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Archived: Ash Cottage Requires improvement

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Inspection report

Date of Inspection: 8 May 2014
Date of Publication: 4 June 2014
Inspection Report published 04 June 2014 PDF | 94.56 KB


Inspection carried out on 8 May 2014

During a routine inspection

During the inspection we spoke with six people who used the service, one visitor, three members of staff and a visiting professional. We also spoke with the registered manager/owner and with the local authority. We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask;

• Is the service safe?

• Is the service effective?

• Is the service caring?

• Is the service responsive?

• Is the service well-led?

This is a summary of what we found:

Is the service safe?

Everyone was very happy with the care and support they received. Comments included, "It's a lovely place; I have no concerns about anything" and "I can choose what I want to do; staff respect my choices". A visitor told us they were very happy with the care and support given to her relative. They said, "My mother is genuinely loved".

People told us they were happy with the staff team and said there were enough staff to meet their needs. Comments included, "They are lovely girls" and "There are enough staff and they are friendly, caring and kind".

People’s records about the care and support they needed and a number of policies and procedures were not up to date, kept under review or accurate. We were told the care records were currently being updated which should ensure they accurately reflected people’s needs and the care and support being given. A compliance action has been set in relation to this. The provider must send us an action plan advising how they will address this.

People told us they enjoyed the meals. Comments included, "The food is very nice" and "I am asked what I would like; if I don’t fancy what is on the menu they get me something else". We observed staff being attentive and supportive during the lunchtime meal. People were supported to eat and drink sufficient amounts to meet their needs.

Staff had received training in relation to the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). This should help staff to understand their responsibilities with supporting people to make their own decisions. We noted staff did not have current guidance to refer to if a referral was needed to safeguard a person’s best interests.

Is the service effective?

Reviews were carried out to record any changes in people's needs. We found reviews were not always done on a regular basis or in response to changes in people’s health. They did not show people’s involvement in discussions about the care they needed and wanted.

We were told the owner worked as part of the staff team, listened to people’s views and responded appropriately. However, there were no formal systems in place to demonstrate regular monitoring of the service. Effective monitoring systems should help to protect people from poor care standards and should identify any areas of non-compliance as noted in this report. A compliance action has been set in relation to this. The provider must send us an action plan advising how they will address this.

Is the service caring?

We saw staff interacting with people in a kind, pleasant and friendly manner and being respectful of people's choices and opinions. It was clear from our observations and discussions with staff they were competent and confident in their work and had a good understanding of people’s needs. Some of the care staff had achieved a recognised qualification in care. This should give them the skills they needed to help them look after people properly. Staff also told us they enjoyed working at the home and described it as "A big family".

We found the care plans contained some useful information about people's preferred routines and likes and dislikes. This should help staff to look after them properly and ensure people received the care and support they needed and wanted.

Is the service responsive?

People told us there were opportunities for involvement in activities. Comments included, “There is always something to keep us interested", "I prefer to do my own thing and spend time in my room" and "We are not bored".

We found appropriate advice had been sought when people’s health had changed. The service had good links with other health care professionals to make sure people received prompt, co-ordinated and effective care.

People told us they were kept up to date and involved with any decisions about the care they needed and about how the service was run. However, the last customer satisfaction survey had been completed some years ago and there had been no resident or relative meetings to show how their views had been obtained or used to improve the service.

People told us they had no complaints about the service but were confident they could raise their concerns with the staff or managers.

Is the service well led?

We were told the manager/owner worked closely with staff and was well known to people using the service and to their visitors. Staff told us the management team was very supportive and worked closely with them. Staff were aware of their responsibilities and were able to raise any concerns.