Inspection on 22/02/06 for Ashmore Nursing Home

This inspection was carried out on 22nd February 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

Ashmore Nursing Home 12/06/07

Ashmore Nursing Home 28/06/05

Ashmore Nursing Home 06/12/04

Ashmore Nursing Home 21/06/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Ashmore Nursing Home Barningham Road Stanton Bury St Edmunds Suffolk IP31 2AD Lead Inspector Iain Smith Unannounced Inspection 22nd February 2006 12:15 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 Ashmore Nursing Home DS0000024327.V284734.R01.S.doc Version 5.1 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. Ashmore Nursing Home DS0000024327.V284734.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Ashmore Nursing Home Address Barningham Road Stanton Bury St Edmunds Suffolk IP31 2AD 01359 251681 01359 251681 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) Ashmore Nursing Home Limited Mrs Deborah Mary Groom Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places Ashmore Nursing Home DS0000024327.V284734.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th June 2005 Brief Description of the Service: Ashmore Nursing Home is privately owned and has provided care and accommodation since 1993. The Home is Registered under the Provisions of the Care Standards Act 2000 to accommodate 23 older persons. Ashmore Nursing Home is situated in Stanton, which is approximately 10 miles from both Diss and Bury St Edmunds. The Home is detached and provides accommodation on two floors that is accessible by shaft lift. There are 19 single and 2 double bedrooms. The double bedrooms do not meet the spatial requirements and planning permission has been approved for an extension. The double bedrooms will be closed and refurbished to provide office and storage space. All bedrooms benefit with en-suite facilities. Service users have access to four communal toilets that are conveniently located within the Home close to communal facilities. Three of these toilets provide disabled facilities. The lounge, dining room and conservatory all have views of the garden that are laid to lawn, with attractive flower beds and a walled garden in a tranquil setting. Car parking is available to the front of the Home. Ashmore Nursing Home DS0000024327.V284734.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was made as an unannounced inspection, the second inspection for the year 2005/2006. The visit commenced at 12.15 and finished at 15.00 hrs a total of 2.45 hrs and was conducted by Iain Smith Regulation Inspector. During the inspection residents were spoken to in addition to the catering and care staff. The manager Debbie Groom was present throughout the inspection and fully contributed to the inspection process. A tour of the premises was made, communal areas were visited and records were examined. What the service does well: What has improved since the last inspection? What they could do better: There were no requirements or recommendations made at this inspection. Ashmore Nursing Home DS0000024327.V284734.R01.S.doc Version 5.1 Page 6 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. Ashmore Nursing Home DS0000024327.V284734.R01.S.doc Version 5.1 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 Ashmore Nursing Home DS0000024327.V284734.R01.S.doc Version 5.1 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): 4 The home and staff who work there, meet service users and their representative’s needs. EVIDENCE: The home has registered nurses who are trained to ensure the needs of the service users are met. The training includes specialist skills for example communication skills, pressure area care and nutrition. The training records evidenced that all staff receive training, both the registered nurses and the carers. When service users are admitted into the home their individual needs have been assessed as part of the pre admission assessment. One relative stated that they had visited the home prior to their relative’s admission. The manager stated that training would be provided for staff if they were required to have some specialist knowledge to care for the service user. An example is diabetes and wound management. Ashmore Nursing Home DS0000024327.V284734.R01.S.doc Version 5.1 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): 9 and 11. The service users are protected by the homes policies and procedures for medication. Service users are assured that at the time of their death, staff will treat them with care, sensitivity and respect. EVIDENCE: The home has a policy for medication. This states clearly that medication must be administered and recorded by a registered nurse. The policy is based on the Nursing and Midwifery (NMC) Administration of Medicines and the manager stated that all registered nurses have a copy. The Medication Administration Records (MAR) were examined and found to include staff signatures relating to all the medication that had been given. There was evidence at the front of the medication charts of a record of signatures for all the registered nurses in the home working both day and night. This ensured that each signature on a MAR sheet could be crossreferenced with the signature. One controlled drug was checked against the record and was found to be correctly recorded. There was evidence of a photograph of each service user at the front of the medication record. This Ashmore Nursing Home DS0000024327.V284734.R01.S.doc Version 5.1 Page 10 ensured that the person administering the drug could identify the individual who the drug is given to. The manager stated that she undertook regular drugs audits in the home. There was evidence that one had been completed on 07.02.06. The audit included checking stocks and ensuring the charts were signed. This is recognised as good practice by the manager. To ensure that service users and their families are treated with care and sensitivity at the time of death the home has a policy and procedure in place. The policy was examined and found to include guidance on the principles of caring for the dying, carers coping with death, religious beliefs and events following a sudden death. There was evidence in records that staff were trained in this element of care. Ashmore Nursing Home DS0000024327.V284734.R01.S.doc Version 5.1 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): 12,14 and 15. Service users are helped to exercise choice and satisfy their social, cultural and recreational interests. EVIDENCE: The home offers a range of social activities. There are trips arranged outside the home for example, river and shopping trips. There is a programme of activities displayed in the home and the service users can chose if they wish to be involved. Examples of the activities are arts and crafts, puzzles and music and movement. Two service users were spoken to in the lounge and one was writing a letter to a relative and the other had a crossword book. One service user stated that ‘my husband comes every day to visit me’. The manager stated that care staff lead the activities and take service users out on the trips. The home compiles a newsletter for the service users, their relatives and staff. This includes updates about the home, staff news and any developments within the home. The home organises religious services and there was evidence that Methodist and Church of England services were arranged in the near future. There was notification displayed on the notice board in the foyer of the home. Ashmore Nursing Home DS0000024327.V284734.R01.S.doc Version 5.1 Page 12 One service user stated that she had brought some personal possessions into the home and had them displayed in the bedroom. These include photographs and pictures. The lunch was being served at the time of the inspection. On the menu was Pork casserole or Cauliflower cheese with mashed potatoes and seasonal vegetables. Service users were seen to be sitting at a dining table and one service user stated ‘this is lovely food’. The care staff were serving the service users with their meals, bringing the plates of food out of the kitchen on a tray and placing the plates on the table. The menu was displayed in the dining room for all the service users to see. One service user was sitting in the lounge having their lunch. The manager stated that this person required feeding up to recently but with assistance from staff and encouragement, the service user is eating independently. The service user stated that’ I am enjoying the food’. Ashmore Nursing Home DS0000024327.V284734.R01.S.doc Version 5.1 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): 17 The service users rights are protected. EVIDENCE: The manager stated that service users had a nominated relative who assisted them with finances. This was evident in the care records and a person was identified as the service users next of kin. Ashmore Nursing Home DS0000024327.V284734.R01.S.doc Version 5.1 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): 20,21 and 22 Service users live in a safe, well-maintained environment with specialist equipment. EVIDENCE: On day of inspection the home was in the process of being redecorated. The manager’s office, the dining room and upstairs corridor were being redecorated. The communal area had a variety of chairs, tables and a fish tank that one service user was responsible for feeding. The home was clean, warm and well decorated. The toilet, washing and bathing facilities were assessed. There was a toilet on the ground floor, clearly marked and close to the dining area and lounge. A number of the service users require moving and handling with specialist equipment, for example a hoist. There are two Arjo Trixie hoists in the home, one of which has recently been replaced with a new one. This equipment enables the staff to lift and move service users appropriately and safely. Ashmore Nursing Home DS0000024327.V284734.R01.S.doc Version 5.1 Page 15 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 Service users needs are met by sufficient numbers and skill mix of staff. EVIDENCE: The home is required to have a trained nurse on duty throughout each 24 hour period. The staff rota evidenced that a trained nurse, registered with the Nursing and Midwifery Council (NMC), was allocated to take charge of the home, one in the morning, one for the afternoon and one member of staff for the night duty. In addition to the trained staff there were four carers and a student nurse on duty in the morning. This student nurse was on a placement from the West Suffolk Hospital undertaking her community placement. There were two students currently at the home. Ashmore Nursing Home DS0000024327.V284734.R01.S.doc Version 5.1 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): 33,34,35,37 and 38 The home is run in the best interests of the service user. The health, safety and welfare of service users is promoted and protected. EVIDENCE: The home operates a quality assurance system that includes auditing. The manager stated that she is responsible for auditing medication and care planning as examples. The audits are completed on a monthly basis and feedback is given to staff. The home display information relating to each inspection. This information is also included in the newsletter to inform relatives of planned inspections. The manager stated that the nominated next of kin manages each service users money. No money was seen on the premises and fees are paid directly in to a bank account. Ashmore Nursing Home DS0000024327.V284734.R01.S.doc Version 5.1 Page 17 The home has a policy and procedure file where health and safety information is kept. The policies include risk assessments, manual handling, infection control and managing aggressive behaviour. This information is available for all staff to read and is included in the staff induction. The training records evidenced that staff received health and safety instruction. Ashmore Nursing Home DS0000024327.V284734.R01.S.doc Version 5.1 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 X 3 X x HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 3 18 x X 3 3 3 X X X x STAFFING Standard No Score 27 3 28 X 29 X 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 3 3 X 3 3 Ashmore Nursing Home DS0000024327.V284734.R01.S.doc Version 5.1 Page 19 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 Ashmore Nursing Home DS0000024327.V284734.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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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