Inspection on 09/12/05 for Ashridge House

This inspection was carried out on 9th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Ashridge House 08/04/10

Ashridge House 29/04/08

Ashridge House 17/12/07

Ashridge House 23/05/07

Ashridge House 20/07/06

Ashridge House 23/06/05

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Ashridge House 132 Dorset Road Bexhill-on-sea East Sussex TN40 2HT Lead Inspector Melanie Freeman Unannounced Inspection 9th December 2005 10:00 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 Ashridge House DS0000062830.V254973.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. Ashridge House DS0000062830.V254973.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Ashridge House Address 132 Dorset Road Bexhill-on-sea East Sussex TN40 2HT 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) 01424 222200 Sarojini Sivayogarajah Vacant Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29) of places Ashridge House DS0000062830.V254973.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. That only older people will be accommodated. That service users accommodated will be aged sixty-five (65) years or over on admission. That the maximum number of service users to be accommodated will be twenty nine (29). 23rd June 2005 Date of last inspection Brief Description of the Service: Ashridge House is a large detached property situated on the outskirts of Bexhill on Sea. The town centre with its shops and access to bus and rail routes is approximately a mile and a local shopping centre is approximately half a mile. Accommodation is provided on three floors and a shaft lift is fitted to assist those service users who may have mobility problems. Bedroom accommodation is provided in 25 single and two double rooms. The home is registered to accommodate up to 29 older people and the registered owner is a Mrs Sivayogarajah. Ashridge House DS0000062830.V254973.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001 often use the term ‘service user’ to describe those living in care home settings. For the purpose of this report those living at Ashridge House will be referred to as ‘residents’. This report should be read in conjunction with the report of the inspection that took place on 23 June 2005 for an overview of the core standards inspected over the year. This was an unannounced inspection carried out on a weekday in December 2005. The acting manager was on duty and was able to contribute to the inspection process and received the inspector’s feedback. The inspector spent time with residents and visitors and was able to review the homes progress in meeting the requirements made at the last inspection. Staff were spoken to and observed whilst working. The care documentation for 2 residents were reviewed in depth and the home was toured to review the facilities. What the service does well: What has improved since the last inspection? The homeowner and acting manager have responded positively to the requirements made at the last inspection and it is clear that they are committed to improving the home. The arrangements for entertainment and activities for residents including contact with the community are being improved. Staff training in the home is being developed with staff taking the opportunity to undertake NVQ training. Staff supervision has been formalised and is now recorded. Record keeping in the home in respect of resident’s monies and staff recruitment has been improved. Ashridge House DS0000062830.V254973.R01.S.doc Version 5.1 Page 6 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. Ashridge House DS0000062830.V254973.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 Ashridge House DS0000062830.V254973.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): 1 and 4 Ashridge House provides appropriate information about the home and the services it offers. Pre-admission procedures ensure residents can make an informed choice about the home. EVIDENCE: A review of the information available to people on the home confirmed that this is full and comprehensive and displayed in the front entrance area. It was however noted that the last inspection report was not displayed or referred to within this documentation and this was discussed with the acting home manager. The admission process encourages all prospective residents to visit the home spending time with the staff and other residents to ensure the home is suitable before making a decision to move in. The home also operates one months trial period to provide time for settling in without a full commitment being made. Ashridge House DS0000062830.V254973.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): 7 and 10 The home was found to be meeting resident’s health and care needs with the support and advice of community health care professionals, however the care documentation needs to be improved to provide clear guidance to care staff. The inspector judged that resident’s privacy and dignity rights were upheld and respected. EVIDENCE: The care documentation pertaining to 2 residents were reviewed in depth. The assessment and planning of care systems have been changed recently and although the assessment of resident’s care needs is full the planning of care has not been established. During the inspection it was clear that the health and care needs of the residents were being responded to appropriately. Observation of staff also confirmed that they treated residents and visitors with respect. Residents preferred term of address is recorded and used. Ashridge House DS0000062830.V254973.R01.S.doc Version 5.1 Page 10 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 and 14 Service users have choices in all areas of their daily living. Some work is required to ensure more access to the local community and meaningful activities. EVIDENCE: Discussion with the acting home manager confirmed that improvements are being made to the activities and entertainment provided in the home and a trip to the theatre was being arranged. A local disabled taxi service is also being accessed. During the inspection residents were either sitting in the communal lounge/dinning room or in their own rooms, interaction between staff and residents was minimal and not being facilitated at the time of this inspection. When speaking to residents they confirmed that they made decisions about how, and where they spent their days and when they did things. Ashridge House DS0000062830.V254973.R01.S.doc Version 5.1 Page 11 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): 18 Adult protection procedures and training in the home are not fully developed and therefore vulnerable adults may not be fully protected. EVIDENCE: The home has a policy and procedure for the protection of vulnerable adults this needs to be updated to provide clear guidance to staff as to what action to take if there is an allegation or suspicion of abuse with relevant contact numbers. Discussion with the manager identified the need for further training on adult protection issues including the POVA register. Ashridge House DS0000062830.V254973.R01.S.doc Version 5.1 Page 12 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): 19,22,21,23 25 and 26 Ashridge House provides a home like environment that is attractive however further redecoration and improvement to the facilities to provide a safe, pleasant environment is needed. EVIDENCE: Ashridge House is a converted property that provides a home like environment. Some redecoration and upgrading has taken place but there is no planned programme for regular maintenance and renewal of the fabric and furnishings of the home. During the inspection it was noted that some areas in the home were in need of general maintenance it was also noted that some radiators accessible to residents were unguarded posing a possible risk. An immediate requirement form was left with the acting home manager in respect of this concern at the time of the inspection. She has since written to the CSCI confirming that all unguarded radiators have been risk assessed and will be removed or guarded within the month. Ashridge House DS0000062830.V254973.R01.S.doc Version 5.1 Page 13 Residents have the use of one large lounge/dining room; furnishings here are domestic in style, in addition there is a ground floor smoking area for residents. Accommodation is on three floors and a shaft lift is fitted to assist those residents who may have mobility problems to access all areas. Sufficient bathrooms and WCs are available for the residents living in the home currently however as occupancy of the home increases these will need to be improved. It was also noted that cleaning substances were being stored in the bathing areas. Since the inspection the acting manager has confirmed in writing that all cleaning agents are now being stored in accordance with the COSHH requirements. A review of the communal hand washing areas identified that adequate hand washing facilities are not provided. This shortfall was discussed with the acting home manager. At the time of the inspection the home was found to be warm and clean. Resident’s rooms were found to be very personalised and individual with many having the resident’s own furniture. Although a laundry room is provided this is combined with a sluice facility and storage area for used incontinence pads. During the inspection it was noted that clean linen was drying next to the sluice and incontinence pads storage area. This area of concern was discussed with the acting manager who confirmed that the dryer was not working and this was being dealt with. Ashridge House DS0000062830.V254973.R01.S.doc Version 5.1 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 and 28 Staffing arrangements in the main were satisfactory with sufficient numbers of skilled staff employed to meet resident’s needs. EVIDENCE: At the time of this inspection 15 residents were living at Ashridge House. Residents and a visitor spoken to were very positive about the staff in the home, their comments included; ’the girls are very helpful’ ‘staff are nice and friendly’ ‘staff are friendly and will do anything for you’. Two care staff work in the home during the day supported by catering and domestic staff and the manager. At night there is one waking care staff on duty with a further carer sleeping on the premises ready to provide extra support if required. Discussion with the acting manager confirmed that 2 care staff have completed and NVQ level 2 in care and that she has arranged for a further 5 care staff to start this training in the near future. Ashridge House DS0000062830.V254973.R01.S.doc Version 5.1 Page 15 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 and 33 The acting manager has establish clear leadership and there is evidence to confirm the home is managed in the best interest of residents tacking into account their and their representatives views along with the views of staff. EVIDENCE: The acting home manager was appointed in June 2005 by the new homeowner, her application has not yet been received by the CSCI and this was discussed during the inspection. She is developing well into her management role which she takes seriously and is completing the required management qualification. The home has systems in place to monitor the quality of care in the home, which includes resident/visitors questionnaires and regular residents meetings. The feedback provided via these is mostly very positive and any comments are Ashridge House DS0000062830.V254973.R01.S.doc Version 5.1 Page 16 responded to on an individual basis, there is however no audit or report generated that could be included in the service users guide and provided to the CSCI. It was also noted that the homeowner is not completing the required regulation 26 reports despite the fact that she visits the home regularly. Residents spoken to confirm that they liked living in the home saying ‘I love it here’ ‘I enjoy living here’. Examination of records confirmed that formal staff supervision has been established. Ashridge House DS0000062830.V254973.R01.S.doc Version 5.1 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X X 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 2 3 3 X 3 X 2 2 STAFFING Standard No Score 27 3 28 3 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X X X X X Ashridge House DS0000062830.V254973.R01.S.doc Version 5.1 Page 18 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 OP7 Regulation 15(1) Requirement That each resident has a written care plan that records residents health, perosnal and social care needs. That plans of care are drawn up in consultation wth residents or their representatives as appropriate and are reviewed regularly. That the improvements made in relation to residents entertainment, activities and contact with the community is further developed. That the adult protection procedure is updated and further staff training is provided. A programme of routine maintenance and renewal of the fabric and decoration of the premises is produced followed and sent to the Commission. That the bathing facilities in the home are reviewed to ensure suitability for residents living in the home. That any unguarded radiators are removed or guarded. That any hazardous substances are stored safely. DS0000062830.V254973.R01.S.doc Timescale for action 01/02/06 2. OP12 16 (m)(n) 01/02/06 3. 4. OP18 OP19 13(6) 23(2)b 01/02/06 01/03/06 5. OP21 23(2)j 01/02/06 6. 7. OP25 OP25 13(4)c 13(4)c 17/01/06 01/01/06 Ashridge House Version 5.1 Page 19 8 OP26 13(3) 9 10 OP31 OP33 8(1)(2) 26 That appropriate hand washing facilities are provided at all communal hand basins. That the laundry facilities are reviewed to ensure high standards of infection control are maintained. That the registered owner appoints a registered manager. That the registered provider visits the home in accordance with regulation 26. 01/03/06 01/02/06 01/02/06 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 Refer to Standard OP1 Good Practice Recommendations That the last inspection report is readily available to any interested party. Ashridge House DS0000062830.V254973.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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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