Inspection on 06/07/06 for Ashmeadows Residential Home

This inspection was carried out on 6th July 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 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 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 6th July 2006 08:25 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.V294796.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.V294796.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 Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places Ashmeadows Residential Home DS0000064583.V294796.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th December 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. The Provider informed the Commission for Social Care Inspection on the 4.6.06 that the fees range from £321.21 to £344.71 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.V294796.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 8.25am and left at 5.20pm. During this visit the inspector spoke to some of the service users, visiting relatives, some of the staff and the home’s acting manager Ms Alison Dent. The inspector read care records, audited a sample of medications, reviewed staff recruitment and training records, and carried out a tour of the building. Prior to this site visit the Commission for Social Care Inspection sent ten questionnaires to service users living at Ashmeadows. Two completed questionnaires were returned. There were seventeen service users living at the home on the day of this site visit. Surveys were sent to ten service users relatives, two GP’s and seven social workers. At the time of writing this report the inspector had received four responses from relatives. There was no response from GP’s or social workers. Other information used as part of the inspection process included notifications from the home to the Commission for Social Care Inspection about deaths, illnesses, accidents and incidents at the home, copies of the monthly management visit reports produced by the registered provider, and a pre inspection questionnaire completed by the acting manager. The inspector would like to thank everyone for their assistance during this inspection process. What the service does well: No service user moves into the home until their care needs have been assessed. The two service user questionnaires received by the Commission for Social Inspection stated that service users receive enough information prior to admission into the care home. The service users spoken with said that the staff working at the home are supportive and helpful. There were many positive comments such as: “Wonderful here. The staff have allowed me to maintain my independence” “ The staff are wonderful”. The questionnaires received by the Commission for Social Care Inspection indicated that service users usually receive the help and support they need. Ashmeadows Residential Home DS0000064583.V294796.R01.S.doc Version 5.2 Page 6 The staff are working hard to meet the needs of the service users. The inspector noted that the service users have good relationships with the staff, and the staff were respectful when supporting the service users. The home has identified the diverse needs of service users and work well to support service users in their chosen activities and in promoting their independence. There are seven staff who have achieved NVQ level 2 and a further two staff working towards this qualification. Since the last inspection Ms Alison Dent has taken the position of acting manager. She has worked hard during this period and has commenced the course for NVQ level 4. 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. Ashmeadows Residential Home DS0000064583.V294796.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.V294796.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 needs of the service users are assessed by the home prior to admission. Quality in the outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The care records for three service users were looked at, and the records contained information from a pre-admission assessment. The acting manager said that the home works with potential service users and those who may be involved in their care as part of the pre-admission assessment. Two service user surveys received by the Commission for Social Care Inspection said they received sufficient information about the home prior to admission. Ashmeadows Residential Home DS0000064583.V294796.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. Generally the service users health, personal and social care needs are set out in the individuals’ plan of care. However, greater care should be taken to ensure healthcare needs are properly recorded. The home’s medication policy and procedure sufficiently protects the service users. Service users are treated with dignity, respect and privacy. Quality in the outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The staff have worked hard since the last inspection to improve the detail and information in the service users plan of care. The service users care plans are regularly audited by the acting manager and senior care staff. Three service users’ care records were audited. Generally the information held within these records is good, and gives sufficient detail of the personal and social care needs of the individual. An identified healthcare need for one service user was not specified in their plan of care. However, the information was recorded in the service user review Ashmeadows Residential Home DS0000064583.V294796.R01.S.doc Version 5.2 Page 10 of care documentation. This was discussed with the acting manager. Wherever a healthcare need is identified, a plan of care must be written. Risk assessments were in place and up to date. The manager made accident records available. All accidents are monitored and a judgement is made regarding any further action that may be required. This is good practice. The daily records audited gave sufficient details of how service users had spent their day and generally reflected the individuals’ plan of care. As part of this key inspection the medication system was audited and the medication checked was accurate. The service users were seen to be supported in a respectful and dignified manner with their privacy maintained. All the service users spoken with said that the staff are helpful and supportive. One service user said she could not wish for anything better. There were other comments such as “The staff are wonderful”, “ Its wonderful here, the staff have allowed me to maintain my independence”. Ashmeadows Residential Home DS0000064583.V294796.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): 12,13,14 and 15. The service users cultural, religious, social and recreational needs are generally being met, and they are supported to maintain contact with their family and friends. The service users are able to exercise choice and control over their lives. The home provides the service users with a varied and nutritious diet. Quality in the outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: During this key inspection a series of activities were carried out with service users throughout the day. Planned activities are displayed on the homes notice board. The service users preferred lifestyle and leisure interests are recorded in the individuals plan of care. One service user commented that the staff are “wonderful” and had supported her to take part in activities such as knitting, talking books, quizzes and accessing the garden. Ashmeadows Residential Home DS0000064583.V294796.R01.S.doc Version 5.2 Page 12 The relatives spoken with said they are made to feel welcome when visiting the home. The service users said that they are able to see their relatives in private if they wish. The surveys received from three relatives stated that they can visit their relative in private. During a tour of the building three service users rooms were looked at and these rooms had been personalised by the service user. The home offers a four weekly menu that offers a choice of food. All service users were consulted as to their choice of food during this visit. The meal served during this visit looked appetising and the service users commented that the food was nice. The staff were observed appropriately supporting individual service users during mealtimes. The preferred times for eating and the service users choice of food is recorded in their plan of care. Ashmeadows Residential Home DS0000064583.V294796.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. The service users, their relatives and friends are confident in raising any concerns or complaints, and the service users are protected from abuse. Quality in the outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The home does have a complaints procedure, however this procedure is in need of updating to include the required information regarding timescales for responding to complaints. The service users and relatives spoken with said they would feel confident to raise any concerns or complaints with the acting manager of the home, Alison Dent. The questionnaires received stated that service users usually knew how to make a complaint. There have been three complaints made to the home in the last twelve months, and these are now resolved. The staff have received adult protection training. The 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.V294796.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. The service users live in an environment that is generally safe and well maintained. Quality in the outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The acting manager said that there are maintenance visits carried out at the home on a weekly basis. In addition the home carries out health and safety checks of the premises. The acting manager said she discusses renewal of the home with the provider and agreements are reached regarding replacement of fixtures and fittings in the home. During a tour of the home the inspector noted that the identified bath was showing signs of wear and tear. This poses a potential risk of cross infection and was discussed with the acting manager. Ashmeadows Residential Home DS0000064583.V294796.R01.S.doc Version 5.2 Page 15 A service user commented that she had a “Nice” room and other service users commented that they like the home. Two service user surveys said that the home is always fresh and clean but one comment was that there is sometimes an odour from the toilet and this was discussed with the acting manager. During this visit three service users rooms were seen, these rooms had been personalised by the service users. Generally the home is clean and hygienic. The work recommended by Environmental Health has been completed. Since the last inspection the acting manager has taken action to improve infection control in the home’s laundry facilities. However, the facilities for hand washing should be prominently sited in areas where infected material and clinical waste are being handled. Ashmeadows Residential Home DS0000064583.V294796.R01.S.doc Version 5.2 Page 16 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 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. Quality in the outcome area is poor. Although there are positive outcomes in this area this is reduced by the homes recruitment procedures. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: There are staff employed at the home in sufficient numbers to meet the care needs of the service users. The two service user surveys said that staff are usually available when needed. There was one concern that staff are not always available in the lounge areas and there is no way of alerting staff. This was discussed with the acting manager who advised that service users would be made aware of the call systems available in this area. There are seven staff who have achieved NVQ level 2 (with a further two staff working towards this qualification) or NVQ level 3. The acting manager Alison Dent has commenced NVQ level 4. Ashmeadows Residential Home DS0000064583.V294796.R01.S.doc Version 5.2 Page 17 Three of the staff files were audited. Not all the required information was held in these records. Gaps in information included, a POVA first check, a CRB check, gaps in employment histories, and references sought not matching those identified in the individuals’ application. These issues were discussed with the acting manager. There was evidence that the staff undertake induction training. The acting manager said the home was implementing induction training for staff in line with the “Skills for care” standards (The National training Organisation). The acting manager said all the staff had undertaken adult protection training. And one of the staff has completed a four day training course in order to train the staff in safe movement and handling. Ashmeadows Residential Home DS0000064583.V294796.R01.S.doc Version 5.2 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): 31,33,35 and 38. The home is run and managed by an acting manager. Generally the home is run in the best interests of the service users. The financial interests of the service users are safeguarded. Generally, the health and welfare of service users and the staff is promoted and protected. Quality in the outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The home does not have a registered manager. The acting manager Ms Alison Dent should now make her application to the Commission for Social Care Inspection. Ms Dent has commenced NVQ level 4. The service users and the staff spoken with said that they are happy with the acting manager. Another member of staff complimented the acting manager Ashmeadows Residential Home DS0000064583.V294796.R01.S.doc Version 5.2 Page 19 stating that that she offers lots of support. There were similar comments from all the staff spoken with. Ms Dent should be commended for her hard work during recent months. The home has a quality monitoring system in place. Copies of the monthly management review reports are sent to the Commission for Social Care Inspection. Quality audits are completed by the home at six monthly basis intervals. In addition questionnaires are sent to a sample of service users monthly, and are sent to relatives at six monthly intervals. The published results of consumer surveys are made available within the home. A sample of three service users financial records was audited. These were correct. Service users are supported to handle their own finances should they wish to do so and lockable facilities are provided for this purpose. The hot water temperatures in the identified service user bedrooms was high and poses a potential health and safety risk to service users. However, the temperature of the water for bathing was running close to the required temperature. The home has an up to date fire risk assessment. The fire records were checked and there is weekly testing of the homes fire alarm system and emergency lighting. The acting manager said that all staff receive fire safety training every six months and the night staff receive this training every three months. The staff records audited showed that staff were up to date with movement and handling training. The home now has a suitable trained worker to train staff in safe movement and handling techniques. Ashmeadows Residential Home DS0000064583.V294796.R01.S.doc Version 5.2 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 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 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 2 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Ashmeadows Residential Home DS0000064583.V294796.R01.S.doc Version 5.2 Page 21 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 OP7 Regulation 15(1)& 15 (2) Requirement 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, and 12/02/06 not met. Timescale for action 06/09/06 2. OP29 19 (1) a, b(I) (Regs - 19 (1) a, b(I) para 1-9 of 06/07/06 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. Previous Timescale 12/01/06 not met. Ashmeadows Residential Home DS0000064583.V294796.R01.S.doc Version 5.2 Page 22 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 OP16 OP19 OP26 OP31 OP38 Good Practice Recommendations 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. To further improve infection control, hand washing facilities should be sited directly in the laundry area. The acting manager should now make her application to the Commission for Social Care Inspection to become the registered manager. The hot water temperatures in bedrooms should be suitably adjusted to prevent any risk to service users. Ashmeadows Residential Home DS0000064583.V294796.R01.S.doc Version 5.2 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. Extracts may not be used or reproduced without the express permission of CSCI Ashmeadows Residential Home DS0000064583.V294796.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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