Inspection on 16/11/05 for Ascot Lodge

This inspection was carried out on 16th November 2005.

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

The inspector found no outstanding requirements from the previous inspection report, but made 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ascot Lodge 04/11/08

Ascot Lodge 07/11/07

Ascot Lodge 27/06/06

Ascot Lodge 08/06/05

Ascot Lodge 29/09/04

Ascot Lodge 21/04/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Ascot Lodge 17 Ascot Road Moseley Birmingham West Midlands B13 9EN Lead Inspector Sarah Bennett Unannounced Inspection 16th November 2005 09:30 Ascot Lodge DS0000017108.V266006.R01.S.doc Version 5.0 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 Ascot Lodge DS0000017108.V266006.R01.S.doc Version 5.0 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. Ascot Lodge DS0000017108.V266006.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ascot Lodge Address 17 Ascot Road Moseley Birmingham West Midlands B13 9EN 449 3849 or 247 8760 9999 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) Dr Kandiah Somasundara Rajah James White Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Ascot Lodge DS0000017108.V266006.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Residents must be aged under 65 years That the manager undertakes appropriate training in Autism and forwards confirmation of completion to the Commission no later than December 2005. 8th June 2005 Date of last inspection Brief Description of the Service: Ascot Lodge is situated on the ground floor of a three storey Victorian house in a quiet cul-de-sac in Moseley. The upper floors of the property are let to private tenants with a front entrance shared by tenants and care home residents. Ascot Lodge comprises of three bedrooms, a small kitchen, bathroom and WC, lounge, dining area, office and rear garden with a shed and garden furniture. There is off road parking available for three cars at the front of the property, which is shared with private tenants who occupy the rest of the building. The home provides a vehicle, which is used by residents to access community based facilities, attend appointments and day trips. All bedrooms at the home are single and there are no en suite facilities. The home provides a service to three adults who have a learning disability and autism spectrum disorders. The home is not suitable for people who have mobility difficulties. Ascot Lodge DS0000017108.V266006.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors undertook this inspection over one afternoon. The information was collected in a number of ways including talking to a person who lived in the home, talking with two members of staff and a tour of the premises. Health and Safety records, medication and the files about two of the people who live there, were sampled. The inspectors would like to thank the people who live in the home and the staff for their help and support on the inspection. This was the second inspection of this year and not all the standards were looked at on this inspection, to have a full report of what the inspections found, this report should be read in conjunction with the earlier report from June 2005. What the service does well: What has improved since the last inspection? The staff have worked hard to meet all the requirements from the last inspection and to improve the lives of the people who live in the home. The staff have started doing Health Action Plans with the people who live there to make sure their health needs are met. They are still in the process of developing these plans further. Ascot Lodge DS0000017108.V266006.R01.S.doc Version 5.0 Page 6 There are more care plans and risk assessments in place, to ensure the people who live in the home are supported safely to lead a full and active life. The staff have had lots of training to help them meet the needs of the people who live in the home and this is all up to date. Nearly all events, that affect the well being of the people who live there, are now being reported as required to the CSCI. The recommendations from the gas engineers report about the cooker are now nearly met. There were no fire doors wedged open on the visit. Water temperatures are regularly checked and where the temperature has been recorded as low, the staff have taken action so that it is not too cold for the residents. 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. Ascot Lodge DS0000017108.V266006.R01.S.doc Version 5.0 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 Ascot Lodge DS0000017108.V266006.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not looked at during the inspection. There have been no new admissions to the home and the residents who live there have lived there a number of years. EVIDENCE: Ascot Lodge DS0000017108.V266006.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9, 10 The care planning system is not comprehensive so that staff do not have all the clear information they need to support individual residents. Some further development is needed to ensure that residents are always supported to make decisions about their lives and take part in the running of the home. Further development is needed to ensure that residents are supported to take risks as part of an independent lifestyle. Arrangements are in place to ensure information about residents is handled appropriately and their confidences are kept. EVIDENCE: Two resident’s records were sampled, including looking at care plans and risk assessments. On each of the files sampled, the residents had personal profiles, assessing their needs in respect of activities for daily living. There was also evidence of Health Action Plans and Behaviour Management Guidelines. Ascot Lodge DS0000017108.V266006.R01.S.doc Version 5.0 Page 10 On one resident’s file sampled, needs in respect of maintaining a healthy weight, challenging behaviour around cigarette smoking and aggression were identified. There needs to be care plans in place, in respect of these needs and the care plan must be clear and explicit in the guidelines to staff. The information in the residents profile needs to be up to date. e.g. social worker details. One residents care plan stated that they needed to lose weight and how they were going to do this was detailed. However, it did not state how much weight they needed to lose so there is no way of monitoring whether they have achieved their target weight or not. All care plans and risk assessments need to demonstrate evidence of discussions with individual residents about their involvement in the formulation of these plans. These should also reflect a resident’s agreement via the resident’s signature. There was evidence of regular residents meetings within the home. A number of issues relevant to the residents, their home and their care were discussed with them. There was also the opportunity for the residents to bring up any other issues they wanted to talk about at these meetings. One of the meeting minutes read, “informed the residents that they are not allowed to swear at staff, just as staff are not allowed to swear at them. If residents swear at the staff they will lose any reward money they have earned for that day. All agreed to this”. Staff must ensure that the residents feel the meetings are about them, as opposed to being told what they can do in the home. Inappropriate behaviours by residents, need to be looked at individually and not as a group issue. Residents should be encouraged through individual discussions and care plans to look at their behaviour, resident’s money must not be stopped because staff feel their behaviour is inappropriate. Although a risk assessment was found to be in place for challenging behaviour around cigarette smoking, it needs to be comprehensive in identifying all risks and explicit in it’s guidelines to staff to ensure consistency. The reviews of risk assessments whilst done six monthly and dated, need to ensure that there is always a staff members signature on the plans, ideally where possible the residents signature. There should also be notes on the risk assessment review, detailing a review had taken place, to include the residents involvement and reflect if the risk assessment is to be changed or if it is ongoing. All confidential records/information pertaining to the residents were stored adequately, ensuring information is kept confidentially. No inappropriate discussions/conversations between staff about the residents were observed. Ascot Lodge DS0000017108.V266006.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17 Arrangements are in place so that people living in the home experience a meaningful lifestyle. EVIDENCE: Residents are supported to attend college and undertake courses that support their personal development. One of the residents was sharing with the staff different things she had been learning about at college. Residents said that they walk part of the way to college and get the bus for the rest of the journey. Residents have their own bus pass. One resident goes to college by taxi as he has a fear of sliding doors and becomes very anxious when using the bus. On one of the residents files sampled, the activities sheet reflected a number of activities they undertook each week, including seeing friends, shopping, going to college, seeing relatives, going to parks and going to the leisure centre. The plans included evidence of the staff actively encouraging and supporting the residents to take part in activities. Ascot Lodge DS0000017108.V266006.R01.S.doc Version 5.0 Page 12 Residents said they go to a relaxing sensory room, go to the gym, for walks, discos and shopping. Residents said that during the college holidays other activities are planned so they don’t get bored. Residents have been on holiday twice this year to Weston and to Blackpool. Residents said that their family visit them at the home and they go to visit their family. One relative visited during the afternoon. One resident said that since they have lived at the home they have learnt to do things for themselves and become more independent. Since the last inspection a reward system of £2 per day has been put in place for each resident. The Business Manager said that this comes out of the home’s budget and is in addition to resident’s benefits. To earn the £2 per day residents have to achieve their three individual targets written on the whiteboard in the dining room. These include assisting with making lunch, going for a twenty - minute walk, washing up, cleaning bedroom and having a foot spa. The daily targets vary each day. Residents were positive about this and felt that it helped to ensure household chores were divided equally and their independence skills were increasing. They also liked having a bit of extra money to spend as they wish to. The staff said that the residents plan their choices of meal each morning for that day. The residents are encouraged to make a variety of choices, and staff encourage them to eat a healthy diet, with a high intake of fruit and vegetables. Resident’s food records indicated that a variety of food is offered with fresh fruit and vegetables. The residents have access to individual fruit bowls in their rooms as well as there being a fruit bowl in the communal area. The residents have been supported to take part in the houses training on healthy eating, which helps them understand the foods they need to eat for their own well -being. Ascot Lodge DS0000017108.V266006.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, 21 An assessment is in place to ensure residents receive personal care in the way they prefer. There are plans in place to meet the residents emotional and health needs. The arrangements for the medication ensure the residents are protected from harm. The residents would benefit from a ‘homely remedies’ list to enable staff to give out medication quickly for minor aliments, instead of arranging appointments to see the GP each time. Resident’s individual wishes of what should happen in the event of their death have been sought. EVIDENCE: The care records sampled demonstrated evidence of assessments of how the residents prefer to receive personal care. These need to be signed by the residents and must demonstrate the resident’s involvement. Ascot Lodge DS0000017108.V266006.R01.S.doc Version 5.0 Page 14 All the residents have health action plans in place, which is pleasing to see. Further development of these plans is needed to ensure the residents physical and emotional needs are well met. They need to be more specific about what residents target weight is and how much and what type of exercise residents are to do to ensure they stay healthy. The Business Manager said that residents have changed their GP. The previous surgery they were registered with employed only locum doctors. Residents were unhappy with this and complained that they did not know the doctors so felt anxious about going. The Business Manager wrote to the PCT about the difficulties of trying to change the GP and they have now changed. This is to be commended and shows an awareness of the residents needs. There are records in place for residents detailing weekly checks, on their weight, which is relevant as they have issues in this area. The dietician has been involved with the residents care in respect of eating plans for individuals. In one of the residents file sampled there wasn’t a care plan in respect of problems they have with their diet. Resident’s records sampled included details of health appointments attended. Including GP’s, psychiatry and the optician. The Speech and Language therapist has worked with one resident and has set up a communication book for them. The resident has now chosen not to use this. Staff said that the Speech and Language therapist has said that the resident does not need to use it as they can communicate when they choose to. Medication is stored safely in a locked cabinet on the wall. Medicines are regularly booked in and out, when medication is returned. All medication administration sheets had been signed and there is a photo in place with each resident’s record. PRN medication must also be signed in and signed out when it is returned. Residents currently need to see their GP each and every time they require medication, or creams. The home needs to obtain a ‘homely remedy list’ to enable residents to have access to medication as required. All residents have risk assessments in place to support them to develop safe skills in working towards administering their own medication, staff support them with this as appropriate. The training matrix showed details of all the staff that had attended medication training. There were plans in place demonstrating discussions with the residents, to ensure residents individual wishes would be met by the staff team in the event of their death. Ascot Lodge DS0000017108.V266006.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Arrangements are adequate to ensure that resident’s views are listened to and acted upon. There are generally adequate arrangements in place to protect the residents from abuse. EVIDENCE: There is a complaints policy on clear display on the notice board. This is in an accessible format for the current residents who live in the home. It also includes details of how to contact the CSCI. The staff said that the complaints policy is discussed regularly with the residents in a number of ways, both individually and at residents meetings. The staff said that if asked the residents could explain what they would do if they were unhappy with something in the home. There have been no complaints since the last inspection. None of the residents currently have advocates, but the staff said that the resident’s families are very involved in their care and advocate for the residents. The home has a policy on Protecting Vulnerable Adults from abuse and there are completion dates on the training matrix to indicate staff have attended training in this area. Staff records were not inspected on this occasion. The financial records were robust. Each resident has their own bank account that their benefits are paid into. Receipts are kept of all expenditure. Ascot Lodge DS0000017108.V266006.R01.S.doc Version 5.0 Page 16 The resident who uses a cash point card had a care plan and risk assessment in place to ensure they are supported to use this safely. The plans attempted to manage any possible financial abuse to them, via this system, as much as possible. The home contributed to the cost of both holidays that residents went on this year. Behaviour management guidelines are in place for residents where appropriate so that all staff manage individual behaviours in a consistent way. One resident’s records recorded an incident at 10.30pm where it stated that the resident had “been demanding, verbally aggressive and stormed out of the building.” The resident returned 20 minutes later. The Business Manager said that the resident went to the organisations other home two doors away and staff knew they were there. This was not recorded in their records and it appeared that the resident could have been wandering in the local area. Records should be clear and record all details of incidents. Ascot Lodge DS0000017108.V266006.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 28, 30 Adequate arrangements are not in place to ensure that residents live in a homely, clean and comfortable environment. Residents bedrooms suit their needs and lifestyles and promote their independence. EVIDENCE: One resident’s bedroom was seen with their permission. It included many personal possessions. They said they had everything they needed in their bedroom and were able to choose the decoration and furniture. The bathroom is in need of total redecoration, the radiator requires a cover to prevent accidental scalding. The paper on the bathroom ceiling is coming off and the bath panel does not fit to the wall properly. The bin in the bathroom requires replacing as it is stained, along with the heavily stained shower curtain. There is no extractor fan in the bathroom so the window is often left open to provide ventilation. This means that during the winter months it is cold in the bathroom. The bathroom would benefit from a deep clean as the paintwork around the skirting board and on the door is stained with splash marks. Ascot Lodge DS0000017108.V266006.R01.S.doc Version 5.0 Page 18 The cupboards in the kitchen need replacing as they are worn, one has a handle missing and the covering on the kitchen cabinets is starting to peel away from the cupboard doors and frames. The work surfaces also need renewing, they are stained and not watertight as the seal is starting to disintegrate. The kitchen would also benefit from a cleaning schedule to ensure regular deep cleaning, many of the underneath areas of the cupboards were noticeably stained and marked with food substances. Ascot Lodge DS0000017108.V266006.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 35 Adequate arrangements are in place to ensure that residents are supported by an effective staff team who have the skills to meet their individual needs. EVIDENCE: The Business Manager said apart from the managers position there are no staff vacancies. They are planning to recruit more bank staff to cover holidays and absences. With the exception of the manager, no members of staff have left since the last inspection. Rotas showed that minimum staffing levels are being met at all times. All but one member of staff has completed NVQ level 2 or 3 in care. The senior has completed NVQ level 4 and the Registered Managers Award. The Business Manager and the senior have completed a six-day course on autism. They plan to deliver some in-house training to staff from the knowledge they have gained from this course. All staff and residents were planning to do fire safety training the next day. The home has achieved the ‘Investors in People’ standard. The Business Manager said that because of this the Birmingham Chamber of Commerce fund 60 – 80 of the non-mandatory staff training. Staff have completed all mandatory training including food hygiene, first aid, manual handling and medication. Staff have also completed training in communication, epilepsy, autism and managing behaviour. Ascot Lodge DS0000017108.V266006.R01.S.doc Version 5.0 Page 20 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 The home currently has no manager in place; this makes it difficult to ensure the resident’s benefit from a well managed home. The home has a policy outlining a Quality Assurance System that includes resident’s views. Resident’s rights and interests are safeguarded by the home’s policies and procedures. Much progress has been made since the last inspection so that arrangements are in place to ensure the health, safety and the welfare of the residents is generally promoted and protected. EVIDENCE: Since the last inspection the registered manager has left the home. The Business Manager said that the position has been advertised but little response has been received. Ascot Lodge DS0000017108.V266006.R01.S.doc Version 5.0 Page 21 The owner is considering offering the post to someone within the organisation who has the necessary experience and qualifications. The home can demonstrate a comprehensive Quality Assurance System, and follow many of the procedures in place to support this system. Further work is required to produce a twice - yearly report as per the policy. The staff say that they are going to look at this next year when a manager has been appointed to the home. Fire records indicated the fire systems are regularly inspected. The staff undertake regular fire drills, recording times of the drills and outcomes. All weekly fire checks were completed. Fire training for the staff had been scheduled for the following day; the residents attend fire training along with the staff to ensure they fully understand what to do in the event of a fire. No doors were wedged open with plastic wedges. Portable Electrical Appliances were tested in June this year. There was a five year hard wiring check completed on 11/11/2002. Staff test the water temperatures regularly, and they were observed to never be recorded over 43 degrees centigrade. The bath temperatures were recorded regularly at lower than this. The staff member said that these had been checked regularly since the last inspection and that staff didn’t let the water run longer enough before taking the reading. The staff member tested the water at the time of the inspection and this was recorded at 42 degrees centigrade. There was no Legionella testing of the water, taking place annually. The Business Manager is going to contact Environmental Health to check this is necessary for the premises. A certificate of employer’s liability insurance was seen, and this was valid until 9/1/06. The home had a current controlled waste transfer note in place. The cooker now had a hook chain fitted; a stability bracket was not seen to be in place at the time of the inspection. The cooker could be pulled away from the wall easily. The vehicle the home provides for the residents use, had a current MOT certificate 04/07/05 and a current insurance certificate 18/07/05. No other details pertaining to this vehicle were checked at this time. Fridge and freezer temps were undertaken every day and recorded. The temperatures were found to be in acceptable ranges. Ascot Lodge DS0000017108.V266006.R01.S.doc Version 5.0 Page 22 Cigarette ends were found in the kitchen bin. When extinguished they must be placed in the bin outside. This bin must be regularly emptied. Work on the homes generic risk assessments remains ongoing. The Homes Policy and Procedure file was looked at. There is a comprehensive list of Policies and Procedures in place to support the management of the home. Ascot Lodge DS0000017108.V266006.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 2 2 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 1 x 3 2 3 x 2 LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score x 3 3 x 3 x CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Ascot Lodge Score 3 2 3 3 Standard No 37 38 39 40 41 42 43 Score 1 x 2 3 x 2 x DS0000017108.V266006.R01.S.doc Version 5.0 Page 24 No 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 YA6 Regulation 15 (1) (2) Requirement Timescale for action 31/12/05 2. 3. YA6 YA8 Schedule 3 12 (2) (3) (4) (a) 4. YA9 13 (4) (a – c) There must be care plans in place for all residents needs. Care plans must be clear and explicit in the guidelines to staff. They must demonstrate evidence of discussions with individual residents about their involvement. These should also reflect their agreement and where possible their signature. The information in the residents 31/12/05 profile needs to be up to date. e.g. social worker details. Staff must ensure that residents 17/11/05 meetings are about what residents want to discuss and they must have the opportunity to make decisions about their lives. Risk assessments must be 31/12/05 comprehensive in identifying all risks and explicit in it’s guidelines to staff to ensure consistence. All risk assessments must include a staff members signature and where possible the residents signature. There should also be notes on the risk assessment review, detailing a review had taken place, to DS0000017108.V266006.R01.S.doc Version 5.0 Ascot Lodge Page 25 include the resident’s involvement and reflect if the risk assessment is to be changed or if it is ongoing. 5. YA19 12 (1) (a) (2) 6. 7. YA20 YA24 13 (2) 23 (2) (b, d, p) 23 (2) (b, d) 16(2)j,k 23(2)d 8 (1) (a) (2) 8. 9. 10. YA24 YA30 YA37 11. YA42 13 (4), 23 (2) c 12. 13. YA42 YA42 13 (4) (ac) 13 (4), 23 (4) Health Action Plans in line with Valuing People must be developed further for each resident. A Health Action Plan is a personal plan about what a person with a learning disability can do to be healthy. It lists any help people might need to do those things. It helps to make sure people get the services and support they need to be healthy. Protocols must be in place for all PRN (as required) medication prescribed to residents. The bathroom must be redecorated and refurbished. An extractor fan must be provided in the bathroom. The kitchen units and worktops must be replaced. Deep cleaning must be undertaken in the kitchen and bathroom at regular intervals. A manager must be recruited to work at the home. Once appointed an application for registration must be submitted to the CSCI. The recommendations from the gas engineers report must be actioned. A stability bracket must be fitted to the gas cooker. (Previous timescale of 30/06/05 not met). A radiator cover must be provided in the bathroom. Used and extinguished cigarette ends must not be put in the kitchen bin. They must be placed in the bin outside and this bin must be emptied regularly. DS0000017108.V266006.R01.S.doc 31/01/06 31/12/05 31/03/06 30/04/06 31/12/05 28/02/06 09/12/05 31/12/05 16/11/05 Ascot Lodge Version 5.0 Page 26 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. 4. 5. Refer to Standard YA6 YA20 YA23 YA39 YA42 Good Practice Recommendations Residents care plan should be more specific i.e. what target weight the resident who is aiming to lose weight is hoping to achieve. There should be a ‘Homely Remedies’ list to enable staff to give out medication, when needed to residents for minor ailments e.g. Headaches, upset stomach. Resident’s daily records should clearly detail what happens in incidents of behaviour that can be challenging. The quality assurance system should be reviewed twice yearly. Staff should contact the Environmental Health Department to find out if an annual Legionella check is required for this premises. Ascot Lodge DS0000017108.V266006.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Ascot Lodge DS0000017108.V266006.R01.S.doc Version 5.0 Page 28 - 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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