Inspection on 01/08/06 for 134 Ashland Road

This inspection was carried out on 1st August 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

134 Ashland Road 17/01/06

134 Ashland Road 02/09/05

134 Ashland Road 31/03/05

134 Ashland Road 28/02/05

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 134 Ashland Road Sutton In Ashfield Nottinghamshire NG17 2HS Lead Inspector Susan Lewis Key Unannounced Inspection 1st August 2006 10:15 134 Ashland Road DS0000008619.V301965.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 134 Ashland Road DS0000008619.V301965.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. 134 Ashland Road DS0000008619.V301965.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 134 Ashland Road Address Sutton In Ashfield Nottinghamshire NG17 2HS 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) 01623 401668 01623 401668 cherry.ackroyd@ncha.org.uk www.ncha.org.uk NCHA Mrs Cherry Ackroyd Care Home 10 Category(ies) of Learning disability (10) registration, with number of places 134 Ashland Road DS0000008619.V301965.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users shall be within category LD Date of last inspection 17th January 2006 Brief Description of the Service: The fees for 2006/07 are £1140. 134 Ashland Road West is a purpose built bungalow providing personal care and accommodation for up to ten adults with learning difficulties who may have additional physical disabilities. The home is situated in a residential area, close to the town centre amenities of Sutton in Ashfield. The home has its own vehicle, which enables residents to access a variety of activities. Two of the service users are over 65, and are therefore outside of the registration category. However, as they have been resident at the home for a number of years, conditions of registration were set to ensure that their needs could be met within the home. These have now all been complied with, including staff training in care of older people with learning disabilities. The accommodation is homely and comfortable and was refurbished earlier in 2006. 134 Ashland Road DS0000008619.V301965.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of the inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service users and their views of the service provided. The primary method of Inspection used was ‘case tracking’ which involves selecting clients and tracking the care they received through looking at their records, talking with them where possible, and looking at their accommodation. The inspection was unannounced and took place over 6 hours one Tuesday in August 2006, and was conducted by one inspector as part of the key annual inspection process. A partial tour of the building took place and a selection of residents’ bedrooms was inspected. Residents’ records were inspected and residents and staff on duty were spoken with. What the service does well: What has improved since the last inspection? New Carpets have been laid in the corridors and communal lounge as well as some residents bedrooms, it was also clear that residents had chosen their carpets themselves. The three requirements made at the last inspection are outside of the registered manager’s control and are reliant on the Nottingham Community Housing Association management ensuring that issues relating to contracts and staff files are resolved. 134 Ashland Road DS0000008619.V301965.R01.S.doc Version 5.2 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. 134 Ashland Road DS0000008619.V301965.R01.S.doc Version 5.2 Page 7 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 134 Ashland Road DS0000008619.V301965.R01.S.doc Version 5.2 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 5 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective users have the information they need to make an informed choice where to live and their individual needs and aspirations are assessed. EVIDENCE: There are currently no new residents. Evidence was seen that assessments are obtained regarding residents needs prior to their being admitted. The home develops with each resident a plan based on the assessment that details any restrictions on freedom, services or facilities and looks at their needs. Discussion with staff showed that plans are discussed with residents and attempts are made to ensure that they are in agreement with their plans. Evidence was seen that where possible residents are asked to sign the plan ensuring that they are involved in the plan. The licence agreement that is currently available for residents is a complicated document and needs to be more applicable to the needs of residents with a learning disability. This is an outstanding requirement from the last inspection, however as the residents are not being placed at risk this will now be a good practice recommendation 134 Ashland Road DS0000008619.V301965.R01.S.doc Version 5.2 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are assured that their needs are assessed and changing needs are reflected in their plan. Residents are supported to take risks and have an active independent lifestyle. EVIDENCE: Support plans are created from the assessment carried out by the social worker. These plans enable staff to work appropriately with residents to meet their needs and ensure they maintain an independent lifestyle. Support plans cover all aspects of the resident’s daily life and provide clear information on how the resident prefers to receive their care. There are risk assessments to ensure the safe participation of chosen activities. Plans are reviewed regularly and staff spoken with confirmed that residents are asked about their care and if they feel there are any changes. 134 Ashland Road DS0000008619.V301965.R01.S.doc Version 5.2 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 16 and 17 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents take part in age appropriate activities, are part of the community and are able to maintain personal relationships with family and friends. Residents’ rights are respected and responsibilities recognised. Residents are offered a healthy diet. EVIDENCE: A resident spoken with confirmed that staff were very supportive in ensuring that they were able to visit relatives and that relatives were welcomed to visit regularly, staff spoken with were able to discuss how they supported residents in visiting relatives. Evidence was seen that residents were involved in a variety of different activities other than just attending the day service such as going to discos or attending a local church. Evidence was seen that support plans identified what household responsibilities the resident had and what staff support was required to enable them to carry this task out ensuring that the resident was actively involved in the day to day running of the home. 134 Ashland Road DS0000008619.V301965.R01.S.doc Version 5.2 Page 11 Staff were observed interacting with residents when they returned from the day service and not exclusively with each other showing that staff valued the residents and respected them. Support plans detailed how staff were to maintain residents privacy and dignity and staff spoken with clearly understood the importance of promoting this with residents. Although the main meal was not observed, evidence was seen that every effort is made to ensure that residents are provided with nutritious meals. Staff spoken with were able to demonstrate how residents were involved in choosing the menu for the week and evidence was seen that residents were given a wide choice. 134 Ashland Road DS0000008619.V301965.R01.S.doc Version 5.2 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected by the home’s policies and procedures for dealing with medicines and receive their personal support as they prefer and require. EVIDENCE: Support plans viewed show that residents are able to receive their care as they wish, staff spoken with understood the different needs and preferences of residents and understood the importance of ensuring residents needs were met this way. There was evidence in support plans and diary notes of residents attending GP appointments and other health care visits as well as GP advice being sought regarding residents’ behaviour and medication. It was possible to follow an audit trail for this information from the diary notes, support plan to the Medication Administration Records (MAR) sheets to show that appropriate action had been taken. MAR records seen were in order, and provided clear instructions for the administration of medication. Photographs of each resident was attached to the MAR sheet ensuring that staff gave the right medication to the resident. 134 Ashland Road DS0000008619.V301965.R01.S.doc Version 5.2 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported to make complaints. Residents are protected against abuse. EVIDENCE: Staff spoken had a good understanding of the importance of enabling residents to voice their complaints, residents spoken with said that they would speak to the manager if they were not happy with something. The Commission has received no complaints regarding this service and has no concerns in this area. There are clear policies and procedures for staff to follow in the event of a complaint. Staff spoken with had a clear understanding of what constituted abuse and what responsibilities they had to ensure residents remained safe. Residents spoken with said that they felt safe in the home and staff were nice to them. 134 Ashland Road DS0000008619.V301965.R01.S.doc Version 5.2 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is homely and well maintained internally providing a safe environment, however externally poor maintenance places residents at risk. The home is clean and hygienic. EVIDENCE: A tour of the premises took place, four residents bedrooms and the communal areas were viewed. New carpets have been fitted along the corridor and in a number of bedrooms. Bedrooms are personalised and provide residents with a pleasant space to relax in. One bathroom viewed had been customised and provided residents with a pleasant environment where they could relax with pleasant sounds and sights. The other bathrooms remained functional and clean if somewhat stark. The garden is a pleasant environment for residents to relax in, however the path leading from the house round the side of the home is still cracked and has caused residents and visitors to fall. Evidence of this was seen in accident records. 134 Ashland Road DS0000008619.V301965.R01.S.doc Version 5.2 Page 15 A requirement has previously been set to repair this fault and remains outstanding. The Registered Person must carry out repairs to ensure residents are not placed at risk. The laundry meets the standards ensuring that residents’ clothes are washed appropriately and that soiled articles are not taken through where food is to be prepared, stored or eaten. A new system for delivering washing liquid to the machine has been added and ensures the correct amount is administered at all times, providing a safe area for residents. 134 Ashland Road DS0000008619.V301965.R01.S.doc Version 5.2 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are supported by staff who are competent and qualified. Recruitment records are not held appropriately making it difficult to inspect records on a regular basis. EVIDENCE: Evidence was seen that staff received training and were able to attend a variety of courses relating to the needs of the residents. It was noted on one staff members file that the food hygiene certificate was over three years old the manager said she was told by the Environmental Health Officer that it was not necessary to renew it. It is indeed not a requirement to renew them every three years but is seen as good practice to do so. Therefore a recommendation is made that the Registered Person renews all food hygiene training over three years old. It was clear from talking with staff that they are positive about providing quality care and support to the people that live at the project. There were seven staff out of 13 with NVQ level 2 or above, this ensure residents benefit from a competent trained staff team. 134 Ashland Road DS0000008619.V301965.R01.S.doc Version 5.2 Page 17 There has been an outstanding requirement to make staff files available for inspection at the home, however on 9th March 2006 the inspector visited Nottingham Community Housing Association head quarters to view staff files that are held centrally and were found to have two references and a Criminal Records Bureau check completed. Recruitment procedures were followed and residents are protected by this action. However the requirement will remain, as the Registered Person is not making the files available for inspection at all times. 134 Ashland Road DS0000008619.V301965.R01.S.doc Version 5.2 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from a well run home, there are systems in place for monitoring and reviewing the quality of care that aim to be underpinned by the views of residents and the health, safety and welfare of service users are promoted and protected. EVIDENCE: Staff spoken to felt that the home was well run, the manager was supportive and listened to staff residents spoken with also felt the manager was helpful. Nottingham Community Housing Association has a various monitoring tools including regular internal audits that use staff and residents from other services to visit the home and make comments on the service. There are also residents meetings held every month with information on the support plans detailing what support residents need to attend the meeting and express their views. The health and safety monitoring is carried out and evidence was seen that fire tests are carried out. Accidents are recorded on SuRe system and action taken as necessary to minimise risk to residents. This ensure that the environment is not only safe for residents but for staff also. 134 Ashland Road DS0000008619.V301965.R01.S.doc Version 5.2 Page 19 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 X 2 3 3 X 4 X 5 2 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X 134 Ashland Road DS0000008619.V301965.R01.S.doc Version 5.2 Page 20 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA24 Regulation 13 Requirement Timescale for action 01/10/06 2. YA34 Sch2 The registered person must ensure that all parts of the home that residents have access to be free from hazards to their safety. The pathway in the garden must be repaired. (Outstanding requirement from 01/03/06) The Registered Person must 01/10/06 make available to the inspector staff recruitment files containing two references and evidence of a Criminal Records Bureau check. (Outstanding requirement from 01/02/06 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 YA5 Good Practice Recommendations The Registered Person should develop a standard form of contract for the provision of service and facilities by the registered provider to service users; that is more applicable to the needs of residents with a learning disability. The Registered Person should ensure that Continence aids are stored in a cupboard. The Registered Person renews all food hygiene training over three years old. DS0000008619.V301965.R01.S.doc Version 5.2 Page 21 2 3 YA24 YA35 134 Ashland Road Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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. 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