This inspection was carried out on 28th 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.
CARE HOMES FOR OLDER PEOPLE
Ashwood Burwash Common Etchingham East Sussex TN19 7LT Lead Inspector
Lindy Latreille Unannounced Inspection 28th February 2006 10:10 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 DS0000013957.V269217.R01.S.doc Version 5.0 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 DS0000013957.V269217.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Ashwood Address Burwash Common Etchingham East Sussex TN19 7LT 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) 01435-883434 Ashwood Nursing Home Ltd Miss Ann Elizabeth Morrissey Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19), Physical disability (19) of places Ashwood DS0000013957.V269217.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. That Ashwood remains registered to accommodate nineteen (19) older people not falling into any other category, and those with a physical disability. That a Variation to accommodate a named service user under the age of sixty five (65) on admission, is granted solely in respect of this identified service user. 19th September 2005 Date of last inspection Brief Description of the Service: Ashwood is a nursing home that provides care up to nineteen older people or those with physical disabilities over the age of 65 years. There is a variation in progress to accommodate another resident under sixty-five years with a learning disability. At the time of inspection, nineteen residents were accommodated. The home is owned and managed by Miss Ann Morrissey. Ashwood is in the hamlet of Burwash Common and set in grounds with flat access for residents. The nearest town is Heathfield; the village of Burwash is two miles away. Accommodation is provided over two floors. There is a large accessible rear garden. The home provides eleven single rooms, and four shared rooms. Eight rooms provide en-suite facilities. There is a well-decorated combined dining and seating area. A passenger lift allows level access throughout the home. Ashwood DS0000013957.V269217.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the second unannounced inspection and took place between 10.10 and 14.45. Some of the standards were assessed in the last report, 19/09/2005, and this should be read to provide a balanced view. A tour of the premises took place with the Registered Manager and residents who could, or wished to, spoke with the Inspector. The requirements of the last report were discussed with the Registered Manager. Care plans were sampled, also the financial records of the management of one resident’s monies, staff files, health and safety information and medication records. What the service does well: What has improved since the last inspection? What they could do better:
The laundry room has been identified to be in need of upgrading, following normal wear and tear, and to have a replacement impermeable floor. 50 of carers must be qualified at National Vocational Qualification level 2. The quality assurance programme should be operational. Carers should have formal supervision six times a year. Ashwood DS0000013957.V269217.R01.S.doc Version 5.0 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ashwood DS0000013957.V269217.R01.S.doc Version 5.0 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 DS0000013957.V269217.R01.S.doc Version 5.0 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): 1 and 3. The statement of purpose does not correctly identify the registration organisation where a complaint may be lodged. The pre-admission assessments are completed and kept on file. EVIDENCE: The statement of purpose does inform the reader that should they wish to make a complaint they can contact the Regulatory Commission in East Sussex. The name in the statement of purpose should read the Commission for Social Care Inspection not National Care Standards Commission. Pre-admission assessments are carried out on all prospective residents and kept on the file. A variation is in place to accommodate a resident who is out of category but has high nursing needs and this was supported by a sound preadmission assessment and liaison with the appropriate agencies. Ashwood DS0000013957.V269217.R01.S.doc Version 5.0 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. Some care plans had been regularly reviewed but one had not been reviewed since October 2004. Arrangements for the administration of medication have been updated and re-sited. EVIDENCE: Of the care plans sampled some were regularly reviewed. One care plan of a resident receiving hospital outpatient care had not been reviewed since October 2004. There were letters to support the involvement of the home in the care and liaison with the necessary external agencies and the qualified staff were aware of all the holistic needs. Guidance to the daily care needs were in the daily log book. As there are Adaptation nurses in the home who have recently joined the service, and for whom English is a second language, there is additional risk of misunderstanding when records are not kept fully updated. The management of medication is to be re-sited to a locked area in the home, out of the office, and a wash hand basin has been installed. A drug trolley is on order. Medication records seen were in order.
Ashwood DS0000013957.V269217.R01.S.doc Version 5.0 Page 10 Ashwood DS0000013957.V269217.R01.S.doc Version 5.0 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): EVIDENCE: Ashwood DS0000013957.V269217.R01.S.doc Version 5.0 Page 12 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): 16 There have been no complaints and the informal nature of the home allows for concerns or complaints to be discussed with the Registered Manager or other registered nurses. EVIDENCE: There have not been any complaints made to the service. In walking round with the Registered Manager it was clear that some of the residents are able to voice their concerns and feel able to do so. The Registered Manager feels that she is aware of concerns that the residents have and these matters are dealt with at an early stage. Ashwood DS0000013957.V269217.R01.S.doc Version 5.0 Page 13 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 and 26. The environment is well monitored by staff and supported by good maintenance. The staff maintained a tidy home that was free from odours. EVIDENCE: The home was tidy and the lounge, and some bedrooms, have recently been decorated with new carpets and curtains. Bedrooms were suitably furnished and a pleasant environment, with specialised equipment as needed. There were no odours in the home. The Registered Manager commentated that the laundry is next to be updated and a replacement impermeable floor will be laid. There was no excessive laundry to be washed or in the process of drying. The ironing is done in another part of the home where residents cannot have access. Ashwood DS0000013957.V269217.R01.S.doc Version 5.0 Page 14 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): 28,29 and 30. 50 of the carers are not trained at National Vocational Qualification level 2. Recruitment and training of overseas nurses is robust. EVIDENCE: One carer has just finished her National Vocational Qualification level 2 and is to continue to follow NVQ level 3 in Care. Overseas nurses are placed from an agency and all checks are done to protect the vulnerability of the residents. As yet these staff have not undergone assessment to judge their level of competence against the NVQ standard. Recruitment checks for overseas nurses are made by the agency. Staff files contained the required information and work permits. There was evidence that staff had attended training in fire prevention. Prior to beginning training adaptation staff follow an induction programme to assess their skills for the adaptation course that is run in collaboration with Manchester Metropolitan University. Ashwood DS0000013957.V269217.R01.S.doc Version 5.0 Page 15 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): 31,33,35,36 and 38. The Registered Manager has achieved the required management standard. A quality assurance programme has been purchased but is not in operation yet. One resident’s finances are securely handled. Informal supervision is in place but is not part of a structured framework. Health and safety are addressed within the home. EVIDENCE: The Registered Manager has completed her National Vocational Qualification Level 4 in Management and has received her certificate. A quality assurance programme has been purchased but is not operational yet. The Registered Manager is assured that as the service is small she has a good overview of it all. General repairs, COSHH and prevention of Legionella are the responsibility of the maintenance man; the catering staff carry out all catering
Ashwood DS0000013957.V269217.R01.S.doc Version 5.0 Page 16 checks. The Registered Manager confirmed that she does use a dependable team of tradesman to ensure that work is carried out quickly. The home manages only one resident’s monies and this is done in close liaison with the funding authority. All records seen were robust and detailed monies in, out and receipts. The small staff team have good liaison and are aware of the needs of the residents. The Registered Manager is aware that this does not fulfil the requirements of the National Minimum Standards, but felt that she is in close touch with the staff. Health and safety is well managed within the home and staff all observe and contribute to the safety of the residents in a safe environment. Ashwood DS0000013957.V269217.R01.S.doc Version 5.0 Page 17 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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 x 3 X X X X X X 3 STAFFING Standard No Score 27 X 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 3 Ashwood DS0000013957.V269217.R01.S.doc Version 5.0 Page 18 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 OP1 Regulation 6(a) Requirement That the statement of purpose is updated to show the name of the Commission (CSCI). That 50 of carers are trained at National Vocational Qualification level 2. That a programme for quality assurance is operational. That all carers have formal supervision six times a year. That care plans are kept updated. Timescale for action 28/06/06 2. OP28 19(5)(b) 19/12/06 3. OP33 24(1)(a&b ) 18(2) 19/06/06 4. OP36 19/06/06 5. OP7 15(2)(b) 28/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Ashwood DS0000013957.V269217.R01.S.doc Version 5.0 Page 19 No. 1 Refer to Standard OP26 Good Practice Recommendations That the planned refurbishment of the laundry is completed. Ashwood DS0000013957.V269217.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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