Inspection on 14/08/06 for Ardsley House

This inspection was carried out on 14th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ardsley House 12/06/08

Ardsley House 31/07/07

Ardsley House 12/01/06

Ardsley House 21/09/05

Ardsley House 01/11/04

Ardsley House 02/06/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

Pennine Camphill

Muston Road (70)

Grayling

The Cornerstone

John Street Nursing Home

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

CARE HOME ADULTS 18-65 Ardsley House 55a Royston Hill East Ardsley Wakefield West Yorkshire WF3 2HG Lead Inspector Dawn Navesey Key Unannounced Inspection 14th August 2006 09:30 Ardsley House DS0000001413.V307350.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 Ardsley House DS0000001413.V307350.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. Ardsley House DS0000001413.V307350.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ardsley House Address 55a Royston Hill East Ardsley Wakefield West Yorkshire WF3 2HG 01924 835220 01924 872618 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) J C Care Ltd Mrs Robina Richmond Care Home 16 Category(ies) of Learning disability (16) registration, with number of places Ardsley House DS0000001413.V307350.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th January 2006 Brief Description of the Service: Ardsley House is owned by J C Care, which is a subsidiary of Craegmoor Health Care. The care home is registered to provide accommodation and care services for up to sixteen residents with a learning disability. However, two double bedrooms are being used for single occupancy, therefore fourteen residents can live at Ardsley House at present. Two of the bedrooms have en-suite facilities, comprising of a toilet, hand washbasin and a shower. There are two communal bathrooms available to residents. Ardsley House is situated on a busy main road. It is set back with gardens to three sides. There is a good range of local amenities and shops and the area is well served by public transport. The home is within easy reach of major motorway links. There is ample parking available to the front and the rear of the house. There is a single storey detached building in the back garden. This is used as a day centre. An activity organiser, who is employed for thirty hours a week, works with residents in the centre and uses the building as a base. A support worker assists when necessary. The home is spread over two floors. There is no passenger lift or level access to the home, however some ground floor bedrooms are available. Respite care is not provided in the home. The weekly charge for living at the home is £518-94. Additional charges are made for chiropody, hair dresser, toiletries, horse riding, gym magazines and holidays. Ardsley House DS0000001413.V307350.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk This unannounced visit was carried out by one inspector between 9-30am and 5-10pm. The purpose of the inspection was to monitor progress in meeting the requirements and recommendations made at the last inspection, and to make sure the home was providing a good standard of care for the people living there. The people who live at the home prefer the term resident; therefore this will be used throughout the report. The methods used at this inspection included a tour of the building, looking at care records, observing working practices and talking to residents and staff. Information gained from a pre inspection questionnaire and the home’s service history records were also used. Surveys and comment cards were sent to residents, their relatives and a number of visiting professionals to the home, asking for their views about the home. Three comment cards were received from relatives and seven surveys returned by residents. This information has also been used in the preparation of this report. There were no visitors to the home on the day of the visit. Feedback was given to the manager at the end of the day. Requirements and recommendations made during this visit can be found at the end of the report. Thank you to everyone for the pre inspection information, returned comment cards and surveys and for the hospitality and assistance on the day of the visit. Ardsley House DS0000001413.V307350.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Some good work has been done on the care and support plans. These are now more accessible to the residents and evaluated on a monthly basis. The residents now have up to date signed contracts. This information is also produced in an easy read format. A resident said, “These are all about the money.” Staff training is up to date and relevant to the resident’s needs. A new washing machine has been purchased for the home. Ardsley House DS0000001413.V307350.R01.S.doc Version 5.2 Page 7 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. Ardsley House DS0000001413.V307350.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ardsley House DS0000001413.V307350.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are given sufficient information to enable them to make a choice about the home. Residents’ contracts are up to date and produced in a format that residents can more easily understand. EVIDENCE: There have been no new admissions to the home for some time; however, the manager described the pre- admission assessment procedure, which would include visits for any new residents. The residents who currently live at the home had all had some form of pre-admission assessment to make sure the home could meet their needs. In conversation with a resident about the moving in process she said she was happy with how this was managed. She said all the staff had been really helpful. In the returned surveys from residents, the majority of people said they had been asked whether they wanted to move in and most people felt they had been given enough information about the home before they moved in. One Ardsley House DS0000001413.V307350.R01.S.doc Version 5.2 Page 10 resident said she wasn’t happy being moved in to this home but agreed that it was out of the control of the home, at the moment, to change this for her. The manager has produced a statement of service and information for residents in a pictorial and easy word format. Residents said they liked these, especially all the pictures. These were mainly held on residents’ files. A few residents said they would like a copy to hold on to themselves. The manager said this could be arranged. All the residents now have an up to date contract, written in easy words and pictures. Most residents had signed these and were aware of what they were for. One resident said, “They are about the money.” The manager has plans to ask relatives to sign these contracts on behalf of residents who are unable to do this. Ardsley House DS0000001413.V307350.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Individual plans meet the health and welfare needs of residents but must be reviewed to make sure they are up to date. Risk assessments do not have clear, detailed and up to date plans in place to show how risk is managed. Residents are involved in the day to day running of the home and can influence what happens there. EVIDENCE: Individual plans have been developed from assessments of residents’ needs. Some of the assessments were completed some time ago and may not reflect residents’ current needs. The manager said that the organisation is in the Ardsley House DS0000001413.V307350.R01.S.doc Version 5.2 Page 12 process of introducing a new assessment tool which will be used for all residents. Key workers evaluate the plans on a monthly basis. It would be good practice to include residents in this to make sure their views are known. Most residents had not had a formal review of their needs and placement at the home for a number of years. One resident said she would like to move to a smaller home but nothing seemed to be happening. The manager said a referral had been made to this resident’s social worker asking for a meeting. This had not been written in her file. Some of the care planning records have been produced in a pictorial and easy word format. Residents said they had been involved in drawing up these plans and completing the pictorial questionnaires. Residents’ own words had been recorded in some of the plans. The life history work was person centred and gave a good picture of the residents, their previous experiences and their individuality. One resident said she would like a full copy of her care plans to keep in her own room. The manager said she would arrange this. Risk assessments had been carried out for all residents. However, some of this information had not been reviewed since 2003. The format for the risk assessments uses a system of codes. Most of the staff could not say what the codes meant and therefore may not properly support residents with risk issues. Risk assessments need to be completed for residents where there is a limitation placed on them. For example, the locked kitchen door must be supported by plans to show that this limitation is in the residents’ best interests and has been formally agreed with the residents or their representatives. Residents meetings are held approximately twice per year. The manager said that residents can ask for more meetings if they want to. Topics discussed are around food choices, holidays and any dissatisfaction residents may be feeling. Some residents said they were involved in recruitment for the home and enjoyed doing this. During the visit staff were seen to offer people choices about things like what to eat, what to wear and how to spend their time. Residents were encouraged to prepare their own lunch and wash dishes with staff’s support. A rota system is in place for washing up after the evening meal. All residents said they had agreed to this and were happy with how it worked. Residents also said they were involved in the food shopping for the home; they write down what they want and the weekly shop is based on this. Residents had chosen the colour schemes and furnishings for their own rooms and jointly made decisions about the décor in the other parts of the home. Residents have a copy of a Bill of Rights on their file. It is difficult to say whether the residents have an understanding of this, as it is not produced in a format that meets the needs of residents who cannot read. Ardsley House DS0000001413.V307350.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 14, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have opportunities to regularly take part in a variety of activities and occupation both in the home and the community. Residents have a healthy and varied diet according to their needs and choices. EVIDENCE: Residents are involved in a variety of activities each week. Some residents attend day centres in the community; others attend the day centre on the site of the home. One resident talked about the paid and voluntary work she does. She also goes to a local college, something she said she really enjoys. She is hoping to gain more paid work in the future and said staff at the home have Ardsley House DS0000001413.V307350.R01.S.doc Version 5.2 Page 14 been “great in helping and encouraging me.” Other residents spoke of concerts they had been to or are planning to go to in the future. A number of activities seemed really popular with residents particularly horse riding and the gym sessions. Residents who are unable to actually ride a horse are given the experience by having carriage rides. Residents had photographs of themselves doing these activities and were very happy to show them. Two residents keep their own pet dogs. All residents seemed to be involved with the dogs in some way and spoke very positively about their presence in the home. One of the dog owners was on holiday and another resident had volunteered to look after his dog while he was away. She said, “I am always happy to help out.” On the survey cards returned, all residents had said they can do what they want throughout the week. One resident said “ I always decide what I want to do each day whether it be household jobs, gardening or out shopping.” Residents are all given the opportunity to go on holiday each year. At the time of the visit, two groups of residents were away on holiday. Holidays have ranged from seaside resorts in this country to holidays in places of interest abroad. One resident said she is hoping to go on a cruise this year. A staff member said this was currently being organised. Residents choose which other resident or residents go on holiday with them. One resident said she would be going with her best friend. All the residents use local facilities such as shops, libraries and pubs. A number of residents are able to go to nearby towns such as Morley and Wakefield using public transport and, as they said “do their own thing.” Another resident said “I like it here, we do all sorts.” On the day of the visit residents went out shopping, used the adjoining day centre facilities, watched concerts on video, helped with cooking and did some sewing. A few of the female residents were planning a “girls pamper day” for later in the week, trying out new face creams and having manicures. Residents all said they liked the food in the home and that there is plenty of choice. One resident said “you can always have something different if you don’t like what’s on.” Residents and staff said there is always fresh fruit available and plenty of vegetables on the menu. It was disappointing to see that some food, which had been opened, was not dated and covered while being stored in the fridge. This was made a requirement at the last inspection and staff must do this properly in the future to avoid any possible food poisoning incidents. Ardsley House DS0000001413.V307350.R01.S.doc Version 5.2 Page 15 The mealtime was a social, pleasant occasion. Residents set the tables and assisted with preparing and serving the meal. Residents and staff sit down together for meals. There was plenty of interaction and chatting. Anyone who needed any support at mealtimes was given this discreetly and with courtesy. Staff encourage residents to keep in contact with their family and friends. Family members have been on holidays with residents and staff from the home. Many of the residents spoke of their family coming to see them or that they go to the homes of their family. Staff have made real efforts to try and assist residents to keep in touch with family and friends. The manager spoke of how they had been trying to trace the family of a resident who has lost touch with his family. Ardsley House DS0000001413.V307350.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are, in the main, supported properly with their personal and health care needs. Residents are protected by the homes policies and procedures regarding medication. EVIDENCE: Residents have a pictorial and easy words health action section of their individual plan. Key workers complete them with residents. It would be good practice to date and sign these plans so that everyone is aware of what is current information. Any health professionals involved with the residents are recorded in these plans with details of any contact with them, for example, outcomes of appointments or treatment. Ardsley House DS0000001413.V307350.R01.S.doc Version 5.2 Page 17 Most of the residents in the home are fairly independent. Staff offer support and assistance regarding personal hygiene when needed. Some residents are supported with the use of visual prompt cards to record their preferred routine on getting bathed, dressed, shaved and attending to personal laundry. Staff were able to describe residents’ routines and the support they give to maintain residents’ independence and dignity. Some of the care plans to support residents with their emotional needs did not have detailed plans of how to do this, however, staff could say what they did. Staff have received training on topics such as dementia and epilepsy in order that they can support residents whose needs may be changing. Guidelines for the management of residents behaviours should they ever need to be in hospital are available in the files and can easily be taken with staff who accompany residents in hospital. Medication administration is well managed at the home through the use of a monitored dosage system. Staff have received accredited training in dealing with medicines. Homely remedies are used and each resident’s GP has given written consent to this. Ardsley House DS0000001413.V307350.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents concerns are listened to and acted upon. Residents are protected from abuse by the home’s policies and procedures on adult protection. EVIDENCE: The home has a complaints procedure. This is displayed in the entrance to the home and a pictorial, easy word procedure has been produced for residents. During conversations with residents they said they knew how to complain and who to complain to in the home. A number of residents gave the name of the person they would complain to. On the survey cards returned all residents said they knew how to complain. Three relatives had returned comment cards. Two of them were aware of how to complain, one didn’t know but had not had cause to complain and was happy with the service at the home. The home has not received any complaints since the last inspection. Ardsley House DS0000001413.V307350.R01.S.doc Version 5.2 Page 19 All the staff spoken to had received training on the protection of vulnerable adults and were able to say what action they would take if they suspected abuse or had an allegation of abuse made to them. The majority of the residents had said, in the returned surveys, that staff treat them well. One resident said, “The staff are wonderful.” A recent adult protection issue in the home has now been investigated and appropriate action has been taken. During the visit, a resident spoke about her concerns regarding two members of staff. On reporting this to the manager, she was already aware of the concerns and showed written evidence of how this will be addressed. Many of the residents spoke of a resident who has hit out at them in the past. They said they would report any behaviour like this to the staff. Some staff have been trained in the use of de-escalation techniques in order to support anyone with this type of behaviour. All residents have their own bank account or a company account with monies held on their behalf. There are systems in place to protect residents’ finances and the manager checks transactions on a regular basis. Residents do not receive statements on money held in company accounts, they can however, request one. Residents’ property lists were not fully up to date. The manager is aware and is currently working with residents and key workers to address this. The organisation has introduced a new format for recording of property. Ardsley House DS0000001413.V307350.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 29 and 30 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 homely, comfortable, clean and safe environment. EVIDENCE: Some of the residents chose to show the inspector round and spoke with great pride about their home and their rooms. It was clear that they had chosen the colour schemes and furnishings in their rooms and had also had a say in the décor of communal areas such as the sitting room and bathrooms. All the residents’ rooms were individual to them and reflected their hobbies and interests. The communal areas are clean, bright and airy with plenty of space for all the residents to sit and eat together if they wish. Ardsley House DS0000001413.V307350.R01.S.doc Version 5.2 Page 21 Residents and staff said there are enough toilet and bathroom facilities. One resident said, “You never have to wait long for the bathroom.” Some residents’ rooms have en-suite bathrooms. The manager is currently looking into giving more of the rooms this facility. The kitchen is mainly kept locked due to the needs of some of the residents. This does not promote independent use of the kitchen. Residents said they knew why the kitchen was locked and were happy to ask staff when they want to use the kitchen. For more details regarding this please see the Individual Needs and Choices section of this report. The laundry is clean and tidy and has been upgraded with a new washer that has a sluice cycle. All staff were aware of their responsibilities in terms of managing infection control. However, paper towels were not provided for hand drying which could increase the possibility of the risk of infection. Ardsley House DS0000001413.V307350.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff are competent and understand the needs of the residents. Staff work well as a team and need to be properly supervised now the manager is back in this home. Residents are protected by the home’s recruitment procedures. EVIDENCE: There are three staff on duty throughout the day and evening. During the week the manager is also available 8am-4pm. At night there is one member of staff who sleeps in and another member of staff who is on a waking duty. Residents said they feel they have enough staff apart from times of staff sickness and vacancies. Staff agreed with this but said they always try to be flexible to help out and do additional shifts. A number of staff said they wished they had more time to spend with residents, either going out or just Ardsley House DS0000001413.V307350.R01.S.doc Version 5.2 Page 23 chatting and socialising. A relative, in a returned comment card, said they didn’t feel there was always enough staff on duty. All staff said felt there was good teamwork and communication in the home. Staff meetings take place, albeit, only one this year and the manager plans to make sure that staff are receiving regular supervision now that she is back in this home on a permanent basis. Recruitment records showed that all the necessary checks were obtained for staff prior to their employment. However, the photographs of staff were photocopies and not very easy to see. A new induction programme based on the “Skills for Care” induction has been introduced by the organisation. The manager intends to use this with the current staff team as a refresher. This is good practice. Staff’s training records were well maintained and up to date. The manager has a system for checking and planning staff’s training to make sure needs are met and updates are done when required. Almost 50 of the staff have achieved an NVQ (National Vocational Qualification) level 2 or above in care. Four more staff have now enrolled to do this qualification or the level 3 NVQ. Ardsley House DS0000001413.V307350.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40, 42 and 43 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed. Staff and residents receive good support from the manager. Overall, health, safety and welfare are promoted. EVIDENCE: The home is well managed by an experienced and qualified manager. She holds an NVQ level 4 in care and has almost completed the Registered Managers Award. Residents said “we like the manager, she sorts things out for us.” Staff said the manager was supportive and approachable. Ardsley House DS0000001413.V307350.R01.S.doc Version 5.2 Page 25 The area manager visits the home on a monthly basis to carry out regulation 26 visits, which involve talking to residents and staff about the home. These visits must be carried out separately for this registered home. The organisation has another home close by and the visits have been combined for the two for some time. The organisation has a quality assurance system where residents, relatives and staff are asked to complete questionnaires on their satisfaction with the service. The manager analyses this information to see where improvements can be made. The manager did not have any completed questionnaires available on the day of the visit. The home’s handyman carries out weekly health and safety checks around the home such as fire alarms, water temperatures and any repairs that are needed. The homes electrical wiring safety check was due in July this year. The manager has asked the organisation to arrange for this as soon as possible and has been given in a date in September 2006 for the work. Health and safety records were reasonably well maintained. Appropriate environmental risk assessments have been completed and accident records are completed and analysed. It would be good practice for accident records to have a section where any follow up from an accident could be recorded. The home has all relevant policies and procedures in place. The organisation is currently in the process of reviewing its policies and procedures. The manager has produced local guidelines and protocols that have a direct relevance to Ardsley House. Ardsley House DS0000001413.V307350.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 3 30 2 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 3 X 3 3 Ardsley House DS0000001413.V307350.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 Requirement Care plans must be reviewed to make sure the home can meet the needs and changing needs of the residents properly. This requirement is outstanding from 21st September 2005 and 12th January 2006. All identified risk must be assessed with an up to date action plan put in place to minimise the risk and explain any limitations placed on residents. This requirement is outstanding from 21st September 2005 and 12th January 2006. 3. YA17 16 The manager must make sure that food is stored properly. This requirement is outstanding from 12th January 2006. Paper towels must be provided for hand drying in all bathrooms, toilets and kitchen. DS0000001413.V307350.R01.S.doc Timescale for action 14/10/06 2. YA9 YA16 13 14/10/06 14/10/06 4. YA30 13 14/10/06 Ardsley House Version 5.2 Page 28 5. YA36 18 The manager must make sure that all staff receives regular supervision. This requirement is outstanding from 21st September 2005 and 12th January 2006. Visits by the registered provider must take place individually for this registered home. 14/10/06 6. YA39 26 14/09/06 Ardsley House DS0000001413.V307350.R01.S.doc Version 5.2 Page 29 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. 3. Refer to Standard YA6 YA34 YA42 Good Practice Recommendations A plan of care with information on how the last wishes of residents would be met should be in place for all residents. An original photograph should be kept on file in the home for all staff. Accident reports should have a section for any follow up or outcome of the accident. Ardsley House DS0000001413.V307350.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Ardsley House DS0000001413.V307350.R01.S.doc Version 5.2 Page 31 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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