Inspection on 05/01/06 for Ashmeade

This inspection was carried out on 5th 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

Ashmeade 19/11/08

Ashmeade 19/06/07

Ashmeade 19/07/05

Ashmeade 09/11/04

Ashmeade 01/07/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Ashmeade 379 Padiham Road Burnley Lancashire BB12 6SZ Lead Inspector Mrs Julie Playfer Unannounced Inspection 5th January 2006 12:45 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 Ashmeade DS0000009464.V271152.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. Ashmeade DS0000009464.V271152.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ashmeade Address 379 Padiham Road Burnley Lancashire BB12 6SZ 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) 01282 425142 01282 454956 Ashhfe@aol.com Mrs Kathleen Mary Rhodes Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15) of places Ashmeade DS0000009464.V271152.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th July 2005 Brief Description of the Service: Ashmeade is registered with the Commission for Social Care Inspection to provide accommodation and personal care for 15 Older People. The home is a detached property set in its own grounds with well-maintained and attractive gardens. There are car-parking facilities at the rear of the building. The home is located close to local shops and is on a major bus route. Accommodation is provided on two floors, linked by a passenger lift, in 9 single rooms and 3 double rooms. Three of the single rooms have an ensuite shower room and one shared room bedroom has an ensuite toilet and hand wash basin. Communal space is provided in two lounges and one dining room. A visitors room is also available adjacent to the green lounge. The staffing levels provided in the home reflect guidance previously issued by the Local Authority. Ashmeade DS0000009464.V271152.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over five hours on 5th January 2006. The previous inspection was carried out on 19th July 2005. No additional visits have been made to the home since the last inspection. On the day of inspection there were 15 residents accommodated at the home. Information was obtained from staff records, care records and policies and procedures. The inspector also spoke to the residents, the staff on duty and the registered person. A partial tour of the premises was also undertaken. What the service does well: What has improved since the last inspection? Since the last inspection, the activities arranged in the home had been developed in line with suggestions made by the residents. In addition two holidays had been arranged for the residents, which they described as a “lovely break” and “thoroughly enjoyable”. Ashmeade DS0000009464.V271152.R01.S.doc Version 5.0 Page 6 The staff had completed a questionnaire as part of the quality assurance process. The results were being collated at the time of the inspection. A comprehensive file had been developed about the safe storage and use of all substances used in the home, including cleaning products. 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. Ashmeade DS0000009464.V271152.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 Ashmeade DS0000009464.V271152.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): 1, 2, 3 and 4 The admission procedure was well managed. Residents were provided with appropriate written information and received assurances their needs could be met by the home. EVIDENCE: Written information was available for residents in the form of a statement of purpose and service users guide. Both documents met regulatory requirements and were presented in a readily accessible format. All residents were issued with a copy of the statement of purpose and service users guide prior to admission. All residents were issued with a statement of terms and conditions of residence, which included details about fees, insurance and the complaints procedure. The ‘case tracking’ process demonstrated that residents had their needs assessed prior to admission by the registered person and social worker, where applicable. The registered manager also informed residents in writing that Ashmeade DS0000009464.V271152.R01.S.doc Version 5.0 Page 9 having regard to the assessment the home was suitable for meeting their needs. There were admission policies and procedures in place along with a resident’s admission checklist, to ensure the resident has been fully informed about life in the home. Ashmeade DS0000009464.V271152.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, 8 and 10 The care planning system fully addressed the needs of the residents and provided clear guidance to staff on how these needs were to be met. Care practice in the home took full account of the residents’ rights to privacy and dignity. EVIDENCE: From the case files seen, it was evident each resident had a plan of care, based on an assessment of needs. The plans set out in detail the action needed to be taken by staff to ensure all needs were met. It was apparent the plans had been reviewed once a month and agreed with the resident and/or their representative. The plans had been updated in respect to any changing needs. The care plans were comprehensive and were written in a suitable format for both the staff and residents. Personal profiles had been incorporated into the care plans and provided details of past life experience. Information provided in the daily care records and care plans indicated that attention was given to the residents’ healthcare needs. Risk assessments had been carried out as necessary in relation to mobility and skin condition. Ashmeade DS0000009464.V271152.R01.S.doc Version 5.0 Page 11 Residents spoken to felt their right to privacy was respected by the care staff and personal care was carried out with respect to their dignity. All residents were referred to by their preferred mode of address, which was documented on the care plan. Ashmeade DS0000009464.V271152.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): 12, 13, 14 and 15 Residents were able to make choices about their life at the home so that their lifestyle met their preferences. Resident’s social, cultural and recreational needs were met through links with their family and friends being maintained and opportunities to undertake activities both inside and outside the home. The meals offered at the home were varied and nutritious and to the liking of the residents. EVIDENCE: The residents said the daily routine was flexible and they were able to get up and go to bed at a time of their choosing. The plan of care gave information of the resident’s preferred daily routine and for staff to support residents to make decisions wherever possible. The residents’ interests were documented in the care plans. A range of activities were planned and implemented by staff and a programme was displayed. Activities arranged in the home included arts and craft, dominoes, music and singing, and aromatherapy. Residents were also involved in activities outside the home which included visiting the pub, going to the theatre and visiting nearby towns. In addition, two holidays had been arranged during the year, which the residents described as “thoroughly enjoyable”. Since the last inspection the activities arranged in the home had been Ashmeade DS0000009464.V271152.R01.S.doc Version 5.0 Page 13 developed in line with suggestions made by residents at the Residents’ meetings. Resident’s meetings were held approximately every once a month and a record was made of the discussion and any agreements made. Visitors were welcome at the home. The residents were able to entertain their guests in any area of their choice. Residents were encouraged to exercise choice and control over their lives. As such residents were supported to manage their own finances. Residents were also able to bring in personal belongings and arrange their rooms how they wished. The menu was on display in the home and the choice of meals was discussed with the residents prior to every mealtime. The residents were satisfied with the quantity and variety of meals, which were homemade. Drinks and snacks were available at set times throughout the day and evening and at all other times on request. Ashmeade DS0000009464.V271152.R01.S.doc Version 5.0 Page 14 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 and 18 Residents were confident that any complaints would be taken seriously and acted upon. The procedures at the home ensured residents were protected from harm. EVIDENCE: A copy of the complaints procedure was displayed behind wardrobe doors in each of the bedrooms and included in the information given to prospective residents. This gave clear directions on whom to make a complaint to and the timescales for the process. The home had a recording system in place should any complaints be made. There had been no complaints received since 2001. There was a whistle blowing procedure and an appropriate procedure for staff to follow should they suspect or witness an incident of abuse. These issues were discussed with staff during the induction period. Ashmeade DS0000009464.V271152.R01.S.doc Version 5.0 Page 15 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, 20, 21, 22, 23, 24, 25 and 26 The residents were provided with a clean, comfortable and well- maintained environment, which was furnished and decorated to a good standard. EVIDENCE: Ashmeade is a detached house set in its own grounds. The home is located close to local shops and other amenities. Accommodation is provided in nine single bedrooms and three shared bedrooms. Four of the single rooms have ensuite facilities. The home also provides two bathrooms and three separate toilets. Communal space is provided in two lounges, a dining room and a visitors’ lounge. It was evident from a partial tour of the home that residents had personalised their rooms with their own belongings and decoration was good throughout. The residents said their rooms were comfortable and warm. Residents had been provided with aids and adaptations to assist their independence skills, these included grab rails, handrails, raised toilets and an oxford hoist. The passenger lift provided access to first floor accommodation. Ashmeade DS0000009464.V271152.R01.S.doc Version 5.0 Page 16 The provision of specialist equipment was determined by the needs of the residents. There was a call facility in every room. The doors to residents’ bedrooms had been fitted with appropriate locks and keys had been distributed to residents, as appropriate. Radiators had been guarded or had a guaranteed low temperature surface. All water outlets with the exception of the kitchen had been fitted with preset valves to guarantee water was delivered close to 43 degrees Celsius. The home was clean and odour free at the time of the inspection. A resident said, “the home is always kept spotlessly clean”. The systems for maintaining hygiene included procedures for infection control. Plastic aprons and gloves were available to staff when undertaking care duties. There was a separate laundry room, which had sufficient and appropriate equipment to meet the laundry needs of the number of residents accommodated. Ashmeade DS0000009464.V271152.R01.S.doc Version 5.0 Page 17 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 The numbers, skill mix and competencies of staff on duty met residents’ needs. The recruitment procedures were thorough and ensured the protection of residents at the home. EVIDENCE: A recorded staff rota was completed in advance, which indicated which staff were on duty and how many hours they had worked. All staff providing personal care were aged over 18 and all staff left in charge of the building were aged over 21. The number of staff rostered for duty was in excess of the guidance previously issued by the Local Authority. All new employees undertook an in house induction programme and competed a “Skills for Care” induction. The latter provided underpinning knowledge for NVQ level 2. At the time of inspection the equivalent of 66 of the care staff were trained to NVQ level 2 or above and 5 members of staff were working towards either NVQ level 2, 3 or 4. Staff also attended in house training courses, which were usually incorporated into staff meetings. The recruitment procedures included completion of an application form, face-to –face interview, obtaining two written references and a POVA first and CRB check. The files of three employees were checked. These showed that the procedures had been followed and all relevant details had been obtained. Ashmeade DS0000009464.V271152.R01.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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, 32, 33, 36, 37 and 38 The staff and residents enjoyed positive relationships, which promoted an open and friendly atmosphere. Effective systems were in place to supervise the staff and maintain all mandatory records. The health, safety and welfare of residents was promoted and protected. EVIDENCE: The registered person had the overall responsibility for the management of the home and had completed NVQ 4 in Management and the Registered Manager’s Award. The registered person also has a Registered General Nurse qualification. There was evidence to indicate the registered person had undertaken periodic training to update her knowledge and skills whilst managing the home. Relationships within the home were good and staff spoke about the residents with respect. The residents valued the help and support they received from the staff, who they described as “very good” and “absolutely lovely”. The staff Ashmeade DS0000009464.V271152.R01.S.doc Version 5.0 Page 19 received supervision at least six times a year; topics discussed during supervision were recorded on a suitable format. The home achieved an Investor’s in People Award in 2001 and this was reaccredited in 2004. The registered person had developed systems to monitor the quality of care in the home and had an annual development plan based on a systematic cycle of planning, action and review, which reflected the aims and outcomes for residents. A satisfaction survey had been carried out of residents and their relatives/representatives. Results of the surveys had been collated, published and feedback to all interested parties. Since the last inspection the staff had completed a questionnaire and the results were being collated at the time of the visit. Policies and procedures had been reviewed and the dates of review had been recorded. The home had well-established administrative systems and all regulatory records seen were complete and up to date. Staff received health and safety training, which included moving and handling, food hygiene, first aid and fire safety. Documentation was seen during the previous inspection which, confirmed gas and electrical systems were serviced at regular intervals. The home had a full set of health and safety policies and procedures, which were signed and dated. Monthly checks were carried out on both the internal and external environment. Since the last inspection a comprehensive file had been developed which detailed the safe storage and use of substances in the home, which included cleaning materials. Ashmeade DS0000009464.V271152.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 3 3 3 3 3 3 3 STAFFING Standard No Score 27 4 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X 3 3 3 Ashmeade DS0000009464.V271152.R01.S.doc Version 5.0 Page 21 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. Standard Regulation Requirement Timescale for action 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 Ashmeade DS0000009464.V271152.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB 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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