Inspection on 25/07/06 for Ashlyns Residential Home

This inspection was carried out on 25th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Ashlyns Residential Home 17/07/07

Ashlyns Residential Home 30/01/06

Ashlyns Residential Home 08/08/05

Ashlyns Residential Home 09/02/05

Ashlyns Residential Home 29/07/04

Ashlyns Residential Home 11/02/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Ashlyns Residential Home Chesham Road Berkhamsted Hertfordshire HP4 2ST Lead Inspector Bijayraj Ramkhelawon Key Unannounced Inspection 25th July 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 Ashlyns Residential Home DS0000019271.V305543.R01.S.doc Version 5.2 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. Ashlyns Residential Home DS0000019271.V305543.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashlyns Residential Home Address Chesham Road Berkhamsted Hertfordshire HP4 2ST 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) 01442 870565 01442 861601 Colley Care Limited (Trading as B & M Care) Mrs Diane Delicate Care Home 58 Category(ies) of Dementia - over 65 years of age (19), Old age, registration, with number not falling within any other category (39) of places Ashlyns Residential Home DS0000019271.V305543.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th January 2006 Brief Description of the Service: Ashlyns, provided by B & M Care, is a purpose built residential care home for 58 service users in the older people category. The home has a Dementia Unit (for 19 service users) and a Residential Unit (for 39 service users). The building, part of a large country estate, is situated on the outskirts of Berkhamsted, close to the A41. There are ample parking spaces nearby. The home has a front driveway and the main entrance to the building is security locked. Both units have ample communal spaces. All the bedrooms have ensuite facilities. Some bedrooms are double bedrooms. They are accessible to wheelchair users. The Dementia Unit has 19 bedrooms, two lounges, a small nurses station, a kitchenette and a dining room. Overlooking the lounge is the sensory garden. The interior décor and furnishing are designed to provide a homely and comfortable atmosphere. Security locks are in place at both ends of the Dementia Unit for the safety of the service users. The corridor extends into the Residential Unit, with 39 bedrooms, a lounge, a laundry room, a main kitchen and two dining rooms. The building is generally well maintained, both externally and internally. In the centre of the building is the courtyard that is well designed with an ornamental fountain, attractive potted and climbing plants and comfortable garden furniture. There is a large sun lounge, adjacent to an activity room and overlooking the back garden, which is well kept and accessible to wheelchairs. The ‘Statement of Purpose’ and ‘Service User’s Guide’ including the ‘Complaints Procedure’ are available at the home. A copy of the CSCI inspection report is given to anyone on request. On the day of the inspection the figure given for fees charged was from £400 to £800 per week. Ashlyns Residential Home DS0000019271.V305543.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a positive inspection. The atmosphere in the home was very relaxed and service users feedback was very positive. Generally, service users said that they were being ‘well looked after’ and ‘well cared for’. There were a dedicated staff team who were aware of service users’ individual needs and good interaction between staff and service users were observed. Staff confirmed that they had attended all the mandatory training. There were areas for further development and these included documentation in care plans, the management of medicines, repair and maintenance work, systems and processes for reviewing the quality of care, recording of service users personal allowances and adherence to recruitment procedures. (Please see below for details of the inspection findings). What the service does well: What has improved since the last inspection? What they could do better: Care plans must include all aspects of services users needs and how these needs were being met, their lifestyle and involvement in daily social and leisure activities. Care plans should be agreed and signed by service users or their representatives and these should be accessible and readily available to staff rather than locked away. Risk assessment must be carried out for service users on Warfarin medication, medicine containers and bottles must be dated when first opened for ease of reconciliation and auditing and a regular audit of all medicines must be undertaken on a regular basis. The bath, which has been out of use for over 6 months, must be repaired or replaced. POVA first and CRB checks must be carried out prior to an offer of employment is made. A Ashlyns Residential Home DS0000019271.V305543.R01.S.doc Version 5.2 Page 6 system for reviewing at regular intervals and improving the quality of care must be implemented. A robust system for recording and management of service users personal allowances must be devised and put in place. Time taken for the evacuation after a fire drill should be recorded. Fire risk assessment should be carried out as advised by the Hertfordshire Fire and rescue services. 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. Ashlyns Residential Home DS0000019271.V305543.R01.S.doc Version 5.2 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 Ashlyns Residential Home DS0000019271.V305543.R01.S.doc Version 5.2 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 quality outcome in this area is good. This judgement has been made using all available evidence including a visit to this service. Each service user has an assessment of needs carried out prior to an offer of placement being made. EVIDENCE: Adequate information was available to current and prospective service users about the home. Care plans examined included an assessment of needs for each service user. Ashlyns Residential Home DS0000019271.V305543.R01.S.doc Version 5.2 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): 7,8,9 and 10 The quality outcome in this area is adequate. This judgement has been made using all available evidence including a visit to this service. Good care practices and interactions between staff and service users were observed. Service users confirmed that they were well cared for and that their privacy and dignity was respected. Generally, care plans were adequate. However, documentation and recording of individual’s assessed needs and objectives must be detailed so that staff are aware how these needs could be met. Shortfalls in the management of medicines were identified which could leave service users at risk. EVIDENCE: Service users spoken to said that they were well looked after and cared for. All service users were appropriately dressed and well groomed. Staff members on duty were observed to deliver care and attend to service users’ needs in a manner that respected their privacy, dignity and wishes. Care plans examined had the relevant documentation in place. However, recording in the care plans was generalised rather than specific to identified needs. Assessment forms and Ashlyns Residential Home DS0000019271.V305543.R01.S.doc Version 5.2 Page 10 other forms were not fully completed and signed. Care plans were also identified with numbers and not names of service users. These were locked away, not readily accessible and available to staff and were not signed by individual service users or their representatives. Service users confirmed that they received their medication as prescribed. However, it was noted that a risk assessment was not carried out for the service user who was on Warfarin medication. It was also noted that the medicines containers and bottles were not dated when first opened for ease of reconciliation and auditing. An audit of all medicines has not been carried on a regular basis with records kept. Ashlyns Residential Home DS0000019271.V305543.R01.S.doc Version 5.2 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): 12- 15 The quality outcome in this area is good. This judgement has been made using all available evidence including a visit to this service. Service users maintain contact with their family and friends. Autonomy and choice were being promoted. A programme of activities was displayed and service users spoken to were aware of the day-to-day activities being held in the home. Wholesome, well-balanced and appealing food was served at appropriate intervals and in comfortable surroundings. However, records of activities must form part of the care plans so that a full picture is shown of service users life style in the home. EVIDENCE: Service users confirmed that there were a variety of activities provided for them. The activity and recreation room was equipped with books and materials for art and craft. The activity programme was varied and planned following consultation with service users. However, individual care plans did not have records of activities for service users. The menu showed that the meals provided were varied and wholesome. Ashlyns Residential Home DS0000019271.V305543.R01.S.doc Version 5.2 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 & 18 The quality outcome in this area is good. This judgement has been made using all available evidence including a visit to this service. The home has a robust Complaints’ Policy and Procedures, which were readily available to the service users and their relatives. Training of staff in the area of protection was arranged by the home. EVIDENCE: A copy of the complaints procedure is available to prospective and current service users. Those spoken to said that they were aware of the complaints procedure but would prefer to speak to a member of staff or the manager if they had any concerns. A list of care staff who had completed the training in Protection of Vulnerable Adults was also available. Staff spoken to had knowledge of the Whistle Blowing Policy. No complaints have been received since the last inspection. Ashlyns Residential Home DS0000019271.V305543.R01.S.doc Version 5.2 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 & 26 The quality outcome in this area is adequate. This judgement has been made using all available evidence including a visit to this service. Service users live in a safe, comfortable and homely environment. The premises were well maintained. However, the broken bath must be repaired or replaced so that service users’ choice and personal care is maintained. EVIDENCE: The home and its surroundings offered a pleasant and comfortable environment to its service users. These were kept clean and generally well maintained. Bedrooms were personalised offering a homely, lived in feel. Service users spoken to said that they were happy with their bedrooms and other facilities. However, the parker bath in bathroom 5 was broken, water pipes were disconnected and according to service users and staff, this has been out of use for over 6 months. Ashlyns Residential Home DS0000019271.V305543.R01.S.doc Version 5.2 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- 30 The quality outcome in this area is adequate. This judgement has been made using all available evidence including a visit to this service. The staffing level has been maintained and is adequate. Staff received regularly formal supervision. Service users are supported and protected by the home’s recruitment and selection policies and procedures of the home. However, new members of staff must have a POVA first check and CRB check carried out prior to an offer of employment is made. EVIDENCE: There was adequate number of staff rostered on duty per shift during the day and night. Staff spoken to confirmed that they have received appropriate training, this included statutory training. They also said that they receive regular supervision and an annual appraisal and they have been given a copy of the General Social Care Council Code of Conduct. Staff files examined had all the relevant documents required by this Standard but some staff did not have their POVA first and CRB check carried out prior to an offer of employment was made. Ashlyns Residential Home DS0000019271.V305543.R01.S.doc Version 5.2 Page 15 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 & 38 The quality outcome in this area is good. This judgement has been made using all available evidence including a visit to this service. There were policies and procedures in place to ensure that service users’ rights were protected. There was an enthusiastic, dedicated and caring staff team. Staff received regular planned supervision. However, a system for reviewing at regular intervals and improving the quality of care must be implemented so that regular monitoring of service provision is maintained. Fire safety regulations must be adhered to so that every possible fire risk is assessed and minimised. A proper system for accounting of service users personal allowance must be implemented so that accurate recording of all incomes and expenditures are maintained. Ashlyns Residential Home DS0000019271.V305543.R01.S.doc Version 5.2 Page 16 EVIDENCE: Staff confirmed that the registered manager operated an open door policy to staff, service users and to their representatives. Good professional interaction between staff and service users was observed. Staff confirmed that they had undertaken all the mandatory training. At present service users personal allowances were kept in separate envelopes and locked in a filing cabinet. Each expenditure is recorded on the envelopes. A safer system must be implemented. However, a system for reviewing at regular intervals and improving the quality of care was not devised and implemented. All statutory records were available for inspection and maintained in accordance with legislation. Staff spoken to were aware that service users can access their records and information held about them in accordance with the Data Protection Act 1998. There were policies and procedures in place to ensure that the health, safety and welfare of service users. However, a fire risk assessment as recommended by Hertfordshire Fire and Rescue Service was not carried out and the length of time taken for the evacuation after a fire drill was not recorded. All accidents and injuries are recorded in the accident book and RIDDOR forms have been completed where applicable. The CSCI has been kept informed of all accidents. A valid insurance certificate was displayed in the reception area and this offered cover of no less than £5 million. Ashlyns Residential Home DS0000019271.V305543.R01.S.doc Version 5.2 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 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 2 X 2 X X 2 Ashlyns Residential Home DS0000019271.V305543.R01.S.doc Version 5.2 Page 18 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 OP7 Regulation 15 (1) & (2) 13 (2) Requirement Care plans must include service users needs and objectives and all documentation must be fully completed and signed. a) Risk assessment for service users on Warfarin medication must be carried out. b) Medicines containers/bottles must be dated when first opened for ease of reconciliation and auditing. c) An audit of all medicines must be undertaken on a regular basis with records kept. Records of activities must be included in care plan Service users choices and preferences must be respected. Broken bath must be repaired or replaced. Staff must have a POVA first and CRB check carried out prior to an offer of employment is made A system for reviewing at regular intervals and improving the quality of care must be devised DS0000019271.V305543.R01.S.doc Timescale for action 15/09/06 2. OP9 15/09/06 3. OP12 16 (2) (m) (n) 23 (2) (c) 19 (1) (b) (i) 24 (a) & (b) and (2) 15/09/06 4. 5. 6. OP19 OP29 OP33 22/09/06 22/09/06 27/10/06 Ashlyns Residential Home Version 5.2 Page 19 7. OP35 16 (2) (l) and a copy of the report supplied to the Commission. A proper accounting system for 15/09/06 the management of service users personal allowance must be devised and implemented. 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 OP7 Good Practice Recommendations a) Care plans should be identified with service users names and not numbers. b) Care plans should be available to staff rather than locked away. c) Care plan should be signed by individual service users or their representatives. a) Timescale for the evacuation taken after a fire drill should be recorded. b) Fire risk assessment should be carried out as advised by the Hertfordshire Fire and rescue services. 2. OP38 Ashlyns Residential Home DS0000019271.V305543.R01.S.doc Version 5.2 Page 20 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ 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. 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