Inspection on 27/10/05 for Ashley Park Nursing Home

This inspection was carried out on 27th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 Park Nursing Home 07/08/07

Ashley Park Nursing Home 25/05/06

Ashley Park Nursing Home 17/05/05

Ashley Park Nursing Home 17/11/04

Ashley Park Nursing Home 15/06/04

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

CARE HOMES FOR OLDER PEOPLE Ashley Park Nursing Home The Street West Clandon Guildford Surrey GU4 7SU Lead Inspector Denise Debieux Unannounced Inspection 27th October 2005 10:15 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 Park Nursing Home DS0000017588.V257595.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 Park Nursing Home DS0000017588.V257595.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ashley Park Nursing Home Address The Street West Clandon Guildford Surrey GU4 7SU 0113 381 6100 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) BUPA Care Homes Limited Mrs Ladan Roxanna French Care Home 47 Category(ies) of Old age, not falling within any other category registration, with number (47), Physical disability (1) of places Ashley Park Nursing Home DS0000017588.V257595.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home may accommodate service users from the age of 60 years Up to one (1) service user may be a person with physical disability from the age of 50 years 17th May 2005 Date of last inspection Brief Description of the Service: Ashley Park is a large, attractively presented detached property set in pleasant grounds in the village of West Clandon. The home is owned by BUPA and the service is registered to provide care, accommodation and facilities for up to 47 older persons requiring nursing care. The accommodation and facilities are set over three floors with a passenger lift access to all floors. However, there are two bedrooms that require service users to negotiate two sets of four stairs from the lift to the rooms. These rooms are reserved for respite care or people who are independent and mobile. The communal areas are all found on the ground floor and consist of a sun lounge, a drawing room, a large dining room and a very large activities room that is also used as the hairdressing salon and physiotherapy room. The home has very large gardens that run down to the neighbouring golf course. The grounds closest to the home are well maintained, with many seating areas around the house and a sun gazebo in the grounds. There is plenty of parking to the front and around the side of the home. Ashley Park Nursing Home DS0000017588.V257595.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 5.5 hours and was the second inspection to be undertaken in the Commission for Social Care Inspection year April 2005 to March 2006. This inspection was carried out by Denise Débieux, Lead Inspector for the service. Ms Marilyn Stevens (Deputy Manager/Head of Care) and Ms Jackie Grout (Administrator) were present as the representatives for the establishment. A tour of the premises took place. Seven of the thirty service users were spoken with in private, with a further three service users and six on-duty staff being spoken with during the tour. Some of the comments made to the inspector during the inspection are quoted in this report. The pre-admission assessments, care plans, staff training log, complaints log, activity records and staff recruitment records were all sampled. The inspector would like to thank the staff and service users for their time, assistance and hospitality during this inspection. What the service does well: What has improved since the last inspection? The ongoing maintenance, redecoration and refurbishment programme provides service users with a safe and comfortable environment in which to live. Ashley Park Nursing Home DS0000017588.V257595.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 Park Nursing Home DS0000017588.V257595.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 Park Nursing Home DS0000017588.V257595.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 The home needs to ensure that comprehensive pre-admission assessments are carried out prior to offering a service user a place. EVIDENCE: Four care plan files were sampled and all were found to contain pre-admission assessments. However, in the files sampled, these forms had not been completed in full and some had not been signed by the person carrying out the assessment. It is important that a comprehensive needs assessment is carried out prior to a service user being offered a place at the home and a requirement has been made to this effect. All service users spoken with confirmed that they felt they had everything they needed and, in conversation with one visitor, it was clear that they were confident that their relatives’ needs were being met. Ashley Park Nursing Home DS0000017588.V257595.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 The home needs to ensure that all service users have an individual care plan that details the care required to fully meet their health, personal and social care needs. EVIDENCE: Care plans were sampled during this inspection. One service user recently admitted had no care plan in place. Other care plans were incomplete and did not include all areas of identified needs. No care plans included social care needs and none sampled had been signed by service users or their representatives to signify their agreement with the contents. Not all care plans had risk assessments for falls and one ‘Waterlow’ risk assessment, which identified that the service user was at risk of developing a pressure sore, had not been reviewed since July 05. Another service user had been admitted for respite care post operatively. There was no care plan or instructions to staff on precautions that all should have been aware of to prevent post operative complications. The above issues were discussed at some length during this inspection and a requirement has been made. Ashley Park Nursing Home DS0000017588.V257595.R01.S.doc Version 5.0 Page 10 In discussions with service users, all expressed their satisfaction with the care received. All interactions observed between the staff and service users were seen to be respectful and caring. One service user, when asked if the staff looked after her well, replied ‘Oh, the staff are very good.’ Ashley Park Nursing Home DS0000017588.V257595.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): 15 Meals are well-balanced and varied with individual choices and preferences catered for. EVIDENCE: The lunchtime meal was taking place during the inspection and the food was presented in an appetising manner. Ample staff were present and offered help or assistance where needed in a discreet and sensitive way. The atmosphere in the dining room was convivial and unhurried. One service user confirmed that the staff always help her with her meals and know what assistance she needs. Other service users spoken with said that the food was nice and that they were able to have something different if they did not like the food that was on the menu. Ashley Park Nursing Home DS0000017588.V257595.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 The home has a simple, clear and accessible complaints procedure which includes timescales for the process. EVIDENCE: The home’s complaint log was inspected. From the documentation in the log it was seen that complaints are acknowledged and dealt with in line with the procedure. The actions taken to resolve the complaint and the outcomes are clearly recorded. All service users spoken with were aware of who to talk to if they had a complaint and all are given a copy of the complaints procedure, which is also available in the home’s service users’ guide. Ashley Park Nursing Home DS0000017588.V257595.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 20 The location and layout of the home and gardens is suitable for it’s stated purpose. It is accessible, safe and well-maintained. The home was found to meet service users’ individual and collective needs in a comfortable and homely way. EVIDENCE: The and and and home was toured and found to be well-maintained with fixtures, fittings furnishings of a high standard. The bedrooms seen were all well decorated many contained the service user’s own items of furniture, photos, pictures ornaments. The home provides a number of communal areas including a sun lounge, activities room, dining room and drawing room. The drawing room has an interconnecting door to the sunroom which, on the day of inspection, was left open to create space between the two rooms. Ashley Park Nursing Home DS0000017588.V257595.R01.S.doc Version 5.0 Page 14 The gardens are extensive and well maintained, providing additional seating areas and pleasant surroundings in finer weather. Ashley Park Nursing Home DS0000017588.V257595.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): 28, 29 and 30 The home has a comprehensive staff training programme which is designed to ensure, as far as reasonably possible, that service users are in safe hands at all times. Immediate action must be taken to improve the staff recruitment procedures to ensure that service users’ safety is protected. EVIDENCE: The home is working towards having 50 of their care workers qualified to National Vocational Qualification (NVQ) level 2 in care or higher by 31st December 2005. Seven of the eighteen care workers have already achieved the qualification and two are currently on the course. The home has a comprehensive training programme which covers all areas required by the Skills for Care organisation (previously TOPSS). Staff training records were inspected and found to be well maintained with all staff training up to date. During the inspection four staff files were sampled. The home obtains two written references and proof of identity was available in the files. However, inconsistencies and gaps in employment were not always fully explained and, for three of these members of staff, there were no Criminal Records Bureau (CRB) certificates in place. All three were working without having had a POVAfirst check, CRB certificate applications had been sent for two of the staff members but for the third member of staff the CRB certificate application form had not been sent. Ashley Park Nursing Home DS0000017588.V257595.R01.S.doc Version 5.0 Page 16 In addition and in instances where staff commence employment on the basis of a POVAfirst check whilst waiting for the CRB certificate to be returned, the staff were unaware that additional measures had to be put in place in line with recent legislation. Immediate requirements were made regarding these areas of recruitment (one of which has been brought forward from the last inspection as not met.) Ashley Park Nursing Home DS0000017588.V257595.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): 36 Service users benefit from well supported and supervised staff. EVIDENCE: As noted at the last inspection, formal supervision has been commenced and the proposed programme means that staff will receive up to six sessions of supervision in a year. All service users spoken with were complimentary about the staff at the home with one service user stating ‘they are a good staff team’ and a visitor commenting that the manager had done a good job in building the present staff team. All service users spoken with said that they felt safe at the home. Ashley Park Nursing Home DS0000017588.V257595.R01.S.doc Version 5.0 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 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 3 X X X X X X x STAFFING Standard No Score 27 X 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X 3 X X Ashley Park Nursing Home DS0000017588.V257595.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? YES 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 OP3.1OP3. 3 Regulation 14(1) (a-d) Requirement The registered person must ensure that new service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. The assessment to cover all areas identified in the National Minimum Standards for Older People standard 3.3. The registered person must ensure that each service user has an individual plan of care and that the plan includes the following: • A comprehensive assessment of needs covering all areas of health, personal and social care needs • Risk assessments, to include prevention of falls and risk of pressure sore development • Details of individual needs identified • Goal/objective for each DS0000017588.V257595.R01.S.doc Timescale for action 27/11/05 2 OP7.1OP7. 2OP7.3OP7 .4OP7.6 14(2)(a) (b) 15(!) 15(2) (a-d) 27/01/06 Ashley Park Nursing Home Version 5.0 Page 20 3 OP29 4 OP29 5 OP29.3 need Actions to be taken to ensure the goals are met • Daily report writing to evidence that identified needs and goals are being met • Monthly reviews with newly identified needs or problems promptly added to the care plan • Signature of service user/representative to signify their agreement with the plan 19(1)(a-c) The registered person shall not Sched 2 employ a person to work at the care home unless the person is fit to work at the care home and he/she has obtained, in respect of that person, the information and documents specified in paragraphs 1 to 9 of Schedule 2 of the Care Homes Regulations 2001, as amended by The Care Standards Act 2000 (Establishments and Agencies)(Miscellaneous Amendments) Regulations 2004. (Timescale of 20/05/05 not met.) 19(1)(a-c) With reference to the three Sched 2 members of staff currently working without CRB certificates or POVAFirst checks. The registered person must take immediate action to ensure the safety and protection of service users and provide the CSCI, Eashing Office, with details of the measures taken. 19(11) Where the registered person (a-c) permits a new worker to start work with a POVAfirst check but prior to receipt of a valid CRB certificate the registered person must: • Appoint a member of staff • DS0000017588.V257595.R01.S.doc 27/10/05 27/10/05 27/10/05 Ashley Park Nursing Home Version 5.0 Page 21 • • (the staff member), who is appropriately qualified and experienced, to supervise the new worker. So far as possible, ensure that the staff member is on duty at the same time as the new worker. Ensure that the new worker does not escort service users away from the care home premises unless accompanied by the staff member. 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 Park Nursing Home DS0000017588.V257595.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Park Nursing Home DS0000017588.V257595.R01.S.doc Version 5.0 Page 23 - 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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