Inspection on 19/11/07 for Ash Lea House

This inspection was carried out on 19th 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 found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ash Lea House 17/11/08

Similar services:

Hillside

Applegarth

122 Scorer Street

St Marys Nursing Home

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

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

CARE HOME ADULTS 18-65 Ash Lea House Chesterfield Road Alfreton Derbyshire DE55 7DT Lead Inspector Steve Smith Unannounced Inspection 19th November 2007 09:30 Ash Lea House DS0000070377.V354486.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 Ash Lea House DS0000070377.V354486.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. Ash Lea House DS0000070377.V354486.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ash Lea House Address Chesterfield Road Alfreton Derbyshire DE55 7DT 01773 521763 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) Clearwater Care (Hackney) Ltd Mrs Dawn Elizabeth Maris Care Home 14 Category(ies) of Learning disability (14) registration, with number of places Ash Lea House DS0000070377.V354486.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Provider may provide the following category of service only: Care home - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: Learning Disability - Code LD The maximum number of service users who can be accommodated is: 14 This was the first inspection of this Home under the current Registered Providers 2. Date of last inspection Brief Description of the Service: Ash Lea House is a large detached period house set in its own substantial grounds. The home is situated on the edge of Alfreton, which offers easy access to a large range of shopping facilities and amenities. The Home offers accommodation for 14 people with Learning Difficulties, aged between 18 to 65 years of age. The Home has three lounge areas, one of which includes the dining area. The bedrooms are all single bedrooms, except for one double bedroom, and all are of a good size. The kitchen area is accessible by the Residents, dependent on the Residents ability and the activity being addressed there at the time. The Home offers 24-hour staffing, three meals per day, personal laundry, lighting, heating, and a range of social activities. The charges made for a place at Ash Lea range from £1434.60 to £3854.40 a week, dependent on the needs of the Resident. Details of previous inspection reports can be found on the Commission for Social Care Inspection’s website: www.csci.org.uk Ash Lea House DS0000070377.V354486.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place in just under 7.5 hours. Discussion was held with two Residents, and the needs of a further two Residents were ‘case tracked’. The Manager was spoken with, and one member of staff was also seen. A number of records were examined, and the bedrooms of five Residents were looked at and all public areas of the Home were examined. The Commission’s Annual Quality Assurance Assessment, sent to the Manager, was not available at the time of this visit to the Home. The Commission’s questionnaire sent out to the Residents, was also not available at this time. What the service does well: What has improved since the last inspection? What they could do better: The statement of purpose needed updating to ensure it contained the name and address of the Registered Providers. The Residents Guide also needed considerable work to ensure it held all of the information required by Regulation 5 and Standard 1.2. Ash Lea House DS0000070377.V354486.R01.S.doc Version 5.2 Page 6 Since taking over the Home, the Registered Providers and Manager had discovered that the Home previously had not provided all Residents and their relatives with a Contract/Statement of Terms and Conditions of Residency. This was found to be still outstanding at this visit to the Home. Fully detailed risk assessments were needed for each Resident staying at the Home. Formal reviews of care were also needed, completed on a 6 monthly basis. Residents files also needed to contain a confidential section. Improvements in the recording on the Medication Administration Record sheets was needed. It was recommended that able Residents should be placed on the electoral register in the area in which the Home was situated. It was also recommended that the Registered Providers provide an annual week long holiday as part of the basic fee for the placement. Care staff needed to be encouraged to knock and await a reply from Residents able to do this before entering their bedrooms. It was also recommended that Residents bedrooms be provided with appropriate locks on the doors. Residents should also be encouraged to help in the preparation of meals provided in the Home. Within the complaints procedure, Residents and relatives needed to be informed that they would not be victimised for making a complaint. The Manager was encouraged to obtain a copy of the Public Interest Disclosure Act of 1998. It was also suggested that she informed staff, in the staff’s procedures manual, that they could not benefit in any way from Residents wills. Some slight work was needed on the fabric and condition of the Home to ensure it met recommended standards. When new staff were appointed to the Home a photograph needed to be obtained. At least 50 of Care staff also needed to be trained to at least NVQ level 2 in Care, and the Manager should also be encouraged to obtain an NVQ level 4 in Management and Care. The Manager needed to obtain copies of the Management of Health and Safety at Work Regulations 1999, the Workplace (Health, Safety and Welfare) Regulations 1992 and the Provision and Use of Work Equipment Regulations 1992. She also needed to ensure that these were operational within the Home. The Manager needed to provide risk assessments, for all staff, on all working practice topics in order to ensure that significant findings were recorded and that all staff were safeguarded. The Registered Providers and Manager need to ensure that a complete quality assurance programme was provided and updated on an annual basis. Ash Lea House DS0000070377.V354486.R01.S.doc Version 5.2 Page 7 A large percentage number of staff needed training in basic subjects such as First Aid, Food Hygiene and Infection Control. 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. Ash Lea House DS0000070377.V354486.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 Ash Lea House DS0000070377.V354486.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): Standards 1, 2 & 5. The quality in this outcome area was Adequate. This judgement was made using available evidence including a visit to this service. The Registered Providers needed to provide Residents with a completed Residents Guide and up to date contract/statement of terms and conditions of residency to ensure that Residents were fully informed about the operation of the Home. EVIDENCE: The Home’s statement of purpose and Residents Guide were reviewed during this visit. The statement of purpose was well laid out, although did not include details of the address of the Registered Providers. A Residents Guide was also available, although it contained little that was listed in Standard 1.2 or Regulation 5. The statement of purpose and Residents Guide did not include details of the physical environment standards met/not met by the Home. The Registered Providers and Manager had also not provided a copy of the Residents Guide in a form that was accessible by Service Users, for example in either ‘Widget’ or ‘Makaton’. The Manager said that the Home would normally receive referrals of new Residents via the Care Management teams of Social Services Depts or Health Authorities from various places around the country. However, since the new Registered Providers had taken over the Home no new referrals had been made. The Manager said that all new Residents would be assessed by her Ash Lea House DS0000070377.V354486.R01.S.doc Version 5.2 Page 10 prior to the beginning of their placement, and a report completed on her assessment. The Registered Providers and Manager were in the process of reviewing the contact/statement of terms and conditions between Residents and the Registered Providers, although all Residents living in the Home were placed there prior to the Home being taken over. Once this had been done, new contracts/statement of terms and conditions of residency would be provided to all Residents in the Home. At that time, the Registered Providers or Manager needed to ensure that Residents, or their Representatives, signed the contract or statement of terms and conditions of residency. It was found that this had not been done under the previous Registered Providers. Ash Lea House DS0000070377.V354486.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): Standards 6, 7 & 9. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. The Manager and staff ensured that Residents needs were met, allowing for their differing abilities and disabilities. EVIDENCE: To help assess Standard 6, the Residents Plan of Care, the records of two Residents were examined, for the purpose of case tracking. All of the basic information, concerning the Residents, was found to be in the files examined. That was, their name and date of birth, their next of kin, their GP, Care Manager, their keyworker and their date of entry to the Home. The content of the files was information formulated by the previous Registered Providers. The current Registered Providers and Manager had started to improve the content of the files, although further work was Ash Lea House DS0000070377.V354486.R01.S.doc Version 5.2 Page 12 need. Basic risk assessment data was available, although more detail was needed to make the information on each Resident useful. The files showed that good records of events affecting the Residents were kept. Entries were seen to be made at least twice a day, every day. The Residents formal reviews of care had been undertaken by Social Services Depts on an annual basis, but none had been done by the current or passed Managers of the Home. The Residents records were easy to read, and the files were also well organised. However, the files did not contain a confidential section. The Manager was able to say that a number of Residents had an independent Advocate, who visited on a monthly basis. The Advocate was provided by a local agency, not affiliated to the Registered Providers in any way. Staff spoken with said that to assist Residents to make choices in their daily lives, the staff regularly explained the options available and encouraged the Residents to make their choice. For example, some Residents were able to make choices about places to go out to in the evening, while others could only make much more limited choices, such as what clothing to wear. In enabling Residents to take appropriate risks, staff were able to indicate that one Resident regularly goes out of the Home unaccompanied. Staff also said that other Residents were encourage to take appropriate risks by enabling them to carry their meal from the hatch of the kitchen to their table or being enabled to take a shower or bath safely. Ash Lea House DS0000070377.V354486.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): Standards 12, 13, 14, 15, 16 & 17. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. Links with the local community were good and supported and enriched Residents social opportunities. Varied meals were also provided to the satisfaction of all Residents. EVIDENCE: Staff were able to describe the varied activities undertaken by Residents. These included such things as time spent at work or undertaking a voluntary job, or attending day centres, which included most of the Residents. One Resident was also described as doing numeracy and computer work. Staff also said that the Manager contacted the Benefits Agency, when necessary, to ensure that Residents benefit difficulties were appropriately resolved. Residents were enabled to visit the shops, library and cinema as they chose. They were also able to visit public houses, leisure centres and places of worship. To enable them to do this the Home’s own transport was used. Staff Ash Lea House DS0000070377.V354486.R01.S.doc Version 5.2 Page 14 and the Manager also said that they regularly took Residents out in the evenings to such places as ‘pubs’, to bingo, cinema, social clubs and to late night shopping. The Manager said that Residents were on the electoral role, which enabled the more able Residents to take part in elections, if they chose to do so. One Resident said that she enjoyed listening to ‘tapes’ and watching TV and DVDs in her bedroom. She also said that some staff bring in DVDs and that she and other Residents were regularly taken out to ‘places’ by the staff. The Manager said that some Residents enjoyed horse riding on a regular basis. A Resident was able to say that a number of Residents went on a short holiday to Blackpool recently. The Manager said that all Residents had an annual holiday, but that this was paid for entirely by the Residents, including the cost of staff time. Staff also said that regular day trips out were provided by the Home. One Residents said that her mother and father were able to visit the Home, when they wished, and that she had been out with them, which was also confirmed by staff. Residents and staff also said that Residents made a lot of friends at the day centres they attend. Residents were able to say that some staff would always knock on their bedroom door and wait an invitation to go in before doing so, while other staff would simply knock and enter. One Resident said that she had not been given a key to her bedroom, but would like to have one. The Manager said that currently all Residents bedroom doors could be provided with a key, but that more appropriate door locks were needed to make this a realistic possibility. A Resident said that letters sent to Residents were always opened by the Residents, or beside the Resident if they could not open it themselves. Staff also said that Residents were always called by their preferred name. A Resident, and staff, said that one other Resident was able to go out of the Home when he liked. Staff also confirmed that housekeeping tasks were undertaken by all Residents, dependent upon their ability. Residents and staff said that smoking was allowed at the Home, but that this could only take place outside of the Home. They also said that alcohol was also available, but was only given under staff guidance/supervision. Residents said that ‘good meals were provided’ and that a lot of choice was available at all meals. Although staff said that Residents helped plan some meals, they also said that this was seldom done. One Resident spoken to said that Residents did not help plan any meals. The Manager and staff said that all meal times were unrushed and were flexible to suit Residents activities, which was observed during this visit to the Home. Ash Lea House DS0000070377.V354486.R01.S.doc Version 5.2 Page 15 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): Standards 18, 19 & 20. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. Residents’ personal needs were well met, ensuring that their privacy, dignity and independence were maintained. The system of administering medication was good, and ensured Residents medication needs were met. EVIDENCE: A Resident, and staff, said that personal support was always provided in private, and that to enable the Resident to do this staff sometimes had to remind her to undertake washing and other person tasks. This Resident also said that she could do very much ‘what I please, when I please’ within the Home. She said she got up in good time to attend the Day Centre, although she said that she did get up later at the weekends. She also said that she did not need staff help to maintain her personal hygiene – ‘I just do it.’ However, she did say that some Residents needed help to choose their clothing and maintain their appearance, - ‘but not me!’ Residents had a keyworker, which were listed by the Residents and the Manager. Residents were supported to maintain good health, and a 6 monthly health check-up took place with the Resident’s GP. Should a GP need to visit the Ash Lea House DS0000070377.V354486.R01.S.doc Version 5.2 Page 16 Home, they saw the Resident in private, although supported by staff, with the Resident’s agreement. A Resident said that staff went with them to the Dentist. During this visit the Medication Administration Record (MAR) sheets were examined and in general all was found to be well managed and maintained. However, the following two issues needed attention: The Medication Administration Record (MAR) sheets contained a number of handwritten entries completed by staff from the Home. These additional medications had not been signed by two staff, to confirm the correct entry had been made, nor did the record show the name of the Doctor who authorised the medication, or the date on which the new medication was to start/had started. A number of drugs were seen not to have been given to Residents, but the codes, provided at the bottom of each MAR sheet, were not used to define the reason why. Ash Lea House DS0000070377.V354486.R01.S.doc Version 5.2 Page 17 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): Standards 22 & 23. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. Complaints made to the Registered Providers or Manager were appropriately addressed to meet Residents needs. The protection policies and procedures provided by the Registered Providers meant that Residents were well protected. EVIDENCE: The Commission had received two notices of complaint since the Home was registered with the Commission in July 2007. These were passed to the Registered Providers to investigate, and the outcomes were reviewed during this visit to the Home. A satisfactory outcome was found to have been made in each case. A good complaints procedure was provided in the Residents Guide, detailing that each complaint would be responded to within 28 days. However, the procedure did not state to Residents, or their relatives, that they would not be ‘victimised’ for making a complaint. The Safeguarding Adults procedure was seen. The Manager had a Whistle Blowing policy, and the Dept of Health guidance called ‘No Secrets’. However, she did not have a copy of the Public Interest Disclosure Act of 1998. The Manager said that all allegations and incidents of abuse would be followed up and action would, if necessary, be taken. She also said that any incidents of abuse by her staff would be passed on to the Protection of Vulnerable Adults register. The policies and practices of the Home ensured that physical or Ash Lea House DS0000070377.V354486.R01.S.doc Version 5.2 Page 18 verbal aggression by Residents was understood by staff and that staff would only intervene as a last resort to protect the Resident, other Residents or staff. The Home had satisfactory policies and procedures to deal with Residents money and financial affairs. However, the Manager said that the Home did not have a policy to inform staff that they could not benefit, in any way, from Residents wills. Ash Lea House DS0000070377.V354486.R01.S.doc Version 5.2 Page 19 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): Standards 24, 25, 26, 27, 28, 29 & 30. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. The Home was well maintained throughout, providing all Residents with a safe, and comfortable environment in which to live. EVIDENCE: The premises of the Home were judged to be suitable for caring for Residents, as they were found to be safe and well maintained. At the time of this visit, each Resident had their own bedroom, apart from two Residents who had made a definite choice to share, and all bedrooms were seen. The bedroom spaces was well designed and laid out to suit the needs of the Residents, and were provided with all the necessary furniture, aside from the 3 items mentions below. The Home was attractively decorated throughout, and the lounges and dining room were pleasant to sit in, and were provided with appropriate items for the Residents. Ash Lea House DS0000070377.V354486.R01.S.doc Version 5.2 Page 20 Toilets were easily available to all Residents, and were clearly marked. All radiators were appropriately guarded, and could be controlled within each bedroom. The Home had an appropriate laundry and clothing was washed at appropriate temperatures. However, the following issues needed attention: All bedrooms seen were large and spacious, but had only been provided with one armchair, rather than two as recommended within the Standards. The main lighting in Residents bedrooms should be provided with a 100 watt bulb, however, in some of the bedrooms visited only a 60 watt bulb had been provided. All bedroom doors should be lockable by the Resident, on both the inside and outside of the room. However, staff should also be able to use a master key to gain entry in emergencies. Ash Lea House DS0000070377.V354486.R01.S.doc Version 5.2 Page 21 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): Standards 32, 33, 34, 35 & 36. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. Appropriate levels of staffing were provided consistently within the Home to meet the needs of Residents. EVIDENCE: At the time of this inspection it was found that only 25 , 3 out of a total of 12 staff, held at least a qualification of NVQ level 2 in Care. Almost all the staff were new to the Home, in July 2007, when the Home was taken over by the current Registered Providers, and this was given as the reason for such a low percentage. However, the Manager was able to show that 4 staff were currently undertaking courses to achieve and NVQ level 2 in Care, and a further 2 staff were in the process of undertaking an NVQ level 3 in Care. The target set by the Standards was 50 of staff to hold at least an NVQ level 2 in Care. The Manager therefore anticipated that within the next 12 months the Home would have 75 of staff holding at least an NVQ level 2 qualification in Care. The Registered Providers was found to be providing good levels of staffing to meet the care needs of Residents living in the Home. Ash Lea House DS0000070377.V354486.R01.S.doc Version 5.2 Page 22 The records of the last two staff employed at the Home were examined to see whether the Manager had obtained all relevant information about them, and it was found that almost all information had been obtained. However, neither member of staff had provided a photograph of themselves, although the Manager said that she had asked for one. All new staff were also supplied with copies of the code of conduct set by the General Social Care Council. A member of staff said that induction training was provided for all new staff, and that foundation training was also provided. The Manager said that at least 5 days of training were provided for staff each year, and that the Learning Disability Award Framework accredited training, was also provided for all staff. A staff member was asked about the supervision received from the Manager. She said that this was provided once every two months by the Manager, which the Manager later confirmed. Ash Lea House DS0000070377.V354486.R01.S.doc Version 5.2 Page 23 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): Standards 37, 39, 42 & 43. The quality in this outcome area was Adequate. This judgement was made using available evidence including a visit to this service. Management arrangements at the Home were not sufficiently robust to ensure that residential care was maintained at a positive standard. EVIDENCE: The Manager had only been in post since July 2007, and as a result she had not as yet obtained a qualification of NVQ level 4 in Management and Care. However, she anticipated completing the training by October 2008. The Manager was aware of many of the issues required to address the Quality Assurance information needed in the Home, and indeed had started work on some of them. However, none had been completed or published at the time of this visit to the Home. Discussions with staff, however, showed that staff were aware of the development needs of Residents. Ash Lea House DS0000070377.V354486.R01.S.doc Version 5.2 Page 24 The training required by the Regulations was examined. As all but three staff were new to this Home, considerable training was found to be needed. Ten staff were in need of Moving and Handling training. Five staff were found to need twice yearly training in Fire Safety, because of working nights, and five staff needed this training once this year. Five staff were also found to need training in First Aid and six senior staff needed First Aider training. Six staff needed Food Hygiene training and a further 5 staff needed training in Infection Control. A member of staff was asked about having undertaken any of this training and she said that she had received Fire Safety and Food Hygiene training, but was still awaiting training in Moving and Handling, First Aid and Infection Control. In addition to the above required training the Manager was able to say that training was provided by the company on the following: Medication, POVA, Health and Safety, Dealing with Death and Bereavement, Working with Challenging Behaviour, Autism, COSSH, Risk Assessment and NVQs. The Manager was able to show that the Home had complied with the majority of legislation applicable to its operation, although she said she did not have information on the Management of Health and Safety at Work Regulations 1999, the Workplace (Health, Safety and Welfare) Regulations of 1992 or the Provision and Use of Work Equipment Regulations of 1992. The Manager was also not able to show that the Registered Providers had provided risk assessments on all safe working practices of staff; that is for care staff, catering staff and domestic staff. Nor had they provided a written statement of the policy, organisation and arrangements for maintaining these safe working practices. The Manager was able to confirm that all accidents, injuries and incidents of illness or communicable disease were recorded and reported to the relevant government bodies. She also confirmed, that with the assistance of the Fire Service, fire safety notices were posted in relevant places around the Home. The Home was visited by a senior manager in the organisation, on at least a monthly basis to complete the monthly ‘inspections’ of the Home. Copies of these documents were seen during this visit. Ash Lea House DS0000070377.V354486.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 2 2 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 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 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 2 3 Ash Lea House DS0000070377.V354486.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? This was the first inspection of the Home under the current Registered Providers. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 4(1)(c) Sch 1, No 1 Requirement The statement of purpose must include the name and address of the Registered Providers, to ensure that Residents and relatives are appropriately informed. The Residents Guide must contain all of the information listed within Regulation 5 of the Care Homes Regulations, to ensure that Residents and relatives are appropriately informed. The Registered Providers and Manager must provide all Residents with a contract/statement of terms and conditions of residency, as detailed throughout Standard 5, as new owners of the Home. If an alteration or an additional medication is necessary on the Medication Administration Record (MAR) sheet, this must always be signed by two staff, dated and state the name of the Doctor authorising the change to the DS0000070377.V354486.R01.S.doc Timescale for action 14/01/08 5 2. YA5 5 31/01/08 3. YA20 13.2 14/01/08 Ash Lea House Version 5.2 Page 27 medication. When a drug is not given to a Resident the code provided at the bottom of each MAR sheet must be used to define the reason why. 4. YA34 19 & Sch 2 The Manager must ensure, when appointing new staff, that all the Requirements listed in Regulation 19 and Schedule 2 of the Care Homes Regulations 2001, as amended during 2004, are obtained. Of two staff’s records examined, it was found that both staff had failed to provide a photoggraph of themselves. The Registered Providers and Manager must address and complete the Quality Assurance issues listed within Standard 33.1 to 33.7. All necessary staff must be provided with mandatory training in Moving and Handling, Fire Safety, First Aid, Food Hygiene and Infection Control. 14/01/08 5. YA39 24 31/01/08 6. YA42 18 & 13 31/03/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Refer to Standard YA1 No. 1. Good Practice Recommendations The Registered Providers should provide a summary of the environmental standards, detailed in Standard 1.1, and include these in the statement of purpose, and in the Resident’s Guide to the Home. Ash Lea House DS0000070377.V354486.R01.S.doc Version 5.2 Page 28 The Residents Guide should be summarised in a format that can be easily understood by the Home’s Residents, e.g. in ‘Widget’ or ‘Makaton’. 2. YA6 Risk assessments for each Resident need to be provided, detailing the actual risks the Resident is susceptible to. The Manager should complete formal 6 monthly reviews of care with Residents. Those attending the review should include the Resident, where possible their relatives and representative, and staff from the home. Where Social Services Depts carry out annual reviews of care this could be one of the 6 monthly reviews. Residents files should contain a confidential section. 3. 4. YA14 YA16 Residents should be provided a week’s annual holiday paid for by the Registered Providers. The Manager and staff should agree on which Residents bedrooms they should knock and wait to be invited in, and which Residents bedroom they should knock, pause and enter. Residents bedroom doors should be provided with appropriate locks to allow Residents to lock their doors, should they chose to do so. 5. 6. YA17 YA22 Residents should be encouraged to plan, prepare and serve some meals in the Home. Within the procedure for making a complaint it should be stated that neither Residents nor their relatives will be ‘victimised’ for making a complaint. Copies of this amendment should be placed within the Residents Guide. A copy of the Public Interest Disclosure Act 1998 should be obtained. Staff should be informed that they cannot benefit in any way from Residents wills. 8. 9. YA24 YA26 Residents bedrooms should be provided with main lighting of at least 100 watts. Each Resident’s bedroom should be provided with two comfortable chairs to allow Residents to entertain guests within their bedrooms. DS0000070377.V354486.R01.S.doc Version 5.2 Page 29 7. YA23 Ash Lea House Residents bedroom doors should be lockable from both the inside and outside of the room, with the expectation that staff will be able to gain entry in an emergency situation. 10. YA32 50 of care staff should be qualified to National Vocational Qualification Level 2 in Care, within as short a time as possible. Six senior staff should be trained to become First Aiders. The Registered Providers should ensure the Home complies with the Management of Health and Safety at Work Regulations 1999, the Workplace (Health, Safety and Welfare) Regulations 1992 and the Provision and Use of Work Equipment Regulations 1992, and ensure that copies of these Regulations are available within the Home. The Manager should ensure that the Home is provided with risk assessments, for all staff, on all working practice topics in order to ensure that significant findings are recorded and acted upon. A written statement should also be provided on the policy, organisation and arrangements for maintaining safe working practices in the Home. 11. YA42 Ash Lea House DS0000070377.V354486.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 Ash Lea House DS0000070377.V354486.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. 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