Inspection on 08/02/08 for Ashlee Lodge

This is the latest available inspection report for this service, carried out on 8th February 2008.

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 found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ashlee Lodge 14/02/06

Ashlee Lodge 09/08/05

Ashlee Lodge 03/02/05

Ashlee Lodge 03/08/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Ashlee Lodge 5 Jameson Road Bexhill on Sea East Sussex TN40 1EG Lead Inspector Michele Etherton Unannounced Inspection 8th February 2008 10:30a Ashlee Lodge DS0000061465.V347076.R01.S.doc Version 5.2 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 Ashlee Lodge DS0000061465.V347076.R01.S.doc Version 5.2 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ashlee Lodge DS0000061465.V347076.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashlee Lodge Address 5 Jameson Road Bexhill on Sea East Sussex TN40 1EG 01424 220771 01424 220771 ashleelodge@tiscali.co.uk 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) Ashlee Lodge Limited Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Ashlee Lodge DS0000061465.V347076.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated may not exceed five (5). That the category of registration be learning disability with challenging behaviour, not falling within any other category. Service users must be aged between eighteen (18) and sixty-five (65) years on admission. 21st November 2006 Date of last inspection Brief Description of the Service: Ashlee Lodge is a small detached Victorian house, providing residential and social care for adults with a learning disability and potentially challenging, or self-injurious behaviours. The home was re-registered in June 2004 under the ownership of the parent company, Allied Care Limited, which owns a large number of similar care homes, in the Southeast region. The home is registered for five people. Residents private rooms are on the first and second floors. There are sufficient communal spaces, including a spacious lounge, dining room a sensory room and bathroom facilities on each floor. The home is located in a quiet residential area of Bexhill-on-Sea, within easy walking distance from the shops and seafront. Fees Charged are £1350.00 to £1500.00 per week. Ashlee Lodge DS0000061465.V347076.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 2 star. This means the people who use this service experience good, quality outcomes. A Key inspection of this service has been carried out, which has included an unannounced site visit to the home on the 8th February 2008 lasting 5.5 hours; this has also included an appraisal of information received by CSCI about the home and from the home since the last inspection in November 2006. All key inspection standards except standard 2 have been assessed for this inspection. As no change has occurred to the present resident group since the last inspection standard 2 has not been assessed on this occasion. The site visit comprised a partial tour of the premises including some bedrooms and communal areas. Samples of documentation including support plans, risk assessments, medication administration records (MARS), and staff recruitment files were examined. Survey information has been distributed to relatives, people living in the home, staff, care managers and other professionals. People living in the home were observed and spoken with throughout the site visit; discussions were also undertaken with support staff, and the acting manager. Feedback from survey responses from staff and relatives has also been assessed. All these responses and observations have been influential in the compilation of this report. Since the last inspection there have been two adult protection alerts raised, these are now both closed and the home has taken appropriate action to better safeguard residents and their finances as a result. What the service does well: The home provides a pleasant, clean and comfortable environment for the people who live there. Residents have their own bedrooms, these are spacious, and they are supported to personalise them to their own taste. The home is well located within the town and makes good use of local facilities and ensures people in the home maintain a strong community presence. The home enables and facilitates the opportunity for people in the home to lead busy active lives and make choices and decisions about their daily lives. Ashlee Lodge DS0000061465.V347076.R01.S.doc Version 5.2 Page 6 The home has provided some opportunities for residents to become more independent, but there is scope for this to be extended to other areas of their daily routines. The home is supportive and enabling of the maintenance of family links and friendships for people living in the home. The home maintains good working links with multi disciplinary teams. Staff enjoy working at the home. “Generally I am very happy with the service I have regular contact with my sister” “The home helps clients reach their full potential” “Overall I think the home is a very good place for my daughter, she always seems contented, so if she is happy so am I, I don’t think there’s much room for improvement” What has improved since the last inspection? What they could do better: To better safeguard people in the home they are required to address a lack of consistency in the scheduled documents that should be retained e.g. references within staff files. In addition the home is unable to evidence that gaps in employment history detailed in application forms have been fully explored at interview or that verification of reasons for leaving previous care settings has been sought and recorded. The home is recommended to make improvements to present practice to: ensure all staff sign and date hand-written entries on medication sheets. Ashlee Lodge DS0000061465.V347076.R01.S.doc Version 5.2 Page 7 That restrictions imposed for individuals are fully discussed and debated within placement reviews by all relevant stakeholders. The current staff induction should be checked for compliance with skills for care and LDAF induction standards. That a training matrix is developed to identify individual staff and team training needs. That all staff experience a minimum of two fire drills annually and this is clearly recorded by the home. That the home publish the findings of quality assurance questionnaires and audits and evidence how these have influenced service development. 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. The summary of this inspection report can be made available in other formats on request. Ashlee Lodge DS0000061465.V347076.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 Ashlee Lodge DS0000061465.V347076.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Information provided to prospective residents about what the home provides should more accurately reflect the dual use of some parts of the communal accommodation. People are admitted to the home only after an assessment of their care and support has been undertaken and made available to the home to inform their decision-making. EVIDENCE: A tour of the premises indicated that some communal rooms have a dual purpose, e.g. sensory room/staff sleep in room, dining room/activities area. Consideration should be giving to updating information given to prospective residents and their representatives regarding accommodation and resources within the home as this may have a bearing on their decision-making. The home is currently full and no new admissions have been made since the last inspection. The manager has reported that in the event of vacancies arising the admissions procedure would be implemented. This requires that all prospective resident referrals be only considered following a comprehensive assessment of their needs and the ability of the home to support them. Ashlee Lodge DS0000061465.V347076.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service user plans are detailed and provide staff with information about individual support needs. People living in the service mostly make decisions about their day-to-day lives including taking responsible risks; there is scope to extend decision-making opportunities to all areas of their day-to-day routines. EVIDENCE: Two out of five care plans were examined during the site visit. These are detailed and show evidence of updating and internal and external review processes, although timescales in respect of the latter have slipped in one case in particular, but lies outside the control of the home. Staff had a good understanding of individual user needs and support but service user plans would benefit from being in a more accessible format with clear goals and aspirations recorded. Ashlee Lodge DS0000061465.V347076.R01.S.doc Version 5.2 Page 11 Observation of residents during the site visit and discussion with the acting manager indicated that the home promotes decision making and choices by individuals and supports them to do so by using communication resources relevant to their needs. Opportunities for having more involvement and control in some areas of daily activity deemed of a higher risk could be improved upon with staff supervision e.g. medication, finances, access to the garden, holding own room key, answering the door with staff. Risk assessments are in place and evidence that these are reviewed as required. Ashlee Lodge DS0000061465.V347076.R01.S.doc Version 5.2 Page 12 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): 12,13,15,16,17 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People in the home lead busy, active lives making use of community and in house resources; they are supported to maintain relationships. People in the home are encouraged to make decisions and choices but the scope for this could be broadened. They enjoy a varied and wholesome diet. EVIDENCE: Home staff when not attending to work around the house were observed in close contact with residents either sitting conversing or undertaking an activity with them. There is a good range of activity materials in the home for use with residents. Contacts between staff and residents were seen to be adult, friendly and encouraging. People in the home have individual programmes of activities, some use is made of college, and the home ensures that everyone has regular opportunities to access the local community and its facilities maintaining a Ashlee Lodge DS0000061465.V347076.R01.S.doc Version 5.2 Page 13 strong community presence. Those residents spoken with during the visit, confirmed contacts with families and access to holidays away with home staff. The acting manager is hopeful that this opportunity can be extended to all the people living in the home this year, where this has not previously been the case. The home is well staffed to ensure a good level of support is available to people in the home when accessing activities inside and outside the home. Relatives report that: “My daughter seems to be happy where she lives”, “Generally I am very happy with the service I have regular contact with my sister” “The home helps clients reach their full potential” An Aroma therapist session was in progress during the site visit and discussion with some residents confirmed this was a regular event, which they clearly enjoyed. The therapist confirmed she has worked with some of the people for some time and that there had been a steady progression in gaining their trust and them allowing her to provide head massage in addition to hands and feet. Residents clearly enjoyed the experience and one was relaxing having a cup of tea whilst receiving head massage. People in the home have opportunities to make simple decisions about their everyday lives, and are supported in their communication by use of reference objects, pictorial prompts etc. Promotion of independence and innovative ways of working with residents has been somewhat stifled by the previous style of management, and there is scope for enabling people in the home increased freedoms appropriately risk assessed e.g. keys to bedrooms, access to the garden, involvement in medication under supervision. The acting manager feels that both she and longer-term staff have been inhibited in taking a more proactive approach to working with individual resident. This is now changing although she acknowledges there is some way to go. People enjoy the meals they receive which are freshly cooked in the home and staff take account of individual preferences and needs in respect of eating. Meals are taken in the dining room, which would benefit from some reorganisation of furniture and storage of activity materials. Ashlee Lodge DS0000061465.V347076.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home have their personal and health care needs met. EVIDENCE: Examination of documentation, observations of staff responses to situations, discussion with the acting manager and support staff indicated that people living in the home are mostly supported in accordance with their own preferences. They choose whom they wish to support them with personal care, and the home can offer female staff support for this at all times. Staff practice was observed to protect the privacy and dignity of individuals. People in the home are helped to access routine or more specialist healthcare appointments, records of health contacts are maintained. The home makes appropriate referrals to health care professionals and maintains a good relationship and communication with multi disciplinary teams in the best interests of the people in the home. The home ensures that only staff trained in medication administration undertake this role in the home, relevant signature records were noted for this Ashlee Lodge DS0000061465.V347076.R01.S.doc Version 5.2 Page 15 An examination of current medication (MAR) sheets, highlighted handwritten entries are not routinely being signed and dated. The acting manager demonstrated an awareness of good medication practice and has already addressed this matter with staff. Clearly some staff are not adhering to agreed practice and will need to be reminded of this and this is a recommendation. It is important for the acting manager to monitor the satisfactory completion of medication records and to take appropriate action where this is not happening. The home has implemented some good practice around the recording of individualised PRN medication guidelines. People living in the have are not involved in their present medication regime and thought should be given to how they can take a more active role under the supervision of staff. Since the last inspection, improvements have been made to the storage of medication separating external preparations from oral medications. Ashlee Lodge DS0000061465.V347076.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People feel confident about raising concerns with staff but some need reminding of how to progress a complaint. Systems are in place to better protect people living in the home from harm or abuse. Restrictions and their rationale are clearly documented by the home but should be more widely discussed with all stakeholders, and the evidence to support their continuation reviewed. EVIDENCE: The home has reported in pre-inspection information to CSCI that only one complaint has been received by the home and this has been resolved. No complaints have been received by CSCI about the home since the last inspection. Some relatives indicated in survey feedback, that whilst they had no concerns in approaching the home staff with their concerns, they did not have a full understanding of how to formally make a complaint if they so wished. As it is some years since most of the present people in the home were admitted, it is suggested that the home re-issue this information to families and friends. Ashlee Lodge DS0000061465.V347076.R01.S.doc Version 5.2 Page 17 A training programme has been implemented to ensure that staff have access to important training i.e. adult protection, managing challenging behaviour and appropriate use of restraint. Service user plans indicated that the home has developed guidelines for staff to follow in the management of individual behaviours, and restrictions imposed are clearly recorded with the rationale for these. There is scope for the home to revisit some of the current restrictions in place, as they have not clearly evidenced how these decisions have been arrived at. It is recommended that any restrictions are openly discussed within review settings to ensure that funding authorities, residents, families etc are fully aware of them and can debate their implementation. Two adult safeguarding alerts have occurred since the last inspection, these have been fully investigated and now closed. As a result of one of these alerts the home has made some changes in the way it manages the finances of people living in the home. The home has been proactive in supporting one client to access their money by themselves, and consideration should be given as to how and if this could be extended to other residents now, who should also be enabled to have more involvement in other aspects of their daily life. A check of financial records and cash balances for two people living in the home were found to be accurate. Ashlee Lodge DS0000061465.V347076.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home generally provides a clean, and homely environment that would benefit from being more reflective of the residents and their interests. EVIDENCE: The home mostly offers a clean, bright and pleasant environment that is well maintained and has a programme of planned maintenance. The Acting Manager acknowledged that the hallways and stairwells would benefit from more homely touches and has plans to make these changes; she is keen for the home to be more reflective of the client group and people living there. A problem with odour on the top floor has been mostly addressed, there remains a slight underlying odour and the acting manager was reminded of the need to ensure that air fresheners in place are replaced and increased where necessary for the benefit of the individual concerned and other people on that floor. Paintwork on bottoms of doors and along sills on the stairs in this area Ashlee Lodge DS0000061465.V347076.R01.S.doc Version 5.2 Page 19 would benefit from improved cleaning and this was pointed out to the manager, this was not reflected elsewhere in the home. Some thought should be given as to whether bare light bulbs are necessary on stair landings or whether a small cover can be provided that provides a more pleasing look. The home offers a sensory room as a stated resource but this is also a staff sleep in room. Whilst these two functions do not impact on each other the dual use of this room should be clearly stated within service information for prospective residents as there could be an assumption that this is a sensory room only. Some of the people in the home have their own sensory lights and these can be moved around to wherever they want to be either in their bedroom, the sensory room or the lounge. Much of the sensory work takes place in the lounge, which has large comfortable seating, and a pleasant relaxing environment. None of the present residents have room keys, rooms are generally kept locked during the day. Whilst there are sufficient staff available for residents to access their bedroom without waiting, the rationale for them not having keys should be revisited on an individual basis and tested out. There is scope for some people in the house to have responsibility for their keys or to have keys that they ask for from staff to open their rooms. The dining room serves the dual purpose of dining and activities area, and also contains a desk and chair for staff, consequently it is cluttered, and less pleasant that its sunny location onto the garden would suggest. Consideration should be given as to whether there needs to be a desk and chair in the room for staff, and whether this impacts on the homely environment they are trying to create. Also a rearrangement of furniture and better use of storage for activity equipment would benefit the overall appearance of this room. The home has addressed a previous recommendation to provide staff with paper hand towels in the staff toilet to promote improved infection control. The home benefits from a small but well kept patio style rear garden, one resident confirmed that they use the garden from time to time. The garden is fairly secure but residents are unable to access the garden unless supervised, owing to staff concerns at possible absconding. Consideration should be given as to whether this is a risk for some people and not others and whether some people could access the garden independently. An environmental health officer visit has occurred since the last inspection and the home has already implemented a good practice recommendation from that visit. Ashlee Lodge DS0000061465.V347076.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There are enough competent staff on duty at all times. All necessary checks are undertaken to ensure suitability of staff but this would benefit from improved recording and examination of employment histories. Training is provided to ensure staff have the necessary skills and competencies to support people in the home. EVIDENCE: Four staff were on duty at the site visit in addition to the acting manager who reported that the staffing level is usually 3:5 with an extra staff member between 9-5 during the week at most times. At night there is one waking and one sleep-in staff member. A staff survey comment reported that sometimes there are not always enough staff, but this was not supported in either conversations with staff or the acting manager at the visit or feedback from relatives. Staff were visibly sitting with residents and encouraging them in activities or conversation. A programme of training to ensure staff have the necessary basic skills to support people in the home is provided. One staff survey Ashlee Lodge DS0000061465.V347076.R01.S.doc Version 5.2 Page 21 comment indicated that staff do not always have the right skills. Whilst this again was not supported in discussions held with members of staff on duty during the visit, the acting manager should ensure that where staff’ identify gaps in knowledge and skills, these are met through the training programme. The home has a high number of overseas staff; a recent audit of documentation by the immigration service identified that there were irregularities in the papers of three staff employed by the previous manager, as a consequence of these findings the staff have now left and the home is recruiting to these vacancies; CSCI has not been formally advised by the home of this incident. New staff are provided with induction training that includes the completion of a workbook. The acting manager was unclear whether this complied with skills for care induction standards and incorporated LDAF, it is recommended that this is checked and any gaps and omissions incorporated. Three new staff files were examined; these highlighted a lack of consistency in the documentation made available to the home either by head office or the recruitment agency used for overseas staff. Some files contained references and others not, in addition there was no evidence that the recruitment process had explored gaps in employment with applicants. The home is required to ensure that staff files contain copies of the scheduled documents to ensure that minimum suitability checks have been undertaken and can clearly evidence that gaps in employment histories have been fully explored and that reasons for leaving previous caring roles have been verified. Because of the communication difficulties for some people living in the home it is important that support staff can understand them and also be understood. The home actively encourages overseas staff to improve their spoken English. Two overseas staff on duty on the day of the visit had a good command and understanding of English and their spoken responses were very good. One relative reported that “there are members of staff I meet when I visit my daughter, they seem reluctant to spend time with me or to forward any information. It is unclear from this comment whether this may be due to staff lacking confidence in their spoken English, or their authority to engage with relatives and is area that the acting manager should work with staff on. Staff spoken with reported that they felt well supported by the manager, that they had opportunities to meet with her on their own and were given access to formal training, People living in the home have no clear role within staff recruitment at present and consideration should be given as to how they can be included within the process. Ashlee Lodge DS0000061465.V347076.R01.S.doc Version 5.2 Page 22 The home has an active formal NVQ training programme, has more than 50 of staff trained and has a rolling programme of providing new staff with mandatory training and updating others. Staff spoken with confirmed attendance on both basic skills training and NVQ courses. The acting manager has implemented individual staff training files and would benefit from developing a training matrix to keep track of gaps in skills and training and this is a recommendation. Ashlee Lodge DS0000061465.V347076.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The acting manager has ensured that people continue to receive the support they need during a period of change. She has identified shortfalls within the service and areas for development that will enhance the experience of people living in the home. The health safety and welfare of those in the home is promoted and protected. EVIDENCE: The acting manager has tried to maintain stability for the people in the home and staff during a period of change following the sudden departure of the previous manager and a number of difficult events over the past year. She acknowledges that she has not completed all the required training expected of a registered manager and is still to make application to register. Feedback Ashlee Lodge DS0000061465.V347076.R01.S.doc Version 5.2 Page 24 from staff and relatives indicates that they feel she has succeeded in maintaining the good outcomes for people in the home and a good quality of care and support overall. “The acting manager always sits down with me and I always feel well informed” “Overall I think the home is a very good place for my daughter, she always seems contented, so if she is happy so am I, I don’t think there’s much room for improvement” The completed AQAA returned for the inspection would benefit from improved detail as this failed to illustrate any areas identified for improvement, or what the home felt they could do better or future planning. These omissions were discussed at the site visit, and it was acknowledged that this was a first experience for the acting manager of preparing for an inspection. Since taking on the present role the acting manager has actively sought to address shortfalls within the service that impact on the people living in the home. She has implemented a new finance system for the monitoring of expenditure of client monies to better safeguard them. All requirements from the previous inspection have been addressed and all but one recommendation for improved practice implemented. There are sound policies in place these are updated at a corporate level, with copies sent through to the home. Records viewed were mostly in good order and evidenced updating. There are already good quality assurance systems in place, including internal auditing by the company. Some residents have communication problems and the home has developed boxes of reference objects, pictures etc to engage individual residents in making choices and decisions on a day to day basis. Their views about the service are sought, however, analysis of these and the publication of quality assurance findings and how residents views are incorporated into the whole and influence change remains an outstanding recommendation. A check of the servicing certificates revealed that the PAT (portable appliance testing) has been carried out within the last year and the electrical installation is not due for rechecking until May 2008. A review of the accident book revealed that accident levels in the home are minimal. The fire book indicated that health and safety checks are being undertaken weekly and that this includes testing of fire equipment and alarm system. Staff attend fire training and have fire drills, the frequency and attendance at drills Ashlee Lodge DS0000061465.V347076.R01.S.doc Version 5.2 Page 25 is not recorded sufficiently to ensure that all staff attain the necessary experience to ensure they are prepared and act appropriately in the event of an incident. It is recommended that all staff have participated in at least two fire drills within a 12-month period and evidence of this should be recorded Ashlee Lodge DS0000061465.V347076.R01.S.doc Version 5.2 Page 26 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 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 4 14 X 15 4 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 3 X X 3 X Ashlee Lodge DS0000061465.V347076.R01.S.doc Version 5.2 Page 27 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. 2. Standard YA34 Regulation 19 (1-7) Schedule 2(6) Requirement Staff files must contain the range of documents specified within schedule 2 of the Care Homes Regulations 2001. The home must evidence clearly that gaps in employment histories have been explored and that verification has been sought of reasons for leaving previous care roles where this does not feature as a reference. Timescale for action 08/04/08 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 YA23 Good Practice Recommendations All handwritten entries on MAR sheets are to be signed and dated by the staff entering the information All restrictions imposed on individuals must be openly DS0000061465.V347076.R01.S.doc Version 5.2 Page 28 Ashlee Lodge 3. YA35 discussed and debated with relevant stakeholders within annual review The current induction package to be checked for compliance with skills for Care and LDAF induction standards and any omissions addressed A training matrix to be developed to identify individual and staff team training needs The registered manager to publish the findings of quality assurance questionnaires and audits. Home to evidence clearly that individual staff have participated in a minimum of two fire drills annually. 4. 5 YA39 YA42 Ashlee Lodge DS0000061465.V347076.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Ashlee Lodge DS0000061465.V347076.R01.S.doc Version 5.2 Page 30 - 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. 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