Inspection on 23/04/09 for Ashdale

This is the latest available inspection report for this service, carried out on 23rd April 2009.

CQC found this care home to be providing an Excellent service.

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.

Other inspections for this house

Extracts from inspection reports are licensed from CQC, this page was updated on 18/02/2010.

Key inspection report CARE HOME ADULTS 18-65 Ashdale 14 Beresford Park Sunderland SR2 7JU Lead Inspector Andrea Goodall Key Unannounced Inspection 23rd April 2009 09:00 Ashdale DS0000068282.V375266.R01.S.doc Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Ashdale DS0000068282.V375266.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Ashdale DS0000068282.V375266.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashdale Address 14 Beresford Park Sunderland SR2 7JU 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) 0191 515 4656 Tyne and Wear Autistic Society Peter James Mountain Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Ashdale DS0000068282.V375266.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following category 2. Learning Disability - Code LD, maximum number of places 4 The maximum number of service users who can be accommodated is 4 Date of last inspection Brief Description of the Service: The small care home at Ashdale is a family house that provides 4 places for young adults with Autistic Spectrum Disorder. It is owned and operated by the North East Autism Society (formerly known as Tyne & Wear Autistic Society), which operates several care and educational services for children and adults. The house is a detached two-storey property in a desirable residential area near the City centre. It is sited on a private road with gated access. The home is only intended for use by young adults who are physically fit and mobile. However it has ramped access at the front entrance for any visitors who may have mobility needs. The ground floor comprises a large lounge with a split level area. There is a family sized kitchen/diner, utility room, shower room with WC, and staff office (that will double as a staff sleep-in room). On the first floor there are 4 good sized bedrooms and two bathrooms. The home is near to the City centre shops, pubs and sports centres. Residents also have use of a family-sized vehicle for transport to other facilities. The weekly fee is based on an individual assessment of needs and is agreed with the local placing authority. The Society should be contacted for up to date information about fee levels. Ashdale DS0000068282.V375266.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 stars. This means the people who use this service experience excellent quality outcomes. Before the visit: We looked at: • information we have received since the last inspection visit on 25/04/07 and annual service review on 27/03/08 • how the service dealt with any complaints & concerns since the last visit • any changes to how the home is run • the Provider’s view of how well they care for people in their annual quality assurance assessment (called an AQAA) The Visit: An unannounced visit was made to the home on 23/4/09. During the visit we: • talked with people who use the service, staff and the manager • joined residents for a meal and looked at how staff support the people who live here • looked at information about the people who use the service & how well their needs are met • looked at other records which must be kept • checked that staff had the knowledge, skills & training to meet the needs of the people they care for • looked around parts of the building to make sure it was clean, safe & comfortable • checked what improvements had been made since the last visit We told the manager what we found. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations – but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. What the service does well: People who come to live here have good chances to look around and try it first, if they want. Staff keep records called care plans about how people are learning to do things for themselves. The records also show what people can do for themselves and what they need help with. Ashdale DS0000068282.V375266.R01.S.doc Version 5.2 Page 6 People go out to lots of different activities that they choose. Staff help people to talk about what they would like to do. Everyone joins in the housework and doing the shopping. People enjoy healthy, tasty meals that they help to make. The house is very nicely decorated and furnished. It is modern and bright so it is good for the young people who live here. Everyone has a big room where they can spend time in private if they want. Staff have lots of training so they know how to help people in the right way. Staff have lots of training in health and safety so that they know how to keep the house safe for the people who live here. The manager makes sure that the home is run in the best way for the people who live here. What has improved since the last inspection? What they could do better: There were no requirements made at this inspection. Two recommendations might make the service even better. It would be better if the information about medication was printed onto the medication records by the pharmacist. It would be better if the two people who do not have chairs in their bedrooms could choose these. Ashdale DS0000068282.V375266.R01.S.doc Version 5.2 Page 7 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Ashdale DS0000068282.V375266.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ashdale DS0000068282.V375266.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2. People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have a full assessment of their needs before they move here so they can make sure that Ashdale can meet those needs. EVIDENCE: The home has a Statement of Purpose and a Service Users Guide that are written in plain language. Following a requirement at the last inspection the Service Users Guide now includes some brief information about Ashdale in pictures and photographs to help people understand what it is like at the home. The manager plans to support residents and staff to produce their own picture/video brochure about Ashdale so that they could give it to prospective new residents. Since the last visit two years ago, there have been three changes to the resident group. It is very good practice that two people have been supported by the Provider to move into semi-supported living arrangements in their own home area of Durham. One other person’s needs have changed so he has moved to another home run by the Provider where his needs can be better met. Ashdale DS0000068282.V375266.R01.S.doc Version 5.2 Page 10 Over the past year three new people have moved into the home. North East Autistic Society has very clear guidelines about referral and assessment to its services. Before any new resident moves to Ashdale, their needs are fully assessed by social, health care and educational professionals. The prospective residents, their relatives and the registered manager of the home are also involved in making a decision about whether Ashdale can meet their needs. The three new people had already been using the Society’s educational services so there has been continuous and comprehensive assessments of their needs. Each person had a 3-day residential assessment (either at Ashdale or another similar house). All new residents have a period to adjust to the home and to see if the home can provide the right care for their individual needs. A review is then held after around three months to see if the placement is successful. Ashdale DS0000068282.V375266.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Clear care planning means that residents are supported towards achieving their goals. People are supported to make their decisions and to take acceptable risks so that they have a lifestyle that promotes their independence. EVIDENCE: Support plans (or care plans) are records that are used by all care services to show what sort of support each person needs and how staff should provide that care. At Ashdale there are individual support plans in place for each of the people living here. These records are detailed and show each persons abilities and strengths, as well as a baseline assessment of their support needs. From these assessments a small number of independent lifestyle goals (SMART targets) are set out for each person to work towards. For example, ironing their own clothes, Ashdale DS0000068282.V375266.R01.S.doc Version 5.2 Page 12 cooking, and learning how to manage their own finances. The plans show detailed instruction for staff about how to help people towards their goals, and a monthly record is kept of the progress they have made so far. The aim of Ashdale is to support people to maximise their independent living skills so that they can move on to semi-supported living in the future. It is very good that a goal for one person is to learn how to travel independently. It was clear from talking to some residents that they are involved in their own care records where they can be. For example, one person completes their own finance records, and one person has written a list in his care file of his likes and dislikes of places, activities and foods. Support plans are discussed between staff and the individual resident. Care files are kept in the office/sleep-in room and so are accessible to residents at most times. The people who live here are encouraged to make their own choices and decisions, such as their appearance, clothes, menus, activities and holidays. One person said, “One of the best things about this home is that we can make a lot of our own choices ourselves.” People living here have good verbal communication skills but some people find it very difficult to make choices. The Society now employs two Speech & Language Therapists who are working with these residents to help them find ways of making decisions and expressing their own choices. Also there is now a computer in the home so that residents can use internet websites to provide them with visual information to support choices, for example holiday destinations, activities and social events. The people who live here are supported to take acceptable risks to maximise their independent lifestyle. There are detailed risk assessment records in place to show whether the risks are acceptable and manageable. For example, using kitchen equipment, rock climbing, and keeping their own front door key. It is good practice that the risk assessment records are sent to parents and social workers for their information, and are reviewed at least annually (or more often if necessary). Ashdale DS0000068282.V375266.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: 12,13,15,16 and 17. People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have excellent opportunities to engage in activities so that they enjoy a fulfilling lifestyle. EVIDENCE: The young people who live here have busy and purposeful daytime occupations. Three people have just finished school and now attend the Society’s college. One other person does gardening, some administrative work at the college offices, and works one day a week as a volunteer of a museum library. This person is also being supported to look for some paid employment. Every evening and week-ends the home staff make sure that they also have very good opportunities to take part in any leisure activities that they enjoy. For example some Ashdale DS0000068282.V375266.R01.S.doc Version 5.2 Page 14 people like the theatre, cinema and discos, whilst others like rock climbing, trampolining and bowling. The home is a former family residence and is indistinguishable from other properties in this area. It is very close to the city centre so people have a good range of shops and leisure resources nearby. In this way people are supported to participate fully in their local community. The people who live here are not from Sunderland so they are supported to keep in touch with their relatives, if they want, by telephone, mobile ‘phone, email and visits to their family home. Ashdale has records to show that it continues to have very good contact with all parents, sending them any new information from the Society informing them of incidents or events. Staff encourage and promote conversations with residents to involve and include them in discussions and decisions about their own home. Staff are supportive and clear in their discussions with the people who live here. People have written information in their care files about their rights and what to expect from the service here. There are also regular house meetings which reinforce their rights to make decisions about the running of the home. It was clear from discussions with people and staff that everyone is fully involved in menu planning, grocery shopping and preparing meals. The home has a large, well-equipped family kitchen with a large dining table where residents and staff can dine together. Meals continue to be nutritious, healthy and suit the age and preferences of the young people who live here. Ashdale DS0000068282.V375266.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. 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. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive very good support to access health care services so that their health and welfare is well met. EVIDENCE: The four people who live here are young and physically fit. They are able to manage their own personal care needs, with occasional verbal prompts and guidance. No-one needs physical support. It is very good practice that since the last inspection the people who live here now have access to two Speech and Language Therapists and an Occupational Therapist who are employed by the Society. In this way people who need support with their communication or decision-making needs now have better access to these resources. All four people are registered with a local GP. The home also makes sure that everyone has access to any community or specialist health care services when needed, such as psychology and specialist nursing services. Ashdale DS0000068282.V375266.R01.S.doc Version 5.2 Page 16 It is good practice that one person has been supported to manage their own medication on a weekly basis, as part of their continuing progress towards independence. There is a clear risk assessment in place about their capability to manage this and their ability to keep it secure stored in their bedroom. The home is now looking to support this person to order their own medication now. This shows that staff are very positive in their promotion of peoples’ independence. The remaining three residents have only recently moved into the home. At this time they have not yet been assessed as capable of managing their own medication so senior staff do this for them. Each persons care records includes comprehensive information about their medical background, and a consent from their GP about medications that they can (or cannot) take. Medication is delivered to the home by a local pharmacist in suitable containers that make it easy for staff to give the right medication at the right times. Medication is securely stored in a locked, alarmed medication cupboard. Records of the administration of medication are generally in good order, and are signed by staff and by the respective resident so that they are included and involved in this task. At this time the details of one person’s medication has to be hand-transcribed onto the record by staff, rather than being pre-printed onto the record by the pharmacist. Ashdale DS0000068282.V375266.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have good information so that they know how to make a complaint. Staff are well trained in safeguarding adults so residents are protected from potential abuse. EVIDENCE: The home has a clear complaints procedure, which is also in picture format to help the communication needs of the people who live here. It is placed in each person’s file which they have access to at most times. Staff ask residents for their comments at their regular house meetings to see if they are unhappy with anything. Relatives have frequent contact with the home and are also asked formally at annual reviews if they have any concerns with the service. Those people who took part in discussions said that they would feel able to discuss any concerns with staff or the manager. The home keeps a complaints record, but there have been no complaints or concerns about this service since it opened over two years ago. All staff receive training in the City of Sunderland Safeguarding Adults procedures, which are robust procedures for dealing with suspected abuse. In this way staff are aware of their responsibilities to report suspected abuse. A senior manager of the Society has been designated as the organisations Safeguarding Adults Manager, and he takes responsibility for co-ordinating information and training about the safeguarding adults policies. All staff are trained in CALM (Calm Aggression-Limitation Management) which is a method of using the minimum of physical intervention if someones behaviour places them, Ashdale DS0000068282.V375266.R01.S.doc Version 5.2 Page 18 or others, at risk of injury. The manager is a trained Trainer in CALM so he is able to ensure that any new staff also receive this training. CALM methods mainly use redirection, and time and space for people to calm down by themselves. It is approved by the British Institute of Learning Disabilities and ensures that all staff present a consistent, safe approach when supporting residents when they are upset or angry. Detailed records are kept whenever people have needed CALM support. Ashdale DS0000068282.V375266.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27 and 30. People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in excellent quality accommodation that values their lifestyle. EVIDENCE: Ashdale is a family-house that has been refurbished to provide a homely, comfortable home for the 4 people who live here. It is a desirable property in a pleasant residential area near the city centre. Overall the home is decorated and furnished to an excellent standard, and in keeping with the age and interests of the residents. The Society has its own maintenance team that visits the home on a weekly basis to carry out fire tests and to address any minor repairs. In this way these items can be addressed quickly. At this time the wood cladding in the kitchen has started to crack in places. Also the front garden is ready for attention. Otherwise the home is an excellent state of repair. Ashdale DS0000068282.V375266.R01.S.doc Version 5.2 Page 20 People said that their house is a good place to live. One person said, “It’s a very nice house.” Everyone has a big bedroom and their own key so they can keep it private. People have their own televisions and enjoy spending some time in their bedrooms. However at least two people do not have a chair in their room to use. There are plenty of bathrooms for everyone to use, with two bathrooms on the first floor, a shower/toilet and separate toilet on the ground floor room. One person said they were pleased that they were able to have sole use of one bathroom, and that the male residents had use of other bathrooms. Most staff have had training in Infection Control and new staff receive this as part of their induction training. The home was very clean throughout. Residents are supported by staff to carry out their daily household tasks, including laundry. Ashdale DS0000068282.V375266.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides suitable, competent well-trained staff so that peoples needs are met. EVIDENCE: The staff team currently consists of the registered manager, two senior staff and three support staff. At this time there are no male staff other than the manager, and he will transfer to another post in the near future. Whilst the current residents do not have any physical care needs, it may be that they would also benefit to positive male role models. However, the Society is an equal opportunities employer and generally this field of employment attracts mainly female applicants. North East Autistic Society operates very thorough recruitment and selection procedures. Staff are only employed after suitable clearances and checks have been received, including a satisfactory CRB disclosure (police check). Residents have the chance to meet applicant staff during evening visits to see if they have a suitable personality that values and supports young people with Autism Spectrum Disorder. Ashdale DS0000068282.V375266.R01.S.doc Version 5.2 Page 22 Since the last inspection recruitment practices have changed so that the manager is now fully involved in the recruitment process, including shortlisting and interviews. The organisation has an HR department that deals with personnel records. It is good that home managers will now also have copies of the personnel records in order to support them in their management of staff. All new staff receive thorough induction training that includes in-depth workbooks in Autism Spectrum Disorder, Safeguarding Adults, CALM and all health & safety training. They then have the opportunity to train towards a professional care qualification called NVQ (national vocational qualification) in care. At this time three of the six staff have achieved NVQ level 3 (including the manager). The remaining three staff are new and will be working towards NVQ awards after they complete their induction training. In this way the Society aims for all staff to be trained in a care qualification. The home keeps clear records of individual learning plans and training course that each member of staff has attended. It is evident that the Society remains committed to staff training and their professional development so that residents receive support from welltrained, competent staff group. Ashdale DS0000068282.V375266.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. 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 home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people who live here benefit from a well-managed service. Systems, procedures and practices make sure that the health & safety of the people who live here are promoted. EVIDENCE: The current Registered Manager has several years experience of working in care settings with younger adults with autism, and has been registered as the manager of Ashdale since it opened over two years ago. He has attained NVQ level 4 and the Registered Managers Award, which are suitable qualifications for a manager of a care home. He is also currently undertaking a certificate in Autism Spectrum Disorder, which demonstrates his commitment to updating his skills and competence in this specialised area of care. Ashdale DS0000068282.V375266.R01.S.doc Version 5.2 Page 24 There remain clear lines of accountability and management support within the organisation. In this way the residents, and staff, benefit from a well managed service. The Society has a comprehensive quality assurance process to review the service provided at Ashdale. This includes seeking the views of residents through house meetings, annual reviews and occasional picture questionnaires. For example a pictorial survey was carried out in March 2009 to ask residents about their likes and dislikes of the service. For example one person wrote that he “likes all the activities apart from the disco”. It is also very good practice that the Society employs an external consultant to visit all its homes, including Ashdale, on a monthly basis and report back on its operations. Staff training records demonstrate that all staff receive statutory training in all health & safety matters, although the manager commented on the challenges of getting new staff trained quickly in these topics. The home carries out monthly health & safety audits, including checks of appliances, windows, and door security. In this way the safety and welfare of residents is promoted and protected. Ashdale DS0000068282.V375266.R01.S.doc Version 5.2 Page 25 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. 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 3 2 4 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 4 23 4 ENVIRONMENT Standard No Score 24 4 25 x 26 3 27 4 28 x 29 x 30 4 STAFFING Standard No Score 31 x 32 3 33 x 34 4 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 x 4 x LIFESTYLES Standard No Score 11 x 12 4 13 4 14 x 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 X 3 x 4 x x 3 x Version 5.2 Page 26 Ashdale DS0000068282.V375266.R01.S.doc 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. 2. Refer to Standard YA20 YA26 Good Practice Recommendations It would be better if the details of a resident’s medication (e.g. times, dosage and strength) were pre-printed by the pharmacist onto the Medication Administration Record. The two people without chairs in their bedrooms should be offered the chance to choose these. Ashdale DS0000068282.V375266.R01.S.doc Version 5.2 Page 27 Care Quality Commission North Eastern Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.northeastern@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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