Inspection on 31/01/06 for Ashley Manor Nursing and Residential Care Home

This inspection was carried out on 31st January 2006.

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 Manor Nursing and... 05/09/06

Ashley Manor Nursing and... 19/07/05

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 Unannounced Inspection 31st January 2006 10:00 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 Manor Nursing and Residential Care Home DS0000047024.V281106.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 Manor Nursing and Residential Care Home DS0000047024.V281106.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Ashley Manor Nursing and Residential Care Home Winchester Road Shedfield Hampshire SO32 2JF Address 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) 01329 833810 01329 833 810 Mrs Theresa Andrews Mrs Rosamund Jane Heath Care Home 45 Category(ies) of Old age, not falling within any other category registration, with number (45), Physical disability over 65 years of age of places (45) Ashley Manor Nursing and Residential Care Home DS0000047024.V281106.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th July 2005 Brief Description of the Service: Ashley Manor is a registered care home providing nursing care and accommodation for 45 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 thirtyfive single and five shared bedrooms. ****** 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 DS0000047024.V281106.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was the second of two for the inspection year 2005/06. Six members of staff, several residents and visitors were spoken to and the deputy matron assisted with the inspection. Care plans and other documents were looked at, including policies and procedures. Staff files and training plans were also examined. Visitors that spoke to the inspector were very positive about the care their relatives received, commenting that home looked much nicer now that the building work and decoration were finished What the service does well: What has improved since the last inspection? What they could do better: The inspector looked at the files of two new members of staff and found that proper checks had not been completed before they started work in the home. The owner has had problems obtaining CRB disclosures and the matter was discussed with him. A letter of serious concern was sent to the owner, requiring the registered person to take immediate action to ensure the safety of all persons within the home. Ashley Manor Nursing and Residential Care Home DS0000047024.V281106.R01.S.doc Version 5.1 Page 6 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 DS0000047024.V281106.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 Manor Nursing and Residential Care Home DS0000047024.V281106.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): These standards were not examined during this visit EVIDENCE: Ashley Manor Nursing and Residential Care Home DS0000047024.V281106.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): 10 Arrangements ensure the residents privacy and dignity is upheld EVIDENCE: Staff were seen supporting residents in a dignified and respectful manner. Assistance was given at the resident’s own pace and in an unhurried fashion. Staff were seen to knock at bedroom doors before entering. The double bedrooms were seen to have screens in place to provide privacy when residents have personal care or are seen by a healthcare professional such as their GP. The deputy matron said that residents can receive telephone calls, in privacy, on the homes cordless phone. Telephone lines are fitted in each bedroom but none of the residents have chosen to have telephones installed. Ashley Manor Nursing and Residential Care Home DS0000047024.V281106.R01.S.doc Version 5.1 Page 10 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): 13 and 15 Arrangements ensure contact is maintained with family and friends. A wholesome and balanced diet is available. EVIDENCE: The deputy manager said that the home had an open visiting policy and residents could entertain their visitors in their bedroom or in one of the communal rooms on the ground floor. Examination of the visitors book in the hallway showed that visitors came to the home at different times of the day. The inspector saw several visitors during the course of the day, and several commented that they were happy with the care provided in the home. The home has a planned menu, which offers choices and caters for specific needs such as diabetic or liquidised diets. The menu has a four-week cycle and incorporates favourite meals such as fish on Fridays and roast dinners on Sunday and Wednesday. Other favourites such as curry and pasta are also included, the chef knows the likes and dislikes of the residents and plans the menus accordingly. If they book in advance, visitors are also welcome to stay for a meal. Residents may choose where to take their meals, some prefer to have a small table in the sitting room, whilst others prefer the dining table. Residents that spoke with the inspector said that they enjoyed their meals and usually enjoyed the choices that were available. Ashley Manor Nursing and Residential Care Home DS0000047024.V281106.R01.S.doc Version 5.1 Page 11 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): These standards were not examined during this visit EVIDENCE: Ashley Manor Nursing and Residential Care Home DS0000047024.V281106.R01.S.doc Version 5.1 Page 12 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 Arrangements ensure the home is safe, well maintained, clean, and hygienic EVIDENCE: The owners have recently completed an extension to the home, which has provided 25 extra en-suite bedrooms, a hairdressers room and a conservatory. A new car park has also been included at the back of the home. The owner said that he plans to have the gardens landscaped, with raised beds and paved areas to allow wheelchair access to more areas of the garden. As part of the refurbishment of the home all bedrooms and corridors have been decorated as well as the external walls and a new nurse-call system has been installed. The extension also includes a new laundry, which has had new washing machines and dryers installed. The bed sheets and towels are sent to an external laundry and the personal laundry is done in the home. On the day of the visit the home it was seen to be clean, with no unpleasant odours. The care staff in the home are supported by laundry staff, cleaners Ashley Manor Nursing and Residential Care Home DS0000047024.V281106.R01.S.doc Version 5.1 Page 13 and kitchen staff who work a roster to ensure that these services are provided every day of the week. . Ashley Manor Nursing and Residential Care Home DS0000047024.V281106.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): 27, 28, 29 and 30 Arrangements ensure that residents’ needs are met and that they are in safe hands at all times. The recruitment arrangements do not always protect the residents. Arrangements ensure that the staff are trained to do their jobs. EVIDENCE: The home employs a total of fifty staff, this includes thirteen registered nurses, care assistants and ancillary staff such as cooks, cleaner and laundry staff. The home also employs a handyman and gardener. Agency staff are occasionally used, and the agency usually send the same staff, providing continuity of care with staff who know the home and the residents. Nine of the care staff have completed NVQ’s in care and three others will be starting the course this year. (National Vocational Qualifications). The manager is a registered nurse who also has an NVQ4 in management and the deputy is also a registered nurse who has completed an advanced Management for Care course. The home does have a robust recruit policy, which is usually followed. The inspector looked at the files of two new members of staff and found that for one staff member a CRB disclosure from previous job had been accepted and employment started in the home. A new CRB had been applied for, but a Ashley Manor Nursing and Residential Care Home DS0000047024.V281106.R01.S.doc Version 5.1 Page 15 POVAfirst check was not done. CRB disclosures are not transferable. (Criminal Records Bureau disclosure, which is a police check, Protection of Vulnerable Adults Examination of the other staff file showed that it did not contain proof of identification or a photograph of the applicant. A CRB had been applied for, the result had not been obtained and a POVAfirst had not been applied for before employment started in the home. The inspector discussed these matters with the owner, Mr Andrews. He said that there have been problems accessing the POVAfirst system from his office and there have been some delays in disclosure results being received at the home. Mr Andrews said that he would have a suitable computer system installed at the home so that the manager could apply for the necessary checks and possibly reduce the current delays. A letter of serious concern was sent to Mr Andrews, explaining the seriousness of this matter, with a requirement that he take immediate action to address the issues identified and to ensure the safety of all persons within the home. Other staff files were checked and found to contain the correct information, there was evidence that the nurses have had NMC checks on their professional qualifications before starting work in the home. (Nurses and Midwives Council) The home has a rolling programme of training and a record is kept to ensure that all staff are up-to-date. The training programme was seen to contain sessions on continence awareness, manual handling, food hygiene, dementia and abuse awareness and first aid. Ashley Manor Nursing and Residential Care Home DS0000047024.V281106.R01.S.doc Version 5.1 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 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 Arrangements ensure that the home is well run and in the best interests of the residents. The residents’ financial interests are safeguarded. Arrangements are in place to ensure that the health, safety and welfare of the residents and staff is protected. EVIDENCE: The manager is a registered nurse with many years care home experience. A deputy and a well-trained team of nurses, carers and ancillary staff support her. The home has a quality assurance system in place, and the recent survey resulted in only thirteen responses. Residents and their relatives are happy with the care provided, but some would like more activities or entertainment available. Residents and visitors that spoke to the inspector during the visit also indicated that they were happy with the care provided. Ashley Manor Nursing and Residential Care Home DS0000047024.V281106.R01.S.doc Version 5.1 Page 17 The home looks after pocket money for some of the residents. This money is kept in separate, labelled, plastic wallets. Each wallet contains a small account book to record the income and expenditure of each resident and receipts are also kept. The inspector checked the cash and balances on three accounts and all were correct. The inspector was able to see the service contracts for services such as the boilers, the fire safety equipment and the lift, which are all up-to-date. A fire risk assessment for the home has been completed and the record of the weekly fire alarm tests was also examined and found to be up-to-date. The deputy manager said that the new lift was not working properly, so the older one was being used. An engineer was expected to rectify the fault. The home has recently had a mishap with a new Oxford hoist, it is no longer being used and was being checked the next day by an engineer. The deputy manager said that there are arrangements in place to ensure that the home is locked and secure at night. During the day the front door is kept closed and access is gained only by ringing the bell. The back door has a keycode for entry and all other external doors are linked to the alarm system. Ashley Manor Nursing and Residential Care Home DS0000047024.V281106.R01.S.doc Version 5.1 Page 18 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 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 Manor Nursing and Residential Care Home DS0000047024.V281106.R01.S.doc Version 5.1 Page 19 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 OP29 Regulation 19 and Schedule 2 Requirement The registered person must take immediate action to ensure the safety of all persons within the home. Timescale for action 20/02/06 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 Manor Nursing and Residential Care Home DS0000047024.V281106.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Hampshire Office 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 DS0000047024.V281106.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. Re-publishing this information is in breach of the terms of use of that website. 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