Inspection on 13/01/06 for Ashville Care Home

This inspection was carried out on 13th January 2006.

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

Ashville Care Home 20/01/10

Ashville Care Home 09/02/09

Ashville Care Home 20/02/07

Ashville Care Home 30/06/05

Ashville Care Home 04/02/05

Ashville Care Home 20/07/04

Ashville Care Home 16/03/04

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

CARE HOMES FOR OLDER PEOPLE Ashville Care Home 58 Town Lane Idle Bradford BD10 8PN Lead Inspector Steve Marsh Unannounced Inspection 13th January 2006 09:30 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 Ashville Care Home DS0000049481.V273865.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ashville Care Home DS0000049481.V273865.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ashville Care Home Address 58 Town Lane Idle Bradford BD10 8PN 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) 01274 613442 01274 618273 Ashville Care Home Limited Mrs Elizabeth Agnes Hinchliffe Care Home 29 Category(ies) of Dementia - over 65 years of age (15), Old age, registration, with number not falling within any other category (4), of places Physical disability over 65 years of age (10) Ashville Care Home DS0000049481.V273865.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th June 2005 Brief Description of the Service: Ashville Care Home is situated approximately three miles from Bradford City Centre. The property is a former wool merchants house, which has had a number of extensions added to the existing building, and is now registered to provide care for twenty-nine residents both in single and double bedrooms. The business although registered as a Limited Company is family owned and Mrs Hinchliffe (proprietor) is also the registered manager. A second manager Mrs Greathead is also employed at the home and registered with the Commission. The home is well served by public transport and there is adequate parking to the front of the property. There is level access to the main door of the home and a stair lift available to enable residents and/or their relatives with mobility problems reach the bedrooms located on the first floor of the building. All the communal areas used by the residents including the dining rooms and lounges are located on the ground floor of the home, and there are communal bathroom and toilet facilities conveniently situated throughout the building. Ashville Care Home DS0000049481.V273865.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second unannounced inspection visit for the year 2005/06 and was carried out by one Inspector over a period of approximately seven hours. The last inspection of this service was in June 2005 and no additional visits have been made to the home since that date. The methods used in this inspection included the examination of records, observation of care practices, discussion, (group and individual) with residents, visitors, staff/management and a partial tour of the building. Comment cards were left for residents and/or their relatives to allow them to share their views of the service with the Commission. In total seven residents and six relatives returned comment cards prior to the report being published. Feedback was given to Mrs Hinchliffe and Mrs Greathead at the end of the inspection visit. Requirements and recommendations from this inspection are detailed at the end of the report. What the service does well: What has improved since the last inspection? Ashville Care Home DS0000049481.V273865.R01.S.doc Version 5.0 Page 6 The home has carried out a quality assurance survey and made a summary of the results available to the residents, relatives and other interested parties including the Commission. 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. Ashville Care Home DS0000049481.V273865.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ashville Care Home DS0000049481.V273865.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed on this inspection visit. EVIDENCE: These standards were not assessed on this inspection visit. Ashville Care Home DS0000049481.V273865.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,9 Care plans in general are completed to a satisfactory standard, however the managers must ensure that the plans highlight any specific areas of concern, which may affect the general wellbeing of the resident and/or others. To safeguard the residents the managers must ensure that senior members of staff administer medication in line with the policies and procedures in place. EVIDENCE: Care plans have been completed for all residents and there is sufficient information within the documentation to show that the residents and/or their relatives are involved in the care planning process. However, it was noted that for one resident diagnosed with dementia and showing aggressive behaviour towards both other residents and staff, no specific care plan was in place. The care plan is a working document and therefore the manager must ensure that it gives clear guidance to the staff on how to manage specific areas of concern. Ashville Care Home DS0000049481.V273865.R01.S.doc Version 5.0 Page 10 On reviewing the medication system in place it was evident that on one occasion a senior member of staff had failed to sign the Medication Administration Records (MAR) sheet for a number of residents. This clearly indicates that medication had not been administered correctly as medication must be signed for on the MAR sheet once taken by the resident. The manager confirmed that the home continue to monitor the general health of residents taking long term medication and would seek professional advice if they had concerns. In addition, all medication is reviewed on an annual basis by the resident’s general practitioner to ensure that it is still relevant to their needs. Ashville Care Home DS0000049481.V273865.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,14,15 The managers have taken positive steps to answer/address the concerns expressed by some residents/relatives in relation to the level of activities arranged and the meals provided at the home. EVIDENCE: The home does not employ an activities co-ordinator although a member of the care staff team continues to be responsible for organising entertainment and outings for the residents. The manager confirmed that residents are encouraged to continue with the social and leisure activities they enjoyed prior to moving into the home and decide on their daily routines. Residents and relatives spoken to on the day of the visit appeared happy with the level of activities provided. However, two of the seven comment cards returned by residents indicated that they would prefer more outings to be arranged to places of interest. A recent quality assurance survey completed by residents and/or their relatives also makes reference to fact that they would like more activities to be arranged. Ashville Care Home DS0000049481.V273865.R01.S.doc Version 5.0 Page 12 The meals at the home were described by the residents as good although three of the thirteen comment cards returned by residents/relatives indicated that there was a lack of choice at some meal times. The managers have responded to the concerns raised about activities and meals in their summary of the survey findings, which is available to both current and prospective residents and/or other interested parties. Residents are able to bring items of furniture and personal belongings into the home and this is usually negotiated with the manager prior to admission. At present no residents manage their own financial affairs although new admissions to the home would be encouraged to do so if they had the capability. Ashville Care Home DS0000049481.V273865.R01.S.doc Version 5.0 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): 16,17,18 Robust complaint and adult protection procedures continue to ensure that residents are listened to and protected from any form of abuse. Service users rights to participate in the political process are upheld. EVIDENCE: The home has a complaints procedure, which is made available to residents, visitors and staff. Residents and relatives spoken to confirmed that they were aware of the complaints procedure and knew what to do if they were unhappy with the standard of care/service they received. Adult protection policies and procedures are in place at the home although training records indicate that only four members of staff have attended an appropriate course. A number of staff did however confirm that they had covered the subject while studying for a National Vocational Qualification (NVQ) at level two or three. Staff spoken to confirmed that they were aware of the homes policy on “whistle blowing” and their responsibility to protect the residents from any form of abuse. Ashville Care Home DS0000049481.V273865.R01.S.doc Version 5.0 Page 14 The manager confirmed that the resident’s legal rights are protected and they would be assisted to contact the advocacy service if they required impartial advice. Residents are encouraged to vote at both general and local elections and arrangements can be made for them to attend the polling station or make a postal vote. Ashville Care Home DS0000049481.V273865.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,24,25,26 The home continues to provide a comfortable environment for the residents and there is an ongoing programme of refurbishment and renewal in place. However, to safeguard the residents the manager must ensure that members of staff follow infection control policies and procedures. EVIDENCE: Both internally and externally the home is well maintained and there is an ongoing programme of refurbishment and renewal. All the communal areas used by the residents including lounges and dining rooms are situated on the ground floor of the home, conveniently close to toilet facilities. Bedrooms are located on both floors of the home and consist of both single and double rooms, twelve of which have en-suite facilities. Bedrooms are well Ashville Care Home DS0000049481.V273865.R01.S.doc Version 5.0 Page 16 furnished and residents and relatives spoken to confirmed that they were happy with the standard of accommodation provided. On the day of the visit the general standard of hygiene and cleanliness throughout the home was good although the carpet in one dining room requires cleaning as it appeared badly stained. In addition, it was noted that in both a ground floor and first floor toilet, soiled incontinence pads had been place in a clinical waste bin without first being doubled wrapped. The laundry and sluice room are located on the ground floor of the home and the day of the visit they were found to be clean and well organised. Ashville Care Home DS0000049481.V273865.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28,30 The experience and skill mix within the staff team appears appropriate to the needs of the residents and there is a commitment to staff training. EVIDENCE: The manager confirmed that all new members of staff receive induction and foundation training, and additional training both to meet the needs of the residents and for personal development continues to be encouraged. There is also an expectation that all members of staff will achieve a National Vocational Qualification (NVQ) at level two or above. The manager has recently updated the training records for all members of staff and is currently planning the training programme for 2006. Staff spoken to confirmed that they were happy with the level of training provided at the home and received a minimum of three paid training days per year in line with the National Minimum Standards. Ashville Care Home DS0000049481.V273865.R01.S.doc Version 5.0 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): 31,32,33,35,36,37,38 The home appears well managed and there are systems in place to enable the residents and/or relatives air their views and opinion about the standard of care and service provided. EVIDENCE: Both Mrs Hinchliffe and Mrs Greathead are registered managers, each having specific areas of responsibility in relation the care of the residents and the management of the business. Mrs Greathead has achieved a National Vocational Qualification at level four in management and care, a recognised qualification for the post she holds. There appears to be clear lines of accountability within the home and both managers give a clear sense of direction and leadership to the staff team. Ashville Care Home DS0000049481.V273865.R01.S.doc Version 5.0 Page 19 To ensure clear channels of communications both staff and resident meetings are held at regular intervals throughout the year. In addition, senior staff meeting are held on a three monthly basis to ensure that are kept aware of any changes in policies and procedures, which may affect the day-to-day management of the home. All members of care staff receive formal one-to-one supervision with their line manager at least six times a year in line with the National Minimum Standards and an annual appraisal. As previously mentioned in this report the home has also carried out a recent quality assurance survey to seek the views and opinions of the residents, relatives and professionals accessing the service. A summary of the survey has been completed by the manager and made available to the Commission and all interested partied as required. The home holds money in safe keeping for a number of residents and transaction sheets are available indicating income, expenditure and a balance. Financial transactions are only carried out by the managers and the homes administrator and receipts are obtained for all purchases made by staff on behalf of the residents. All records and reports relating to the care of the residents are securely stored on the premises, however the office on the ground floor of the premises is very small and would benefit from reorganising. Policies and procedures are in place at the home to ensue the health and safety of the residents, visitors and staff, which are reviewed on a regular basis to ensure that they meet with present legislation. Ashville Care Home DS0000049481.V273865.R01.S.doc Version 5.0 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 2 3 X X 3 3 2 STAFFING Standard No Score 27 X 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 3 3 Ashville Care Home DS0000049481.V273865.R01.S.doc Version 5.0 Page 21 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 Requirement Timescale for action 28/02/06 2 OP9 13 (2) 3 4 OP20 OP26 23(2) 13(3) The registered manager must ensure that specific areas of concern are highlighted in the individual resident’s care plan. The registered manager must 13/01/06 ensure that all medication is signed for appropriately on the Medication Administration Record (MAR) sheets. The carpet in one dining room 28/02/06 requires cleaning as it is badly stained. The registered manager must 13/01/06 ensure that all members of the staff team follow infection control policies and procedures when dealing with clinical waste. 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 OP37 Good Practice Recommendations It is recommended that the small ground floor office be DS0000049481.V273865.R01.S.doc Version 5.0 Page 22 Ashville Care Home reorganised to enable records and reports relating to the care of the residents and the management of the service to be more easily accessible. Ashville Care Home DS0000049481.V273865.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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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