Inspection on 11/08/05 for Ashville House

This inspection was carried out on 11th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Ashville House 09/02/07

Ashville House 04/02/06

Ashville House 07/02/05

Ashville House 09/11/04

Ashville House 16/02/04

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

CARE HOME ADULTS 18-65 Ashville House 1 Ashville Road Birkenhead Wirral CH41 8AU Lead Inspector Beate Roth Unannounced Thursday, 11 August 2005 th 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 F52 F02 S18862 Ashville House V244545 110805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Ashville House Address 1 Ashville Road, Birkenhead, wirral, CH41 8AU 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) 0151 653 8786 Making Space Mrs Elsie Fisher PC Care Home Only 10 Category(ies) of MD Mental Disorder - 10 registration, with number of places Ashville House F52 F02 S18862 Ashville House V244545 110805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1 Named Elderly person with a mental disorder (other than learning disasbility) may be accommodated. Date of last inspection 7th February 2005 Brief Description of the Service: Ashville House is registered to provide personal care to 10 adults who need support with their mental health. Ashville House is a large, three-storey, detached building set in its own grounds on the edge of Birkenhead Park and is close to local shops, public transport and other amenities. It is within a short bus ride to the centre of Birkenhead. All service users bedrooms are single rooms and are situated on the first and second floors. On the ground floor is a lounge, dining area, laundry and kitchen. An appropriate number of bathrooms and toilets are provided for service users. Access is not currently available to the front of the home for service users or others who are wheelchair users. There is a large car park to the side of the home. The gardens consist of lawns, shrubs, trees and flower beds. There is a patio area with seating provided. Ashville House F52 F02 S18862 Ashville House V244545 110805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over half a day. During the inspection time was spent in the office examining records and policies and procedures and talking to the manager. A tour of the home was undertaken. Staff were observed delivering care to service users. The inspector spoke to service users and to staff. What the service does well: What has improved since the last inspection? What they could do better: A contract/statement of terms and conditions needs to be made available to all service users so that there is a clear basis on which the service is provided. Work needs to take place to ensure that the care plans provide clear guidance to staff on how they are to support a service user to ensure their needs are met. Ashville House F52 F02 S18862 Ashville House V244545 110805 Stage 4.doc Version 1.40 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ashville House F52 F02 S18862 Ashville House V244545 110805 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Ashville House F52 F02 S18862 Ashville House V244545 110805 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 4 and 5 In general, sufficient information is available around the service provided to enable a decision to be made about whether the home is appropriate. All service users need to be provided with a contract on a consistent basis. EVIDENCE: There is a comprehensive service user guide and statement of purpose available that cover all the information detailed in the National Minimum Standards. The manager reported that both documents were completed over 2 years ago and since this time there have been changes to the staff qualifications and experience. The information that accompanies the service user guide refers to legislation that is no longer applicable (Registered Homes Act 1984). These documents need to be reviewed and updated. No new service users have come to live at the home since the last inspection. The service user guide indicates that introductory visits can be made to the home and that service users can move to the home on a trial basis. The records of three service users were seen. Two contained a contract between the service user and the home that contained the required information. One service user did not have a contact. This service user has been living at the home for over 6 months. This needs to be addressed. Ashville House F52 F02 S18862 Ashville House V244545 110805 Stage 4.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 and 8 Some aspects of the care plans need attention to ensure clear guidance is available to staff around how to meet a service users needs. The rights of service users are respected and they participate in life at the home. EVIDENCE: The records of three service users were seen. The care plans cover the information detailed in the National Minimum Standards for Care Homes for Younger Adults. There was evidence of service user involvement and in general evidence that the care plans had been regularly reviewed. The records showed two risk assessments had not been reviewed for 12 months. Some aspects of the care plans did not provide clear direction to staff around the action they are to take to support service users. There was no direction given as to how to manage the behaviour sometimes displayed by two service users, how to support service users to ensure their social and personal development needs are met was also not clear in some of the records seen. Ashville House F52 F02 S18862 Ashville House V244545 110805 Stage 4.doc Version 1.40 Page 10 Respecting the individual rights of the service users forms the basis of the care and support at Ashville House, with extensive policies and procedures in place to guide both service users and staff. The staff induction covers the rights of service users. Detailed information is included in the service user guide regarding rights. There are opportunities for service users to contribute to the day to day running of the home. Service users are encouraged to be responsible for the up-keep of their bedrooms and assist with practical tasks such as laying the table and shopping. Service users are consulted about their views by their key workers, at monthly reviews of their care plans and at house meetings. Service users have been involved in the selection of staff. Ashville House F52 F02 S18862 Ashville House V244545 110805 Stage 4.doc Version 1.40 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 15, 16 and 17 The daily routines, activities and arrangements for visitors ensure that the preferences of service users are provided for. EVIDENCE: Service users have access to educational opportunities in accordance with their wishes. Service users spoken with said they are encouraged to participate in outside activities and to pursue their interests. The service user guide indicates that visitors are welcome at all times. Visitors were observed at the home during the inspection and were greeted warmly by staff. The service users who were spoken to said that their visitors are made to feel welcome by staff. Service users can meet with visitors in their bedrooms which are all single or in the lounge, dining room or garden. Discussions with the manager and service users confirmed that the home’s routines are flexible as much as possible. The records inspected indicated that service users have minimal support around their personal care routines. Staff were observed to speak to service users in a respectful manner and knocked at bedroom doors before entering. Ashville House F52 F02 S18862 Ashville House V244545 110805 Stage 4.doc Version 1.40 Page 12 Service users choose the menus for the home. There is a couple of choices each day for service users who would like something different. Currently there are no service users who require a special diet. All the kitchen staff have obtained their Food Hygiene certificates. The food served on the day of the inspection looked appealing and the service users spoken with said that they had enjoyed it and like the food at the home. Ashville House F52 F02 S18862 Ashville House V244545 110805 Stage 4.doc Version 1.40 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 The practices in place at the home support the health needs of service users. EVIDENCE: Records show that service users are supported to attend health check appointments and have access to health care services when they are needed. Care needs to be taken to ensure that a record is made of each health check as the records for one service user did not indicate a dental check that had taken place. Records demonstrated contact with the primary health team, mental health nurses and outpatient facilities. The monitoring of the service users health is ongoing, and potential complications and problems identified and dealt with at any early stage. Records demonstrated that appropriate referrals were made when required. Ashville House F52 F02 S18862 Ashville House V244545 110805 Stage 4.doc Version 1.40 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 The home’s has a satisfactory complaints system with evidence that the views of service users and their representatives are listened to and acted upon. EVIDENCE: There is a clear, accessible complaints procedure that the service users were aware of. Since the previous inspection there have been 4 complaints to the home made by service users. The records showed that these have been appropriately dealt with. No complaints have been made to the Commission for Social Care Inspection since the last inspection of the home. Ashville House F52 F02 S18862 Ashville House V244545 110805 Stage 4.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 26, 28 and 30 The home is clean and well presented and provides a comfortable and pleasant environment for service users. EVIDENCE: A tour of the home showed that the home is well maintained. Decorative work has taken place to improve the appearance of the home since the last inspection. All bedrooms are for single occupancy and of an appropriate size. Rooms were well decorated, clean and comfortably furnished. Communal areas were well decorated and furnished to a domestic style, with an emphasis on providing a warm and comfortable environment. An intercom was fitted to the main entrance door to provide additional security for service users. A sample of safety check and inspection records were examined and found to be in order. A tour of the home showed that the standards of housekeeping are high. The home was very clean and smelt fresh. It is clear the staff are working hard to ensure good standards of cleanliness are maintained throughout the home. There are procedures for staff to refer to about hygiene and infection control. Ashville House F52 F02 S18862 Ashville House V244545 110805 Stage 4.doc Version 1.40 Page 16 Ashville House F52 F02 S18862 Ashville House V244545 110805 Stage 4.doc Version 1.40 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 and 34 Service users are supported and protected by the home’s recruitment procedure and by the numbers of staff available. EVIDENCE: The number of management, care and domestic staffing hours provided by the home appeared to be appropriate for the number of service users accommodated and their needs. Examination of the staffing rota evidenced a low staff turnover, leading to a high continuity of care for the service users. Some of the staff have been in post for well over 10 years. One new member of staff has been employed since the last inspection. The records of recruitment were examined and contained all the required information. Ashville House F52 F02 S18862 Ashville House V244545 110805 Stage 4.doc Version 1.40 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 and 42 Service users are protected by the health and safety systems in place at the home and by having a qualified and experienced manager. EVIDENCE: The registered manager has managed the home for 11 years. The registered manager has appropriate care and managerial qualifications and records show that she has undertaken training to keep her skills and knowledge up to date. Service contracts and required safety certificates seen were in date and valid. Risk assessments for the environment were in place. Staff have received training around safe working practices. Ashville House F52 F02 S18862 Ashville House V244545 110805 Stage 4.doc Version 1.40 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 x x 3 2 Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x 3 x 3 x 3 Standard No 11 12 13 14 15 16 17 x 3 x x 3 3 3 Standard No 31 32 33 34 35 36 Score x x 3 3 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Ashville House Score x 3 x x Standard No 37 38 39 40 41 42 43 Score 3 x x x x 3 x F52 F02 S18862 Ashville House V244545 110805 Stage 4.doc Version 1.40 Page 20 No 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 1 Regulation 6 Requirement The statement of purpose and service user guide must be reviewed and updated where appropriate. All service users must be provided with a contract/statement of terms and conditions following their admission to the home. Care plans must provide clear direction to staff on how to support a service user. All aspects of the care plan must be reviewed on a regular basis. Timescale for action 11/09/05 2. 5 17 11/08/05 3. 6 15 11/08/05 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 F52 F02 S18862 Ashville House V244545 110805 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection Liverpool Area Office 3rd Floor, 10 Duke Street Liverpool L1 5AS 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 F52 F02 S18862 Ashville House V244545 110805 Stage 4.doc Version 1.40 Page 22 - 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. 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