Inspection on 04/02/06 for Ashville House

This inspection was carried out on 4th February 2006.

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 11/08/05

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 Julie King Unannounced Inspection 3rd February 2006 09:30 Ashville House DS0000018862.V281916.R01.S.doc Version 5.1 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 House DS0000018862.V281916.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. 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 DS0000018862.V281916.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Ashville House Address 1 Ashville Road Birkenhead Wirral CH41 8AU 0151 653 8786 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) Making Space Mrs Elsie Fisher Care Home 10 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (10) of places Ashville House DS0000018862.V281916.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1 named elderly person with a mental disorder (other than learning disability) may be accommodated. 11th August 2005 Date of last inspection 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 flowerbeds. There is a patio area with seating provided. Ashville House DS0000018862.V281916.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This statutory unannounced inspection took place over three hours. A full tour of the premises took place. A range of records such as care plans, staff personnel files, policies & procedures and medication charts were examined. All staff on duty, and most service users were spoken to during the course of this inspection. What the service does well: What has improved since the last inspection? 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 DS0000018862.V281916.R01.S.doc Version 5.1 Page 6 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 Outcomes Statutory Requirements Identified During the Inspection Ashville House DS0000018862.V281916.R01.S.doc Version 5.1 Page 7 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 the following standard(s): 1,2,3,4,5. The service users assessed needs are being met, and the home is able to provide assurances to service users and their representatives that assessments will be a continuous process throughout the person’s stay. EVIDENCE: Service users are only admitted into the home on the basis of a full assessment is carried out prior to they move in. All pre-admission assessments are carried out by either the registered manager or senior care worker, and include direct input from the prospective service users’ family / representative as agreed. Multidisciplinary healthcare team members such as the service users’ social worker, physiotherapist or NHS ward nurse, are part of this process. Specialist healthcare professionals continue to be involved in the care of service users after they are admitted into Ashville House. All the service users spoken to during this unannounced inspection told the inspector that they felt “it’s like a family here”, and “everyone is involved”. Ashville House DS0000018862.V281916.R01.S.doc Version 5.1 Page 8 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 the following standard(s): 6,7,8,9,10. There is a consistent care planning system in place for all service users. This provides staff with the information they need to satisfactorily meet the service user’s needs. EVIDENCE: The service users appeared happy and well cared for, and the ethos of the home, with regard to inclusion and enabling was apparent. A selection of care plans were examined, all of which evidenced service user involvement, and individual needs assessment. Service user questionnaires, kept in service user files, and covering day-to-day routines are in use. These questionnaires also offer information to the service user in where to find policies and procedures, and if they are happy with the running of the home. Individualized risk assessments were in place in each service user’s file, agreed and signed by the key-worker and service user. Multidisciplinary healthcare team input was evident throughout this process and in all care plans seen. Ashville House DS0000018862.V281916.R01.S.doc Version 5.1 Page 9 The service users spoken to during the inspection commented on the standard of care they received. They confirmed they had access to various healthcare professionals as necessary, and stated that the nursing and care staff always respected their privacy and dignity by “treating me well” and “asking me what I want”. Ashville House DS0000018862.V281916.R01.S.doc Version 5.1 Page 10 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 the following standard(s): 11,12,13,14,15,16,17. Links with the local community are good, and support and enrich service user’s social lives. The meals in this care home are good, offering both choice and variety, and catering for special dietary needs. EVIDENCE: The daily routines provided were flexible as far as possible, and service users are encouraged to exercise choice and control over their lives. Friends and family are actively encouraged to participate in the service user’s lives. A varied and nutritious diet was provided with specialist service user’s medical needs (such as diabetes) being catered for. Service users told the inspector that they were “listened to”, and the staff “always knocked” on the door before coming in. They also told the inspector that they felt able to “choose” what they wanted to wear, where to sit, what to eat, what to do, etc. Ashville House DS0000018862.V281916.R01.S.doc Version 5.1 Page 11 Varied activities are offered both in and out of the home, but with limited service user take-up (through service user choice). Some of the service users participate in the weekly shop in town, whilst others choose to stay local and collect the daily newspaper, etc. Ashville House DS0000018862.V281916.R01.S.doc Version 5.1 Page 12 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 the following standard(s): 18,19,20,21 Staff offer and encourage service users to maintained their independence thus offering choice and flexibility regarding service users daily lives. EVIDENCE: The service users appeared happy and well cared for, and the ethos of the home, with regard to inclusion and enabling was apparent. A selection of care plans were examined, all of which evidenced service user involvement, and individual needs assessment. Service user questionnaires, kept in service user files, and covering day-to-day routines are in use. These questionnaires also offer information to the service user in where to find policies and procedures, and if they are happy with the running of the home. Policies and procedures are in place regarding dealing with illness and death of a service user, and MDT involvement would be sought as necessary. Medications were found to be managed in accordance with current good practice guidelines. Ashville House DS0000018862.V281916.R01.S.doc Version 5.1 Page 13 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 the following standard(s): 22,23. An efficient complaint and adult protection policy and procedure are in place to help ensure the safety and welfare of service users. EVIDENCE: Ashville House has an efficient complaint and adult protection policy and procedure in place to help ensure the safety and welfare of service users that they, their relatives and staff can access when necessary. This procedure includes information on ‘whistle-blowing’, in accordance with the Department of Health ‘No Secrets’ guidelines. Most of the staff have, or are in process of completing training in adult protection, with the remaining having training planned for the near future. However all staff do receive basic training in the protection of vulnerable adults during induction. The service users all spoke highly of the staff team and said they “have no complaints about how I’m treated”, and “nothing is too much trouble”. Some advocacy information was available if required by service users or their relatives. Ashville House DS0000018862.V281916.R01.S.doc Version 5.1 Page 14 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 the following standard(s): 24,25,26,27,28,29,30. The overall fabric of the building is of a good standard, with most service users’ rooms being highly personalized. EVIDENCE: The environment inside and outside the home was well kept and very nicely presented. There was a choice of areas for the service users to sit and relax, and separate dining facilities. All the service user areas and bedrooms seen were nicely furnished and had good evidence of individual personalisation by the service users. Risk assessments were available regarding the environment, health, safety and welfare of the service users, both individually and collectively. The house was warm, homely, had adequate stocks and supplies of both food and general provisions Ashville House DS0000018862.V281916.R01.S.doc Version 5.1 Page 15 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36. Staffing levels are adequate to ensure the safety and welfare of the service users. Pre-employment checks are thorough, helping ensure the protection of the service users. EVIDENCE: The home is staffed with satisfactory levels of staff required to meet the needs of the service users, with the registered manager, senior support workers and care staff on duty. Additional staff are brought in to accompany service users to hospital appointments, etc. Staff spoken to during the inspection confirmed that a range of mandatory and specialist training was now available, with the majority of the cost being paid for by the care home. This approach to training is a positive aspect of the care home, as it helps ensure that service users are being cared for properly and their needs are being met in accordance with current good practice guidelines. Staff personnel files were examined, all now evidenced training records, preemployment checks, references, inductions and most had some record of supervision. Ashville House DS0000018862.V281916.R01.S.doc Version 5.1 Page 16 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40,41,42,43. The service users benefit from a manager who is qualified and competent to discharge their duties and who ensures the health and safety of service users is promoted. The home regularly reviews aspects of its performance through a programme of self-review and consultations, which include seeking the views of service users, relatives and staff. EVIDENCE: The manager was been in post for many years. The manager has completed an NVQ Level 4 qualification in management, and has obtained their Registered Manager’s Award. The manager reported that both herself and the senior staff have attended training to keep their knowledge and skills up to date. An examination of the induction and follow on training schedule indicated that staff are provided with sufficient training to ensure that all senior staff are up to date with the various conditions presented by the service users. Ashville House DS0000018862.V281916.R01.S.doc Version 5.1 Page 17 The records of fire safety checks, electricity and gas were examined and the NICEIC (Electrical safety) certificate was UNSATISFACTORY. The inspector was informed that this had already been addressed by the manager who had authorised necessary work to be completed. Fire training records showed that staff had NOT been given appropriate training in safe working practices, and the last recorded fire drill and training session was July 2005. There are policies and procedures in place to promote the health and safety of service users and staff. Regulation 37 (notification of incidents) forms are forwarded on to the CSCI as required for all incidents as listed under the regulation. Also Regulation 26 (provider visit forms) are being received by the CSCI on a regular basis. Ashville House DS0000018862.V281916.R01.S.doc Version 5.1 Page 18 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 Standard No Score 1 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 3 3 3 2 3 3 Ashville House DS0000018862.V281916.R01.S.doc Version 5.1 Page 19 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 YP 42 Regulation 23 (4) Requirement The registered person must ensure that all staff receive appropriate fire training at regular intervals. The registered person must ensure that the NICEIC (Electrical Safety) certificate is brought up to date and is valid – and forwarded on to the CSCI without delay. Timescale for action 28/02/06 2 YP 42 23 (2) 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YP 19.3 Good Practice Recommendations It is strongly recommended that suitable weighing scales are purchased, and that service users who experience either weight loss or significant gain are weighed on a regular basis with these recording accurately kept. Ashville House DS0000018862.V281916.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 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 DS0000018862.V281916.R01.S.doc Version 5.1 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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