Inspection on 31/05/05 for 149 Ash Street

This inspection was carried out on 31st May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 20 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

149 Ash Street 12/03/09

149 Ash Street 14/03/07

149 Ash Street 07/08/06

149 Ash Street 01/09/05

149 Ash Street 16/09/04

149 Ash Street 18/05/04

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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 Ash Street (149) 149, Ash St, Ash Nr. Aldershot Hampshire GU12 6LJ Lead Inspector Helen Dickens Unannounced 31 May 2005 12.30pm 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 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 Stationary 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. Ash Street (149) H58 S13450 149 Ash Street V219194 310505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Ash Street (149) Address 149 Ash St, Ash, Nr. Aldershot Hampshire GU12 6LJ 01252 330529 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) New Support Options Limited 9/10 Commerce Park, Brunel Road, Theale, Berkshire, RG7 4AB Application pending Care Home (CRH) 5 Category(ies) of Learning disability (LD) 5 registration, with number of places Ash Street (149) H58 S13450 149 Ash Street V219194 310505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 The age/age range of the persons to be accommodated will be: 30-55 YEARS OF AGE Date of last inspection 16 September 2004 Brief Description of the Service: 149 Ash Street is a detached Victorian house in the town of Ash near Aldershot. The building is owned by London and Quadrant and support and staffing is provided by New Support Options. The home offers support to five adults with learning disabilities, aged between 27 and 55 years. There are five single bedrooms, two lounges, a dining room, a breakfast area and three bathrooms available in the home. There is a large well-maintained garden available and some parking at the front of the house. The local shops are within walking distance of the home. Ash Street (149) H58 S13450 149 Ash Street V219194 310505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 5 hours and was the first inspection to be undertaken in the Commission for Social Care Inspection year April 2005 to March 2006. The inspection was carried out by Helen Dickens, Lead Inspector for the service. Ms. Jill Woolley represented the establishment. Sophie Fullick, Area Manager for New Support Options, arrived at 3.30pm and joined us for the remainder of the inspection. A tour of the premises took place. Four of the five residents were spoken to during the inspection, the fifth resident was out for the day. The inspector met four members of staff and interviewed one of them at length. This was a positive inspection. The inspector would like to thank the manager, staff and residents for their time, assistance and hospitality. What the service does well: What has improved since the last inspection? The manager continues to work hard to up-date policies and procedures and to improve the administrative processes in the office. In particular good progress has been made up-dating risk assessments. The manager is also working hard on team building with the staff, and a ‘team away day’ was planned for the following day. The day would focus on ‘values and attitudes’ and where the service is going for the future. Staff were Ash Street (149) H58 S13450 149 Ash Street V219194 310505 Stage 4.doc Version 1.30 Page 6 obviously appreciating this input and one remarked that ‘overall things are better’ and felt that ‘the staff team is good and works well together.’ Some of the outstanding requirements from the last inspection have been met including taking formal advice on one resident’s health condition. Also, some of the outstanding repairs have been done and tasteful privacy screening has been applied to one resident’s window. 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. Ash Street (149) H58 S13450 149 Ash Street V219194 310505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Ash Street (149) H58 S13450 149 Ash Street V219194 310505 Stage 4.doc Version 1.30 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 standard(s) 1,2 and 5 The information prepared for prospective residents is clear and comprehensive but a number of outstanding requirements from the last inspection need to be carried out to meet these standards fully. EVIDENCE: The Statement of Purpose and Service Users Guide are well put together and in a format which residents could understand with help. However the documents still need some up-dating to include the change of management in the home. Assessments carried out since the residents have moved into the home are good but the the pre-admission assessments requested from the last inspection have still not been located. The inspector suggested that the funding local authorities must have had copies at the time these placements were made, and their assistance should be sought to obtain copies. The residen’ts agreements (contracts) are very well done and in a format which would be accessible to residents. Contracts should specify which room a resident will occupy and these contracts even contain a picture/photograph of the actual room to make it easier for residents to understand. However, there are no copies of the contracts with the placing authorities and these should be obtained in order to fully meet this standard. Where residents do not hold their own copies of the above documents, and where residents have not signed them, the reasons should be noted on their files. Ash Street (149) H58 S13450 149 Ash Street V219194 310505 Stage 4.doc Version 1.30 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 standard(s) 6,7,8 and 9 Progress is being made so that residents can be confident that their assessed and changing needs and personal goals are reflected in their individual plans. EVIDENCE: The resident’s individual plans are generated from the home’s assessment and now include the ‘personal planning path’ for each resident. Considerations such as aspirations, positives and negatives, and strengths and objectives for the near future are all contained in this document. Other input from parents, friends and care managers is sought when each resident’s path is drawn up. Where residents do not sign and or hold their own plans, the reasons should be clearly documented. Work is continuing to put individual residents plans into accessible formats. There is some evidence from resident’s files and from talking to staff that residents have opportunities to make their own decisions and to take risks. Likes and dislikes were clearly documented and risk assessments were in place One keyworker interviewed had a good understanding of the communication needs of the resident she supported and was therefore better able to ascertain how to support him with decision making and risk taking. Ash Street (149) H58 S13450 149 Ash Street V219194 310505 Stage 4.doc Version 1.30 Page 10 The home has translated some of their relevant policies and procedures into a user-friendly format for residents, for example the fire procedure.. Resident’s meetings are held to give residents the opportunity to receive information and participate in some of the decisions regarding themselves and the home. One staff member has taken responsibility for this and good progress has been made. In addition to the notes which are currently taken, it would also be helpful to have a note of who attended, what was on the agenda, decisions/choices made and how feedback is given to residents. It may be helpful to residents to have a pictorial summary of the meeting which could be displayed on a notice board to remind them of their input. Ash Street (149) H58 S13450 149 Ash Street V219194 310505 Stage 4.doc Version 1.30 Page 11 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 standard(s) 12,13 and14 Residents are assisted to take part in fulfilling activities and this goes some way towards improving their quality of life. EVIDENCE: Resident’s ‘profile’ books are being set up which document, among other things, their likes and dislikes, the activities they enjoy, and gives examples of their capabilities. This will assist existing as well as new staff to be fully conversant with each residents preferences. No residents engage in paid or voluntary work at the moment but a wide range of activities will be considered as part of each resident’s personal planning path. Currently residents enjoy a variety of activities including outings to the pub, art classes, horse riding, shopping, and in-house entertainments such as discos. Some residents also help with household and personal chores. Specific activities are documented for each resident. One resident’s key worker suggested the person she supported may like to go to a day centre and the inspector passed this on to the manager. Ash Street (149) H58 S13450 149 Ash Street V219194 310505 Stage 4.doc Version 1.30 Page 12 Residents do engage in some activities in the community but it was disappointing to hear that one resident had been put off from using their local library as disapproval had been shown by others in the library. Members of the public, including those with disabilities (under the Disability Discrimination Act 1995), should be able to access this service and the home may wish to pursue this with them. Ash Street (149) H58 S13450 149 Ash Street V219194 310505 Stage 4.doc Version 1.30 Page 13 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 standard(s) 18 and 19 There is a clear system in place within the home to ensure that residents receive sensitive and flexible assistance with their personal and healthcare needs. EVIDENCE: Residents preferences about the way they receive personal care were clearly documented on the files sampled. Staff spoken to had a good knowledge of the needs and preferences of the residents they supported. An outstanding requirement from last time was to take formal advice and set up a staff handbook on osteoporosis. Advice was taken from the GP and some leaflets have been acquired and will form the basis of a staff resource on this condition. Ash Street (149) H58 S13450 149 Ash Street V219194 310505 Stage 4.doc Version 1.30 Page 14 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 standard(s) The complaints system within the home needs to be further developed in order to ensure that complaints are dealt with appropriately. The protection of residents is taken seriously within the home and arrangements for protecting residents are satisfactory. EVIDENCE: The complaints book has not been up-dated for some time and the manager needs to review how complaints are recorded within the home. The latest version of the complaints procedure was not readily available. A user-friendly version has been designed for residents. There have been no further complaints since the one noted at the beginning of this report. The protection of vulnerable adults is taken seriously within the home and staff have had access to the latest version of the protection of vulnerable adults policy. Staff now sign to say that they have read and understood the policy. Ash Street (149) H58 S13450 149 Ash Street V219194 310505 Stage 4.doc Version 1.30 Page 15 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 standard(s) 24, 25 26 27 and 28 Residents live in a homely environment but a number of decoration and maintenance issues are still unresolved, thus detracting somewhat from the otherwise pleasant surroundings. EVIDENCE: The home is of a suitable size and allows plenty of space and a homely environment for the residents. Facilities and appliances are domestic in nature and there is a large garden and plenty of outdoor space for residents. The home was clean and free from odours on the day of the inspection. Resident’s rooms were also comfortable and personalised. One of the rooms requiring ‘screening’ at the last inspection had been done very tastefully but another still had to be done to afford privacy and dignity to the resident. This room is also awaiting decoration. Some rotting window frames are still awaiting repair by the housing association. Damaged tiles on the bath have been repaired rather than replaced which spoil the look of the bath and may be difficult to keep clean. The previous requirement to renew the cover of the downstairs WC has been Ash Street (149) H58 S13450 149 Ash Street V219194 310505 Stage 4.doc Version 1.30 Page 16 done well. On the day of the inspection the door handle to the upstairs WC was broken and the WC did not flush properly. The area manager for New Support Options has made a formal complaint to the housing association regarding the outstanding maintenance issues. Ash Street (149) H58 S13450 149 Ash Street V219194 310505 Stage 4.doc Version 1.30 Page 17 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 and 36 Staff morale is improving and despite needing to recruit more permanent staff, the current staff are committed to improving the quality of life of residents. EVIDENCE: The last inspection required that staff receive both mandatory and specialist training to support them in their roles. Since then all staff have had training in the protection of vulnerable adults and autism awareness training. Staff training records showed a variety of specialist and general training sessions attended by staff. The inspector suggested additional specialist training on osteoporosis and coeliac disease may be beneficial to staff. There was a positive attitude from staff about training. There was evidence that staff were feeling well supported and there was regular supervision within the home. A team building day away from the home had been arranged for the following day. Regular staff meetings were held and the agenda comes out one week in advance of the meeting. Ash Street (149) H58 S13450 149 Ash Street V219194 310505 Stage 4.doc Version 1.30 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,38,40,41 and 42 The manager of the home has a good understanding of the areas in which the home needs to improve and has already gone some way towards making those changes. EVIDENCE: The new manager has yet to complete the registration process with CSCI but this is in hand. Significant progress has been made since the new manager took up the post. There is an open and positive atmosphere in the home and the manager communicates a sense of direction to staff. Both staff in the home and the area manager made positive comments about the way the home is being run. The home’s policies and procedures and record keeping need further work but this is progressing well. The manager said she is now half way through the process and expects it to be completed within the next three months. Ash Street (149) H58 S13450 149 Ash Street V219194 310505 Stage 4.doc Version 1.30 Page 19 Risk assessments sampled had all been recently reviewed and were appropriate. The inspector asked for a further risk assessment to be carried out regarding the water having to be turned off in the kitchen. This is to protect the health of one resident but needs to be carefully thought through and documented. The manager is taking advice from the company on this matter. There is also an outstanding requirement from the last inspection to take some health and safety advice of the use of spa equipment in the bathroom. Also from the last inspection, the manager said an occupational therapist was asked to advise on the use of the corner bath and a risk assessment has since been carried out Ash Street (149) H58 S13450 149 Ash Street V219194 310505 Stage 4.doc Version 1.30 Page 20 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 2 x x 2 Standard No 22 23 ENVIRONMENT Score 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 2 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 2 2 3 x x Standard No 11 12 13 14 15 16 17 x 3 3 3 x x x Standard No 31 32 33 34 35 36 Score x x x x 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Ash Street (149) Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score 2 3 x 2 2 2 x H58 S13450 149 Ash Street V219194 310505 Stage 4.doc Version 1.30 Page 21 yes 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. 1. Standard YA1.1, YA1.2 Regulation 6(a)(b) Requirement The Statement of Purpose and Service Users Guide must be up-dated to include the change of management and all other items listed in Standard 1 Pre-admission assessments should be on file for each resident. Copies of local authority contracts for individual residents should be kept in the home and made available to residents (Outstanding from 18.06.04) Copies of residents agreements not signed/held by residents need to be noted and the reasons documented. The residents care plans should be in a format accessible to them. They should be signed and held by the resident unless it is clearly documented to the contrary. The manager to ensure that residents are offered opportunities to participate in the day to day running of the home and contribute to its development. Residents should receive feedback on the outcomes of their participation. Timescale for action 31st July 05 2. 3. YA2.1 YA5 YA5.5 14(1)(b) 5(3) 31st July 05 31st Jul 05 4. YA6.7 15(2)(a) 31st Aug 05 5. YA8.1 YA8.5 24(1)(a) (b) 24(3) 31st July05 Ash Street (149) H58 S13450 149 Ash Street V219194 310505 Stage 4.doc Version 1.30 Page 22 6. YA22.1 YA22.7 21(1) 7. YA24.1 8. YA26.1 9. YA27.1 YA27.6 YA37.1 YA40.1-6 10. 11. 12. 13. YA41.1 YA41.3 YA42.1 and YA42.6 The manager must ensure the complaints procedure is easily accessed and available within the home. The method of recording complaints should be reviewed by the manager.(Outstanding from (18.05.04) 23(2)(b) Outstanding maintenance issues (d) should be documented and a timescale determined for remedial action. A copy of this plan should be sent to CSCI 23(2) One residents room still does (d) not have suitable privacy screening and this must be remedied as soon as possible.(Outstanding from 16.10.04). 23(j) One of the WCs had a broken door handle and the WC did not flush properly. This must be remedied as soon as possible. CSA The manager must register with Section 11 CSCI. 13 The manager must complete the process of creating, reviewing and up-dating polices and procedures and devise a system which complies fully with Standard 40. 17(1)(a), Records required by regulation (3)(a) are kept in good order and up to date. 13(4) The manager must ensure that all risk assessments are comprehensive and up-to-date and cover all risks within the home including the taps being removed in the kitchen for the protection of a resident. 31st July 05 31st July 05 31st July 05 7th June 05 31st Aug 05 31st Aug 05 31st July 05 30th June 05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Ash Street (149) H58 S13450 149 Ash Street V219194 310505 Stage 4.doc Version 1.30 Page 23 No. 1. Refer to Standard Good Practice Recommendations Ash Street (149) H58 S13450 149 Ash Street V219194 310505 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ash Street (149) H58 S13450 149 Ash Street V219194 310505 Stage 4.doc Version 1.30 Page 25 - 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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