Inspection on 24/04/07 for Ashmeadows Residential Home

This inspection was carried out on 24th April 2007.

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

Ashmeadows Residential Home 06/07/06

Ashmeadows Residential Home 12/12/05

Similar services:

Snydale Care Home

Abbey The

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 24th April 2007 09:00 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 Ashmeadows Residential Home DS0000064583.V333499.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. Ashmeadows Residential Home DS0000064583.V333499.R01.S.doc Version 5.2 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 Mrs Alison Dent Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places Ashmeadows Residential Home DS0000064583.V333499.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th July 2006 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. The Provider informed the Commission for Social Care Inspection on the 4.6.06 that the fees range from £335.24 per week. There are additional charges for chiropody, hairdressing, newspapers, magazines, taxis and toiletries. Information about the home and the services provided are available from the home in the statement of purpose and service user’s guide. Ashmeadows Residential Home DS0000064583.V333499.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included an unannounced site visit carried out by the inspector. The inspector arrived at the home at 9.00am and left at 4.00pm. During this visit the inspector spoke to people living at the home, a visiting relative, some of the staff and the home’s manager Ms Alison Dent. The inspector read records relating to people living at the home and the staff, looked at how medication is given and carried out a tour of the building. Prior to this site visit the Commission for Social Care Inspection sent questionnaires to some people living at Ashmeadows. Two completed questionnaires were returned. There were fifteen people living at the home on the day of this visit. Surveys were sent to some relatives and two GP’s. No responses had been received at the time of writing this report. Other information used as part of the inspection process was a pre inspection questionnaire completed by the manager. The inspector would like to thank everyone for their assistance during this inspection process. What the service does well: No individual moves into the home until their care needs have been assessed. Two questionnaires received by the Commission for Social Inspection indicates that people receive enough information prior to admission into the care home. The questionnaires received by the CSCI stated that people always receive the help and support they need. There were many positive comments made about the staff and the manager of the home by people who live and visit Ashmeadows. The staff continues to work hard to meet the needs of people living at Ashmeadows. The home offers a warm and welcoming environment and people living at the home were noted as having good relationships with the staff. The staff were caring and respectful when supporting individuals in the home. The home works well to support people in their chosen activities. Ashmeadows Residential Home DS0000064583.V333499.R01.S.doc Version 5.2 Page 6 Since the last visit to the home Ms Alison Dent has been registered with the CSCI as the registered manager of the home. She has also achieved NVQ level 4 qualification in care. 56 of the staff have achieved NVQ level 2 qualification in care. What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Ashmeadows Residential Home DS0000064583.V333499.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 Ashmeadows Residential Home DS0000064583.V333499.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit Individual needs are assessed prior to people being admitted to the care home. EVIDENCE: The care records for a person recently admitted into the home were looked at. They showed evidence of the social workers assessment and an assessment carried out by the home to show the persons individual needs could be met. Ashmeadows Residential Home DS0000064583.V333499.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit Generally peoples’ health, personal and social care needs are set out in the individuals’ plan of care. The home’s medication policy and procedure does not sufficiently protect individuals. Service users are treated with dignity, respect and privacy. EVIDENCE: The people who use the service were very complimentary about the staff working at the home. One person said that the staff are, “Marvellous”. A visiting relative commented that they were “highly delighted” with the care provided at the home. The care records were looked at for three people. The information held in the records is good and gives sufficient detail of the health, personal and social care needs of the individual. In addition, the records are person centred and reflect how a person wishes to be cared for. Ashmeadows Residential Home DS0000064583.V333499.R01.S.doc Version 5.2 Page 10 The records looked at were up to date and had been reviewed. The staff develop care records with the involvement of each individual. However, this is not presently recorded and was discussed with the manager during this visit. Risk assessments were seen and were up to date. Accident records continue to be monitored with the appropriate judgements made regarding any further actions that should be taken such as contacting an individual’s GP. The daily records generally reflect the individuals care plan and how they have chosen to spend they day. The service users were seen being supported in a respectful and dignified manner with their privacy maintained. The home’s medication system was checked. Four medications were looked at there was errors noted in two. Two tablets had been signed for and not given and a PRN medication (as and when required) could not be reconciled with the records kept. This was discussed with the manager who agreed to take immediate action to address the matter. Ashmeadows Residential Home DS0000064583.V333499.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit Individual cultural, religious, social and recreational needs are generally being met, and people are supported to maintain contact with their family and friends. People are able to exercise choice and control over their lives. The home provides a varied and nutritious diet. EVIDENCE: A visiting relative said that there is always activity provided in the home. During this visit, the hairdresser was visiting and staff were supporting people to take part in their chosen activity. Planned activities are displayed on the homes’ notice board. People’s preferred lifestyle and leisure interests are recorded in their plan of care. One person commented that the staff continues to support them in their chosen activity and they continued to enjoy the home’s garden. Ashmeadows Residential Home DS0000064583.V333499.R01.S.doc Version 5.2 Page 12 A relative spoken with said the staff make them feel welcome when visiting the home. People who use the service are able to see their visitors in private should they wish to do so. One survey received by the CSCI said that there are “always” activities arranged by the home that they can take part in and another said that there are “sometimes” activities arranged. During a tour of the building some individual rooms were seen and had been personalised by the individual. The home offers a choice of food. During this visit people were noted being asked about their choice of meal. The manager said that during residents meetings menus are discussed and planned. People spoken to said the food served at the home was nice. The food served on the day of this visit looked appetising. Individual dietary preferences were recorded in the care records looked at. Ashmeadows Residential Home DS0000064583.V333499.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit. People who use the service, their relatives and friends are confident in raising any concerns or complaints, and the individuals are protected from abuse. EVIDENCE: The people spoken to who use the service said that they knew who to speak with if they were not happy. And the surveys received by the CSCI said that people knew how to make a complaint. A visiting relative said that they feel able to raise any concerns or complaints about the home with the manager, Alison Dent. The home has a complaints procedure. However, the procedure is in need of updating to include the required information regarding timescales for responding to complaints. There have been no complaints made to the home since the last visit by the CSCI. The staff working at the home receives adult protection training. Staff spoken with during this visit had a good understanding of adult protection and the relevant actions that should be taken following any allegations of abuse. Ashmeadows Residential Home DS0000064583.V333499.R01.S.doc Version 5.2 Page 14 Ashmeadows Residential Home DS0000064583.V333499.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. People who use this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit. People live in an environment that is generally well maintained. However, greater must be taken to ensure health and safety issues are addressed promptly to ensure people who use the service are safe. EVIDENCE: The home has regular maintenance visits to complete any required works. Some bedrooms and the dining room have been redecorated. The manager said that there is some refurbishment planned to take place within next few months. During a tour of the home it was noted that window restrictors were missing from windows. This matter was discussed with the manager who agreed to take action in this matter. This is a potential health and safety risk and a requirement is made in this report. Ashmeadows Residential Home DS0000064583.V333499.R01.S.doc Version 5.2 Page 16 The identified bath mentioned at the last visit to the home is still in need of replacing. The manager advised that its replacement is part of the home’s planned refurbishment. The people spoken with said they were satisfied with their rooms. During a tour of the home an odour was noted in a room. The manager agreed to take action to address the matter. It was also noted that some beds were showing signs of wear and tear. The manager agreed to carry out an audit of all beds and purchase replacements accordingly. Generally the home is fresh and clean. Action has been taken to further improve infection control practices and facilities for hand washing are now sited in areas where infected material and clinical waste are being handled. Ashmeadows Residential Home DS0000064583.V333499.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit. The staff are employed in sufficient numbers and receive induction and ongoing training. The recruitment processes must improve to ensure the service users are sufficiently protected by the home’s recruitment policy. EVIDENCE: The people spoken to during this visit were very complimentary towards the staff. One person said that the staff are “Marvellous”. The people who responded to the surveys said that the staff listen and act on what they say. One person said that the staff are “always” available and another person said that staff are “usually” available when needed. Staff are employed in sufficient numbers to meet the care needs of people living at Ashmeadows. The manager has take action to ensure there is additional staff on duty during peak times of activity during the day. The information received by the CSCI shows that 56 of the staff have achieved NVQ Level 2 and one other member of staff is working towards this qualification. Three staff files were audited. Two of the records held the required information. However, one of the records did not contain a full employment Ashmeadows Residential Home DS0000064583.V333499.R01.S.doc Version 5.2 Page 18 history for the individual. This was discussed with the manager who agreed to take immediate action in the matter. The staff undertakes induction training and ongoing training that meets “Skills for Care” standards (The National training Organisation). All the staff working in the care home has either completed the required training, or their mandatory training has been planned. Ashmeadows Residential Home DS0000064583.V333499.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit. The home is run and managed by a person who is fit to be in charge. Generally the home is run in the best interests of the service users. The financial interests of the service people living at the home are safeguarded. Generally, the health and welfare of everyone is promoted and protected. EVIDENCE: The home’s manager is Alison Dent and is registered with the CSCI. She has recently completed NVQ level 4 qualification in care. The people who live and work at Ashmeadows made positive comments about the manager. Everyone said that Mrs Dent is caring and approachable. Ashmeadows Residential Home DS0000064583.V333499.R01.S.doc Version 5.2 Page 20 The home has a quality monitoring system in place. There are staff and meetings held for people living at the home. Quality audits are completed by the home on a six monthly basis. In addition questionnaires are sent to people living at the home and their relatives. The results from the quality monitoring process are published and made available in the home. A sample of three individual financial records was audited. These were correct. People are supported to handle their own finances should they wish to do so and lockable facilities are provided for this purpose. A sample of health and safety maintenance records was checked. They were up to date. The fire records checked were up to date and show there is weekly testing of the homes fire alarm system and emergency lighting. All staff receives fire safety training. A previous concern about the temperature of hot water in individual rooms has now been addressed. All rooms are now fitted with thermostatic valves to prevent any risk to the individual. Ashmeadows Residential Home DS0000064583.V333499.R01.S.doc Version 5.2 Page 21 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 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 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 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Ashmeadows Residential Home DS0000064583.V333499.R01.S.doc Version 5.2 Page 22 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 OP19 Regulation 13.4 (a) Requirement Timescale for action 15/05/07 2. OP9 13.2 The registered person shall ensure that all parts of the care home to which service users have access are so far as reasonably practicable free from hazards to their safety. Window restrictors must be fitted to all rooms. The registered person shall make 24/05/07 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. Ashmeadows Residential Home DS0000064583.V333499.R01.S.doc Version 5.2 Page 23 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. 6. Refer to Standard OP7 OP16 OP19 OP19 OP19 OP29 Good Practice Recommendations Where an individual has been involved in their care plan this should be recorded. The registered provider should review the complaints policy and procedure to include required timescales. The registered provider should replace the identified bath as part of the programme of maintenance. The carpet in the identified room should be cleaned or replaced to ensure the area is odour free. Where beds are showing signs of wear and tear they should be replaced. Any gaps in the staff employment history should be fully explored. Ashmeadows Residential Home DS0000064583.V333499.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Ashmeadows Residential Home DS0000064583.V333499.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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