Inspection on 01/09/05 for Ashville House

This inspection was carried out on 1st September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 House 06/06/07

Ashville House 13/02/06

Ashville House 25/01/05

Ashville House 09/09/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Firstlings

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

CARE HOMES FOR OLDER PEOPLE Ashville House Fairfield Road Downham Market Norfolk PE38 9ET Lead Inspector Jenny Rose Announced 1 September 2005 9.30am st 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 House I55 s27393 ashvillehouse v240732 010905 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Ashville House Address Fairfield House, Downham Market, Norfolk, PE38 9ET 01366 383428 01366 383428 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) FJJ Healthcare Ltd Ms Elizabeth Fielding Care Home 42 Category(ies) of Old age, not falling within any other category registration, with number (42) of places Ashville House I55 s27393 ashvillehouse v240732 010905 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Forty-two (42) Older People, not falling into any other category may be accomodated, the total number not to exceed 42 Date of last inspection 25th January 2005 Brief Description of the Service: Ashville House is a care home providing personal care and accommodation for 42 older people. It has one bed dedicated to intermediate care. It is owned by F.J.J. Healthcare Limited, a company owned and managed by Darrell Jackson, Kate Jackson and Elizabeth Fielding. The home is located in the market town of Downham Market and is close to the shops, pubs and other amenities. The home is a large detached house set in its own grounds. A purpose built extension has been added to this home and this is of a very high standard. Thirty-four of the bedrooms are single and twenty of these have an en-suite facility. One of the four double rooms has an en-suite facility. As a result of this extension, the facilities at the home have been significantly improved, for example, there is now a hairdressing room, two additional lounges, a purpose built laundry room and food stores, a staff room and a car parking area. A passenger lift provides access to the first floor. Ashville House I55 s27393 ashvillehouse v240732 010905 stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection, taking place over 7 and half hours on a weekday. There was preparation in the CSCI beforehand, a pre-inspection questionnaire and a high return of relatives’/visitors’ comment cards, numbering 26 and 3 comment cards from Health and Social Care Professionals with contact with the home. All of these were positive. The Providers/Manager, Mrs Kate Jackson and Miss Elizabeth Fielding were in attendance throughout the inspection. A tour of the building was undertaken. There were 39 service users in residence, 40 during the afternoon, with the arrival of a new service user. Many records were seen, 6 members of care staff were spoken to privately, 1 member of domestic staff, 2 visitors and 3 service users were spoken to in a group, 10 in an activities group and 4 privately. What the service does well: What has improved since the last inspection? * There have been a significant number of rooms redecorated, including the kitchens. * The ensuite facilities in two rooms have been refurbished with new sanitary ware and flooring. * There is a new television and DVD. Ashville House I55 s27393 ashvillehouse v240732 010905 stage 4.doc Version 1.40 Page 6 * Outside, dry stone walls have been rebuilt * The garden pond has been cleaned and restocked. * The home has developed a checklist for new arrivals, which further ensures that the home meets the service users’ needs. * The home has increased the number of hours for domestic / cleaning staff, which were already above the minimum. 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 House I55 s27393 ashvillehouse v240732 010905 stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Ashville House I55 s27393 ashvillehouse v240732 010905 stage 4.doc Version 1.40 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 standard(s) 3 The home has developed a new arrivals checklist, to improve the admission process. There is a clear pre-assessment procedure for new service users, which ensures as far as possible that the service user’s needs will be met. EVIDENCE: There was a new service user moving in on the day of the inspection for a trial period. A detailed pre-assessment form formed the basis of the care plans. It was noted that the Community Psychiatric Nurse would be continuing with her care of the new service user His need for a ground floor room had also been fulfilled. There were hospital and social work assessments which would go to form the basis of his care plan, together with the home’s preassessment. The home has a new arrivals check list and there are various tasks which need to be undertaken on behalf of the service user within certain time limits, within 24 hours and within 48 hours limits for tray labels and care plans and photographs, etc set up Existing hospital appointments are entered in the diary and reminders for ordering transport for these. The allocated member of staff would also spend time reassuring the prospective service user and explaining routines of the home, also gathering information regarding his Ashville House I55 s27393 ashvillehouse v240732 010905 stage 4.doc Version 1.40 Page 9 preferences for food, bedtimes etc. This information would then be available for the night staff. On admission the service user was given the Statement of Purpose, together with the Aims and Objects of the home and the facilities and service and the complaints procedure for which he, and/or his relatives would sign Ashville House I55 s27393 ashvillehouse v240732 010905 stage 4.doc Version 1.40 Page 10 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, 9, 10 Comprehensive care plans ensure that staff meet the service users’ needs. The administration of medication ensures, as far as possible, that service users are protected. EVIDENCE: Six care plans were seen. They were comprehensive, containing photographs, personal care needs, healthcare needs, risk assessments, personal history, hobbies and activities also recorded. Advice was sought from other professionals, such as the Continence Adviser, the Community Nurse and the Sensory Adviser. The plans were signed either by the service user and/or their representative. There were regular reviews, with the service user and relatives’ reactions recorded. There was good evidence that difficulties with service users risk assessments were discussed, where appropriate, with service users and their relatives, if appropriate, and the reactions of all parties was recorded. This is seen as good practice. The Medication round was observed. This was dispensed from a lockable trolley and contained in an MDS system. Any allergies were seen to be Ashville House I55 s27393 ashvillehouse v240732 010905 stage 4.doc Version 1.40 Page 11 recorded on this system. The MAR sheets were seen to be in order and had photographs of service users. Two members of staff who have received medication training administer the medication. Controlled drugs were kept in a double locked cabinet, the stock was recorded on the MAR sheets and the drugs were randomly checked and found to be correct. A Medication Audit was carried out monthly, locks and blister packs checked. The Returns Book was at the Pharmacy. The Deputy Manager said that relationships with the GP’s surgery and the Pharmacy were good and queries were always dealt with. Any homely remedies in the home were recorded on the relevant MAR sheets. Signatures of staff administering medications were recorded in the front of the MAR sheets. There was one service user who administers his own medication, for which there is a risk assessment, which is reviewed every three months and signed by the service user. There was another risk assessment for a service user whose preference it was for her night medication to be left in the room until she was ready to take it. It was observed and confirmed by service users spoken to that service users felt staff treated them with respect and dignity, knocking before entering bedrooms and asking whether they would like to receive a visitor. Ashville House I55 s27393 ashvillehouse v240732 010905 stage 4.doc Version 1.40 Page 12 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, 14, 15 Wide ranging activities, service user participation, support for service users to retain personal autonomy and good food, served in pleasant surroundings, provide a high quality of life for service users. EVIDENCE: There is a comprehensive programme of activities and a designated Activities Co-ordinator, who is also a Carer in the home. She keeps a full record of all activities and notes as to how service users find these. Service users were also canvassed as to their opinion of the activities provided, and this became the basis of further activities. This information was seen. It is then transferred to care plans. The home is to be commended on this practice. During the inspection a group of 10 service users and one visitor were involved in making lavender scones for tea. This has grown out of a previous visit to the Lavender Fields locally. The service users confirmed how much they enjoyed the outings to a country park, a butterfly park and events with another home owned by the same Providers. Two service users spoke about their pleasure in the fact that one of the music entertainers to the home had composed the Ashville House Anthem, which they were pleased to sing. Ashville House I55 s27393 ashvillehouse v240732 010905 stage 4.doc Version 1.40 Page 13 Two service users confirmed how much they appreciated many of the musical entertainers who visited the home and one service user said, “We do some lovely things here”. She confirmed that she particularly enjoyed the craft work and the opportunities to do something different. There had been a summer project with Norfolk Music Works, which was well documented, which this service user particularly enjoyed. The Providers confirmed that there had recently been an inaugural meeting with the local school in a community education project, entitled “Flash Back/Fast Forward, which will ‘match’ teenagers with service users, around the theme of ‘work’. The two visitors spoken to were relatives of service users, who said how much they appreciated the quality of the care received by their relatives. They also confirmed that they were welcome to visit the home at any reasonable time. One relative said that the care her mother received ‘exceeded expectations’. She also confirmed that her mother enjoyed outings and there were stimulating activities taking place in the home. There was a high return of comment cards received, 26 from Relatives and Visitors and 3 from visiting Professionals, all of which were positive It was noted from one service user’s care plan, and it was confirmed by him, that he liked to walk to the shops on his own. Because of his medical condition, there was a risk assessment for this, to which he was agreeable. The lunch was seen to be appetising, nutritious and well presented on attractive crockery. There was choice and service users could choose where they would eat. Some were eating in the pleasant, light dining room and others in their rooms. There were a number of positive comments from service users, visitors and staff regarding the quality of the meals and the choice available. One service user being helped with her meal in her room was overheard to say how much she had enjoyed her lunch. A visitor said she was of the opinion that the food was very good and she had been pleasantly pleased to see that wine was served on birthdays. On one occasion she visited, the service users, who wished, were helping to pod peas for the lunch time meal. Ashville House I55 s27393 ashvillehouse v240732 010905 stage 4.doc Version 1.40 Page 14 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 A clear complaints procedure and good staff training in the issues of the Protection of Vulnerable Adults, ensures as far as possible that the service users are protected. EVIDENCE: There is a clear complaints procedure and a copy of this is given to service users on admission to the home. All the service users spoken to knew to whom to speak if they had any complaints, but there had been none. There is good staff training in the issues surrounding Adult Abuse, which is regularly reviewed. All staff spoken to were clear as to what action to take should there be the necessity to do so. There is a high proportion of staff with NVQ level ll. Ashville House I55 s27393 ashvillehouse v240732 010905 stage 4.doc Version 1.40 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 standard(s) 20, 24, 26 The environment provides an attractive, comfortable, safe and well-maintained home for service users, enhancing their quality of life. EVIDENCE: The buildings of the home are both old and new and are situated in an attractive, well-maintained, older garden and with a pleasant patio area both of which are accessible by service users. There have been improvements in the garden, with restocking the garden pond and dry stone walling repaired. The home was extended recently and all the rooms seen were attractively decorated and furnished to a high standard. The bedrooms in the new wing lead out on to a patio, which is attractive with hanging baskets and flowering pots. There are many communal areas for sitting, providing quiet, more intimate spaces, and the main area is divided into smaller areas by the arrangement of chairs into small groups and leads out on to the patio. There is a new television and DVD player. Ashville House I55 s27393 ashvillehouse v240732 010905 stage 4.doc Version 1.40 Page 16 The parquet flooring in the dining room has a number of gaps between the blocks, but the Providers are in the process of investigating means of putting this right and action should have been taken by the next inspection. The bathrooms and toilets, especially in the new wing are of a high standard. One service user spoken to said “It’s lovely here, I have the patio outside and the birds visit”. Other service users’ rooms seen were seen to be personalised with service user’s possessions, particularly with photographs and pictures. The new call buzzer system in the home has three modes and service users also use alarm pendants to maintain their independence, if appropriate. The home has a clear commitment to cleanliness and hygiene and it is intended that all staff will attend a course on Infection Control; many have done so already. The number of doemstic / cleaning hours has been increased and on the day the home were introducing a new mopping system in compliance with a new regulation regarding infection control. The relative of one service user remarked that the home was always so ‘fresh and clean’. A member of the domestic staff was spoken to on the day. She had many years experience of working in the home, she obviously took a great interest in the high standard of cleanliness in the home, and said that the new procedures were continually being introduced to maintain these standards. All the staff records were well kept with photographs and the necessary recruitment information, Police checks and references. There were also well documented staff reviews, signed also by members of staff. Ashville House I55 s27393 ashvillehouse v240732 010905 stage 4.doc Version 1.40 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 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) 27,29,30 Staff are well supported, as individuals and a team, and trained to meet the changing needs of the service users. EVIDENCE: Six members of the care staff and a member of the domestic staff were spoken to and their staff files seen. They all confirmed how much they enjoyed working in the home and that they all felt well supported by the Providers, with whom there was easy communication. Since May there has been a Manager in post who has had much experience of working in the home. She has been well supported by the home in receiving training with her NVQ4 in management and is now registered for NVQ4 in care. She described the induction of new staff and the awareness of the importance of creating a good staff team over all the shifts. There was evidence that staff on day and night shifts were well supervised and there were six weekly staff meetings, which are minuted. All staff spoken to said that there was sufficient handover time at the end and beginning of shifts. The member of the domestic staff spoken to was a person with many years experience of working in the home and obviously took a great interest in the high standard of cleanliness in the home. As stated elsewhere in this report there is a clear commitment to training in the home with 17 out of 29 carers having NVQ2. One has NVQ3 and 2 are currently undertaking their NVQ3, as well as the managers qualifications mentioned above. The member of staff, whose responsibility it was, for coAshville House I55 s27393 ashvillehouse v240732 010905 stage 4.doc Version 1.40 Page 18 ordinating training demonstrated that Induction training for staff was all up to date, as was mandatory training and training in Adult Abuse. She has completed an NVQlll in Training and Development. She is responsible for coordinating training in the Providers’ other home and it is intended to bring staff together in both homes for training purposes. The training and development file was seen to be well kept. Ashville House I55 s27393 ashvillehouse v240732 010905 stage 4.doc Version 1.40 Page 19 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) 32,33, 38 There is a continuous monitoring process of service users’ views, and a risk management process, which helps to ensure that the home is run in the service users’ best interests and welfare. EVIDENCE: The Providers have obviously been very mindful of the potential issues surrounding integrating previous service users in the older part of the home, together with the longer serving members of staff, with the new service users in the new wing and the most recently employed staff. From discussions with the Providers, service users and staff this appears to have been successfully achieved and the home is to be commended for this. The staff confirm that the management approach is supportive and encouraging The home holds regular service user surveys and there is a monthly meeting with service users to canvass their views on the running of the home. Ashville House I55 s27393 ashvillehouse v240732 010905 stage 4.doc Version 1.40 Page 20 There is a risk management process for the home covering such aspects as window locks, bedrails, radiator covers and manual handling. These records were seen to be up to date and well kept There was also attention paid to security in the home, which was confirmed by several service users, with particular reference to the locking of downstairs, outdoor doors and windows at night. Ashville House I55 s27393 ashvillehouse v240732 010905 stage 4.doc Version 1.40 Page 21 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 x x 4 x x x HEALTH AND PERSONAL CARE Standard No Score 7 4 8 x 9 3 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 3 COMPLAINTS AND PROTECTION x 3 x x x 4 x 4 STAFFING Standard No Score 27 4 28 x 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 4 x x x x 3 Ashville House I55 s27393 ashvillehouse v240732 010905 stage 4.doc Version 1.40 Page 22 N/A 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 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. 1. Refer to Standard Good Practice Recommendations Ashville House I55 s27393 ashvillehouse v240732 010905 stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection 3rd Floor, Cavell House St Crispins Road Norwich NR3 1YF 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 House I55 s27393 ashvillehouse v240732 010905 stage 4.doc Version 1.40 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!