CARE HOMES FOR OLDER PEOPLE
Ashwood 1 Liverpool Road Ashton-in-Makerfield Wigan Greater Manchester WN4 9LH Lead Inspector
Judith Stanley Unannounced Inspection 23rd January 2006 09:30 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 Ashwood DS0000005722.V268734.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 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. Ashwood DS0000005722.V268734.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Ashwood Address 1 Liverpool Road Ashton-in-Makerfield Wigan Greater Manchester WN4 9LH 01942 722553 01942 720577 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) Mr Serge Pascau Mr Dennis Pugh Mrs Sandra Shepherd Care Home 36 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (36), of places Physical disability (2), Physical disability over 65 years of age (8) Ashwood DS0000005722.V268734.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The home is registered for a maximum of 36 service users to include: up to 36 service users in the category of OP (Older People) up to 2 service users in the category of PD (Adults with Physical Disabilities) up to 8 service users in the category of PD(E) (Adults with Physical Disabilities over 65 years) up to 3 service users in the category of DE(E) (Adults with Dementia over 65 years) The 2 PD places are only to be used for service users over the age of 60. The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 2nd June 2005 2. Date of last inspection Brief Description of the Service: Ashwood is a private residential care home registered for up to 36 adults of either sex who are elderly. It is situated in the centre of Ashton-in- Makerfield close to all local amenities including shops and bus routes. Currently all bedrooms have single occupancy. The Home is registered for 36 so there is a possibility some rooms could be used as doubles. The manager advised that there are currently no plans to have shared rooms. Only one room offers an en suite facility, however, all rooms have a hand basin and there are toilets and bathrooms on both floors. The premises are well maintained both inside and outside. Car parking is available to the rear of the Home. Level access to the Home is provided and a passenger lift ensures access is available to both floors. Ashwood DS0000005722.V268734.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place over a 3 ½ hour period on one day. The first part of the day was spent talking with the manager and the deputy manager and looking at some records the home holds on the residents (care plans). The remainder of the time was spent speaking with staff and residents as well as making a tour of the premises. In order to obtain further information about the home comment cards were sent to residents, relatives and other professionals e.g. GPs and district nurses. 13 relatives, 3 residents, 1 GP and 1district nurse returned completed comment cards. What the service does well: What has improved since the last inspection?
There has been another shower room and new carpets in the reception and lounge area. The lounge/dining room on the first floor has had a new floor fitted in the dining area. Staff training is progressing well; only one member of staff does not wish to undertake further training. Ashwood DS0000005722.V268734.R01.S.doc Version 5.1 Page 6 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. Ashwood DS0000005722.V268734.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Ashwood DS0000005722.V268734.R01.S.doc Version 5.1 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 the following standard(s): EVIDENCE: None of the key standards were inspected on this occasion. Ashwood DS0000005722.V268734.R01.S.doc Version 5.1 Page 9 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 the following standard(s): 7 and 9 The standard of care planning and reviewing was good, providing staff with the information they needed to meet the resident’s needs. The arrangement for the management of resident’s medicines was found to be safe. EVIDENCE: Individual care plans were made available for inspection and examination of three care plans indicated that all aspects of resident’s health, personal and social care needs are planned for. The care plans inspected had been updated as required. Risk assessments had been completed for all residents. One resident regularly goes out to the local pub for lunch, a full risk assessment has been completed and agreed by both parties. Staff were knowledge about the needs and preferences of the residents. All medication was noted to be securely stored in individual packs. All medication, when given is recorded on the resident’s drug sheet. Staff who
Ashwood DS0000005722.V268734.R01.S.doc Version 5.1 Page 10 administered medication has undertaken appropriate training. One resident chooses to self medicate and has her medication locked away in her own room, this is suitably monitored. Ashwood DS0000005722.V268734.R01.S.doc Version 5.1 Page 11 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 the following standard(s): 13 and 14 The routines of daily living are flexible enough so that the different needs, expectations and preferences of residents are met. Residents are assisted to maintain contact with friends and family. Residents are kept informed and are helped to maintain a good level of independence, and to exercise choice and control over their lives. EVIDENCE: It was clear from observation, records, and from conversations with residents that they are offered real choices about how they live their lives. Residents meetings are held on a regularly basis, this provides an open forum for residents to express their views and to plan activities, outings and entertainers. Residents spoke about how they went out with relatives and friends, and how they could entertain their own visitors. Residents spoke well about being able to maintain a good level of independence, one resident regularly goes out and does his own shopping and one chooses to maintain overall charge of her own medication. Residents are able to bring some of their possessions, sufficient to make their bedrooms feel more personal.
Ashwood DS0000005722.V268734.R01.S.doc Version 5.1 Page 12 Ashwood DS0000005722.V268734.R01.S.doc Version 5.1 Page 13 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 the following standard(s): EVIDENCE: None of the key standards were inspected on this occasion. Ashwood DS0000005722.V268734.R01.S.doc Version 5.1 Page 14 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 the following standard(s): 19,24 and 26 The standard of the environment at Ashwood is good, providing residents with a safe, clean, pleasant and comfortable place to live. EVIDENCE: From a tour of the building, it was seen that the premises were being maintained to a good standard. Work has commenced on the outside area at the front of the home to make the grounds more accessible and safer for residents to sit out in warmer weather. There was evidence of redecoration and renewal of fabric and furnishings. A new floor had been laid in the dining area, and new carpet in the reception area. A new shower room is in action, this has been tastefully decorated and has proved to be a success with the residents. The premises were clean and free from offensive odours throughout. Comments again, have been made from a member of the district nurse team about the strong smell of smoke that greets you as you walk through the front
Ashwood DS0000005722.V268734.R01.S.doc Version 5.1 Page 15 door. Several resident smoke and the smoking lounge is on the ground floor. This is the dedicated smoking area and the manager and staff acknowledge that there is a heavy aroma of smoke, however they feel that residents choices are being respected. Bedrooms were seen to be comfortable, clean and tidy with furniture and fittings that were well maintained to a good standard. Systems were in place to control the spread on infection. Staff were knowledgeable about infection control procedures and were observed using different aprons and gloves for different tasks. Ashwood DS0000005722.V268734.R01.S.doc Version 5.1 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28 Staff at Ashwood are properly trained to deliver the care that residents need. EVIDENCE: Staff training is progressing well, with all but one member of staff trained to at least NVQ level 2. In house training is on going and staff confirmed that the manager encourages and supports staff in all areas of their development. Ashwood DS0000005722.V268734.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33 and 35 The home was being well managed resulting in a consistent reliable service for people using it. A satisfactory accounting system was in place, which protected resident’s interests. EVIDENCE: The home has effective quality assurance and monitoring systems in place to ensure the home is run in the best interests of the residents. Feedback from residents through service user satisfaction questionnaires and through residents/relatives meetings is sought on how the home is achieving goals for residents. The home has a satisfactory accounting system in place. The administrator could determine exactly how much money the home holding for each resident
Ashwood DS0000005722.V268734.R01.S.doc Version 5.1 Page 18 and how the money was being spent. Receipts were retained for all financial transactions. Ashwood DS0000005722.V268734.R01.S.doc Version 5.1 Page 19 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 x x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 x 3 x x x x 3 x 3 STAFFING Standard No Score 27 x 28 3 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 3 x 3 x x x Ashwood DS0000005722.V268734.R01.S.doc Version 5.1 Page 20 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 Ashwood DS0000005722.V268734.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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