CARE HOME MIXED CATEGORY MAJORITY ADULTS 18-65
Ashwood Court Unit 1 Woodford Avenue Lowton Warrington Cheshire WA3 2RB Lead Inspector
Bernard Tracey Unannounced Inspection 2nd February 2006 09:30 Ashwood Court Unit 1 DS0000005723.V268811.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 Ashwood Court Unit 1 DS0000005723.V268811.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 and 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. Ashwood Court Unit 1 DS0000005723.V268811.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Ashwood Court Unit 1 Address Woodford Avenue Lowton Warrington Cheshire WA3 2RB 01942 275758 01942 722835 makingspace.ashwoodcourt1@virgin.net 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 Care Home 17 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (9), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (8) Ashwood Court Unit 1 DS0000005723.V268811.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The home is registered for a maximum of 17 service users to include: up to 8 service users in the category of MD(E) (Mental Disorder over 65 years of age) up to 9 service users in the category of MD (Mental Disorder over 45 years of age) The service should employ a suitably qualified and experienced Manager who is registered with the CSCI. 26th October 2005 2. Date of last inspection Brief Description of the Service: The company Making Space privately owns Ashwood Court Care Home. The Home is a purpose built and provides accommodation and personal care and support for up to 17 adults who suffer from an enduring mental illness. The Home is set in its own grounds in a residential area of Lowton. The Home provides single accommodation, no rooms offer en suite facilities. There is car parking to the front of the Home and enclosed, private gardens to the rear. The external areas of the Home are well maintained and well presented. Ashwood Court Unit 1 DS0000005723.V268811.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection took place over a four-hour period. The home was not notified that the inspection was going to take place. This was the second inspection of the year and many standards were looked at and reported on in the Inspection report dated 26th October 2005 The following records were read; residents’ records relating to how their finances were managed in the home, staff rosters, complaints received book, training records and staff files. The Inspector spoke to the three staff members on duty, the manager and also spoke at length to five residents during the tour of the home. All of the residents spoken with said they really enjoyed living in the home. They said that the staff were “very helpful and prompt to give assistance”. Residents said that they were pleased with their bedrooms, with one gentleman eager to show me around his personal accommodation. Residents were pleased with the choice and variety of meals available. One resident commented that, “nothing was too much trouble for the staff, you only have to ask”. What the service does well:
This is a care home where residents are well looked after. The staff team work well together and show a good understanding of the needs of the people living at the home. Before a new resident moved in, they were given plenty of time to make a decision about moving and for the home to also find out what help and support they wanted and needed. Residents liked living at Ashwood Court. There were always a lot of activities, both in and outside the home. At the time of inspection residents were in the process of planning their summer holidays. Residents said the staff were also “very good” and they “would rather live here than anywhere else”. Residents lived in a very attractive, clean and comfortable home. Staffing levels were very good, with staff having time to spend with residents. The home also looked after staff very well. Staff said they were “well Ashwood Court Unit 1 DS0000005723.V268811.R01.S.doc Version 5.1 Page 6 supported” by the management team and that Ashwood Court was a “lovely place to work”. New staff got excellent training to help them do their job, saying, “no expense had been spared”. The manager of the home takes a lot of time to get feedback from residents relatives and other professionals who visit the home. A selection of recent questionnaires were looked at. One professional wrote: “I have nothing but the utmost of praise of all staff members of Ashwood Court” A relative had written “they have cared for my brother so 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. Ashwood Court Unit 1 DS0000005723.V268811.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) Ashwood Court Unit 1 DS0000005723.V268811.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The key standards were examined at the last inspection There is a detailed admission procedure, which ensures that staff have a clear understanding of the residents’ needs and how they were to be met. Prospective residents have ample opportunities to visit the home, which helps them to make a decision about whether the placement is suitable for them. EVIDENCE: The key standards were examined at the last inspection on the 26th October 2005. All of the key standards were met Ashwood Court Unit 1 DS0000005723.V268811.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14, and 33 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The key standards were examined at the last inspection There is a clear and detailed care planning system in place that includes residents’ involvement and provides the staff with the information needed to meet the needs of the residents. The risk assessment and management framework supported residents to take responsible risks. EVIDENCE: The key standards were examined at the last inspection on the 26th October 2005. All of the key standards were met. Ashwood Court Unit 1 DS0000005723.V268811.R01.S.doc Version 5.1 Page 10 Lifestyle
The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. 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. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. 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. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. 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. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The key standards were examined at the last inspection Residents were provided with very good opportunities to engage in a wide range of appropriate activities and were supported to use community facilities. The home’s policies and staff practice ensured residents’ rights were upheld.
Ashwood Court Unit 1 DS0000005723.V268811.R01.S.doc Version 5.1 Page 11 EVIDENCE: The key standards were examined at the last inspection on the 26th October 2005. All of the key standards were met. Ashwood Court Unit 1 DS0000005723.V268811.R01.S.doc Version 5.1 Page 12 Personal and Healthcare Support
The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) 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. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The key standards were examined at the last inspection Residents’ personal and healthcare needs were clearly identified and met by staff, with support from the multi-disciplinary team. Staff handled and administered medication in accordance with robust policies and procedures. EVIDENCE: The key standards were examined at the last inspection on the 26th October 2005. All of the key standards were met. Ashwood Court Unit 1 DS0000005723.V268811.R01.S.doc Version 5.1 Page 13 Concerns, Complaints and Protection
The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16-18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 22-23 (Adults 18-65) and Standards 16-18 and 35 (Older People) 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 (Adults 18 – 65 ) 16 17 18 35 ( Older People) There is evidence to show that residents and relatives were able to make their concerns known and they would be acted upon. Staff had a good knowledge and understanding of adult protection procedures thereby reducing the possible risk of harm or abuse to residents. EVIDENCE: The complaints procedure contained the appropriate information about how complaints would be handled. There had been no complaints made directly to the Commission since the previous inspection. The complaints register of the home was examined and three complaints had been recorded. The manager assured the inspector that these issues have now been satisfactorily resolved with the relative who had complained. The complaints procedure was displayed and residents said they knew who to complain to if they were unhappy or concerned in any way. One resident said he had made a complaint in the past and it had been acted upon. Another said that if he had a complaint he would tell his key worker or the manager “who would do something about it”. Staff spoken to were aware of how to receive and deal with complaints.
Ashwood Court Unit 1 DS0000005723.V268811.R01.S.doc Version 5.1 Page 14 Senior staff had recently attended the launch of the recently published Wigan MBC Protection of Vulnerable Adults policy and evidence was seen that training in the above was being rolled out throughout the home to include every member of staff. The home has written policies on Adult Protection and Whistle blowing, which staff were aware of. A copy of the Local Authorities Vulnerable Adults Procedure was in place and a discussion with care staff and management identified that there were very aware of the procedure to follow in the event of any allegation of abuse. Small cash balances were held on some residents’ behalf. These agreements were documented within care plans, with clear transaction records also kept. Ashwood Court Unit 1 DS0000005723.V268811.R01.S.doc Version 5.1 Page 15 Environment
The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The key standards were examined at the last inspection The standard of furnishing and fittings within the home was good providing a homely, safe, well adapted, clean and comfortable environment for residents. Residents were satisfied with the furnishings in their bedrooms, which reflected their individual tastes. Ashwood Court Unit 1 DS0000005723.V268811.R01.S.doc Version 5.1 Page 16 EVIDENCE: The key standards were examined at the last inspection on the 26th October 2005. All of the key standards were met. Ashwood Court Unit 1 DS0000005723.V268811.R01.S.doc Version 5.1 Page 17 Staffing
The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Staff are well trained to ensure they have the competencies to meet residents needs. There is sufficient staff to meet the needs of residents. The homes recruitment procedures are robust and these provide safeguards for the protection of residents. EVIDENCE: New staff received an excellent package of induction training, completing both an in-house induction/ foundation programme and an extensive range of mandatory and service specific training including fire safety, food hygiene, first aid, the needs of people with enduring mental illness, anger management; moving and handling, care planning/key working, and dementia. New staff
Ashwood Court Unit 1 DS0000005723.V268811.R01.S.doc Version 5.1 Page 18 confirmed they had had a comprehensive and “very lengthy induction even though I have worked in care for 16 years.” Staff spoken to informed the Inspector of the training that they had done. One staff member said that “the training here is excellent”. Staff members stated that they are encouraged to attend courses and given the time and support to do this. The Inspector observed the positive manner of the manager and her skill and enthusiasm in obtaining training opportunities for the home. Staff spoken to said that they were clear about their role and work well as a team to ensure the individual and collective needs of the residents are met. In addition to annual appraisals, staff received regular supervision, with good practice noted. Staff said they felt “well supported”, they had a “great staff team” and that Ashwood Court was a “lovely place to work”. The home has a comprehensive recruitment policy and procedure and when three staff files were checked it was evident that the manager follows the procedure, and ensures the interview process are in line with the home’s policy, Pova / CRB checks, written references, health checks and past work history are all obtained and satisfactory before the person starts work. Ashwood Court Unit 1 DS0000005723.V268811.R01.S.doc Version 5.1 Page 19 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. 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. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) 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 homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) 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 39 42 ( Adults 18 – 65 ) 31 33 35 38 (Older People) The manager is supported by the senior staff in providing clear leadership, with all staff demonstrating an awareness of their roles and responsibilities. The home regularly reviews aspects of its performance through a programme of self-review and consultations, which include seeking the views of residents, staff and relatives.
Ashwood Court Unit 1 DS0000005723.V268811.R01.S.doc Version 5.1 Page 20 Regular maintenance and fire safety checks were carried out, promoting the health and safety of both residents and staff. EVIDENCE: Throughout the time in the home the Inspector was able to evidence the professional, capable and approachable manner in which the manager undertook her role when dealing with residents and staff. The manager has completed the registered manager award qualification. Feedback is sought from the residents and relatives through regular meetings and satisfaction questionnaires. Policies and procedures are up dated and reviewed as an ongoing practice and action is taken to ensure the equirements of the inspection reports are met. The home completes in-house audits of its service on a monthly basis, and the manager competently oversees this. The home has recently been awarded 5 stars by the Residential and Domiciliary Benchmarking (RDB), an external quality monitoring service. Staff have meetings with the manager and everyone is encouraged to join in with discussions and voice their opinions. Residents and staff agreed that they are able to express ideas, criticisms and concerns without prejudice and the management team will take action where necessary to bring about positive change. Residents are invited into the staff meetings and a resident also takes the notes of the resident meeting. Staff supervision files show that individuals receive formal supervision with their line managers on a regular basis and staff appraisals are also completed each year. Records required for the protection of residents and the running of the Home are in place, reviewed and up dated as required. Residents are aware that they can access their personal records as and when they wish to do so. Ashwood Court Unit 1 DS0000005723.V268811.R01.S.doc Version 5.1 Page 21 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. Where there is no score against a standard it has not been looked at during this inspection. 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 X 2 X 3 X 4 X 5 X 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 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT Standard No Score 37 4 38 4 39 4 40 3 41 3 42 3 43 3 X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Ashwood Court Unit 1 Score X X X X DS0000005723.V268811.R01.S.doc Version 5.1 Page 22 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. 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 Court Unit 1 DS0000005723.V268811.R01.S.doc Version 5.1 Page 23 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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