Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 09/01/06 for Ashwood Nursing Home

Also see our care home review for Ashwood Nursing Home for more information

This inspection was carried out on 9th January 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

People living in this home are well cared for by a well managed, educated, committed and competent care team. Those residents and 2 visitors who were spoken too expressed satisfaction with the care and service provided by the home. More than one resident commented, "it`s nice here" and "the staff are kind". All residents are assessed before entering the home and there is a recreational and activity programme provided which provides stimulation. There is a thorough assessment and review of care with wherever possible resident and relative/family involvement. There is a comprehensive programme of education provided which ensures that staff know how to care and support people living in the home. People living in the home live in clean, safe, well decorated and attractive accommodation.

What has improved since the last inspection?

A programme of decoration is taking place, which has included the continued redecoration of the ground floor corridor. In addition 6 bedrooms and a number of toilets were or had been repainted. A new disabled access shower has been provided on the ground floor.

What the care home could do better:

The manager needs to ensure that both the statement of purpose and service user`s guide is reviewed to refer to the CSCI rather than NCSC.

CARE HOMES FOR OLDER PEOPLE Ashwood Nursing Home 43 Spalding Common Spalding Lincs PE11 3JZ Lead Inspector Mr Toby Payne Unannounced Inspection 9th January 2006 08:20 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 Nursing Home DS0000002530.V275903.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 Nursing Home DS0000002530.V275903.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Ashwood Nursing Home Address 43 Spalding Common Spalding Lincs PE11 3JZ 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) 01775 723223 01775 713763 St Christopher`s Limited Mrs Suria Kumari Webb Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Ashwood Nursing Home DS0000002530.V275903.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Condition of Registration A condition of registration is that the maximum number of service users in the home with nursing needs does not exceed 23 and the maximum number of service users with personal care only does not exceed 8. 25th August 2005 Date of last inspection Brief Description of the Service: Ashwood Nursing Home is a care home registered to provide nursing and personal care for up to 31 elderly people. On the day of the inspection there were 30 people living in the home. The home is situated on the outskirts of the town of Spalding approximately 1½ miles from the centre of the town. The building was converted for its current use in 1997 and accommodation is on the ground and first floors. The first floor is served by a stair lift. Most of the accommodation is provided in single bedrooms with one shared bedroom on the first floor. All bedrooms have en-suite facilities. The 5 bedrooms on the first floor are registered for personal care only as this accommodation is served by a stair lift. There is limited car parking to the front of the home. The home has gardens and lawns to the front and rear of the property. Ashwood Nursing Home DS0000002530.V275903.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and started at 8.20 am. It took place over 4 hours. The inspector spoke to 10 residents, 2 visitors, 6 staff, a nursing student and the deputy manager. The main method of the inspection was called “case tracking”. This involved selecting 2 residents and tracking the care they received through the checking of records, discussion with them, the care staff and observation of how care was delivered. The inspector also observed how care was delivered and how staff responded to other residents living in the home. One comment card was received from a relative. Comments were “absolutely first class, absolute perfection, everything of the highest standard - 100 dedication”. What the service does well: What has improved since the last inspection? A programme of decoration is taking place, which has included the continued redecoration of the ground floor corridor. In addition 6 bedrooms and a number of toilets were or had been repainted. A new disabled access shower has been provided on the ground floor. Ashwood Nursing Home DS0000002530.V275903.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 Nursing Home DS0000002530.V275903.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 Nursing Home DS0000002530.V275903.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): 1, 4 and 6 The home has produced a detailed statement of purpose and service user’s guide. Staff know how to meet the needs of people living in the home. EVIDENCE: The home has produced a detailed statement of purpose and service user’s guide, which were both comprehensive and plainly written. However some of the information needs to be updated. Staff receive a detailed induction programme. This includes an extensive induction and foundation programme. This also includes supervision and an individual development programme. This programme also includes the needs of people living in the home. . One new member of staff commented, “I received a detailed supported induction programme”. Where required specialist advice can be obtained. The home also has a policy on different religions and cultures. Staff who spoke to the inspector showed their knowledge of the needs of the residents. The home does not provide intermediate care. Ashwood Nursing Home DS0000002530.V275903.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, 10 and 11 Resident’s health and personal care needs were met. The care plans were detailed and identified the individual needs of service users. Residents are treated in a dignified and respectful manner. The home provides support to residents and their relatives at time of death. EVIDENCE: All residents had detailed and up to date care plans. These described their health and welfare needs. Records included medication, diet, weight, communication, mobility, social interests and their daily routine. There was also a life history, which allowed staff to be aware of the resident’s interests and background. Where required these also included moving and handling and risk assessments. Care plans showed evidence of promoting resident’s independence, respect, dignity and choice. There was also evidence to show that residents/relatives had been involved in their care planning. Their signatures showed this. Ashwood Nursing Home DS0000002530.V275903.R01.S.doc Version 5.1 Page 10 All staff receive training on privacy and dignity during their induction programme. The home has a policy on this subject. Reference is also made to privacy and dignity in the statement of purpose and service user’s guide. Residents commented, “staff are very kind, friendly and helpful”. There are locks to all toilet, bathroom and bedroom doors. Staff showed awareness of the need to promote the resident’s privacy and dignity in a sensitive manner. Resident’s commented, “staff are very kind and respect my dignity”. Where required, legal advice can be obtained by the home. The home has a detailed policy on this subject, which gives guidance to staff. Some of the staff have attended a death, bereavement and funeral awareness course. In addition, the manager and deputy manager have undertaken a counselling course on bereavement. Staff told the inspector how they offered support to the residents and their families and what support was offered to staff. The home also has a policy on different religions and cultures. Ashwood Nursing Home DS0000002530.V275903.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): 12, 14 and 15 A written programme of activities was available and displayed on the notice board in the lounge. The home also has a newsletter detailing activities. Activities are carried out by care staff. Outside entertainers also visit the home. Residents were offered a choice of well-balanced and wholesome meals. EVIDENCE: Ashwood Nursing Home DS0000002530.V275903.R01.S.doc Version 5.1 Page 12 The home has an activities programme and newsletter, which gives details of activities in the home. Details are displayed on notice boards at the entrance to the home and in the lounge. The care staff provide activities. On admission to the home details of the resident’s interests and lifestyle are obtained. Activities include board games, music and gentle exercise, quizzes and Bingo, foot and spa massage, cheese and wine, reminiscence, video afternoons, outside entertainment. Residents are also assisted with shopping and library books are also available. A church service also takes place and birthdays are celebrated. The home also holds regular meetings with the residents. None of the residents handled their financial affairs. This is done by their family/advocate with the permission of the resident. Personal allowances are handled by the home for a number of residents and where this occurs records are kept with signatures of all transactions...Examination of the records confirmed this. On admission to the home details of the residents likes and dislikes and dietary needs are obtained. The home has also specific assessments of their nutritional needs. These are included in the care records. At breakfast there is a choice including a hot meal. This is served between 08.30 and 10.00 hours. At lunch there is a set menu with an alternative where required. This is served between 12.30 and 14.00 hours. An evening meal is provided which offers a choice including a hot meal. This is served between 16.30 and 18.00 hours. Snacks and beverages are available at other times. Separate staff provide catering and have food hygiene certificates. In addition care staff have completed a distance learning programme in food hygiene. Meals can be taken in the dining room on the ground floor or in the person’s bedrooms. The menu is displayed in the dining room. Ashwood Nursing Home DS0000002530.V275903.R01.S.doc Version 5.1 Page 13 All residents made positive comments about the food. Comments were, “I enjoy a cooked breakfast on Sunday which I receive” and “I enjoy the food”. Staff were also seen to ask residents what they wished to have for tea in the evening. Staff were seen to sit with residents who could not feed themselves assisting them in a kind and patient manner. Staff were also offering portions of fresh fruit to residents in the lounge. As a result of an Environmental Health Officer’s inspection from South Holland District Council, the home was again awarded a Food Hygiene award in March 2005. Ashwood Nursing Home DS0000002530.V275903.R01.S.doc Version 5.1 Page 14 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 and 17 The home has a complaints procedure in place. Residents and visitors know that any concerns are taken seriously and acted upon. EVIDENCE: All staff receive training in communication and how to deal with a complaint. No complaints have been received by the CSCI and the home since the last inspection. Each resident receives a detailed complaints procedure when they are admitted to the home. The complaints procedure is also clearly displayed with other pieces of information on the wall of the waiting area at the entrance to the home and at the top of the stairs to the first floor. None of the residents and visitors had any complaints about the home and felt they could discuss any concerns with the staff and manager. Staff also knew what to do if they received a complaint from a resident. The home has details of the CALL advocacy service for Lincolnshire. In addition, legal advice can be obtained for any person in the home on request. All are made aware of their voting rights at elections. Ashwood Nursing Home DS0000002530.V275903.R01.S.doc Version 5.1 Page 15 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, 22, 25 and 26 The home is well maintained and clean. Residents are provided with safe and comfortable surroundings in which to live. EVIDENCE: Ashwood Nursing Home DS0000002530.V275903.R01.S.doc Version 5.1 Page 16 Residents who need nursing cannot use the rooms on the first floor as this accommodation is served by a stair lift. The home is in the middle of an extensive redecoration programme with the gradual replacement of wallpaper in the ground floor corridor and painting of bedrooms, bathrooms and toilets. The home has a wheelchair ramp at the entrance to the home, which is accessed through 2 double doors. There are handrails in corridors throughout the home and corridors range from 1.31 to 1.78 metres wide. There are also grab rails in all toilets and bath/shower rooms. The home has 2 mobile, one Standaid hoists and 3 bath hoists. In addition, there are slide sheets, a variety of slings for the hoists, alternating pressure mattresses, high risk mattresses and air flow cushions. Where required, advice can be obtained from a Physiotherapist. There is a laundry with 2 commercial washing machines (with sluice cycles) and one commercial tumble dryer. There are also separate staff employed for laundry services. Residents were very complimentary about the laundry service. Comments were, “my clothes are well looked after “ and “clothes can be returned to me on the same day”. Residents also spoke of how satisfied they were about the cleanliness of the home. Staff were seen to wash their hands thoroughly between residents and one member of staff commented, “we have just had refresher training on the subject of hand washing”. Ashwood Nursing Home DS0000002530.V275903.R01.S.doc Version 5.1 Page 17 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): 27 and 29 Staff are well trained and competent to deliver the care and support to the residents. Staff are correctly recruited. The number of staff was sufficient to meet the needs of the residents. All staff receive training to enable them to meet the needs of people living in the home. EVIDENCE: A new member of staff who had been recruited in September 2005 confirmed that they had been correctly recruited. Comments were, “I received a warm welcome and extensive training which has included, moving and handling training, fire prevention, nutrition, Parkinson’s disease and abuse prevention”. “This has lead me to study for an NVQ level 2”. Residents and visitors were satisfied with the availability of staff. Staffing levels have been increased since the last inspection to reflect the increasing dependency of the residents. Staff felt this had improved and allowed them to spend more times with residents. During the inspection staff were seen to attend to residents needs promptly. Visitors commented, “staff are very good” and “I always receive a warm welcome whenever I visit”. Ashwood Nursing Home DS0000002530.V275903.R01.S.doc Version 5.1 Page 18 Staff also felt they had sufficient time to care and offer support to the residents. Staff commented, “I enjoy putting a smile on the residents faces” and “I have time to spend with the residents”. The home is also a centre for nurses from other European countries undertaking an adaptation programme to enable them to be registered by the Nursing and Midwifery Council. The home also provides training for nursing students. A nursing student on her first placement commented, “this has been an excellent experience”, “I have had good mentorship” and “this has been a very valuable first placement”. The home has a written recruitment and equal opportunities procedure. All staff have been recruited in accordance with these regulations. Staff who have been employed since the 26/7/2004 have had both a POVA and Criminal Records Bureau (CRB) check. Staff confirmed this information. Ashwood Nursing Home DS0000002530.V275903.R01.S.doc Version 5.1 Page 19 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, 34, 35, 37 and 38 There is a competent, well trained, experienced and committed manager. There is a confident, supported and trained staff team. EVIDENCE: The registered manager who is a registered nurse has extensive nursing, teaching and management experience and has completed a recognised management qualification. She is also an assessor in teaching and clinical nursing practice. Staff felt safe working in the home and felt able to approach the manager if they had any concerns. Comments were, “ the manager is approachable and knows what is going on in the home”. There were also regular staff meetings. Visitors and residents commented, “we have an excellent manager”, “I have total confidence in the staff in the home” and “I am very satisfied”. Ashwood Nursing Home DS0000002530.V275903.R01.S.doc Version 5.1 Page 20 In order to obtain the views of people in the home satisfaction questionnaires are sent out to a sample of 5 residents every 6 months. Questionnaires are also sent every 4 months to visitors. The most recent survey results sent out in January 2005 were displayed in the entrance to the home. This showed satisfaction with the care and services provided by the home. The issues cover food, care and approach of staff. A representative of the registered provider visits the home weekly. A person acting on behalf of the registered provider carries an unannounced visit out monthly. A report is now being sent to the Commission for Social Care Inspection. Where requested the home can arrange to keep money on behalf of the residents. Where this occurs records of all transactions are kept and receipts given. The home can also at request, obtain legal and financial advice for any resident. The home has comprehensive policies and procedures for employment, induction, training and supervision. The home has detailed policies and procedures, which include clinical procedures. Care staff and nurses receive formal supervision 6 times a year. Records examined on the day of the inspection were found to be well maintained and up to date. The home also has an access to records policy and records were kept securely. Records examined and discussion with staff showed that all staff have received fire, moving and handling, first aid and health and safety training. Catering staff have received food and hygiene training. The home also has a detailed health and safety policy and where required, risk assessments have been undertaken. Window restrictors are installed to all windows on the first floor. Records examined showed regular tests of fire equipment, staff knowledge including fire drills. The fire risk assessment was reviewed by an outside consultant on the 3/10/2005. There were no concerns. Ashwood Nursing Home DS0000002530.V275903.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 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 x 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 x 9 x 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 x 3 x x 3 x x 3 3 STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 x 3 3 3 x 3 3 Ashwood Nursing Home DS0000002530.V275903.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. 1 Refer to Standard OP1 Good Practice Recommendations It is recommended that the statement of purpose and service user’s guide is reviewed to remove references to the National Care Standards Commission and insert the Commission for Social Care Inspection. In addition to remove references to a member of staff who no longer works in the home. Ashwood Nursing Home DS0000002530.V275903.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ashwood Nursing Home DS0000002530.V275903.R01.S.doc Version 5.1 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!