Inspection on 21/08/07 for 4 Ashley Drive

This inspection was carried out on 21st August 2007.

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 no outstanding requirements from the previous inspection report, but made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

4 Ashley Drive 06/12/08

4 Ashley Drive 26/06/08

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 4 Ashley Drive Tylers Green Buckinghamshire HP10 8BQ Lead Inspector Kerry Kingston Unannounced Inspection 21st August 2007 11.15 4 Ashley Drive DS0000069095.V344528.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 4 Ashley Drive DS0000069095.V344528.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. 4 Ashley Drive DS0000069095.V344528.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 4 Ashley Drive Address Tylers Green Buckinghamshire HP10 8BQ 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) 01494 814569 01494 816280 Turnstone Support Carla Angela Thomas Care Home 6 Category(ies) of Learning disability (0) registration, with number of places 4 Ashley Drive DS0000069095.V344528.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the home may continue to accommodate existing service users over the age of 65. Date of last inspection Brief Description of the Service: The home provides twenty- four hour care for six people of both sexes with learning and associated physical disabilities. The house is owned by McIntyre Housing Association and the care is provided by Turnstone Support. The service has been in existence for many years but was registered in March 2007 when it was transferred from the Health Authority to Turnstone Support, a private provider who offer care to people with diverse special needs. The house is a domestic dwelling that has been adapted into accommodation for six people, there are three bedrooms on the ground floor, with en-suite facilities and three bedrooms on the first floor. The first floor is accessed by a staircase and is not accessible to those with physical disabilities or frailties. Communal accommodation is comfortable and includes a sizeable kitchen and dining area. There is a pleasant rear garden, which is accessible to those with physical difficulties. The home is approximately seven miles from the town centre and there are local facilities within walking distance. The home has its own vehicle and residents are able to access public transport. The fees are £1,317.20 TO £1,379 per week, which includes £179.94 for rent and housing services. 4 Ashley Drive DS0000069095.V344528.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is a report for the first key inspection of the service, which included a routine unannounced site visit. This took place between the hours of 11.15 am and 6.00pm on the 21st August 2007. The information was collected from an Annual Quality Assurance Assessment, a document sent to the home from the Commission for Social Care Inspection and completed by the manager, surveys which were sent to people who use the service, other professionals and families of residents. Five surveys were returned to the Commission, one from another professional, two from family members and two from people who use the service. Discussions with one staff member and the service manager took place. One person who uses the service is able to verbally communicate clearly, others have communication systems learnt by staff over a period of time, people and their interactions with staff were observed during the times that they were present. A tour of the home and reviewing residents’ and other records were also used to collect information on the day of the visit. The home transferred from the Health Authority to Turnstone Support in March 2007 and the home is continuing with transitional and development work created by the transfer. The home is part of a re-provisioning project and is due to be completely refurbished, as part of that project by 2010. All areas of care, with particular regard to the care plans and record keeping are under development, with development goals and plans in place. What the service does well: The home makes sure that people know all about where they live and try to make sure that the information is easy to understand. The home looks at the needs of the residents to make sure that it can look after the people who live there properly. The home tries to make sure that people know who to talk to if they are not happy. The home makes sure that it is a nice place to live in by having new furniture and decorating the house. 4 Ashley Drive DS0000069095.V344528.R01.S.doc Version 5.2 Page 6 The home has a way of making sure that things get better for the people who live there. The staff are all properly checked before they start work so that everyone knows they are safe to work with the residents. What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. 4 Ashley Drive DS0000069095.V344528.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 4 Ashley Drive DS0000069095.V344528.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 and 5. People who use the service experience good quality outcomes in this area. The home ensures people have enough information to make a choice about where they live and their needs are assessed to ensure the home can meet them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The people who use the service have been in residence for many years. The Statement of Purpose is current and the Service Users Guide and handbook have been produced in user-friendly format. The Service Users Guide and handbook provide a comprehensive description of the service and includes a clear outline of the equality and diversity policy. The documents ensure that the people who use the service can understand the service as much as they are able. The service manager explained that the documents are to be discussed with individual residents and individualised with the inclusion of costs and the specific rooms for occupation when the new manager takes up his post at the end of August. All residents had a complete assessment by care managers and the new providers prior to transfer of the service in March 2007. 4 Ashley Drive DS0000069095.V344528.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9. People who use the service experience poor quality outcomes in this area. The home is increasing the involvement of people in the day-to-day running of their home but this is not always evidenced. Each person has an individual care plan but this does not clearly describe how they should be cared for. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans for three people were seen. They are in the process of being updated using new paperwork but little of this work has been completed, as yet. There were several omissions, which could make it difficult to meet the needs of the residents, using the care plans as a guide. One person had no behavioural guidelines, limited details of their likes and dislikes/preferences and daily notes are sometimes of poor quality. Daily routines are not clear or detailed and health care needs/records such as bowel charts are not in evidence. Feeding guidelines are also ambiguous, as are lifting and handling guidelines and the use of cot sides. Communication needs are not clearly 4 Ashley Drive DS0000069095.V344528.R01.S.doc Version 5.2 Page 10 identified, a major omission since five of the six people who use the service do not communicate clearly, verbally. On the day of the inspection staff were seen to be communicating effectively with residents. Paperwork is available but has not been completed for individuals. There has been an increase in people being encouraged to be involved in decision making, two residents meetings are recorded in June and July but the notes of the meeting showed that they lacked relevant content. Policies and procedures are in place with regard to encouraging decision making but there is little evidence that these are used, practically. Choices are occasionally noted on menus and people were observed being given a choice of fruit at the mealtime, people were also observed being asked for their choice of television programmes. A ’talkback’ advocate visits the home on a weekly basis, he was visiting on the day of the inspection. Some risk assessments are in place but some need more detail, such as the use of ‘cot sides’ and lifting and handling of service users. 4 Ashley Drive DS0000069095.V344528.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17. People who use the service experience adequate quality outcomes in this area. People who use the service have daily activities and some opportunities for social activities and holidays. Activities in the community during the evenings and weekends are limited. The food provided is adequate but there is limited evidence of the people who use the service being involved in menu planning or food preparation and purchase. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three care plans were looked at, one person does not have an activity programme. He goes to the centre for two days per week but has no planned activities in the home. Other residents go to day centres for up to five days per week but have few activities noted, during the evenings or weekends. 4 Ashley Drive DS0000069095.V344528.R01.S.doc Version 5.2 Page 12 One person indicated that they get ‘bored’ and would like more things to do. The service manager mentioned activities that had occurred but these were often not recorded in daily notes or on the ‘activity’ records. Records noted only one trip into the community in a two week period in August 2007. One person goes to church every other week collected by other members of the congregation, another person has a minister visit the home as a staff member felt that there were not enough staff to ensure that they could assist them to attend a church service in the community. On the day of the inspection the ‘Talkback’ advocate was seen interacting with people and doing some activities and a staff member took one person for a short walk into the community to access the local shops. Two people have had a holiday this year and one resident told me that he has a week in Norfolk planned, which he is very much looking forward to, he said that he has plenty to do while he is on holiday and gets lots of outings. The home has its own vehicle and public transport is available. Five of the six residents have family contacts and the sixth resident has an advocate. People visit their family homes or are visited in their own home. Families are kept up-to-date with information about their members and two surveys received noted that people were ‘always or usually’ helped to keep in contact with families. Several correspondences with families were seen, including a resident being helped to buy chocolates and a birthday card for a family members’ birthday. The paperwork sent to the Commission prior to inspection noted people being more involved in the running of their home, this was confirmed by one resident being involved in the kitchen and staff telling/asking people if they were going to access their room. Records did not note how people were being encouraged to become more involved in day-to-day activities such as people helping with the food shopping and menu planning but the service manager confirmed that this is beginning to happen. Locks have been fitted to peoples’ bedroom doors and each has a lockable cupboard where they can keep any private items and keep their money. One person has just been helped to purchase bedding of her choice, the cost is to be re-imbursed as she bought from her own money, she indicated that she was very pleased with the bedding, it reflected her age and personality. Menus are well balanced and varied, there was little evidence of peoples’ input into the menu planning process. The mealtime was observed and staff responded to peoples’ needs and wishes appropriately. Feeding guidelines for one person are ambiguous and it is not clear which programme is being followed, there are several in the care plan. This issue is being addressed by the service manager, training has been arranged to ensure everyone is aware of and adheres to the specialist feeding guidelines. 4 Ashley Drive DS0000069095.V344528.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. People who use the service experience adequate quality outcomes in this area. The home support people with their personal care needs but it is not always clear how this happens or if it is in the way preferred by the residents. Health and emotional care are not clearly recorded although this has been recognised and is being addressed. Medication is, generally, administered safely but the home does not always adhere to the guidelines when administering medication prescribed to be taken, ‘when necessary’. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans seen showed some peoples’ likes/dislikes and preferences but they were not detailed or complete in all cases. Staff were observed ensuring peoples’ privacy by closing toilet doors, asking for entrance into bedrooms and knocking on the doors of peoples’ private space. The home has a same gender personal care policy and guidelines to ensure there are staff of both sexes on duty wherever possible. One resident said that it was ‘alright’ to live in the home. 4 Ashley Drive DS0000069095.V344528.R01.S.doc Version 5.2 Page 14 Some records used ‘patronising’ and ‘undignified’ terminology such as someone being referred to as an ‘adventurous angel’ and other references to a resident being ‘naughty and bad’. There were no guidelines for inappropriate behaviours that caused distress to the individuals or others such as inappropriate interactions with staff or selfharm. Health care plans and records are not in place yet, care plans included some health plans and records but many are out of date and it is not clear which are being currently used. Current feeding guidelines, bowel movement charts and weight charts are not consistently available, even though they are noted as being necessary. There are no records of any medical appointments since transfer, the last records that could be located were at the end of 2005, the service manager advised that some records had been archived at transfer and the new Health records had not been completed, as yet. The GP used by most of the residents in the home noted no difficulties or concerns with the home’s care of the residents and no ‘major’ health issues were reported within the home. The Boots Monitored Dosage System is used to administer medication, no one is able to administer their own. Records seen were accurate, as were stock control charts. All staff have completed medication administration training and have been assessed by the new provider as being competent to administer it. Medication is stored in a locked metal cupboard in a locked office. Each person has a medication administration file, which includes a photograph and protocols for the use of medication prescribed to be taken ‘as necessary’. The protocol (guidelines) for the use of ‘when necessary’ medication for one individual was not being followed by staff, as they felt their medication ‘regime’ was more appropriate. The ‘when necessary’ medication protocols were developed between the GP and the service manager and are extremely detailed and safe, if they are adhered to by the staff team. 4 Ashley Drive DS0000069095.V344528.R01.S.doc Version 5.2 Page 15 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 and 23. The people who use the service experience adequate quality outcomes in this area. The home, generally, protects people from all forms of abuse and has a robust complaints procedure. It does not have detailed guidelines to help people with behaviours that may cause themselves or others distress. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has received one complaint, one compliment and three concerns since March 2007; details of the complaint were not available in the house, as it was not considered appropriate to keep it there. There was a discussion with the service manager of methods of ensuring a complaint is recorded in the home, even if there needs to be confidentiality around the nature of it and the complainant. The service manager confirmed that the complaint has been dealt with, was considered to be ‘upheld’ and appropriate action has been taken. There is a robust complaints policy, produced in user friendly formats, families and residents who completed the survey confirmed that they knew how to complain; there was evidence that the complaints procedure had been discussed in staff and resident meetings. A resident confirmed that he knew who to talk to if he was not happy and there was evidence that he had expressed concern about some issues and action had been taken such as a rota board so that people could see who was on duty (now supplied in the dining area) lower handles on the door so that 4 Ashley Drive DS0000069095.V344528.R01.S.doc Version 5.2 Page 16 people in wheelchairs could answer the front door and a telephone at lower level to be more easily accessible to those in a wheelchair (both have been requested). The service manager confirmed that there have been no Safeguarding adults issues since transfer and that staff have received training in this area. People were observed to be comfortable and confident to approach staff on the day of the inspection visit. The Commission has received no information about this service with regard to complaints or safeguarding adults issues. The home does not have detailed guidelines with regard to helping those people who may have behaviours that distress themselves or others. One incident report said that the manager had ‘put him in his room because he had been verbally abusive’; it was not clear what ‘put him in his room’ means as the home does not use physical intervention. There are no guidelines to say what staff should do to consistently approach the behaviour. The service manager explained that she is aware of the situation and is developing detailed guidelines for use by the staff team. The financial affairs of the service users have not been completely resolved, as yet. There are to be several systems, some people having family members as appointees, others are to have the local authority acting as receivers on behalf of the court of protection, therefore being appointees for individuals. It is not clear how residents will be made aware of their overall financial situation, including their income and expenditure when all the financial arrangements have been resolved. Cash is kept by residents in their rooms in locked cupboards but is administered by staff, samples looked at were found to be accurately recorded with receipts kept for all expenditure. 4 Ashley Drive DS0000069095.V344528.R01.S.doc Version 5.2 Page 17 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 and 30. People who use the service experience good quality outcomes in this area. The home provides a good environment for the residents to live in and it is clean and hygienic. The environment is improving with new furniture, equipment and decorating completed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is well kept and cared for. One survey from family noted that there had been improvements in the environment since March 2007 and a compliment had been received with regard to the same issue. The home is due to be completely refurbished in approximately two years time as part of the re-provisioning project. The home has had new chairs and sofa, residents confirmed that they liked the new furniture including the colour. New dining tables and chairs, lockable cupboards in bedrooms and locks on bedroom doors have also been provided. Several areas of the home have been redecorated and there are soft furnishings on order for peoples’ bedrooms. 4 Ashley Drive DS0000069095.V344528.R01.S.doc Version 5.2 Page 18 The downstairs bedrooms have en-suite facilities, suited to the needs of the people who live there, one person is not able to bath as he has a shower in his room and the baths are located upstairs and are inaccessible. Equipment needed to meet peoples’ individual and diverse physical needs are provided. The home has the necessary waste bins to prevent cross infection, they wash peoples’ laundry separately and have a robust cross infection policy. 4 Ashley Drive DS0000069095.V344528.R01.S.doc Version 5.2 Page 19 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): 32,34 and 35. People who use the service experience adequate quality outcomes in this area. The home has a very small permanent staff team, which could compromise the consistency of care for the people who use the service. The provider makes sure that staff have all the necessary checks to ensure their safety before they start work. The staff team need the motivation and opportunity to undertake professional training. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a staff team of seven permanent staff, including two waking night staff. The day staff team consists of three full and two part time staff. There are at least five vacancies for permanent staff. There is currently a major recruitment drive as the home has not advertised for staff for approximately eighteen months prior to transfer. Two surveys received from families note that the home needs more permanent staff. 4 Ashley Drive DS0000069095.V344528.R01.S.doc Version 5.2 Page 20 The home attempts to ensure consistency of care for the residents by using the same bank and agency staff, whenever possible. Two agency staff have just been contracted to work full time in the home to further minimise changes. It is not always possible, currently, to ensure there is a permanent staff member on duty. Guidelines with regard to shift cover were issued in June 2007, which directs that a permanent staff member must be on duty each shift. On the day of the inspection visit there were three agency staff working on the afternoon/evening shift. They were observed to be working effectively with people and showing respect and sensitivity. The home has a minimum of two staff per shift, this can rise to three, for activities or special occasions. One staff member suggested that there were not enough staff to ensure people can do activities such as attend church early on Sunday morning. Three service users use wheelchairs and others have diverse needs, it would be difficult for two staff to offer the flexibility needed for people to be able to access community activities. Limited activities were recorded during the evening or at weekends when residents were not attending the day centres. The home has one waking night staff and one sleeping in person. Records of two staff members were seen and all the necessary documentation was available, to ensure they had been safely ‘vetted’ prior to commencing work within the home. Only two of the seven staff (including the manager) have N.V.Q.2 or above. Training records were not up-to-date although there was some evidence that staff have generally done the ‘core training’. The service manager confirmed that staff have applied for those courses that they need to ensure they have completed all the Health and Safety and Safeguarding adults training. The provider has a comprehensive training programme planned for 2007 and 2008. Two staff have applied to embark on N.V.Q. training before the end of 2007. 4 Ashley Drive DS0000069095.V344528.R01.S.doc Version 5.2 Page 21 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 and 42. People who use the service experience adequate quality outcomes in this area. The home is adequately managed, with support from senior management staff external to the home. The provider has recognised that the service is not progressing as quickly as it should and plans have been made to address this. The quality assurance system is operational and the home, generally, keeps the residents as safe as it is able. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager is registered and is working towards her Registered Managers Award. 4 Ashley Drive DS0000069095.V344528.R01.S.doc Version 5.2 Page 22 Some record keeping and other issues evidence that the current manager needs external support to manage the home effectively and an improvement plan has been developed by senior managers to assist in this area. The manager has been in the temporary post for approximately one year but is to revert to her role as senior support worker on August 27th 2007 as a new manager has been appointed to ensure the service develops at a reasonable pace. The residents have met the new manager and indicated that they liked him. A quality assurance system is in place, it consists of the providers getting feedback from service users, staff and carers through questionnaires, and an observation of staff. This information is collected at different times throughout the year, is summarised and the results are added to a ‘continuous improvement plan’. The team manager monitors the improvement plan, by means of a monthly report on performance indicators, a manager’s report on what’s happened throughout the month and regular Regulation 26 visits take place with a report provided. Health and safety records are regularly completed and checks are made at proper intervals, staff are trained in these areas but records are not always upto-date. All safety certificates were issued prior to registration in March. The home completes a monthly Health and Safety check and can use the expertise of the providers Health and Safety officer for advice and assistance, if necessary. Risk assessments are completed but some lack detail, specifically lifting and handling and the use of ‘cot sides’. The home completes accident and incident forms but they do not, consistently, include detailed records with regard to the action taken to minimise the risk of recurrence. 4 Ashley Drive DS0000069095.V344528.R01.S.doc Version 5.2 Page 23 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 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 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 2 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 2 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 3 X 2 X 3 X X 2 X 4 Ashley Drive DS0000069095.V344528.R01.S.doc Version 5.2 Page 24 New Service. 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 Regulation 5 Requirement To provide the people who use the service with a Statement of Terms and conditions, that includes the costs of care so that they know how much the care costs and who pays for it. To develop a detailed and up-todate service user plan so that staff know how to fully meet the needs of the people in their care. To ensure that people can make as many decisions for themselves as possible so that staff can be sure that residents have as much control over their lives, as they are able to. To produce detailed risk assessments so that any risks are identified and minimised to ensure that people are as safe as possible, whilst retaining some choice and independence. To develop Healthcare plans that clearly show healthcare needs and appointments made to meet those needs. They must be of a quality to enable staff to monitor peoples’ health and address any health issues promptly. Timescale for action 01/12/07 2. YA6 15.1 01/11/07 3. YA7 12.2 3 01/12/07 4. YA9 13.4 5 01/10/07 5. YA19 12.1 01/12/07 4 Ashley Drive DS0000069095.V344528.R01.S.doc Version 5.2 Page 25 6. YA32 7. YA35 8. YA42 To include emotional health, including behavioural guidelines, in the care planning process to ensure that any issues, which cause the people who use the service distress, are dealt with as effectively as possible. 18.1(a)(b) To review the number and deployment of staff to ensure that they can meet the identified needs of the people who use the service, at all times. 18.1(c) To ensure staff have access to professional training so that they are able to demonstrate that they have the knowledge and skill to meet the needs of the people who use the service. 13 (4) To provide all the necessary risk assessments (particularly the use of cot sides) so that the people who use the service are kept as safe as possible. To complete accident/incident forms so that the actions taken to investigate and minimise the risk of recurrence is clear to ensure that the people who use the service are protected from risks, as far as possible. 01/01/08 01/06/08 01/10/07 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 YA13 Good Practice Recommendations To review activity programmes relating to evening and weekends to ensure that the people who use the service are enabled to access the community. To review how residents are encouraged to participate in the daily routines and activities of the home and how this participation is recorded. DS0000069095.V344528.R01.S.doc Version 5.2 Page 26 YA16 4 Ashley Drive 3. 4. YA20 YA23 To ensure that medication guidelines and protocols for the administration of medicines prescribed ‘as necessary’ are clear, up-to-date and adhered to, by all staff. To make sure that people know what their overall financial status is, including their income and expenditure so that the manager can assist them to protect themselves from any form of financial abuse and help them to make informed choices with regard to their expenditure. 4 Ashley Drive DS0000069095.V344528.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Oxford Office Burgner House, 4630 Kingsgate Oxford Business Park South Cowley Oxford OX4 2SU 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. 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