Inspection on 12/12/05 for Ashley House Residential Home

This inspection was carried out on 12th December 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 Residential Home 27/09/07

Ashley House Residential Home 30/10/06

Ashley House Residential Home 09/05/05

Ashley House Residential Home 24/01/05

Ashley House Residential Home 27/07/04

Ashley House Residential Home 19/02/04

Similar services:

The Highlands

Turret Villa Retirement Home

Moor House

Blenheim House

1 Lanark Close

Mendip House

Beaconsfield Court Care Home

Ann Charlton Lodge

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

CARE HOMES FOR OLDER PEOPLE Ashley House Residential Home Ashley House Thornley Road Deaf Hill Trimdon Station Durham TS29 6DA Lead Inspector Mr Stephen Ellis Unannounced Inspection 12th December 2005 2:00 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 Residential Home DS0000034013.V259256.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 Residential Home DS0000034013.V259256.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ashley House Residential Home Address Ashley House Thornley Road Deaf Hill Trimdon Station Durham TS29 6DA 01429 881225 01429 883769 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) Mr Matt Matharu Mrs Jean Kennedy Steven White Care Home 25 Category(ies) of Dementia (25), Old age, not falling within any registration, with number other category (25), Physical disability (5) of places Ashley House Residential Home DS0000034013.V259256.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 5 persons in the category of PD Physical Disability 55 years or above may be accommodated within the overall total of 25. 9th May 2005 Date of last inspection Brief Description of the Service: Ashley House provides residential care services (25 beds) for older persons in the categories: Dementia (25); Old age, not falling within any other category (25); and Physical disability (5). Mr Matt Matharu and Mrs Jean Kennedy own the home. It is located in the small village of Deaf Hill: a large two-storey building with a passenger lift to the first-floor. The home has a pleasant garden area to the rear, which can be readily accessed by service users from the homes large conservatory. Ashley House Residential Home DS0000034013.V259256.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 4.25 hours. The inspector looked around the building and spoke to 11 residents, one relative, 4 staff and the manager. He also spoke with the registered providers (Mr Mattharu and Mrs Kennedy) and examined a number of records that the home is required to keep. What the service does well: What has improved since the last inspection? The new manager (Steven White) has been registered (by the Commission for Social Care Inspection) and he has achieved the Registered Managers Award at NVQ level 4. He has introduced new staff training programmes and quality assurance systems that are going well. The home is being redecorated in a gradual way and there are a number of pleasant, attractive rooms. Mirrors have been fitted in toilets so that service users can check their appearance if they wish. Ashley House Residential Home DS0000034013.V259256.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ashley House Residential Home DS0000034013.V259256.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 Residential Home DS0000034013.V259256.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. All residents have had a full assessment of their needs, prior to their admission, and have been assured that the home will meet those needs. EVIDENCE: Residents said that they were happy with the services and facilities provided, especially the care, and felt that the home was able to help them appropriately. This view was reflected in the comments received from one relative. Three care plans that were examined showed attention to detail and covered all of the important areas to do with health and personal care. They showed that people’s care needs had been thoroughly assessed. Ashley House Residential Home DS0000034013.V259256.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, 9 and 10. There are good arrangements for residents’ health, personal and social care. These take into account their physical and emotional needs, plus personal goals where appropriate. People are supported to act independently within a risk assessment framework. There are good arrangements for dealing with medicines. People are treated with respect and their right to privacy is upheld. EVIDENCE: Residents said that they believed their health and social care needs were well known by staff and were being fully met. They said that the community nurse or doctor would see them whenever required. Their personal and social care needs were known, understood and respected by the staff team. They said that they felt they were treated with respect and sensitivity. As one resident said: “The staff are kind and understanding. They are always ready to help me if I need it”. Care plans were detailed and comprehensive about residents’ health and social care needs, providing clear guidance to staff. They were subject to regular review, in keeping with National Minimum Standards. Ashley House Residential Home DS0000034013.V259256.R01.S.doc Version 5.0 Page 10 Staff training (e.g. NVQ level 2) has included the important issues of privacy and dignity and a high percentage of care staff have achieved NVQ in care. A typical comment from one relative was: “The staff are very responsive and show respect for the individual”. There are good arrangements for the safe administration of medicines. Most care staff members have completed the Safe Handling of Medicines course. There is good support from a local Pharmacist who supplies most of the medication in Monitored Dosage form (in blister packs with the medication clearly identified for the individual resident). There are good storage systems and care staff check all medication when it is received into the home. Medication is kept securely in lockable cabinets and trolleys. Residents may attend to their own medication, but in practice most prefer to delegate this responsibility to staff. Unwanted medicines are returned promptly to the Pharmacist and the home is careful not to stockpile large quantities. The registered manager carries out medicine audits routinely. Ashley House Residential Home DS0000034013.V259256.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): 12, 13, 14 and 15. Residents experience a satisfying lifestyle that matches their expectations and preferences. They are encouraged to maintain contact with family, friends and the wider community as they wish. They are helped to exercise choice and control over their lives. Catering arrangements are good, providing wholesome, appetising menus with wide choice of meals and beverages. EVIDENCE: Residents said that they enjoyed living at Ashley House. They described the staff as being caring and helpful. They could exercise choice in their daily lives. For example, they could decide what clothes they wore and how they spent their days, including what times they got up and went to bed. They said that there was a varied programme of social and recreational activities, including visiting entertainers, reminiscence, music and movement and bingo. One member of staff takes a lead in organising social events for two hours each day. The home is advertising for an activities coordinator to specialise in this important area. Residents may pursue individual interests if they wish, such as reading, television or knitting. People’s religious needs were being addressed. There were services from different denominations held each month within the home. Ashley House Residential Home DS0000034013.V259256.R01.S.doc Version 5.0 Page 12 Residents and one relative said that visitors were always made welcome and could call at any reasonable time. Some residents went out with relatives or friends for part of the day. Many residents said they liked the atmosphere in the home, describing it as being friendly, supportive and caring. They were free to sit in any lounge, in their own bedroom, or dining room. All were satisfied with the arrangements for daily life in the home. However, All the residents spoken to said the catering was good. There was a wide choice and the Cook understood their preferences. They particularly liked the home baking. A cooked breakfast was available for those who wanted one. Residents mainly dined together in the dining room. They could, however, eat their meals elsewhere and at different times if required. Records are kept of meals served, available for inspection. The Cook confirmed the varied, appetising menu. Ashley House Residential Home DS0000034013.V259256.R01.S.doc Version 5.0 Page 13 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): 18. Residents are protected from abuse. EVIDENCE: Pre-employment checks are carried out on staff, including enhanced checks with the Criminal Record Bureau and Protection of Vulnerable Adult checks. Also, two references are obtained in respect of each new employee, with special attention given to the last employment. These steps are taken to prevent unsuitable people being employed to care for vulnerable adults. New staff members go through induction and foundation training to ensure they have the right knowledge and skills to do their jobs competently. All care staff members have completed Protection of Vulnerable Adults training. Residents reported a caring, supportive atmosphere in the home, which is well established. There is good leadership and teamwork evident and these features reinforce the caring culture and provider policies concerning adult protection. Ashley House Residential Home DS0000034013.V259256.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): 19 and 26. Service users live in a safe, well-maintained environment. The home is clean, pleasant and hygienic. EVIDENCE: There were no unpleasant odours and the home was found to be clean in all the areas inspected. Care staff members have completed training in Health and Safety, Infection Control and Food Hygiene. Paper towels and liquid soap were provided in toilets and bathrooms in wall-mounted containers, to promote hygienic practices (although residents have personal flannels and towels in their rooms). Residents said that they were pleased with the premises, finding them comfortable and homely as well as practical. They also described the home as being clean. The home is well maintained with repairs and servicing being carried out promptly and according to schedule. Ashley House Residential Home DS0000034013.V259256.R01.S.doc Version 5.0 Page 15 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, 28, 29 and 30. Staffing numbers and mix of skills are appropriate for the needs of residents. Staff members are trained and competent to do their jobs, with well over 50 having NVQ level 2 or above. The home’s recruitment policy and practices support and protect residents. EVIDENCE: On the day of inspection, there were 24 residents being accommodated. Typically there are 3 care staff members on duty during the day, one of whom is either a senior care assistant or supervisor (day shifts run from 8 am to 8 pm). At night, there are 2 members of care staff on duty (again, one will be a senior). There are sufficient ancillary staff members, including 2 full time cooks. The full time registered manager works weekdays. His hours are not included in the care hours available. A full staff training and development programme is in operation, including moving and handling, first aid, safe handling of medicines, protection of vulnerable adults, positive dementia, health and safety, infection control and food hygiene. Staff confirmed that they had undergone extensive induction and foundation training. Nine out of the 13 members of care staff had achieved NVQ level 2 or 3, which is commendable (69 ). The remaining 4 members of care staff are registered for NVQ training and assessment, to commence early in 2006. Pre-employment checks are carried out on staff, including enhanced checks with the Criminal Record Bureau and Protection of Vulnerable Adult checks. Ashley House Residential Home DS0000034013.V259256.R01.S.doc Version 5.0 Page 16 Also, two references are obtained in respect of each new employee, with special attention given to the last employment. New staff members go through induction and foundation training to ensure they have the right knowledge and skills to do their jobs competently. All care staff members have completed Protection of Vulnerable Adults training. Residents reported a caring, supportive atmosphere in the home, which is well established. There is good leadership and teamwork evident and these features reinforce the caring culture and provider policies concerning adult protection. Ashley House Residential Home DS0000034013.V259256.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, 35 and 38. The manager of the home is fit to be in charge, of good character and able to discharge his responsibilities fully. The home is run in the best interests of residents. Residents’ financial interests are safeguarded in those situations where the home is involved. The health, safety and welfare of residents and staff are promoted and protected. EVIDENCE: The registered manager is experienced and competent in his role. Residents and staff spoke well of his leadership skills and commitment to good outcomes for residents. He was described as being approachable and caring. He has completed the Registered Manager’s Award at NVQ level 4. Good accounting procedures are followed, with receipts and signatures being obtained for all financial transactions involving residents’ personal monies, in Ashley House Residential Home DS0000034013.V259256.R01.S.doc Version 5.0 Page 18 which the home is involved, wherever practicable. Relatives look after the personal monies of many residents. In those situations where the home helps look after residents’ monies, such as pocket monies, clear individual records are maintained. Comments received from staff and management confirmed that there are good health and safety policies and practices that promote the health, safety and welfare of residents and staff. All staff members do refresher training in Health and Safety, such as moving and handling, fire safety and food hygiene. This helps reinforce the registered provider’s written policies on Health and Safety. Health and Safety issues are also discussed at bi-monthly staff meetings. Residents and staff expressed satisfaction with the way the home was run and the good standards that were evident in many instances. They said they believed the home was safe and run in the best interests of residents. For example, a residents meeting is held monthly. Also, there is an annual survey of residents’ satisfaction carried out and the findings are reported within the home. One of the registered providers visits the home frequently, often several times per week, taking a keen interest in the welfare of residents and the progress of the home. The manager invites comments from service users and visitors, with forms for written comments kept in Reception. Ashley House Residential Home DS0000034013.V259256.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 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 Ashley House Residential Home DS0000034013.V259256.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. Standard Regulation Requirement Timescale for action 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 OP12 Good Practice Recommendations Ashley House Residential Home DS0000034013.V259256.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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