Inspection on 02/10/07 for Aashna House

This inspection was carried out on 2nd October 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Aashna House 15/05/06

Aashna House 27/10/05

Aashna House 23/05/05

Aashna House 05/11/04

Aashna House 30/06/04

Similar services:

Ashlong House

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

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

CARE HOMES FOR OLDER PEOPLE Aashna House ASRA Greater London Housing Association 2 Bates Crescent, Off Abercairn Road Streatham London SW16 5BP Lead Inspector Mary Magee Unannounced Inspection 2 October 2007 10.00 X10015.doc Version 1.40 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 Aashna House DS0000022715.V348679.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 Older People. 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. Aashna House DS0000022715.V348679.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Aashna House Address ASRA Greater London Housing Association 2 Bates Crescent, Off Abercairn Road Streatham London SW16 5BP 0208-765-0822 0208 7650622 aashna@asra.org.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) ASRA Greater London Housing Association Limited Mathini Navukkarasu Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (0), Physical disability (0), Physical disability of places over 65 years of age (0) Aashna House DS0000022715.V348679.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To include the current service user aged 56 years Date of last inspection 8th January 2007 Brief Description of the Service: Aashna House is a purpose built residential care home providing care and accommodation for frail elderly people of Asian origin. It is situated in a residential close and is within a ten-minute walk of local shops and public transport. Asra Greater London Housing Association own and manage the home. It is a pleasant and spacious two-storey building with the added advantage of enclosed gardens to the rear. The home is divided into five units, each has its own dining room and kitchen. A large catering kitchen is located on the ground floor. A passenger lift is also provided. The gardens and the buildings are wheelchair accessible. The home has 31 single bedrooms and 3 double bedrooms. Each room has an abundance of space with attached kitchenette and en-suite shower facility. A CCTV is provided by the front door. Fees range from £375 to £500nper week. Aashna House DS0000022715.V348679.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken by one inspector. An interpreter assisted on day one at the home when the inspector interviewed fifteen residents, (for the majority of residents, (English is not the first language for the majority that live at the home). The inspector met with the registered manager, who was present on the day. Management and staff were cooperative and helpful and facilitated the inspection process. Five care staff were spoken to individually, a staff team at handover period were also spoken to. A district nurse supplied the inspector with information on the support given to residents that receive district-nursing service. The relatives of five residents were spoken to. Comment cards in Urdu and Gujarati were sent to residents, of these residents completed eight. A care management team also responded by telephone on the outcome of recent reviews. The inspector examined a selection of staff records at the London office, these brought from Leicester by the human resource manager. Case tracking was used to evaluate the quality of care for residents from time of referral to admission. What the service does well: This home provides a safe and harmonious environment where people feel valued and well cared for. Residents come from a variety of Asian backgrounds, with various individuals sharing similar cultural and religious interests. Staff employed are of similar origins understand and relate well to their cultural needs. The composition of those living at the home includes many with a variety of languages and beliefs. Gujarat, Urdu, Punjabi, are some of the first languages spoken. Staff are knowledgeable and familiar with customs and practices to be observed. All staff employed speak at least two Asian languages fluently. Staff demonstrate the ethos of valuing and respecting people.“ Staff here are very kind and are never too busy to help the residents”, “you never hear a cross word from staff”, Comments such as this were received from a number of residents. Overall the comments received both in writing and in person from residents were positive on all aspects of the service. Aashna House DS0000022715.V348679.R01.S.doc Version 5.2 Page 6 Observations made were that staff are gentle and are totally committed to their role. They are discreet which is important to residents. They enable good access to other statutory services where barriers may be experienced due to communication issues. The care staff continue to develop the necessary skills, all staff permanently employed have all acquired NVQ qualifications. Individual accommodation is spacious and comfortable; facilities such as kitchens are available in each room for residents to entertain guests. Meals served are excellent; staff cater for a variety of dietary, cultural and religious needs. Mealtimes are relaxed and enjoyable and play an important part of life at the home. “I don’t know if any other home could manage to cater so well for such a diverse group of people, meals are great here” was the comments received from a family present. Dining rooms are small and intimate and offer people the chance to relax together in small group settings. What has improved since the last inspection? What they could do better: The home continues to progress and raise the standards of care. A number of requirements are stated in relation to areas of shortfalls. A summary of these are listed, The communal lounge is less attractive as much of the ceiling and walls have become discoloured. It needs attention to address this and make it more comfortable for residents. A requirement is stated. A shortfall was found in the recruitment process for staff recently recruited, this needs to be addressed. A requirement is stated. Aashna House DS0000022715.V348679.R01.S.doc Version 5.2 Page 7 Training and development needs to be ongoing, the staff team need to be familiar with conditions and topics that affect residents including infections. A requirement is stated. Equipment provided such as CCT cameras, filters on kitchen windows need to be serviced and maintained and working efficiently. 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. Aashna House DS0000022715.V348679.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Aashna House DS0000022715.V348679.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 3 4 5 Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. The home completes pre admission assessments for residents to enable them determine if the placement will be appropriate. The home has an appropriate staff team that meets the needs of residents; they share similar cultures and beliefs and know how individuals like to be cared for. EVIDENCE: Case tracking was used to evaluate the quality of care delivered, this included the admission process. Three residents were selected. Two of these people were admitted in recent months. For the newly admitted residents assessments were undertaken prior to admission, assessments were recorded and included all areas where support is needed. They includes all-important cultural personal issues, that relate to promoting personal hygiene, food choice, lifestyle choice. Aashna House DS0000022715.V348679.R01.S.doc Version 5.2 Page 10 For the two new residents that moved recently to the home information was held and provided evidence of the preparations made to enable staff have sufficient information on their needs. For both residents’ assessments were completed and recorded, these indicate all the areas of need and support. I spoke to one resident’s family members, as they were present. The resident referred to experiences dementia but primary needs are support with personal care in the right environment. Prior to admission the family visited the home first to get a feel of the home. The family find that the cultural needs are considered at Aashna House and that these are met. Care management assessments were supplied to the home too to help determine if it is a suitable placement and to contribute to the home’s overall assessment. Records show that a placement review was done after 6 weeks for the resident. The outcome was positive. Family said that they attended the review and are satisfied that the home is making good provision for the resident. A copy of the licence with the home was seen on one of the new resident’s files. Another resident spoken to comes to the home for respite care on a regular basis. She enjoys the experience of living there for short periods of respite and finds staff very supportive and understanding. Aashna House DS0000022715.V348679.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 10 Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. The home promotes individuality and choice. Care arrangements and practices are good. The home benefits from a knowledgeable and professional staff team that consider and respect the views of older people. Medication procedures are safe. EVIDENCE: The inspector used case tracking exercise to evaluate the arrangements in place for delivering care and support. Three residents were selected based on recent history of admission and on health records. Care plans are in place for all three residents, these record all areas of support and social and health care needs. The plans set out clear guidance for staff on how the support be provided, for example preference for time of day for shower, meals, pastimes and hobbies, lifestyle preferences such as engagement, needs associated with cultural requirements. Aashna House DS0000022715.V348679.R01.S.doc Version 5.2 Page 12 While case tracking the care delivered to three residents the evidence presented confirmed that the home is making good provision and meeting all these needs by appropriate care arrangements. There were records held demonstrating that regular monthly reviews take place, also that care plans are updated to reflect any changes that arise. The regular monthly reviews appear very brief and frequently record no changes. It is not always apparent if all areas of need are reviewed at this time. A recommendation is made regarding reviews. Risk assessments are in place that identifies risks associated. Plans are in place to minimise and reduce any identified risks. Daily records maintained for each resident, included are details of changes in conditions. At handovers communication is good to the staff team on any issues that affect residents. The healthcare of residents is promoted. Residents are registered with local GP practices. Many are supported to the surgeries for appointments unless there is an emergency call needed. Skin care is promoted, residents’ preference to keep skin moisturised is taken into consideration. There are no incidents of pressure sores. For those residents that are diabetic the district nurse visits to administer insulin. Residents have a system in place whereby they monitor and record their own blood sugar. Members of staff have received training in monitoring blood sugars and in the action to take if there are indications that an individual is becoming hypoglycaemic. Senior staff (always one on duty) are also competent in monitoring blood sugar levels and taking appropriate action in the event of an emergency. The inspector consulted the district nursing service to find out how staff are managing to support residents with diabetic conditions and particularly those requiring insulin. Their findings are that staff are doing a very good job. They find communication with the staff good, staff at the home can interpret for residents where English is not a first language and this supports the resident to manage appropriately diabetic conditions. Appropriate referrals take place by staff where there is any need for health professional advice. Medication is reviewed regularly by the GP. Medication is administered by senior and competent staff. All staff have received training in administering medication and competency levels have been assessed. A pharmacist locally dispenses and delivers medication. The medication administration procedures observed at the home are good. Care workers work in pairs when administering medication, with care worker assisting the senior carer. MAR sheets were observed for the three residents. No errors were observed. One of the major strengths of this service is the consideration given to retaining a person’s individuality and responding accordingly to personal preferences. Records seen of the plans in place are reflective of the responses required to meet the assessed needs. The home focuses on delivering in a manner that residents like. When a resident enters this home they are able to retain previous practices. It is non institutionalised, full consideration is given to whether a resident likes an check hourly or chooses to be more independent, the times for personal care, daily showers are given at times favoured by residents and not at times determined by staffing rotas. Residents Aashna House DS0000022715.V348679.R01.S.doc Version 5.2 Page 13 told of how this is facilitated, individuals that choose to rise early and have a coffee do so; they are then helped to take a shower. All residents enjoy having a daily shower and at a pace that suits their capacity. Residents dress in traditional attire. Privacy and dignity is promoted throughout by good practice. All residents have individual shower facilities. Staff knock on bedroom doors and only enter when invited to do so. Doors are kept closed when carrying out duties of a personal nature. The home has an excellent staff team, they at all times are respectful of older people, and this is demonstrated consistently in practice. The majority of residents have telephones and link up with family and friends. Aashna House DS0000022715.V348679.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 15 Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. The home understands the particular needs of older people of Asian background. Excellent provision is made to cater for the many dietary requirements of residents and serve wholesome meals that people enjoy. Lifestyle choices are respected and satisfied, and recreational interests are appropriately considered. EVIDENCE: Residents find that the home matches their expectations and lifestyle preferences. Residents are encouraged to and supported to make informed choices of their daily lifestyle. Participation in daily activities, outings and visits are promoted. Photographs are displayed of many group outings held. The majority of activities available are religion orientated; this meets with residents’ preferences. Festivals such as Diwali, Christmas, Eid are celebrated in the lounge according to diversity of religion shared overall. Staff share similar religious beliefs and practices and take the lead on cultural and religious celebrations. Both staff and residents lead on scripture reading and chanting. Aashna House DS0000022715.V348679.R01.S.doc Version 5.2 Page 15 Yoga classes are one of the new activities introduced to improve the overall well being of residents. For one resident staff are pursuing the availability of a day centre in the community to enable her access more suitable stimulation. The majority of residents enjoy the spacious individual accommodation and make use of this. They welcome family and friends into their home, the bedrooms with kitchens and shower rooms enable them entertain in the privacy of their own homes. Residents frequently choose not to engage in many group activities, this is often previous lifestyle choices continued into retirement. From speaking to five relatives and fifteen residents it is evident that individual lifestyle choices not to engage in activities is respected. The meals served at the home are excellent. Regular food committees are held three monthly to discuss menus. Healthy eating is promoted. Residents are encouraged to eat the variety of vegetables and fresh fruit and try the many different dishes available in Asian cuisine. While viewing the kitchen the inspector observed the quantity of fresh fruit and vegetables served to residents. The home employs four time cooks, two always on duty every day. They are to be commended in the provision they make for the meals served. A list is held in the kitchen of individual dietary needs and preferential requirements. The kitchen staff monitor the temperatures of cooked food. However some of the weekends the recordings had been omitted. A recommendation is made. The many Asian dishes served range from Bangladeshi, Srilankan, Madras, Mauritian, Punjabi. Different dishes within this group that have to be prepared include those that are oil free, salt free, spice free. Residents generally find the meals good. Some of the relatives spoken told of experiences at other healthcare establishments, “ No other home could mange to produce this food consistently like Aashna House can” was the quote of a family met during the inspection. Residents are weighed regularly; appropriate referrals are made to health professionals if there are nutritional disorders. Food supplements are also given as necessary if residents require them. Aashna House DS0000022715.V348679.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 18 Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. Residents benefit from living in a home where their views are listened to and taken seriously. Staff know the appropriate procedures to follow that safeguard vulnerable people from abuse or neglect. EVIDENCE: Residents are satisfied that their views are listened to and that any issues including complaints are addressed. This evidence was found from talking to fifteen residents, and five relatives. All expressed confidence in the management of the service. The complaints procedure I (in a variety of languages) is displayed in all the dining and communal areas of the home Records show that no complaints are recorded. The inspector recommends that all issues raised be recorded including verbal complaints. A copy of the complaints procedure is given to all residents on admission, verified through speaking to new residents and their families. The staff team have received training on safeguarding vulnerable adults. From speaking to five of the staff individually as well as to the staff team (seven) indications were that they are knowledgeable on safeguarding adults procedures. A refresher training in safeguarding vulnerable adults with the local authority coordinator was planned for the staff team for November 2007. There have been allegations of concerns or neglect raised at the home. Reports from family demonstrate a confidence in staff following appropriate procedures when caring for residents. Aashna House DS0000022715.V348679.R01.S.doc Version 5.2 Page 17 Aashna House DS0000022715.V348679.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. Residents live in a pleasant, comfortable and clean accommodation with their own possessions around them. It is well maintained and offers good individual and communal space. EVIDENCE: The two storey premises are well designed and purpose built as a care home. Location is convenient for public transport, it is situated in a quiet close with enclosed well-maintained gardens. Gardens are accessible to wheelchair users and offer solace to residents. A passenger lift is available. A large comfortable lounge is available and used by residents. On display are many art and religious objects that reflect Asian culture and religions. A large television with a variety of Asian channels is also in the lounge for residents to enjoy. Aashna House DS0000022715.V348679.R01.S.doc Version 5.2 Page 19 A large part of the planned maintenance programme had been completed. The communal lounge still requires attention and redecorating. A requirement is stated. The home is divided into five homely units, each with own dining room area. Dining rooms are used by residents, many choose to sit with friends after meals enjoying a chat. Since the last inspection the home has continued with a decorating programme and a number of dining rooms bedrooms were decorated Individual bedrooms (fifteen) were viewed, the rooms are comfortable and pleasant. Residents display personal possessions that give a homely touch. All bedrooms are ensuited, they also contain small kitchenettes. The walk in shower facilities available in all rooms enable good access to people with mobility difficulties. Hand rails are fitted to corridors to assist those that need help with walking. The premises throughout are clean and are odour free. Water temperatures in shower and bathroom areas are regularly monitored. A maintenance person is employed to complete light repairs and heavy duty cleaning in the kitchen. The kitchen is clean, however the filter screens on the kitchens need cleaning. A requirement is set. Aashna House DS0000022715.V348679.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. The home employs a valuable and skilled staff team. They share similar cultures and values, the language skills found within the team allow good communication with residents and professionals visiting the home. EVIDENCE: Appropriate staffing levels are on duty. Five care staff as well as one senior are on duty in the morning, in the afternoon there are four carers on duty with a senior carer. According to residents appropriate support is given with personal care, daily showering at a time that is suitable and preferred by residents. Two night carers are on duty covering both floors; there is also a senior carer on sleep over duties, to be called in emergency. Three new staff have commenced employment at the home since the last inspection, one is no longer in employment there. . The newly recruited care staff receive induction, that meets Sector Skills workforce training targets. However the foundation programme is not fully developed. New staff complete probationary periods to demonstrate that they are suitably skilled and competent for the role, performance is also monitored closely during this period with periods of extension given as necessary. Aashna House DS0000022715.V348679.R01.S.doc Version 5.2 Page 21 The recruitment procedures for two of the new staff were examined. Completed application forms as well as two references were held for both care staff, however a stamp or headed notepaper was absent from one professional reference. Confirmation of emigration status was present for both staff members as well as contracts of employment. CRB disclosures were present on both staff files. The disclosures were standard and did not have a POVA check completed. From looking at dates of start of employment there was evidence that one staff member had commenced employment before a new CRB disclosure was received. They had previously worked at the home via an agency placement. The manager confirmed that CRB enhanced disclosures were sought from the agency for those staff engaged via the agency. A requirement is stated in relation to recruitment. Full and satisfactory information must be received for all new staff before they commence work. Enhanced disclosures with POVA checks are required for all staff. Two of the new staff were spoken to. One is very experienced and worked within services for older people for some time prior to her work at the home. Compliments were received from residents about the calibre of staff employed. All fifteen residents spoken to praised staff for their contribution to making life better for those living at the home. The strength in this service is due to the fact that staff share similar cultural backgrounds, communicate well and can speak in a language understood by residents. They provide valuable links to statutory organisations that may otherwise pose difficult due to language barrier. The importance of knowing, understanding and responding appropriately to cultural issues is a factor in the delivery of a good service. Observations made throughout the day were that staff are gentle and patient in their approach, they value and respect people. They have attributes that are necessary for their role. Staff work at the pace that the resident likes. The ethos of caring and respecting people is demonstrated in their working practice, residents know their wishes are respected. Staff understand religious customs where particular fast are observed. When speaking to the staff group and to members of staff individually (5) the inspector found that staff are committed in their role. A handover was observed. Residents’ files are taken to handovers and the welfare of each resident is discussed in detail. Important information is shared, such as monitoring more closely residents that are unwell. Staff receive mandatory training as required, also additional specialist training such as understanding mental health conditions, diabetes management are given. Those employed in the kitchen received food hygiene training. All care staff have achieved NVQ Level 2, senior carers have acquired Level 3. This progress is to be commended. Despite the progress in meeting training needs there are some gaps in the training programme. A programme needs to be developed to include al topics and current conditions that affect residents. Following hospital admissions residents have contacted Aashna House DS0000022715.V348679.R01.S.doc Version 5.2 Page 22 infectious conditions, also viral infections have been experienced. Management are good at ensuring that appropriate action is always taken in these instances. However additional training needs have been identified where staff knowledge is limited, infection control, MRSA, viral conditions that may be experienced in the home. A requirement is stated in relation to developing a training programme that includes these topics where more knowledge is required. Aashna House DS0000022715.V348679.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31 33 35 Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. The health , welfare and safety of residents and staff are safeguarded as a safe environment is promoted. The home is well run by a capable and competent manager. EVIDENCE: The home is well run. It benefits from strong management and clear leadership. The manager has developed more expertise by participating in training to develop further knowledge. Staff are supervised and supported. Regular team meetings and one to one supervision takes place. A close eye is kept on observing working practices. A good relationship has been established between the home and other health professionals. Record keeping is good at the home. Aashna House DS0000022715.V348679.R01.S.doc Version 5.2 Page 24 Safeguards are in place at the home to protect the financial interests of residents. Office administration is good. The inspector viewed the systems to support residents manage their money safely. The administrator maintains accurate up to date records of all financial transactions, a clear audit trail is held. Individual bank account books are held in safekeeping at the office for residents. The AQQA provided a list of policies and procedures in place. The inspector was not confident that all staff have read the policies and procedures, or if these are reviewed to keep up with current legislation. A recommendation is made. Unit meetings are held for residents and relatives as part of a quality monitoring system. Records of servicing and maintenance of the building and equipment were viewed. These confirmed that essential servicing and maintenance are carried out. Health and safety audits are completed for the premises on a regular basis. Repairs lists are held with responses recorded. The CCTV placed at the front of the premises has been out of action for a long period and needs to be repaired. A requirement is stated. On documentation viewed there are records held to demonstrate the following, Fire drills are undertaken in accordance with recommendations; also the testing of fire fighting equipment takes place as required. A recent health and safety audit that included fire risk management took place. Notifications are made to relevant bodies in accordance with regulation. All incidents or incidents are recorded. The inspector did not view any recent copies of Regulation 26 visit reports, as these were not present. A requirement is stated in relation to Regulation 26 visits. The registered person must ensure that visits in accordance with Regulation 26 are undertaken, and that copies of these visit reports are held at the home. The home has continued to develop the service in the best interest of residents. Residents have regular meetings, family are welcomed too. Regular reviews are held of residents’ progress. The opinions of residents are taken into account, residents say they are listened to. Performance issues are addressed. Staff receive annual appraisals. Audits have been completed of the home, these identified any shortfalls in the upkeep of the premises, also staffing provision, finances. More development to the quality assurance system is needed, focusing on outcomes for residents. Aashna House DS0000022715.V348679.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 4 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 2 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 3 3 3 2 3 Aashna House DS0000022715.V348679.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO 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 2 3 Standard OP20 OP26 OP29 Regulation 23 (2) a, b. 23 (2) b, c., d. 19 (1) a, b Requirement The registered person must ensure that the communal lounge is redecorated. The registered person must ensure that filter screens on the kitchen windows are cleaned. The registered person must ensure that an audit is done of staff files to identify any shortfalls in CRB/POVA checks. CRB Enhanced Disclosures must be available for all care staff employed at the home. The registered person must ensure that the training and development programme for care staff is developed. To include foundation training, first aid, infection control, also to reflect the needs, current conditions and diseases that affect residents, infection control namely. The registered person must ensure that unannounced visits by the responsible individual take place at least once a month. Copies of reports made of these visits to be available for DS0000022715.V348679.R01.S.doc Timescale for action 30/12/07 30/11/07 30/11/07 4 OP30 18 (1) c 31/12/07 5 OP37 26 30/11/07 Aashna House Version 5.2 Page 27 6 OP38 23 (2) c inspection at the home. The registered person must ensure that security equipment that includes CCTV camera by the entrance is repaired. 30/12/07 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 OP7 OP12 Good Practice Recommendations The registered person should ensure that reviews consider all areas of need and support, and that the outcome of these reviews is recorded fully. The registered person should ensure that positive efforts are made including encouragement so that residents have the opportunities for stimulation. The registered person should ensure that the temperatures of cooked foods are consistently recorded. The registered person should ensure that all issues raised verbally no matter how minor are recorded in complaints folder. The registered person should ensure that the record of the staff training and development programme is kept up to date. Appropriate provision should be made for identifying and responding to staff training needs. The registered person should ensure that the quality assurance system is developed further to reflect the outcomes for residents using the home. The registered person should ensure that policies and procedures are reviewed, also that the staff are involved and contribute to the process. 3 4 5 OP15 OP16 OP30 6 7 OP33 OP37 Aashna House DS0000022715.V348679.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Aashna House DS0000022715.V348679.R01.S.doc Version 5.2 Page 29 - 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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