CARE HOMES FOR OLDER PEOPLE
Ashley House Ashley House Thornley Road, Deaf Hill Trimdon Station, Durham TS29 6DA Lead Inspector
Stephen Ellis Unannounced 9th May 2005 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 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 B54 S34013 Ashley House V223771 090505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Ashley House Address Thornely Road Deaf Hill Trimdon Station Durham TS29 6DA 01429 881225 01429 883769 Telephone number Fax number Email 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 and Mrs Jean Kennedy Vacant CRH 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 B54 S34013 Ashley House V223771 090505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 24 January 2005 Brief Description of the Service: Ashley House provides residential care services for older persons in the categories: Dementia (25); Old age, not falling within any other category (25); and Physical disability (5).The home is owned by Mr M Matharu and Mrs Jean Kennedy. It is located in the small village of Deaf Hill: a large two-storey building with the benefit of a passenger lift to the first-floor.The home has a pleasant and well-maintained garden area to the rear, that can be readily accessed by service users from the homes large conservatory. Ashley House B54 S34013 Ashley House V223771 090505 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 3.5 hours on the morning of 9th May 2005. The inspector looked around the building and a number of records were inspected. The inspector spoke with 12 of the 22 residents, 4 of the 7 staff on duty, plus one of the owners. What the service does well: What has improved since the last inspection?
There is a new manager in post, although he is not registered yet. He has introduced some new staff training programmes and quality assurance systems that are going well. Service user care plans have up to date risk assessments, and medicine records now include prescribed creams. Staff Criminal Record Bureau checks are being made as required and staff are being appropriately supervised. Ashley House B54 S34013 Ashley House V223771 090505 Stage 4.doc Version 1.30 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 B54 S34013 Ashley House V223771 090505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Ashley House B54 S34013 Ashley House V223771 090505 Stage 4.doc Version 1.30 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 standard(s) 3 and 6 People who move into Ashley House have had their needs assessed and have been assured that these will be met. EVIDENCE: Intermediate care is not provided. The home has an admission policy and procedure that requires a full assessment of people’s needs to be carried out before they are admitted. This usually involves a Social Worker who coordinates the assessment. An examination of 4 case files showed that written assessments of need are carried out and reviewed as required. Staff comments confirmed that the procedure is followed. Service users said that staff were well aware of their needs and tried to ensure that they always received the right health and personal care. Ashley House B54 S34013 Ashley House V223771 090505 Stage 4.doc Version 1.30 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 standard(s) 7, 8, 9 and 10 There are good arrangements for meeting service users’ health, personal and social care needs, including arrangements for medicines, respect and privacy of service users. EVIDENCE: Service users said that they felt that their health and social care needs were well understood by staff who tried hard to ensure that their needs were fully met. For example, one service user said that he needed a new pair of glasses and within a day an Optician had visited. Another service user said that she was happy with the health care service from her local GP and Community Nursing Service, who would attend to her health care needs very promptly. All service users commented that they felt they were treated with respect by staff and their privacy and personal choice was respected. Four care plans were examined and these showed attention to the personal, social and health care needs stipulated in the National Minimum Standards. These personal plans of care were being reviewed at appropriate intervals and
Ashley House B54 S34013 Ashley House V223771 090505 Stage 4.doc Version 1.30 Page 10 any amendments were made in writing and checked with the individuals concerned. A check of the medicine records showed that they were being maintained correctly, in accordance with National Minimum Standards. All care staff have either completed a safe handling of medicines course, or are going through one, or due to start one soon. Staff felt confident about helping to promote good outcomes for service users concerning their health and personal care needs, through team work and liaison with relatives and external agencies, such as doctors, community nurses and hospitals where appropriate. They felt helped in this by the staff training programmes being provided for them. Ashley House B54 S34013 Ashley House V223771 090505 Stage 4.doc Version 1.30 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 standard(s) 12, 13, 14 and 15 There are good arrangements for service users’ daily lives and social activities. EVIDENCE: Service users said that they felt their needs and interests were appreciated by the staff who tried to make sure that these were properly addressed. For example, service users and their families have been recently consulted about menu choices and other matters of interest, via a meeting of service users and their guests held at the home. Also, Quality Assurance questionnaires are left in the entrance foyer for relatives and others to complete and return to the home, with any suggestions for improvements. New menus are being introduced as a result of this consultation. A programme of social and recreational activities was displayed on the notice board and this included a variety of events to suit the different interests of people in the home. Service users said that they were satisfied with these activities and were free to join in or not as they chose. They said that their individuality was respected, including their choice of activity. For example, one couple liked to go out walking regularly; others enjoyed reading the papers or watching TV, as well as group activities. A summer fair is planned for 4th June. Service users said they were encouraged to receive visitors whenever they wanted and to make visits to friends and relatives whenever they wished.
Ashley House B54 S34013 Ashley House V223771 090505 Stage 4.doc Version 1.30 Page 12 Friends and relatives were welcomed and their participation in the life of the home was encouraged. Service users said that they enjoyed the meals and beverages provided and there were always sufficient quantities. They were looking forward to the new menus expected soon. Catering staff commented positively about the catering arrangements and were confident of maintaining good standards, based on service users’ preferences. The kitchen was clean and well organised, with appropriate records being well maintained. Ashley House B54 S34013 Ashley House V223771 090505 Stage 4.doc Version 1.30 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 standard(s) 16 and 18 Service users are confident about making a complaint and are protected from abuse by the home’s policies and practices. EVIDENCE: Service users said they would have no hesitation in discussing any concern or complaint with either the staff or management of the home. They described both as being approachable and supportive. Written policies and procedures within the home are complemented by staff training concerning complaints and adult protection. Staff indicated awareness of adult protection issues and the need for early communication about any suspicion of abuse. Ashley House B54 S34013 Ashley House V223771 090505 Stage 4.doc Version 1.30 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 standard(s) 19 and 26 The home is well maintained, clean and pleasant. EVIDENCE: A tour of the building revealed it to be well maintained and generally in good decorative order. The owner confirmed that the maintenance and servicing schedules were being followed. There is an ongoing programme of redecoration and refurbishment, with some parts having been completed recently. Service users said they liked their accommodation and were pleased with the premises. Only one of the 4 large double bedrooms was being used as a double at present, by a married couple. The home was found to be clean and pleasant with practices in place to promote hygiene (e.g. provision of liquid soap and paper towels in toilets). Ashley House B54 S34013 Ashley House V223771 090505 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30 There are good arrangements in place for staffing. EVIDENCE: The staffing roster showed sufficient numbers and skill mix to meet the needs of service users. For example, during the day there are normally 3 care staff on duty plus the manager who is supernumerary. At night there are 2 care staff. Catering staff are employed between 08.00 and 19.00 each day, and there are dedicated domestic staff as well. A part time administrator is also employed. Staff are carefully recruited and appointed following the necessary checks and procedures (e.g. Criminal Record Bureau checks). They have good induction and foundation training, and are encouraged to train for National Vocational Qualifications. The home expects at least 50 of its care staff to have achieved NVQ level 2 in care before the end of 2005. Ashley House B54 S34013 Ashley House V223771 090505 Stage 4.doc Version 1.30 Page 16 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 The home is run in the best interest of service users. EVIDENCE: Although the new manager was not present, there was much evidence to show that the home is being well run, in the best interests of service users. For example, the recent meeting with service users and their guests, plus Quality Assurance questionnaires and staff training programmes, all point to this conclusion. Also, service users spoke highly of the management and staff, describing them as approachable and supportive. The programme of social and recreational activities is another example of the home being run in the interests of service users. Service users described management and staff as being approachable and supportive. Ashley House B54 S34013 Ashley House V223771 090505 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x 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 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x x x x x Ashley House B54 S34013 Ashley House V223771 090505 Stage 4.doc Version 1.30 Page 18 No Are there any outstanding requirements from the last inspection? 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 31 Regulation 8 Requirement An application for registration is required from the manager. Timescale for action 01/07/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 22 Good Practice Recommendations Mirrors are desirable in toilets so that people can check their appearance. Ashley House B54 S34013 Ashley House V223771 090505 Stage 4.doc Version 1.30 Page 19 Commission for Social Care Inspection No 1 Hopetown StudiosAddress 1 Brinkburn Road Darlington Dl3 6DS National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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