Inspection on 30/06/05 for Ashville Care Home

This inspection was carried out on 30th June 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

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 13/01/06

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 58 Town Lane Idle Bradford BD10 8PN Lead Inspector Steve Marsh Unannounced 30th June 2005 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 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 CS0000049481.V185331.R01.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Ashville Address 58 Town Lane Idle Bradford BD10 8PN Telephone number Fax number Email 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 Ltd Mrs Elizabeth Agnes Hinchliffe Care Home Only 29 Category(ies) of Old Age (4) Dementia Over 65 (15) Physical registration, with number disability Over 65 (10) of places Ashville CS0000049481.V185331.R01.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 04/02/05 Brief Description of the Service: Ashville Care Home is situated approximately three miles from Bradford City Centre. The property is a former wool merchant 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 (registered 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 bathroom and toilet facilities conveniently situated throughout the building. Ashville CS0000049481.V185331.R01.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first unannounced inspection for the year 2005/06, and was carried out by one Inspector over a period of approximately eight hours. The last inspection of this service was in February 2005 and the main purpose of this visit was to assess the homes progress in meeting the requirements highlighted in the inspection report. The methodology used in this inspection included the examination of records, observation of work practices, discussion (group and individual) with residents, visitors, staff and management and a partial tour of the building. Due to their illness (dementia) some residents were unable to express their views and/or opinions about the home, however those that were able felt that the staff team provided a very good standard of care. Comment cards were provided for the residents and/or their relatives to enable them to share their views of the service with the Commission; comments received in this way will be fed back to the registered manager of the home without revealing the identity of the respondent. The Inspector has visited Ashville Care Home over a period of approximately four years and therefore drew on information known about the home when completing this report. People living at the home confirmed that they prefer to be referred to as residents in inspection reports. Feedback was given to Mrs Hinchliffe (registered Manager) at the end of the visit. Requirements and recommendations from this inspection are detailed at the end of the report. Ashville CS0000049481.V185331.R01.doc Version 1.30 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The home could record the pre-admission assessment information in a more user friendly way and make the information available in the care plans more easily accessible. Ashville CS0000049481.V185331.R01.doc Version 1.30 Page 7 The home must also continue to improve its working relationship with the district nursing service for the benefit of the residents. All members of staff must follow infection control procedures to ensure that the residents health is not put at risk, and keep the sluicing facility clean at all times. The registered manager (Mrs Hinchliffe) needs to commence NVQ training at level four in management and care in the neat future. 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 CS0000049481.V185331.R01.doc Version 1.30 Page 8 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 Standards Statutory Requirements Identified During the Inspection Ashville CS0000049481.V185331.R01.doc Version 1.30 Page 9 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 standard(s) 1,3,4,5 Residents and/or their relatives are provided with sufficient information to enable them to make an informed decision about the home. The admission procedure is good and includes pre-admission assessment visits, introductory visits and trial periods if appropriate. EVIDENCE: The manager confirmed that there had been no changes to the homes statement of purpose and service user guide, which are made available to all prospective residents. The records examined provided evidence that pre-admission assessment visits are carried out to see prospective residents, and the needs identified during this visit are reflected in the individuals care plan. The manager was however, asked to look at the way pre-admission assessment information is recorded, as at the moment it can be difficult to find within the case files. Ashville CS0000049481.V185331.R01.doc Version 1.30 Page 10 The majority of admissions are planned, although the home continues to respond to crisis situations and will take emergency admissions provided the staff team can meet their needs. In addition to the pre-admission visit all prospective residents and/or their relatives are invited to visit the home prior to admission, to view the accommodation, meet the staff and other residents and stay for a meal if they wish to do so. Residents are also able to move into the home for a trial period to enable them and/or their relatives consider their long-term future. It is however acknowledged that for some residents diagnosed with dementia it is not always appropriate for them to take up these options as it may cause them to become more confused and/or disorientated. Relatives and residents spoken to confirmed that they had visited the home prior to making a decision about its suitability, and had found the staff to be very helpful in answering their questions about the care/services provided. Staff training continues to be encouraged at the home both to meet the needs of the residents and for personal development. Ashville CS0000049481.V185331.R01.doc Version 1.30 Page 11 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 standard(s) 7,8,9,10 Records and reports about the resident’s welfare show that their healthcare needs are met, and any problems are identified at an early stage and a referral made to the appropriate professional agency i.e. general practitioners etc However, the home must establish a closer working relationship with the district nursing service for the benefit of the residents. 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, some information can be difficult to find within the care plans, and therefore the manager was asked to review the format to see if it could be made more user friendly. All residents are registered with a general practitioner and have access to the full range of NHS services. A district nurse spoken to on the day of the visit confirmed that although in the past the district nursing service had expressed some concerns regarding the Ashville CS0000049481.V185331.R01.doc Version 1.30 Page 12 homes ability to meet the needs of individual residents, they were now establishing a working relationship with the senior staff team, and were quite willing to assist and support them further if requested to do so by the manager. Through discussion with the residents and/or their relatives it is apparent that prompt medical assistance is sought if required, and a record is kept of all visits made to the home by general practitioners and other healthcare professionals. In addition the staff team continue to monitor the general health of residents taking long-term medication, and on reviewing the medication system in place no concerns were raised. Relatives confirmed that they were always contacted if there were any significant changes in the health of the residents, which they found reassuring. It was obvious through observation and discussion that residents are treated with respect, and members of staff maintained their dignity when assisting them with personal care. In addition staff were also observed to always knock on bedroom doors before entering the residents bedrooms, and use their preferred term of address at all times. Ashville CS0000049481.V185331.R01.doc Version 1.30 Page 13 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 standard(s) 12,13,15 The home offers a range of social and leisure activities, and residents are encouraged to make informed decisions about their lifestyle. Meals appear nourishing, and take into account the likes and dislikes of individual residents. EVIDENCE: The daily routines of the home appear flexible and are based around the needs of the residents. The home does not employ an activities co-ordinator although a member of the care staff team has been designated to organised outings etc for the residents. Residents are encouraged to continue with the social and leisure activities they enjoyed prior to moving into the home, and make decision on how they want to spend their day. Residents and relatives spoken to on the day of the visit appeared happy with the level of activities/outings organised, although two of the six residents who completed comment cards said that the home only “sometimes” provides suitable activities for them. Ashville CS0000049481.V185331.R01.doc Version 1.30 Page 14 Residents confirmed that they are able to see visitors in the privacy of their own bedroom and visitors spoken to on the day of the visit said that they were always made to feel welcome and offered refreshments. The meals at the home were described by the residents as good and they confirmed that an alternative was always offered if they did not like what was on the menu for the day. Since the last inspection visit the home has established a second dining room in a little used lounge area, which is used by more independent residents. Residents requiring assistance/prompting with their meals continue to dine in the existing dining room, where it was observed that they received the support and assistance they require to ensure they eat a balanced diet. Hot and cold drinks are freely available to residents both day and night. Ashville CS0000049481.V185331.R01.doc Version 1.30 Page 15 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 standard(s) 16,18 Robust complaint and adult protection policies and procedures ensure that residents are listened to, and protected from any form of abuse. EVIDENCE: The home has a complaints procedure and residents/relatives spoken to said that they where aware of the procedure and knew what to do if they were unhappy with the standard of care or service they received. However, although the complaint procedure is on display within the home two of the eight relatives who completed comment cards and returned them to the Commission indicated that they were not aware of the procedure. Policies and procedures are in place at the home in relation to adult protection and there is an ongoing programme of staff training. Members of staff confirmed that they were aware of the homes policy on “whistle blowing” and their responsibility to safeguard the residents from any form of abuse. A policy is also available in relation to handling the residents financial affairs, which does not allow staff to become involved in the making of, and/or benefiting from their wills. Ashville CS0000049481.V185331.R01.doc Version 1.30 Page 16 Ashville CS0000049481.V185331.R01.doc Version 1.30 Page 17 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 standard(s) 19,20,212425,26 The home provides a pleasant and comfortable environment for the residents, and there is an ongoing programme of refurbishment and renewal to ensure that the present standards are maintained. However, the staff must be more vigilant when cleaning the sluice room, and make sure the residents are protected, by using the correct infection control 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. Ashville CS0000049481.V185331.R01.doc Version 1.30 Page 18 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 furnished and residents are encouraged to bring personal possessions into the home, which makes each room look individual and homely. Residents and relatives spoken to said that they were happy with the standard of accommodation and the fact that they had been able to furnish their rooms with personal possessions had made the move into a residential home easier. Concern was raised about the hot water temperature in one single bedroom, which was very hot and this was dealt with during the course of the inspection visit. However, as highlighted in the last inspection report there appears to be a problem with poor water pressure in at least two bedrooms on the first floor of the home, which still requires attention. The carpet in one bedroom (identified to manager) also requires replacing or repairing as it splitting at the seam and may become a trip hazard, and the emergency call lead also requires replacing in the first floor bathroom. Although the home was clean and tidy on the day of the visit the sluicing facility situated on the lower ground floor of the building, away from the areas used by the residents, was dirty and stained with urine and faeces. Ashville CS0000049481.V185331.R01.doc Version 1.30 Page 19 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 Residents are supported and protected by a robust staff recruitment and selection procedure, which includes Criminal Record Bureau (CRB) checks. Staffing numbers and experience/skill mix within the staff team ensures that the needs of the residents are met. However, the manager must continue to ensure that care staff time spent on cleaning or laundry duties does not affect the standard of care/services received by the residents. EVIDENCE: The manager confirmed that the home has recently experienced quite a high staff turnover, however there has been a successful recruitment drive and two overseas workers (Ukrainian) have also joined the care staff team. Staff interviews were also taking place on the day of the visit. Learning from past experience, the manager confirmed that prior to employing overseas workers the immigration service is now routinely contacted to ensure that they are eligible to work in this country. A number of recent staff files were looked at and they contained all relevant information to ensure a safe recruitment procedure is in place. All members of care staff providing personal care are over eighteen years of age and all senior members of staff are over twenty-one years of age in line with the National Minimum Standards. Ashville CS0000049481.V185331.R01.doc Version 1.30 Page 20 Domestic staff are employed to ensure the home is kept clean and free from offensive odours, however the care staff confirmed that they also carry out some cleaning (toilets and bathrooms) and laundry duties. A discussion was held with the manager regarding the need to ensure that any additional duties undertaken by the care staff are secondary to their role as carers, and care staff hours remain at the agreed level. Staff training continues to be actively encourage at the home and the majority of the care staff team have achieved or are due to commence studying for a National Vocational Qualification (NVQ) at level two or three. Ashville CS0000049481.V185331.R01.doc Version 1.30 Page 21 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,38 Although Mrs Hinchliffe has not yet commenced studying for a NVQ at level four in management and care, both managers are very competent and have the skills and experience to manage the home. Policies and procedures are in place to ensure the health and safety of the residents, visitors and members of the staff team. EVIDENCE: Both Mrs Hinchliffe (proprietor) and Mrs Greathead are registered as managers with the Commission, and they have specific areas of responsibilities in relation to care management and administrative tasks. At the present time Mrs Greathead is still studying for a National Vocational Qualification (NVQ) at level four in management and care, a recognised qualification for the post she holds, and is due to complete the course in the near future. Ashville CS0000049481.V185331.R01.doc Version 1.30 Page 22 Unfortunately Mrs Hinchliffe has not yet registered for the course but is aware that to meet the National Minimum Standards she must do so. There are clear lines of accountability within the home and members of staff confirmed that they knew which manager to approach depending on their query. Policies and procedures are in place to ensure the health and safety of the residents, visitors and members of the staff team, which are reviewed on a regular basis to ensure that they meet with present legislation. However, although the Mrs Greathead has started to complete a fire risk assessment for the home it requires completing, and she must also ensure that all portable electrical appliances are tested on an annual basis. Ashville CS0000049481.V185331.R01.doc Version 1.30 Page 23 Ashville CS0000049481.V185331.R01.doc Version 1.30 Page 24 Ashville CS0000049481.V185331.R01.doc Version 1.30 Page 25 Ashville CS0000049481.V185331.R01.doc Version 1.30 Page 26 Ashville CS0000049481.V185331.R01.doc Version 1.30 Page 27 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 3 2 x 2 2 2 STAFFING Standard No Score 27 3 28 3 29 4 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 2 x x x x x x 2 Ashville CS0000049481.V185331.R01.doc Version 1.30 Page 28 yes Are there any outstanding requirements from the last inspection? 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 OP22 Regulation 23 Requirement First floor bathroom -- The registered manager must ensure that the emergency call lead is replaced. The registered manager must ensure that the carpet in the bedroom identified during the visit is repaired or replaced, before it becomes a trip hazard. The registered manager must ensure that the hot water pressure in the bedrooms identified during the visit is improved. The registered manager must ensure that the sluice room is kept clean, and infection control procedures are followed. The registered manager (Mrs Hinchliffe) must have a NVQ at level four in management and care (or equivalent) by 2005. The registered manager must ensure that all portable electrical appliances are tested on an annual basis. Timescale for action 31/08/05 2. OP24 13(4) 31/08/05 3. OP25 23 30/09/05 4. OP26 13(3) 5. OP31 9(b)(1) Immediate as agreed on day of inspection. 31/12/05 6. OP38 13(4) 30/09/05 Ashville CS0000049481.V185331.R01.doc Version 1.30 Page 29 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. Refer to Standard OP3 OP7 Good Practice Recommendations It is recommended that the registered manager review the way pre-admission assessment information is recorded. It is recommended that the registered manager review the present format used for care planning to see if can be made more user friendly. Ashville CS0000049481.V185331.R01.doc Version 1.30 Page 30 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. Extracts may not be used or reproduced without the express permission of CSCI Ashville CS0000049481.V185331.R01.doc Version 1.30 Page 31 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. 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