock must be mended allowing the fridge to lock. • A yellow sign must be put on the clinic door indicating ‘oxygen in storage’. • The printed instructions on a particular medication must correspond with those printed on the individual’s administration sheet. Timescale for action 01/03/06 Ashley House Nursing Home DS0000016370.V278275.R01.S.doc Version 5.1 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 Nursing Home DS0000016370.V278275.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Nursing Home DS0000016370.V278275.R01.S.doc Version 5.1 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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