Inspection on 06/06/07 for Ashville House

This inspection was carried out on 6th June 2007.

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 13/02/06

Ashville House 01/09/05

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 Unannounced Inspection 6th June 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ashville House DS0000027393.V342553.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ashville House DS0000027393.V342553.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashville House Address Fairfield Road Downham Market Norfolk PE38 9ET 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) 01366 383428 01366 383428 darrell@ashville-house.co.uk FJJ Healthcare Ltd Ms Elizabeth Fielding Mrs Kate Jackson Care Home 42 Category(ies) of Old age, not falling within any other category registration, with number (42) of places Ashville House DS0000027393.V342553.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Forty-two (42) Older People, not falling into any other category may be accommodated, the total number not to exceed 42. 13th February 2006 Date of last inspection 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 DS0000027393.V342553.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Care Services are judged against outcome groups, which assess how well a provider delivers outcomes for people using the service. The key inspection of this service has been carried out, by using information from previous inspections, information from the providers, the residents and their relatives, as well as others who work in or visit the home. This has included a recent unannounced visit to the home. This report gives a brief overview of the service and the current judgements for each outcome group. This was a key, unannounced inspection, taking place over 8 hours on a weekday, 6th June 2007 and was carried out as part of a routine inspection plan. There were 39 people living in the Home on the day. All the Proprietors were present during the inspection. There was a medical emergency on the day of the inspection and a musical entertainment took place in the afternoon. The inspection took the form of a tour of the premises, examination of care plans, staff files and other records. Seven comment cards had been received from relatives and one from a Healthcare Professional, with positive comments overall. There were individual discussions with the Proprietors; a District Nurse and two visitors; several members of staff, four in private; several residents, four in private. The information from the comment cards and from the people spoken to is incorporated in the report. What the service does well: • The Home is a large, detached house set in its own grounds with a purpose built extension, furnished and decorated to a very high standard. It is located in a market town and close to all amenities and public transport. There is a friendly, welcoming atmosphere and one relative’s comment was: “The Home gives them the care and support they need, and they are always so helpful and very pleasant.” “The Home (is) one of the best I have ever visited”. Relatives and visitors are welcomed into the Home at any time, offered refreshments, and are involved with decisions regarding their relatives’ care, if appropriate. Fifty percent of people living in the Home have phones in their rooms; several have mobile phones, or can use the Home’s phone, to keep in touch with family and friends. • • Ashville House DS0000027393.V342553.R01.S.doc Version 5.2 Page 6 • • • There is an enthusiastic, well-trained staff team, with a substantial number of long serving members, encouraged to use their initiative. A Healthcare Professional spoke of the ease of working with the staff team to promote the healthcare needs of the people living in the Home. The Management are experienced in running care homes for older people, are committed to staff training and development, which promotes the knowledge and skill of the staff team and hence the quality of the Service. There are good management systems, record keeping and continuous improvement guided by the best interests of the people living in the Home. There is an example of good practice in the Home’s monitoring of residents’ falls and reducing the risk of reoccurrence. All comments expressed satisfaction with the meals in the Home, the choice available, with fresh vegetables and home made puddings and cakes, as well as special diets. These can be taken in the light, attractive dining room with well presented tables with flowers, or where residents feel most at ease, if they need assistance; some take their meals in their rooms. There are various links with the local community and with the sister home, Eastgate House. Residents can take part in a Norfolk Music Works scheme and a project with the local school, as well as a creative activities programme organised by a designated Activities Co-ordinator. “A wonderful way to lift spirits”, said one comment card. At the same time, the Home manages to respect individuals’ privacy needs, which may not include such social interaction. The Home gives high priority to cleanliness, hygiene and infection control with well-managed procedures. • • • • What has improved since the last inspection? • • The Home has recently won an award as Learning Communities Project of the Year 2007 – Downham Life. A further Project is being created. The Home have recently been successful in obtaining a grant to re-landscape the garden with ramps, raised beds and sensory planting areas to be completed in 2008. Ashville House DS0000027393.V342553.R01.S.doc Version 5.2 Page 7 • Since the last key inspection the parquet floor in the dining room has been re-laid and finished to a high standard; redecoration has taken place with “modern art” prints, much appreciated by many residents. There is a rolling programme of refurbishment and redecoration. • 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. The summary of this inspection report can be made available in other formats on request. Ashville House DS0000027393.V342553.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Ashville House DS0000027393.V342553.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Detailed assessments are made prior to admission and all the people living in the Home are having their assessed needs met. The Home no longer offers intermediate care. EVIDENCE: From previous inspections, the Home has a sustained track record for comprehensively assessing prospective residents’ needs and whether these can be met. This assessment forms the basis of the care plans. There was evidence that the pre-assessment procedure included visits by the Providers, followed by a visit to the Home, with relatives/carers, as appropriate. In addition, information was obtained from other healthcare professionals. One resident spoken to said she came to the Home (her sister had been a resident) and she wanted to be sure of a vacancy. All the comment cards revealed that their relatives had received sufficient information before admission and the Home provide advocacy information to both residents and carers on admission. Ashville House DS0000027393.V342553.R01.S.doc Version 5.2 Page 10 Information is gathered from a range of sources and prospective residents are supported and encouraged to be involved in the assessment process. If this is not appropriate, the reasons are recorded on the assessment and care plan. Reasons for seeking residential care are noted and carers’ interests are taken into account. Several residents stay in the Home for respite care before deciding to become a permanent resident. On admission an allocated member of staff gives the resident information, special attention, help them to feel comfortable in their surroundings, enable them to ask questions about life in the Home. A member of staff spoken to said it was her job to reassure the new resident and to complete a check list of tasks to be completed, within specified time frames, to help the person feel secure in their new surroundings. Although it is not the policy of the Home to admit people in an emergency, there is a clear procedure to do so, with full assessment taking place thereafter, which one visitor said had been reassuring for him and his relative; although, in this case, information had been available from the hospital and social worker. Ashville House DS0000027393.V342553.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People living in the Home are very happy with the way that staff deliver their care and respect their dignity. EVIDENCE: All comment cards, including one received from a Healthcare Professional, one spoken to, seven relatives and residents spoken to, were very positive about the healthcare delivered in the Home. Four care plans were examined. These all included a photograph of the resident and comprehensive details necessary to enable staff to deliver the particular care needed. The plans are holistic and focussed on the individual’s personal preferences in numerous aspects, including preferred times for daily routines, social contacts and interests. There are good details of individual’s religious and cultural needs and participation in activities. Evidence shows the involvement of Healthcare Professionals, the GP, District Nurse, Community Psychiatric Nurse, Occupational Therapist, Physiotherapist, Dietician, Continence Advisor and in one case, Sensory Therapists. There was evidence of eye tests, dental care, immunisation, audiologist, X-rays, Diabetic Ashville House DS0000027393.V342553.R01.S.doc Version 5.2 Page 12 Clinic and more. Nutrition and dietary requirements, monitored by weight charts in care plans. The resident and/or relatives signed care plans, if appropriate; these were regularly reviewed, well kept and up to date. The Proprietors said that they work closely with the Falls Team who have undertaken staff training in falls prevention and the Home have introduced a monitoring programme to analyse effectiveness of their procedures. A District Nurse was spoken with and she confirmed there was a good relationship with the staff and they worked together as a team for the benefit of the residents. She said the staff were supportive and quick to highlight possible problems and that any advice was readily accepted and acted upon. The District Nurse team were also involved with ‘on the job’ training in such aspects as the care of pressure areas, catheters and diabetes. There are risk assessments where appropriate for individuals, for example, the monitoring of the risk of falls and these were discussed with the residents and relatives, as appropriate. “I have nothing but praise for the Home. They have a deep knowledge and understanding of the problems of the elderly”, was one comment from a relative. Another relative remarked how much his relative’s health had improved since being cared for in the Home and one resident spoken to said “You couldn’t find anywhere better”. Observation of the medication round demonstrated that the administration of medication was appropriately and safely carried out. It was administered by two care assistants who have completed training. The MAR sheets were seen to be in order and contained photographs of the respective resident. The Manager and Deputy Manager carry out a monthly, medication audit when security locks and blister packs are checked. The Deputy Manager said that relationships with the GP’s surgery and the Pharmacy were good and advice could always be sought. The Returns Book was at the Pharmacy on the day. At present, only one resident chooses to have responsibility for ordering his own medication and there is a corresponding risk assessment for this. It was observed, and residents spoken to confirmed, that they were treated with respect and that their privacy was protected. Ashville House DS0000027393.V342553.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People living in the Home have choice in all areas of their life, including well balanced meals, and have the opportunity to lead fulfilling lives according to their personal preferences EVIDENCE: The Home actively encourages and provides varied opportunities for people to develop and maintain social, emotional, communication and independence wherever appropriate. There are some individuals who prefer to lead a distinctly personal way of life, keeping to their own rooms, with their own routines. This is respected; one person said, “I couldn’t find anywhere better”. This particular person likes to walk every day, for which there is a risk assessment, with his consent. This person’s choice is also to take his meals in his room. For many other people living in the Home, the Activities Coordinator organises many, creative activities, silk painting, cooking and other craft projects, as well as ongoing individual pursuits, such as knitting, crosswords, jigsaws, reading newspapers and books and watching TV, which residents were observed engaged in on the day. Ashville House DS0000027393.V342553.R01.S.doc Version 5.2 Page 14 The Home has recently won an award in the Learning Communities Project of the Year 2007, for a project undertaken with a local school on the subject of ‘work’. Several residents had visited the Town Hall in the previous week to collect the Award. In addition, the Home participate in, with a Theatre/Dance Company, a Project named “Falling About”, again with the local school, including seated dancing. There is an ongoing Project entitled “Sunshine Abroad” and recent Classical Music evenings have proved popular. In addition, there are regular outings to places of interest and there are visits from the sister Home, Eastgate House. The Activities Co-ordinator, who is also a Carer in the Home keeps a full record of all activities and notes as to how residents find the activities and individuals’ feelings about what is on offer is transferred to the care plans. The Home is once more to be commended for this practice. All Comment cards and the relatives spoken to said that they were kept up to date with their relatives’ care. One visitor said that he visited several times a week at different times, ”I come and go at will” and that he has filled in a questionnaire as part of the quality assurance process. People living in the Home are encouraged to maintain control over their lives. One of the details on the pre-admission assessment are preferred times of going to bed and getting up. One person said that he preferred to spend time in his room and a member of staff spoken said that two people enjoy watching videos and sometimes they choose to go to bed after midnight. The lunch-time meal was seen to be well presented and appetising. As a result of consultation at a recent residents’ meeting salad was served at lunchtime on the day. The Minutes of recent residents’ meetings revealed food and changes of menu were often a topic on the agenda and the Home makes every effort to accommodate individual preferences and dietary requirements. On the day of the inspection, the cook had made a sugarless birthday cake for one person with special dietary requirements. People were observed being able to exercise choice at the meal time. Some were eating in the attractive, light dining room, others in their rooms and those needing assistance in the area just off the dining room, where staff were patiently helping and allowing residents time to finish their meal comfortably. Particular nutritional requirements and weight are closely monitored in the care plans. A relative spoken to said the food was very good, portions were good and he saw many clean plates. There was choice at tea time “anything from kippers to sandwiches”. “I’m often asked if I want to stay to lunch” and that he was always offered refreshments at other times of the day. On his relative’ s birthday, all the residents had wine if they wished. All cakes are home made and there was evidence of a stock of fresh, seasonal vegetables. Ashville House DS0000027393.V342553.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the Home feel that complaints and concerns would be listened to and acted upon, and the Home’s policies and procedures ensure that residents are protected from abuse. EVIDENCE: There is a complaints procedure and details of this are made available to everyone coming to live in the Home, as well as their relatives. Comment cards, residents and a visitor spoken to said they would know how to make a complaint if necessary, but they had had no cause. The Proprietors said that they were committed to taking all concerns and comments seriously and had recently acted on a relative’s comment in a questionnaire. Polices and procedures for safeguarding adults are in place. There is good staff training in the issues surrounding the protection of vulnerable adults. All members of staff spoken to gave a good account of their knowledge of these issues. There is a high proportion of staff with NVQ2. Ashville House DS0000027393.V342553.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People living in the Home enjoy a high standard of accommodation, which is fresh, clean and well maintained, with access to appropriate facilities and equipment. EVIDENCE: The Home is located close to public transport and to the market town with its community facilities and services. The old and new buildings of the Home are situated in an attractive, well maintained, older garden with a well stocked pond and there is a pleasant patio area with flowering baskets and pots and garden furniture, both areas are accessible for residents to enjoy. There are several, very pleasant, varied communal areas, including a conservatory with a grape vine, for small groups and quiet, more private, use. Some of the bedrooms have access to the patio area, whilst some of those on the first floor have good views of the river. All the residents’ rooms seen were personalised and furnished to a high standard and there are several items of specialist equipment to meet the individual needs of the people in the Home. All residents have mobile call bells Ashville House DS0000027393.V342553.R01.S.doc Version 5.2 Page 17 wherever they are in the Home, which promote their choice and independence. Residents have the choice to lock their doors, if they wish. There is a staff room with lockers, an arts and crafts/hairdressing room and ample storage space for wheelchairs and other equipment. A maintenance man is employed for four days a week. There is an ongoing redecoration programme in many areas. The dining room has recently been refurbished with modern prints, which are appreciated by many residents. The Home has recently been granted an award for the re-landscaping of the garden; to provide residents’ wheelchairs with ramps, a summer house, sensory and raised bed gardens. The Proprietors said that they hoped to involve the residents in planning the planting of the garden. On the day of the inspection, the Home smelt fresh and was observed to be spotless. The Management have a good track record of a pro-active commitment to cleanliness and hygiene and all staff attend a course on Infection Control. One visitor remarked that he had a received a letter regarding the Home being possibly vulnerable to a particular infection, together with guidance on this. He felt this had been the proper course of action, which he appreciated. One comment card said “The Home has never failed to be clean, sparkling and most welcoming”. There is a rolling programme of contract carpet cleaning and a record seen of frequent, extra cleaning in those areas where there were particular problems. Spot cleaning of carpets takes place on an ‘as and when’ basis. Ashville House DS0000027393.V342553.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People living in the Home and their relatives are very satisfied with the care they receive, that it meets their needs and is delivered by a highly trained staff team. EVIDENCE: “We cannot fault Ashville House staff – they do everything expected of them and more” said one comment card and there were generally very positive comments regarding the staff team from the residents, one visitor and District Nurse spoken to. The five members of staff spoken to said they enjoyed working in the Home and felt they all worked well together and looked forward to coming to work. The majority of the staff have much experience and have worked in the Home for one to five years and more. They all said they felt they were well supported by the Management, who they saw as being very approachable, and were offered many training opportunities. The Care Manager has much experience and has recently completed her NVQ 4 in Care. She had covered a night shift for reasons of staff sickness and was not available on the day. All the Proprietors were available during the inspection, and confirmed that the staffing levels never fall below those appearing on the staff rota. There are six members of staff on duty at peak times of the day and that, if particular circumstances arise, they are committed to being flexible and providing the staff cover necessary. This was borne out by the fact that during the afternoon of the inspection, there was entertainment in one of the sitting rooms and a medical emergency, as well as residents in their rooms; albeit, the daily routine continued to run smoothly. Ashville House DS0000027393.V342553.R01.S.doc Version 5.2 Page 19 All the staff records were well kept with photographs and the necessary recruitment information, Police checks and references. There was evidence that staff are well supervised on a regular basis and the notes from these sessions signed by the staff and the supervisor. These are also used for specific training on particular new developments, as well as the six weekly staff meetings, which are minuted. All staff spoken to said there was sufficient handover time at the end and beginning of shifts and very often a member of staff would stay on in order just to answer buzzers during the handover time. Staff are encouraged by the Management to use their initiative and such is their confidence that they feel comfortable to ask advice, or question other healthcare professionals if necessary to achieve the best outcomes for residents, for example when residents are returning from hospital with changed medications. The Management have a good track record in providing training at all levels. Each member of staff has their own training development plan and 67 have an NVQ2 qualification, eight are registered. Four members of staff have NVQ3, one NVQ4 and another registered. In house, there are two NVQ Assessors, one Moving and Handling Trainer and 2 First Aid Trainers. Training over and above statutory induction training is offered, such as Stroke Workshops, Dementia Care, Meaningful Activities and Aromatherapy Activities. Ashville House DS0000027393.V342553.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People living in the Home feel their interests are safeguarded and the quality of care continuously monitored by the management approach of the Home. EVIDENCE: Two of the Proprietors are Registered Nurses, NVQ Assessors and have undertaken much further training, as well as attending elderly peoples strategy and implementation group meetings and are members of Social Services, Health and Mental Health Services for elderly people. The other Proprietor is a graduate in Social Sciences and Economics and has spent several years working in Project Management for Charities, including Save the Children Fund. He has been actively involved in residential care management for over 17 years and is very much involved in the day-to-day running of the Home. Ashville House DS0000027393.V342553.R01.S.doc Version 5.2 Page 21 The Care Manager has completed the Registered Managers Award and recently the NVQ level 4 in Care. The Proprietors are in the process of registering her as the Manager. She is an NVQ Assessor and Trainer for Manual Handling and First Aid and has completed many other relevant training courses, including Safeguarding Adults. The Deputy Manager, who also has many years experience is undertaking an NVQ4 qualification. The Home uses an outside agency’s Quality Assurance system to ensure continuous improvement. The Home holds regular residents’ meeting which are well minuted and circulated in large print, which is good practice. The views of the residents on all aspects of the running of the Home are sought, from food, activities, health and safety, extra furniture, medication and buzzers, to name some issues. One relative confirmed that he had completed a questionnaire as part of a regular survey of relative’s views; and there was evidence that the Management had acted on one relative’s comments from a survey. Residents also completed questionnaires on a regular basis. There is a Compliments Book, and the Home has achieved the Investors in People status, thus demonstrating the Management’s people skills, strong leadership of staff and responsiveness to the needs of those who use the Service. The Home has a policy not to handle any of the residents’ money. People living in the Home are encouraged to control their own finances for as long as they are able and then the family, or an advocate, may become involved. The families or advocates are invoiced for any money due for hairdressing, chiropody or newspapers, for example. One of the Proprietors has responsibility for health and safety matters in the Home. Risk assessments were seen for window closers, maintenance issues and bedrails and many other safety checks. The Management are proactive in seeking specialist advice in several areas, but, in particular, as noted elsewhere in this Report, in consulting with the Falls Awareness Team and monitoring the Home’s procedures in this area. Staff training in Moving and Handling, Safeguarding Adults, First Aid, Food Hygiene are all kept up to date, thus ensuring as far as possible that the health, safety and welfare of residents and staff are protected. Ashville House DS0000027393.V342553.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 4 X x N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 4 STAFFING Standard No Score 27 4 28 4 29 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 3 X X 3 Ashville House DS0000027393.V342553.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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. Refer to Standard Good Practice Recommendations Ashville House DS0000027393.V342553.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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