Inspection on 07/11/07 for Ascot Lodge

This inspection was carried out on 7th November 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

Ascot Lodge 04/11/08

Ascot Lodge 27/06/06

Ascot Lodge 16/11/05

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 Key Unannounced Inspection 7th November 2007 11:15 Ascot Lodge DS0000017108.V355420.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 Ascot Lodge DS0000017108.V355420.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. Ascot Lodge DS0000017108.V355420.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ascot Lodge Address 17 Ascot Road Moseley Birmingham West Midlands B13 9EN 0121 247 8760 F/P 0121 247 8760 lornastreasure@yahoo.co.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) Dr Kandiah Somasundara Rajah Vacant post Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Ascot Lodge DS0000017108.V355420.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years Date of last inspection 27th June 2006 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 the people who live in the care home. 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 the people living there 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. The service users guide did not include the fees charged to live there. Inspection reports are on display in the home and available to visitors if they wish to read them. Ascot Lodge DS0000017108.V355420.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The visit was carried out over one day; the home did not know the inspector was going to visit. This was the homes key inspection for the inspection year 2007 to 2008. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provisions that need further development. Prior to the fieldwork visit taking place a range of information was gathered to include notifications received from the home and a questionnaire about the home – Annual Quality Assurance Assessment (AQAA). Two people who live in the home were case tracked this involves establishing individuals experience of living in the care home by meeting or observing them, discussing their care with staff, looking at care files, and focusing on outcomes. Tracking people’s care helps us understand the experiences of people who use the service. The people who live at the home and the staff on duty were spoken to. The people who live there completed the Commissions ‘Have your say’ survey that asks for their views on the home and the support they receive. What the service does well: The people who live there are asked what they want to do, what they want to eat and drink, where they want to go and what would make the home a better place to live in. Each person who lives there has their own care plan and risk assessments. This gives staff the information they need so they can help people to meet their needs and reach their goals. The people living there help to write their care plan. The people who live there often go out to the places they want to go to. They go to college and have planned activities during the week such as going to the gym and swimming. Ascot Lodge DS0000017108.V355420.R01.S.doc Version 5.2 Page 6 The people living there are encouraged to do things for themselves. They do their washing, ironing, clean their bedrooms, wash up and help to prepare their meals. Staff help them as much as they need to. One person said, “I’m very happy here and would like to stay here for some time. I’m happy it is just a small place and there are only two other people living here.” The people who live there are supported to attend health appointments when needed. Staff follow the advice of health professionals so that people can be as healthy as possible. The staff often have training to help them meet the needs of the people who live there. What has improved since the last inspection? What they could do better: There should be information about what it costs to live there in the service users guide. This will make sure that people have all the information they need about the home. Staff should be aware of the Mental Capacity Act and how this affects the people who live there in making decisions about their lives. A carbon monoxide detector that finds out if there is a gas leak should be fitted so that the people living there and staff are safe. Ascot Lodge DS0000017108.V355420.R01.S.doc Version 5.2 Page 7 Some records about health and safety need to be looked at again or sent to the Commission. This will make sure that the people who live there and the staff are safe and well. 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. Ascot Lodge DS0000017108.V355420.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 Ascot Lodge DS0000017108.V355420.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Generally arrangements ensure that prospective service users have the information they need so they can make a choice about whether or not they want to live there. Before people move in their needs are assessed to ensure they can be met at the home. EVIDENCE: The statement of purpose and service users guide generally included the required and relevant information so that prospective service users would have the information they need about the home. The service users guide should also include the fees charged so that all information is available. The manager said they would be adding a paragraph on the compatibility of the people living there in the statement of purpose. They think this is important in ensuring that people are happy living there. The manager said they hope to develop the service user guide in video format to make it easier for the people living there to understand. One person living there said, “I did get a lot of information before deciding to move to this home.” The people who live there have lived there for a number of years and there are no vacancies. The pre-admission assessment procedure stated that before a person moved into the home the manager would visit them and carry out an Ascot Lodge DS0000017108.V355420.R01.S.doc Version 5.2 Page 10 assessment of their needs and risks. They would also assess their compatibility with the other people living there. As well as visits to meet the person where they are living they would be encouraged to visit the home and meet the staff and the other people living there. Ascot Lodge DS0000017108.V355420.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff have the information they need so they can support the people living there to meet their needs and achieve their goals whilst ensuring they are safe. The people living there are supported to make choices and decisions about their day-to-day lives. EVIDENCE: Two records of the people who live there were looked at. The manager said that new care plans are being developed and these were being completed electronically so paper copies were not available for one person. The new care plan was looked at on the computer. This was detailed and stated the agreed care requirements for the individual. Their care plan for communication included staff being aware that they should not use jargon or slang as because of the person’s autism this may confuse them. Ascot Lodge DS0000017108.V355420.R01.S.doc Version 5.2 Page 12 The care plan stated how staff are to support the person with their behaviour, personal safety, sleep, medication, health needs, diet and nutrition, personal hygiene, spiritual needs and social and leisure needs. Where there was a risk assessment in place or behaviour management guidelines this was stated so pointing the reader to the current information to ensure the person is supported appropriately. Records showed that the person was involved in developing their care plan. The manager said that they would ask the person to sign their care plan when it is printed to show that they agree with it. Records showed that regular meetings are held with the people who live there. Minutes of these showed that people talked about going on holiday, college courses, activities, cooking, key workers and shopping. People had signed the minutes of the meeting to show that they agreed with them. Records included individual risk assessments. These stated how staff are to support individuals to minimise risks to ensure that they are as safe as possible. They included their behaviour, using gym equipment, their health needs and medication, using sharp knives, having keys, road safety, going out on their own and activities. Risk assessments were detailed and signed by the person and staff to show that they were aware of it and agreed with it. Ascot Lodge DS0000017108.V355420.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that the people living there experience a meaningful lifestyle. People are offered a varied and healthy diet so ensuring their health and well being. EVIDENCE: Staff said there had been difficulty with supporting the people living there to access college courses as funding has been cut and some of the colleges are closing. Two people attend a weekly cookery class and one person is doing a current affairs course. Records showed that people choose what activities they want to do. Two people go to a local sensory/relaxing room each week. One person said that they do not wish to go but would prefer to go for a walk or read the newspaper instead. Records showed that staff had respected this and supported the person in the activity of their choice. Ascot Lodge DS0000017108.V355420.R01.S.doc Version 5.2 Page 14 Records sampled showed that people take part in a range of activities inside and outside the home. These included watching TV, going shopping, listening to music, relaxing in the garden, using the bus to go to cafes and restaurants, going to sensory/relaxing room, to church, going to the gym, for walks and going to parks. Records showed and people said that they had a Halloween party the week before that they had enjoyed. People said that they go to a local disco once a month. One person said, “I love to go for long drive in minibus at weekend and go out with my family.” One person was celebrating their birthday later that week. As they were spending their birthday with relatives they went out in the afternoon with the other people who live there and staff. They chose to go into the city centre, go to McDonalds to eat and then look around the shops. When they returned late afternoon they said that they had a good time. They said they wanted a chocolate birthday cake and during the day staff went out to order it. They were not sure what they wanted for their birthday as they said they have everything that they want but they are going to get a free view box. Staff said this would give the person a choice of more channels when watching TV in their bedroom. They said that would get an aerial fitted so it would work in the area. Two people went with staff to Blackpool for a long weekend in August. One person chose not to go so they were supported to stay at home. All the people who live there went on a day trip to Weston in the summer. Records showed and people said that they are supported to keep in contact with their family and friends where appropriate. This is through visits to them and visits from them, going out with them and telephone calls. One person’s relative who lives abroad had recently sent them a book about their family and the things that the individual likes and dislikes. This included pictures, photographs and easy to read information so that they can communicate with people and tell them who they are and what they like. Staff asked their permission to show their book to the inspector, which they agreed to. This person has their own email address so they can keep in contact with their relatives abroad. As the inspector arrived the people living there were cleaning their bedrooms with support from staff as needed. Records sampled showed that people are supported to develop their skills in independence. This included doing their own laundry and ironing, cleaning their bedrooms and communal areas, making their breakfast and helping to prepare meals. The provider pays therapeutic earnings to the people who live there when they complete their household tasks. This encourages people to do the tasks that will improve their skills in independence and reward them with money that they can spend how they choose. The people living there had all agreed that they save the money so they can go out for meals more regularly. Ascot Lodge DS0000017108.V355420.R01.S.doc Version 5.2 Page 15 Food records sampled showed that people living there are offered a variety of food that includes fresh fruit and vegetables to ensure their diet is healthy. Records showed that the food offered is appropriate to the cultural background of the people living there. However, they are encouraged to try out different cultural dishes if they want to. The people living there go with staff to shop for their food and are involved in preparing meals. People said that they could choose what they eat. Ascot Lodge DS0000017108.V355420.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that individual’s personal care and health needs are met so ensuring their health and well being. The management of the medication ensures that people get the medication they need at the right time so ensuring their health needs are met. EVIDENCE: Care plans sampled stated how staff are to support the individual to meet their personal and health care needs. Care plans for personal care stated that the person should be encouraged to be as independent as possible so staff needed to prompt and give guidance on clothing for the weather. The people living there had independent styles of hair and dress. This was appropriate to their age, gender, the weather and the activities they were doing. Records showed that the people living there are supported to attend appointments with health professionals as appropriate and to have regular eye and dental check ups. Records are kept of the outcome of these appointments Ascot Lodge DS0000017108.V355420.R01.S.doc Version 5.2 Page 17 and if staff need to follow any guidelines or advice given to ensure individual’s health needs are met. Records included an individual health action plan. This is a personal plan about what a person needs to sty healthy and what healthcare services they need to use. At the last inspection these included a lot of information about the person that was not related to their health needs. This information had been removed so it was clear for staff how to meet the individual’s health needs. One person’s plan stated that they needed to be weighed weekly. Records showed that this had been done and their weight had been monitored by staff to ensure their health and well being. Medication is stored in a locked cabinet. The people living there have been assessed as to their ability to administer their own medication to ensure they are as independent as possible. Depending on their assessment they do this but are not able to store their own medication. Staff observe when people take their medication out of the pack and ensure that they take it as prescribed. People had recently had their medication reviewed by their GP to ensure it is effective in meeting their health needs. There was a photograph of the person at the front of their Medication Administration Records (MARS) so that unfamiliar staff would know who to give the medication to. All the MARS had been signed appropriately indicating that medication had been given as prescribed. The pharmacist visits regularly to audit the medicine management systems. Since their last visit each person now has an individual list of homely remedies that they can take with their prescribed medication to ensure that taking homely remedies does not have a detrimental effect on their health. Ascot Lodge DS0000017108.V355420.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements ensure that the views of the people living there are listened to and acted on. The people who live there are protected from abuse, neglect and self-harm. EVIDENCE: The AQAA stated that there have been no complaints received by the home in the last twelve months. The Commission has not received any complaints about this service during that period. The complaints procedure is displayed in the home and is included in the service users guide so that the people living there know how to make a complaint. The manager had received training in the Mental Capacity Act that came into force in April this year. She said that she would deliver awareness training of this to staff so they know about the Act and the implications it has for the people who live there. This Act requires an assessment of individual’s capacity before they make a decision regarding their welfare. If they do not have the capacity to make the decision arrangements are made for another person to do this who may be an independent advocate. All staff had received training in adult protection and the prevention of abuse and physical intervention training. Where people display behaviour that can be challenging their records included behaviour management guidelines. These Ascot Lodge DS0000017108.V355420.R01.S.doc Version 5.2 Page 19 were detailed and showed staff how to manage the person’s behaviour using distraction techniques and only use physical intervention as a last resort. Each person has an inventory of their belongings so it is clear what belongings they have which if they should go missing can be tracked easily. These had been updated regularly as the person had bought new things. The individual and staff had signed their inventory. One person’s financial records showed that staff support the individual to look after their money. They have a bank account that their benefits are paid into. Their bank statements showed that their benefits are being paid in, their fees are paid by standing order and they withdraw their personal allowance regularly. Their finance records for money that they had withdrawn crossreferenced with their bank statement indicating that their money is being handled appropriately. All receipts for money withdrawn are kept securely, as are receipts of all purchases they had made. The other person’s finance records sampled showed that their relative looks after their money and they give them money when required. Receipts were available for all purchases they had made and records showed that their money was spent in the way they wanted. Ascot Lodge DS0000017108.V355420.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27, 28, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Although there is limited space in the home improvements have been made to ensure as much as possible that people live in a homely, safe, clean and comfortable environment. EVIDENCE: Space in the home is limited. Communal areas include a lounge, small dining room and a small kitchen. There is one small bathroom with a toilet for the use of the people living there, staff and visitors. The washing machine and tumble dryer are located in an alcove off the hall. The office is accessed through the garden. The garden is private and has grassed areas, flowerbeds, trees and shrubs. There is a garden shed and facilities are available for drying washing. The manager said that solid wooden flooring is to be fitted in the lounge and dining room. This had been delivered and was seen to be of good quality. One Ascot Lodge DS0000017108.V355420.R01.S.doc Version 5.2 Page 21 person had also requested that this be fitted in their bedroom so this was to be done. The manager said that a new three-piece suite is to be ordered for the lounge but the people living there had not yet decided which one to order. To enable this to be delivered the windows of the lounge would need to be removed so it is planned to renew the windows at the back with double glazing at the same time. New curtains had been provided in the lounge and it looked homely with pictures and photographs on the walls. During the day a fire door was being fitted to the alcove where the washing machine and tumble dryer are stored. A new vent and extractor fan had been fitted in the larder to ensure that food is stored at the correct temperature. Since the last inspection a new dining room table and chairs had been provided and the room had been redecorated, a new light fitting had been installed and the carpet had been cleaned. This made the dining room brighter and more homely and comfortable. Staff said they are getting new net curtains and new curtains in the dining room. New doors had been fitted to the kitchen cupboards and new flooring had been fitted. This will help to reduce dirt from collecting around the bottom and edges of the cupboards so reducing the risk of infection. The manager said that an electrician is going to replace the extractor fan in the kitchen to reduce odours and condensation. All areas of the home were clean and free from offensive odours. There were hand towels and soap provided in the bathroom and kitchen to reduce the risk of cross infection. Colour coded mops and buckets had been provided so that staff know which to use to clean the bathroom and kitchen so minimising the risk of cross infection. Ascot Lodge DS0000017108.V355420.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements for staffing, their support and development ensure that staff have the skills and knowledge to meet the needs of the people who live there. EVIDENCE: Five of the seven staff that work in the home staff have National Vocational Qualification (NVQ) level 2 or above in Care. The manager has NVQ level 4 and is currently undertaking the Registered Managers Award. One member of staff who has not had NVQ training had recently enrolled to do NVQ level 3. Another member of staff is doing NVQ level 4. This exceeds the standard that at least 50 of staff have NVQ level 2 or above so ensuring they have the skills and knowledge to meet the needs of the people living there. One member of staff was on maternity leave. There were no staff vacancies. Rotas sampled showed that the minimum staffing levels were always met. One person living there said, “Staff help me a lot with everything.” Ascot Lodge DS0000017108.V355420.R01.S.doc Version 5.2 Page 23 Staff meeting minutes showed that these are held regularly so that staff are kept updated with the changing needs of the people living there, ‘best practice’ and any changes within the organisation. Two records of staff that work there were looked at. These included the required recruitment records including evidence that a Criminal Records Bureau (CRB) check had been undertaken ensuring that ‘suitable’ people are employed to work there. Records showed that staff had regular formal, recorded supervision sessions with their manager to ensure they are supported and have the skills, knowledge and training they need to work with the people living there. A new appraisal form was in place and staff were being asked to complete their part of this. The appraisal included identifying training needs so that all staff have the skills and knowledge to meet the needs of the people living there. A staff training matrix and development plan was available for 2007. This showed that all staff had received training in basic food hygiene, moving and handling, fire safety, abuse, physical intervention and first aid. Training records sampled confirmed that staff have had this training. One member of staff’s records sampled showed they had received training in infection control, autism, challenging behaviour, health and safety, report writing, risk assessment and epilepsy. Other staff had received some of this training in – house training in October and further in – house training was arranged during November. The manager has completed the ‘Train the Trainers’ award and will be delivering in –house training. Five members of staff have had accredited training in the ‘Safe Handling of Medicines’. The manager is planning to do a six – day course on autism starting in January 2008. Ascot Lodge DS0000017108.V355420.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Generally the management arrangements ensure that the people living there benefit from a well run home. Arrangements ensure that the people living there can be confident that their views underpin the self-monitoring, review and development by the home. Generally the health, safety and welfare of the people who live there is promoted and protected so ensuring their well being. EVIDENCE: The manager has been employed at the home since May this year. They have nearly completed the Registered Manager’s Award. After this inspection they attended the Commission’s office for their interview for Registered Manager. The owner owns another home two doors away for three people and the Ascot Lodge DS0000017108.V355420.R01.S.doc Version 5.2 Page 25 Commission had previously agreed that the manager could be registered for both. However, the manager had only applied to be registered for the other home and did not apply for registration for this home. They were successful at interview but now need to make an application to be the Registered Manager for this home also. An independent consultant completes the monthly visits to the home on behalf of the provider. A report of these is written and sent to the Commission. Their visits include asking the views of the people living there. Since the manager had been employed there they have completed two night audits to ensure that the needs of the people who live there are met during the night. A report had been made of the audit and where appropriate recommendations were made to improve the service offered. An independent company visit to undertake health and safety audits and give advice on how this can be improved. The manager demonstrated that she understood the quality assurance process and had incorporated this into the home’s recording systems so that audits were regularly completed as part of the day-to-day running of the home. Fire records showed that staff regularly test the fire equipment to make sure it is working. Regular fire drills are held so that staff and the people who live there would know what to do if there was a fire. Fire safety training was arranged for the following week. An Environmental Health Officer visited in September this year and left a report of their visit. They made three recommendations and the findings of this inspection showed that these had been complied with so that the hygiene and food safety standards had improved making it a safer place to live. A Corgi registered engineer completed the annual test of the gas equipment in October this year and stated that it was safe to use. They advised that a carbon monoxide detector be purchased. The manager said this had been ordered. Risk assessments were in place for all relevant areas including staffing, the premises, accessing the community and equipment used in the home. They had all been reviewed in July 2007 and the review had said no changes for all assessments. Although all relevant risks had been assessed they were not that detailed. The manager had recently completed risk assessment training. It is recommended that following this they review the risk assessments again to ensure that action is taken so that all risks are minimised as much as possible. The home has a vehicle that staff drive to enable the people who live there to access the community. A valid certificate of vehicle insurance was available. Ascot Lodge DS0000017108.V355420.R01.S.doc Version 5.2 Page 26 An electrician had tested the portable electrical appliances the week before to ensure they were safe to use. They had also completed a test of the electrical wiring as required every five years to ensure it is safe. The certificate for this was forwarded to the Commission following the inspection to evidence that the electrical wiring is safe. Staff test the water temperatures weekly to make sure they are not too hot or cold. Records showed that at the last test these were within the recommended safe limits so that the people who live there are not at risk of scalding. Ascot Lodge DS0000017108.V355420.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X 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 2 25 X 26 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 4 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 4 X X 2 X Ascot Lodge DS0000017108.V355420.R01.S.doc Version 5.2 Page 28 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. Standard Regulation Requirement Timescale for action 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 YA1 YA23 YA37 YA42 YA42 Good Practice Recommendations The service users guide should include the fees charged so that people have all the information they need about living at the home. Staff should be aware of the Mental Capacity Act and the implications it has for the people who live there. The manager needs to make an application for registration with the Commission for this home also so that the people living there continue to benefit from a well run home. A carbon monoxide detector should be installed to ensure the safety of the people living there and staff. Risk assessments for the premises, food and staff should be reviewed again to ensure that all action to minimise risk is taken so that people living there and staff are safe. Ascot Lodge DS0000017108.V355420.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Ascot Lodge DS0000017108.V355420.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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