Inspection on 03/11/05 for Ashlyn

This inspection was carried out on 3rd November 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 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

Ashlyn 27/04/09

Ashlyn 02/05/08

Ashlyn 22/08/06

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

CARE HOMES FOR OLDER PEOPLE Ashlyn Vicarage Wood Harlow Essex CM20 3HO Lead Inspector Sharon Thomas Unannounced Inspection 3rd November 2005 09:30 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 Ashlyn DS0000062965.V264675.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. Ashlyn DS0000062965.V264675.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ashlyn Address Vicarage Wood Harlow Essex CM20 3HO 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) 01279 868330 Excelcare Holdings Miss Jean Leitch Care Home 43 Category(ies) of Dementia - over 65 years of age (7), Old age, registration, with number not falling within any other category (43) of places Ashlyn DS0000062965.V264675.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 43 persons) Persons of either sex, aged 65 years and over, who require care by reason of dementia (not to exceed 7 persons) The total number of service users accommodated in the home must not exceed 43 persons Service user bedrooms with an area of less than 10 sq.m. will be used only following a written assessment. The assessment should include consideration of whether the facilities in the room are suitable, and acceptable to, the service user, taking into account their mobility needs. The service user plan should reflect the assessment findings The registered person must ensure that no new service users who have dementia are admitted to the home 24th May 2005 5. Date of last inspection Brief Description of the Service: Ashlyn is a care home owned by Excelcare Holdings PLC. It is located approximately 2 miles from the centre of Harlow but is within walking distance of shops, and local amenities. Ashlyn is a purpose built home that provides residential accommodation for 43 older people with low to high dependency needs, 7 of who have Dementia. The home provides personal care to those service users who have been assessed as needing this. The home aims to provide 24-hour individual care and is successful in meeting the physical, emotional and social needs of the service users who live there. The home has bedrooms located on both the ground and first floor; the upper floor of the house is accessible to all residents through the passenger shaft lift. The home is well decorated and offers a homely atmosphere to the individuals living there. Ashlyn DS0000062965.V264675.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on 3rd November 2005, and took 6 hours to complete. Ten of the thirty-eight National Minimum Standards were inspected: one was not met, three were nearly met, and six were met, five requirements have been made. These can be found at the end of this report. For the purpose of this report the individuals living in the home spoken with on the day stated that they would prefer to be referred to as residents. The inspection process included: discussions with two residents, the acting manager, and three members of staff. The tour of the premises included observation of six bedrooms, all of the bathrooms and toilets, and the communal areas. There was an opportunity to spend a considerable period of time observing the care being provided by the staff. The inspection covered the examination of a sample of policies and records (including any records of notifications or complaints sent to the CSCI since the last inspection). It must be noted that the acting manager was overseeing the management of the home and had not previously had management experience this issue was acknowledged at the point of inspection. The home has been successful in appointing a permanent manager who is taking up the post in mid-November. The home was warm and comfortable with good furnishings and a good level of decoration. The residents were cared for by a team of well-trained, skilled and caring staff. The level of concerns reported in the previous inspection report appears to have resolved. What the service does well: The home provides a warm and homely atmosphere for residents. The home has created a family atmosphere despite its size. Ashlyn has a good caring staff team, and has a low staff turnover; staff that have left have done so for genuine reasons, such as retirement. The staff group in Ashlyn are enthusiastic, knowledgeable and skilled. Ashlyn DS0000062965.V264675.R01.S.doc Version 5.0 Page 6 All of the residents spoken with on the day stated that the manager and staff were ‘kind and caring’ and the home was ‘very nice’. Residents reported that relatives and visitors are welcomed into the home at all times. Much of the activities provided in the home are specifically designed to provide stimulation for residents with dementia, including chair games to promote physical exercise and interaction with the other residents and staff. The staff were observed to chat continually with the residents and involve them as they went about their work throughout the day. The home has close links with the health care team in the area, and works with both professionals and residents to promote and maintain the residents’ health. The home promotes the rights of the residents and staff provide care that ensures privacy and dignity. The residents interacted comfortably with the staff. What has improved since the last inspection? What they could do better: The home did not gather appropriate information prior to the admission of prospective residents. The care plans used in the home are not satisfactory and do not provide staff with clear information to enable them to deliver appropriate safe, care. The care plans used in the home did not have satisfactory risk assessments available to staff. The home did not have a robust recruitment procedure. Staff personnel files did not contain all of the information required to ensure that appropriate staff are employed. The home did not provide evidence that appropriate training is being provided to staff employed in the home. Ashlyn DS0000062965.V264675.R01.S.doc Version 5.0 Page 7 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. Ashlyn DS0000062965.V264675.R01.S.doc Version 5.0 Page 8 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 Ashlyn DS0000062965.V264675.R01.S.doc Version 5.0 Page 9 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 did not receive all of the appropriate information required prior to admission. The lack of information may result in the inappropriate admission of a resident and place that person at risk. EVIDENCE: One of the four care plans looked at was that of the newest admission into the home. It did not contain a social services assessment and there was no evidence that the resident and their family were involved in the care planning process. The home had used its own pre-admission assessment and the information gathered within this was insufficient to enable the delivery of effective care. The other three care plans all contained a social service assessment and a copy of the home’s pre-admission assessment. The manager confirmed that she would visit the prospective resident in their own setting prior to admission to assess whether the home could meet the individual’s needs. Ashlyn DS0000062965.V264675.R01.S.doc Version 5.0 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 the following standard(s): 7 Care plans examined indicated that the home’s care planning systems are insufficient. The residents’ care needs were not fully identified, planned for, or monitored in an appropriate manner. The shortfalls identified have the potential of placing residents at risk. EVIDENCE: Four care files were examined on the day. None of the four contained sufficient information regarding the resident’s need, the action to address this need, and the long-term outcome of the care given. The care plans did not cover all aspects of a resident’s physical, mental and social needs, and were not reviewed on a monthly basis. Risk assessments and manual handling assessments were not completed with enough detail to enable staff to deliver care that is safe and appropriate. One care plan was that of the newest admission into the home. This care plan did not contain any information at all regarding the needs of the resident, or the action needed to ensure that the resident was well cared for. This care plan did not contain risk or manual handling assessments. The concerns regarding the lack of information contained in care plans was discussed with the acting manager and it was agreed that urgent action to address this situation would be taken by the staff. Ashlyn DS0000062965.V264675.R01.S.doc Version 5.0 Page 11 The inspector left an immediate requirement notice at the home details of this may be found at the end of this report. There was no that residents signed care plans or were involved in the planning However, residents spoken with confirmed that the staff in the home them with a good level of support and assistance. and the evidence process. provided Ashlyn DS0000062965.V264675.R01.S.doc Version 5.0 Page 12 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 & 14. The home provides the residents with flexibility and choice with regard to their daily lives. The home encourages contact with families, friends and the local community. EVIDENCE: Staff spoken with confirmed that residents see relatives and professionals in private. Visitors to the home are welcomed at any time and there are no restrictions on visiting time. External entertainment is provided in the home and this was displayed in the foyer. The staff are provided with training regarding resident choice and providing a flexible service. The staff confirmed that residents choose who they wish to see and when. The manager confirmed that the home does not act as appointee for any of the residents living there. The residents spoken with on the day were aware of the advocacy service; one resident reported that they “knew that there was someone to speak to”. This information was displayed in the home. Arrangements for residents to bring in possessions were discussed prior to admission, and records of possessions were available. Routines observed in the home were flexible and residents’ individual choices were addressed. Staff encouraged residents to leave the home with relatives and friends. Ashlyn DS0000062965.V264675.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. The home has an effective system in place to enable residents, relatives and others to make complaints. The home operates appropriate practices and procedures to protect vulnerable adults. The manager and staff actively promote awareness of adult protection issues. EVIDENCE: Ashlyn has amended the complaint procedure, and this was found to be clear and concise. The document directed the individual how and to whom, to make a complaint. It contained timescales for action, and the details of the CSCI. It was written in plain language and was user friendly. All of the residents spoken with confirmed that they were aware of the Complaint procedure, and they were able to confirm that they knew who to complain to. The complaint log was examined and was accurate and well maintained. The staff spoken with confirmed that they were aware of the importance of enabling residents to make complaints. The home had a comprehensive and clear set of protection of vulnerable adult abuse policies and procedures. The home had clear guidelines for staff to follow should an allegation of abuse be made. Copies of the relevant national guidelines were available to staff. Two members of staff spoken with on the day were aware of the guidelines and all of these had been on training courses that deal with this issue. One resident stated that they “felt very safe in the home” and “trusted the staff”. Ashlyn DS0000062965.V264675.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of the above standards were inspected – please see previous report (23rd May 2005). EVIDENCE: Although the standards regarding the environment were not inspected the inspector, through the tour of the premises is able to confirm that the home remains clean, tidy and well maintained. Ashlyn DS0000062965.V264675.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 & 30. Staffing numbers were sufficient to meet the needs of the residents. Staff were not provided with training appropriate to the needs of the current resident group. The stable staff group ensured that residents received consistent care delivery. The recruitment procedure in the home was not robust and did not provide the safeguards to ensure that appropriate staff were employed, potentially putting the residents at risk. EVIDENCE: The staffing levels on the day of the inspection met the levels agreed with the CSCI; from discussion with staff and residents, staffing levels were well maintained, and were appropriate to the needs of residents. The home occasionally used agency staff, and any staff shortages due to sickness or annual leave were covered by care staff working extra shifts; this enabled good continuity of care within the home. The three staff personnel files examined did not contain information necessary to ensure the safety of residents through the recruitment process. Two files did not contain the two required references. Two staff files did not contain a CRB check and the references attached did not contain enough information regarding the skills and knowledge of the individual. One of the staff had started work while another had not been given a start date. This issue was discussed on the day, and the manager was reminded that staff must not commence employment until the appropriate documentation was in place. Ashlyn DS0000062965.V264675.R01.S.doc Version 5.0 Page 16 There is a requirement made regarding this issue and this may be found below. The evidence presented to the inspector suggested that the home did not provide the staff with a full and comprehensive programme of training. The home did not provide the inspector with a formal programme of training. The newly appointed care manager’s training file provided no evidence that a formal induction had taken place. This must be evidenced and records forwarded to the CSCI. The training records for staff were poorly maintained and indicated that little training was being provided. Ashlyn DS0000062965.V264675.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): 35 The home safeguards the residents’ financial affairs. EVIDENCE: Since the home was transferred to Excel care the home no longer manages any residents’ financial affairs. If the resident does need money, the home will pay for goods and services and invoice the relative or representative. Ashlyn DS0000062965.V264675.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 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X 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 X X X X 3 X X X Ashlyn DS0000062965.V264675.R01.S.doc Version 5.0 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 OP3 Regulation 14 (1) (a) Timescale for action The registered person must 03/11/05 ensure that all professional assessments are received prior to the admission of prospective residents. An Immediate Requirement Notice was issued for the above. The registered person must 03/11/05 ensure that care plans include all relevant and up to date information. The care plans must be reviewed on a monthly basis. The care plans must provide evidence that the resident is involved in the decision making process. All new admissions into the home must have a detailed care plan within 5 days of admission. An Immediate Requirement Notice was issued for the above. This is a repeat requirement. The registered person must 03/11/05 ensure that all care plans contain an up to date, relevant risk assessment that directs staff on the safe delivery of care. DS0000062965.V264675.R01.S.doc Version 5.0 Page 20 Requirement 2 OP7 15 (1) (2) 3 OP7 15 (1) (2) Ashlyn 4 OP29 7, 9, 19, Schedule 2 5 OP30 12 (1) (a) (b) & 18. The registered person must 03/11/05 ensure that all recruitment checks are undertaken prior to appointment. No member of staff should work in the home until all checks have been carried out. The registered person must 31/12/05 ensure that an appropraite programme of training is available for inspection, all training undertaken must be accurately recorded.The records of the induction programme for the care manager must be sent to the CSCI. 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 Ashlyn DS0000062965.V264675.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Ashlyn DS0000062965.V264675.R01.S.doc Version 5.0 Page 22 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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