Inspection on 12/12/05 for Ashmeadows Residential Home

This inspection was carried out on 12th December 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

Ashmeadows Residential Home 24/04/07

Ashmeadows Residential Home 06/07/06

Similar services:

Snydale Care Home

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Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Ashmeadows Residential Home Westering House Moorbottom Cleckheaton West Yorkshire BD19 6AD Lead Inspector Bronwynn Bennett Unannounced Inspection 12th December 2005 08:35 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 Ashmeadows Residential Home DS0000064583.V261747.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. Ashmeadows Residential Home DS0000064583.V261747.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ashmeadows Residential Home Address Westering House Moorbottom Cleckheaton West Yorkshire BD19 6AD 01274 861049 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) Mr Stephen John Oldale Miss Susan Jane Leigh Miss Annmarie Birch Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places Ashmeadows Residential Home DS0000064583.V261747.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th September 2005 Brief Description of the Service: Ashmeadows is a privately owned and managed care home providing personal care and accommodation for up to seventeen elderly men and women. Ashmeadows is a detached property set in attractive gardens and grounds. A sloping drive leads to a small car parking area. There is a ramped access to the rear of the property via the conservatory and stepped access to the front. The home is on two levels, the upper level being accessed via a shaft lift or stairs. The care home is staffed twenty-four hours a day. Ashmeadows Residential Home DS0000064583.V261747.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and the second inspection carried out this inspection year. The home changed ownership 17th October 2005 and the new providers are Mr Stephen Oldale and Miss Susan Leigh. Miss Leigh is aware of the requirements and recommendations of this report and assured the inspectors that these would be addressed in a timely manner. Two inspectors carried out this unannounced inspection during a seven-hour period. The inspectors made a tour of the building and looked at a sample of records kept by the home. The inspectors also spoke to some of the residents, staff and relatives. The inspection was conducted with help from the manager and the provider of Ashmeadows. What the service does well: What has improved since the last inspection? What they could do better: Although there has been some development in the care records kept for the residents, there is insufficient detail within the records to ensure their health and welfare needs can be met. Ashmeadows Residential Home DS0000064583.V261747.R01.S.doc Version 5.0 Page 6 There must be record kept of all complaints made to the home and details kept of any investigations and action taken. The registered manager must be able to fully discharge her duties and action must be taken, by the manager and the provider to address the issues identified throughout this inspection. The recruitment process is not sufficiently robust to protect the residents. 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. Ashmeadows Residential Home DS0000064583.V261747.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 Ashmeadows Residential Home DS0000064583.V261747.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 resident’s needs are assessed before they move into the care home but there was no written confirmation available during this inspection that the home could meet the resident’s needs. EVIDENCE: The care records for three residents were looked at and there was evidence that the manager had completed a pre-admission assessment. There was no evidence in the care records kept that the manager had confirmed in writing, that having regard to the assessment the home is suitable to meet the needs of the resident. A requirement is made. Ashmeadows Residential Home DS0000064583.V261747.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): 7,8,10. Not all the residents’ health and personal care needs are set out in the individual plan of care. Generally the residents feel that they are treated with respect and their right to privacy is upheld. EVIDENCE: The residents said that they feel appropriately cared for by the staff, and the inspectors observed that the residents continue to have good relationships with the staff. The care records for three residents were examined. Although there has been some progress made with care planning, there is insufficient information to enable the staff to meet the health and welfare needs of residents. There was evidence of nutritional assessments and a record of the residents’ weight. However, where there was an assessed need in one nutritional assessment, a care plan had not been formulated. The personal care and oral hygiene needs of residents were not clear in the individual records kept. This was also identified at the last inspection. Ashmeadows Residential Home DS0000064583.V261747.R01.S.doc Version 5.0 Page 10 The daily recording in the residents’ care records did not reflect their plan of care. And some care plans had not been reviewed, dated and signed. The residents spoken with said that they feel that they are treated with respect and that their privacy is upheld. One resident spoken with said they had a key worker who understood their personal care needs. Other residents said that they are offered choices about how to live their daily lives and felt they are treated in a dignified and respectful way by the care staff. The inspector noted at the last inspection that screening was not available in one of the shared rooms. This issue was addressed during this inspection and the manager said that there continues to be a shared room without the appropriate screening available. A requirement is now made in this matter. Ashmeadows Residential Home DS0000064583.V261747.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): 13,14. The residents maintain contact with family and friends and are supported to make choices and have control in their lives. EVIDENCE: The residents said that they are able to maintain relationships with family and friends. The residents are able to choose activities, interests, and hobbies, choice of food and where to eat. Evidence of family contact and the residents’ choice of activity are recorded in the residents’ care records. Ashmeadows Residential Home DS0000064583.V261747.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 current practice for dealing with complaints does not ensure that residents’ complaints or concerns are taken seriously. EVIDENCE: The inspectors found evidence of a number of complaints made by the residents relating to the working practice of a previous member of staff. These issues had not been recorded in the home’s complaints record, nor had the Commission for Social Inspection been notified as is required under The Care Homes Regulations 2001. Ashmeadows Residential Home DS0000064583.V261747.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): 26 There is a lack of suitable hand washing facilities in the home’s laundry and this poses a health and safety risk. EVIDENCE: The manager said that the home has now implemented a plan of maintenance. Some areas have been redecorated and the home now has a handyperson to carry out minor repairs. The manager advised that hand washing facilities have not yet been provided in the laundry room. This was a requirement at the last inspection and is carried forward in this report. Ashmeadows Residential Home DS0000064583.V261747.R01.S.doc Version 5.0 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. The staffing rotas do not show that there are sufficient numbers and skill mix of staff to meet the needs of the residents. The home’s recruitment practices are not sufficiently robust to protect the residents. A lack of staff training means that some staff are not trained and competent to do their job. EVIDENCE: The staffing rotas kept by the home were examined. The rotas are confusing and do not give a clear indication of the staff working on each shift. All the staff that work in the care home must be included on the rota. A concern has been raised with the CSCI regarding the levels of staff on duty in the care home. Any reduction in the required staffing levels is not acceptable. The home must be suitably staffed at all times. The home has achieved the required fifty per cent of its staff with the NVQ level 2 qualification in care. The records for three staff were examined. The inspectors were concerned about the home’s poor recruitment practices. There were gaps in the employment histories for all the staff records looked at. One application form had not been completed in the applicants’ own handwriting or signed by the applicant. This is not acceptable and must be addressed, as the general Ashmeadows Residential Home DS0000064583.V261747.R01.S.doc Version 5.0 Page 15 content of the staff records does not meet the required standard. A requirement is made in this matter. There was no evidence on the day of this inspection that staff receive structured induction or foundation training. This was discussed with the manager and the provider. And a requirement is made. Some of the staff have not yet completed movement and handling training and this is of particular concern where some staff have little experience of work in a care setting. There was no record of the staff completing adult protection training. The manager must ensure that all staff working in the care home undergo training for the protection of vulnerable adults. Ashmeadows Residential Home DS0000064583.V261747.R01.S.doc Version 5.0 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,37,38. The manager is not fully discharging her responsibilities as a registered person. Processes are in place to ensure that the home is run in the best interests of service users. Generally the residents’ finances are protected. The home’s record keeping practice does not safeguard the resident’s best interests. Health and safety shortfalls have the potential to place residents at risk. EVIDENCE: The manager is registered with the Commission for Social Care Inspection and has a qualification in NVQ level 4 in management. Ashmeadows Residential Home DS0000064583.V261747.R01.S.doc Version 5.0 Page 17 During this inspection there was evidence to suggest that the manager is not fully discharging her responsibilities. Action must be taken by both the manager and the provider to address the issues identified during this inspection. The home does operate a quality monitoring system. A formal questionnaire was completed approximately eight weeks ago and the findings from this will be published and made available to all interested persons. Feedback is actively sought from the residents through meetings and consumer questionnaires and a suggestion box is to be put in place. The money for three residents was checked and reconciled with the financial records kept. Advice was given during this inspection about the appropriate storage of valuables and money kept by the home. The inspectors found that, generally, the records kept in the home were not up to date, well maintained or in good order. Particular attention should be paid to staff rotas, staff files and training records. The outstanding fire safety works are now completed. The home has a fire risk assessment in place and the fire alarm system is checked on weekly basis. The testing of the emergency lighting was overdue; this should also be tested on a weekly basis. Not all of the staff has received fire safety training and action must be taken to rectify this as soon as possible. Action should also be taken to ensure that the staff take part in fire drills on a six monthly basis. There has been a previous concern about the heating in the residents’ rooms. The provider has taken some action to repair the heating system. A relative did share some concern with an inspector about the temperature in a resident’s room and this was passed on to the provider. The inspectors found that some of the hot water temperatures in residents’ rooms and communal bathrooms were too high. The hot water should run at a temperature close to 43 degrees centigrade to minimise the risk of scalding. Ashmeadows Residential Home DS0000064583.V261747.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 1 X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 X 10 1 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 1 17 X 18 X X X X X X X X 1 STAFFING Standard No Score 27 1 28 3 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 3 X 2 X 1 1 Ashmeadows Residential Home DS0000064583.V261747.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 Regulation 14(1) (b) Requirement The registered person must confirm in writing to the resident, that having regard to the assessment the care home is suitable for the purpose of meeting the residents’ needs in respect of their health and welfare. The registered person shall prepare a written plan for each resident in respect of meeting health and welfare needs. Where there is an assessed need, or a high risk is identified for a resident, a specific care plan for these issues must be devised complete with measurable outcomes. Previous timescale 8/10/05 not met. The registered person shall ensure that the care home is conducted so as to promote and make proper provision for the health and welfare of the residents, and make proper provision for the care of the residents. The registered person must DS0000064583.V261747.R01.S.doc Timescale for action 12/01/06 2 OP7 15(1)& 15 (2) 12/02/06 3 OP8 12 (1) 12/02/06 4 OP10 16(2)(c) 12/01/06 Page 20 Ashmeadows Residential Home Version 5.0 5 OP16 17(2) sch 4-11 6 OP26 13 (3) 7 OP27 18(1)(a) 8 OP27 17 (2) sch 4-7 19 (1) a, b(I) 9 OP29 10 OP30 12(1)(a) provide screening in shared bedrooms. The registered person shall keep records in the care home as specified in schedule 4. A record must be kept of all complaints made by residents, their representatives or relatives or by persons working in the care home about the operation of the care home, and the action taken by the registered person in respect of any such complaint. There must be suitable arrangements to prevent the spread of infection in the care home. A sink, hand wash dispenser and paper towels should be made available in the laundry facilities. Previous timescale 30/10/05 not met. The registered person shall ensure that at all times suitably qualified, competent and experienced persons at working at the home in such numbers as are appropriate for the health and welfare of service users. A copy of the duty rota of persons working in the care home, and a copy of whether the rota was worked must be kept. (Regs - 19 (1) a, b(I) para 1–9 of sch 2,c.) The registered person must ensure that prior to staff working at the care home all checks must be carried out in accordance with requirement stated opposite. (Regs - 12(1)(a)18(1)(a) (c) (i)(ii) CSA 2000 (Miscel-laneous Amend-ments) Regs 2004) The registered person shall ensure that the care home is conducted so as to promote and make proper provision for the 25/12/06 12/01/06 12/02/06 12/01/06 12/01/06 12/02/06 Ashmeadows Residential Home DS0000064583.V261747.R01.S.doc Version 5.0 Page 21 health and safety of the residents. The registered person shall ensure that at all times suitably qualified, competent and experienced staff are working at the home in such numbers as are appropriate for the health and welfare of the residents. The registered person must ensure that the staff who work in the care home receive, training appropriate to the work they are to perform; and suitable assistance, including structured induction training and time off, for the purpose of obtaining further qualifications appropriate to such work. The registered provider and the registered manager shall, having regard to the size of the care home, the statement of purpose, and the number and needs of the residents, carry on or manage the care home with sufficient competence and skill. The registered person shall ensure that records referred to in paragraphs 1 & 2 of the regulation are kept up to date, and are at all times available for inspection in the care home by any person authorised by the Commission to enter and inspect the care home. The registered person shall ensure that all parts of the care home to which the residents have access are so far as is reasonably practicable free from hazards to their safety. The registered person shall after consultation with the fire authority make arrangements for persons working in the care home to receive suitable training DS0000064583.V261747.R01.S.doc 11 OP31 10 (1) 12/01/06 12 OP37 17 (3) a & b 12/01/06 13 OP38 13 (4) (a) 12/01/06 14 OP38 23 (4) (d) (e) 12/02/06 Ashmeadows Residential Home Version 5.0 Page 22 in fire prevention; and must ensure, by means of fire drills and fire practices, at suitable intervals, that the persons working in the care home and so far as is practicable, residents, are aware of the procedure to be followed in case of fire. 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 2 3 4 5 Refer to Standard OP7 OP7 OP27 OP30 OP35 Good Practice Recommendations Daily records should evidence delivery of the care plan and any outcomes. Care planning documentation should be dated and signed to ensure currency of the information. The registered person should develop a clearer rota system. The registered person should develop a system to evidence clearly the training that the staff have received. The manager and the provider should develop a safer system for the storage of residents’ finances and financial records. Ashmeadows Residential Home DS0000064583.V261747.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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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