Inspection on 19/07/05 for Ashley Manor Nursing and Residential Care Home

This inspection was carried out on 19th July 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.

Other inspections for this house

Ashley Manor Nursing and... 05/09/06

Ashley Manor Nursing and... 31/01/06

Ashley Manor Nursing and... 23/09/04

Ashley Manor Nursing and... 03/03/04

Ashley Manor Nursing and... 14/01/04

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

CARE HOMES FOR OLDER PEOPLE Ashley Manor Nursing and Residential Care Home Winchester Road Shedfield Hampshire SO32 2JF Lead Inspector Pat Griffiths Unnannounced 19.07.05 10:00 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 Manor Nursing and Residential Care Home 20050921 H54 S47024 Ashley Manor V239667 190705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Ashley Manor Nursing and Residential Care Home Winchester Road Shedfield Hampshire SO32 2JF 01329 833810 Address 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) Mrs Theresa Andrews Mrs Rosamund Jane Heath Care Home 30 Category(ies) of Old Age - OP - 30 registration, with number Physical Disability, over 65 - PD(E) - 30 of places Ashley Manor Nursing and Residential Care Home 20050921 H54 S47024 Ashley Manor V239667 190705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11.02.05 Brief Description of the Service: Ashley Manor is a registered care home providing nursing care and accommodation for 30 service users of both sexes in the older people category. Accommodation is provided on three floors, which are accessed by stairs and passenger lift. The home has large well-maintained gardens and parking is available in the grounds. The accommodation comprises of sixteen single and seven shared bedrooms. Two of the single rooms have en suite facilities provided. The home is privately owned and situated on the outskirts of Southampton close to the village of Wickham. Ashley Manor Nursing and Residential Care Home 20050921 H54 S47024 Ashley Manor V239667 190705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was the first of two for the inspection year 2005/06. The inspection was completed in six hours. Six members of staff, several residents and visitors were spoken to and the matron and her deputy assisted with the inspection. The home owner discussed the building plans for the new extension of the home, which should be completed during the autumn and will provide 24 extra beds. Care plans and other documents were looked at, including policies, procedures and training plans for the staff. Visitors that spoke to the inspector were very positive about the care their relatives received, commenting that things had improved since the new owners had taken over. What the service does well: What has improved since the last inspection? The home now has separate a service user guide and statement of purpose in place; previously this had been just one document. New staff have been recruited to ensure there are sufficient staff in place for the extra numbers of residents that are will be accommodated when the extension is completed. The manager has implemented a structured supervision programme for the staff, which ensures that care staff have six supervision sessions per year. Ashley Manor Nursing and Residential Care Home 20050921 H54 S47024 Ashley Manor V239667 190705 Stage 4.doc Version 1.40 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 Manor Nursing and Residential Care Home 20050921 H54 S47024 Ashley Manor V239667 190705 Stage 4.doc Version 1.40 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 Manor Nursing and Residential Care Home 20050921 H54 S47024 Ashley Manor V239667 190705 Stage 4.doc Version 1.40 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) 1 and 3 Standard 6 does not apply to this service. Potential residents of the home can read the homes statement of purpose and service users guide whilst deciding which home to move into. Arrangements for assessing prospective residents ensures that their individual needs can be met in the home. EVIDENCE: The home has a statement of purpose and a service users guide, which are now available as two separate documents for all residents or potential residents. This was a requirement from a previous inspection, which has now been met. The inspector was advised that the manager or her deputy assess all potential residents before they are offered a place at the home. The inspector saw Ashley Manor Nursing and Residential Care Home 20050921 H54 S47024 Ashley Manor V239667 190705 Stage 4.doc Version 1.40 Page 9 several assessment records and it was noted that comprehensive assessments provided the relevant information needed regarding the residents personal, health and social needs. These records are stored separately from the case files and it was recommended that they should be included in the individual residents personal files as they form the basis for the care plans. The home does not provide intermediate care. Ashley Manor Nursing and Residential Care Home 20050921 H54 S47024 Ashley Manor V239667 190705 Stage 4.doc Version 1.40 Page 10 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 and 9 Arrangements for care planning and risk assessment ensure that the residents assessed and changing needs are met. The residents’ health care needs are met by visiting healthcare professionals. The homes medication policy and staff training ensures that staff have the knowledge and skills to protect them and the residents when dealing with medication. EVIDENCE: The individual care plans for the service users have been developed, providing information on how the assessed needs of the resident should be met. The care plans contain nutritional assessments and there is guidance on the assessed manual handling needs. These are requirement from the last inspection, which have been met. The home has a medication policy in place; observation of a medicine round by the inspector and discussions with trained staff indicate that the policy is followed. None of the residents are responsible for their own medication. The inspector and the manager discussed the recent changes in the regulations regarding the disposal of unwanted medication; the manager will be investigating a suitable system for the home. Ashley Manor Nursing and Residential Care Home 20050921 H54 S47024 Ashley Manor V239667 190705 Stage 4.doc Version 1.40 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 and 14 The home ensures that there are a variety of activities available for the residents and an open visiting policy. Residents are encouraged to exercise control over their lives. EVIDENCE: The activities available within the home include musical movements, arts and crafts and visiting entertainers with ‘music from the shows’. The inspector was advised that extra activities had been organised to compensate for the lack of access to the gardens during the summer. Visitors also bring in pets, which all the residents enjoy. On the day of the visit the activities organiser was making paper flowers with a group of residents, who where thoroughly enjoying themselves. Representatives from different local churches visit and conduct services in the home for those who wish to join in. Residents are encouraged to make choices and exercise control over their lives; this can be limited because of their health problems. Some residents choose to stay in their bedrooms and not mix with the other residents; some are able to make choices about every aspect of their daily life, whilst others are happy that choices are made for them. Residents that were able to talk with the inspector said that they were happy with their life in the home and a Ashley Manor Nursing and Residential Care Home 20050921 H54 S47024 Ashley Manor V239667 190705 Stage 4.doc Version 1.40 Page 12 visitor commented that ‘things had improved all round’ since the new owners had taken over. A complaint had been made previously that staff were feeding residents their breakfasts at 6am, when care plans indicated their preferred time of waking was 7.30am. The allocation of work and staff at this time of the morning has changed to ensure that the needs of the residents are met properly; a member of the day staff starts at 7am to assist with breakfast when necessary. The manager has provided a breakfast menu, which indicates preferred breakfast times and staff sign it when breakfast is served. Ashley Manor Nursing and Residential Care Home 20050921 H54 S47024 Ashley Manor V239667 190705 Stage 4.doc Version 1.40 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 The home has a complaints procedure in place, enabling residents, relatives and staff to make complaints should they wish. Staff training in Adult Protection would further promote the safety of the residents. EVIDENCE: The home has a complaints and whistle-blowing policy in place, details of which are available for staff, residents and their visitors. Visitors that spoke with the inspector felt happy that they could take any complaints to the manager and that it would be dealt with properly. The manager and the inspector discussed the need for confidentiality regarding the complaints file; the details regarding any complaints will now be stored separately and securely in a locked cabinet. The Commission has received one complaint in the last year regarding the home and this has been documented in a separate report. Staff that spoke with the inspector indicated that they understood the prevention of abuse and adult protection policies, but formal training has not yet been undertaken. It is a requirement that this training is organised within the next three months. Ashley Manor Nursing and Residential Care Home 20050921 H54 S47024 Ashley Manor V239667 190705 Stage 4.doc Version 1.40 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 Arrangements for maintaining the home ensure that residents stay in a safe environment. An extension of the home that is being built will increase bed capacity by 24 beds. EVIDENCE: The inspector was able to tour the home and see some of the bedrooms, dining and sitting room areas. The rear garden is fenced off during the building work, for the safety of the residents and staff. Extra activities have been arranged to compensate for the lack of access to the garden. The building work has caused some noise and disruption to the home; most of the residents are uncomplaining about this, as they know it will be finished very soon and some will be moving into new rooms. There are four bedrooms in a port-a-cabin, which will be removed when the new bedrooms are available. The temporary bedrooms have all utilities connected and climatecontrol heating/cooling systems in place. The main part of the home is also being decorated and refurbished; a new Ashley Manor Nursing and Residential Care Home 20050921 H54 S47024 Ashley Manor V239667 190705 Stage 4.doc Version 1.40 Page 15 nurse-call system is being installed and the manager’s office has been refurbished and extended to provide a meeting room and secure storage for documents. Ashley Manor Nursing and Residential Care Home 20050921 H54 S47024 Ashley Manor V239667 190705 Stage 4.doc Version 1.40 Page 16 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 The numbers and skill mix of staff ensure that needs of the residents are met. The home has a recruitment policy and procedure, but is not currently following it. Arrangements for induction and training ensure that the staff are able to meet the needs of the residents. EVIDENCE: The home has adequately trained staff, in sufficient numbers to meet the assessed needs of the residents. The manager was required at the last inspection to ensure that ‘care’ hours were not eroded by ‘non-care’ duties, such as food preparation. Arranging breakfasts to be served at the times chosen by the residents and ensuring that there are at least four staff on duty at this time have met this. The home also has catering and cleaning staff. The home has a recruitment policy in place, but is not currently undertaking CRB or POVA checks before taking on new staff. This is an outstanding requirement from the last inspection. The registered owner of the home applied for registration with the CRB in February 2005, to undertake his own CRB disclosures, this has not yet been completed. During this period the home has not applied for CRB disclosures with their previous umbrella body, so ten disclosure applications are outstanding. Satisfactory references have been obtained and the new staff are working under supervision. Staff training is on going, with training in adult protection a requirement of this Ashley Manor Nursing and Residential Care Home 20050921 H54 S47024 Ashley Manor V239667 190705 Stage 4.doc Version 1.40 Page 17 inspection. Induction training and updating of all statutory training will be continued and documented, as required in the last inspection; two members of staff still require Manual handling training. Infection Control and Food Hygiene training have been booked for dates in August. Ashley Manor Nursing and Residential Care Home 20050921 H54 S47024 Ashley Manor V239667 190705 Stage 4.doc Version 1.40 Page 18 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, 36, 37 and 38 The quality assurance questionnaire devised by the home will enable them to collect service users views and develop the service accordingly. Arrangements are in place to ensure that staff receive appropriate, documented, supervision. The home has arrangements in place to promote and protect the resident’s rights and interests. The home ensures that staff training promotes the health, safety and welfares of the residents and staff. EVIDENCE: The service user survey has been initiated, but has not been completed by the registered providers. When completed, the results of the survey should be made available to current and prospective residents and a copy sent to the Commission. Ashley Manor Nursing and Residential Care Home 20050921 H54 S47024 Ashley Manor V239667 190705 Stage 4.doc Version 1.40 Page 19 Staff supervision and appraisal has been started and all sessions are documented. The manager’s office has recently been extended and refurbished. The storage of all records and documentation is secure and accessibility is being reviewed. The home has policies on moving and handling, fire safety, food hygiene and infection control. During the course of the inspection all fire doors were found closed. The inspector was advised that all fire doors are to be replaced as part of the building works in the home; the new doors will have automatic closers fitted and will be linked to the fire alarm. Fire training is undertaken on a regular basis. Extra training must be incorporated when the extension of the home is completed and the new fire alarm system is installed. Staff that attend fire training sign attendance sheets to confirm attendance. Ashley Manor Nursing and Residential Care Home 20050921 H54 S47024 Ashley Manor V239667 190705 Stage 4.doc Version 1.40 Page 20 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 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 x COMPLAINTS AND PROTECTION 3 x x x x x x x STAFFING Standard No Score 27 3 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x x 2 x x 3 3 2 Ashley Manor Nursing and Residential Care Home 20050921 H54 S47024 Ashley Manor V239667 190705 Stage 4.doc Version 1.40 Page 21 Yes 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 18 Regulation 13(6) & 18(1) 19 Requirement The registered person must ensure that staff have formal training on adult protection and the prevention of abuse. The registered person must ensure that the recruitment policy is followed and ensure that all checks are undertaken prior to commencement of employment. Staff records must be maintained as detailed in Schedule 2 This requirement is repeated from 11/02/05 The registered person must ensure that the service user survey is completed and the results made available to current and prospective residents and a copy sent to the Commission. This a repeated requirement from 11/02/05 4. 5. Timescale for action 31/10/05 2. 29 31/08/05 3. 33 24 31/10/05 Ashley Manor Nursing and Residential Care Home 20050921 H54 S47024 Ashley Manor V239667 190705 Stage 4.doc Version 1.40 Page 22 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 3 Good Practice Recommendations It is recomended that the pre-admission assessment records should be included in the individual residents personal files as they form the basis for the care plans. It is recomended that any information or details regarding a complaint should be stored separately from the complaints log and kept securely in a locked cabinet. 2. 16 Ashley Manor Nursing and Residential Care Home 20050921 H54 S47024 Ashley Manor V239667 190705 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection 4th Floor, Overline House Blechynden Terrace Southampton SO15 1GW 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 Manor Nursing and Residential Care Home 20050921 H54 S47024 Ashley Manor V239667 190705 Stage 4.doc Version 1.40 Page 24 - 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. 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