Inspection on 10/05/06 for Ashbridge Lodge

This inspection was carried out on 10th May 2006.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 26 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ashbridge Lodge 19/11/07

Ashbridge Lodge 14/09/06

Ashbridge Lodge 22/09/05

Ashbridge Lodge 19/05/05

Ashbridge Lodge 31/03/05

Ashbridge Lodge 18/08/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Ashbridge Lodge 5 Ashbridge Road Leytonstone London E11 1NH Lead Inspector Sandra Jacobs-Walls Unannounced Inspection 10th May 2006 09:30 Ashbridge Lodge DS0000007276.V293412.R01.S.doc Version 5.1 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 Ashbridge Lodge DS0000007276.V293412.R01.S.doc Version 5.1 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. Ashbridge Lodge DS0000007276.V293412.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Ashbridge Lodge Address 5 Ashbridge Road Leytonstone London E11 1NH 020 8989 7767 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) Mr Siddicq Yadallee Mrs Emma Louise Kathleen Brown Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Ashbridge Lodge DS0000007276.V293412.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home can provide care for one named service user with a mental health needs. 22nd September 2005 Date of last inspection Brief Description of the Service: Ashbridge Lodge is a residential home for five persons (currently 3 women and 2 men) with learning disabilities. Four of the residents, whose ages range from 32 to 62 years, have lived there for 9 years. The most recent resident was admitted in February 2004. Residents have a pet cat. The house is located in a residential area of Leytonstone within the London Borough of Waltham Forest. The home is situated close to local amenities; a post office and mini convenience store are a road away and other facilities, which include places of worship, public transport, leisure centre, public library, shopping centre and restaurants are within walking distance for staff although too far for most of the residents to manage. All service users have their own bedrooms; two of which are on the ground floor. There is no lift. Three of the rooms have en suite toilets; the other two have wash hand basins in the room. There is a communal lounge/diner, a kitchen and a good size back garden accessible by steps. The office is on the first floor. A small room downstairs has been made into a separate seating area and smoking room. At the time of the inspection, the registered manager was due to go on extended leave from the end of May. The registered provider has been made aware that it is CSCI’s expectation that any manager appointed during the interim is required to promptly submit an application to become the home’s registered manager. Ashbridge Lodge DS0000007276.V293412.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection of Ashbridge Lodge took place on May 10th 2006 for the duration of seven hours. The purpose of the inspection was to assess the home’s performance against key National Minimum Standards and review progress made in addressing outstanding requirements (24) made at the last inspection that was conducted in September 2005. Assisting the inspector was the home’s registered manager and deputy manager. The inspection process included discussions with managers and the home’s five service users, review of key policies and procedures, review of two service user files and six staff files. The inspector also participated in a tour of the home’s premises. As a result of the inspection twenty-seven (27) requirements and two (2) recommendations were made. The inspector would like to thank all service users and staff who co-operated and contributed to the inspection. What the service does well: What has improved since the last inspection? Service users files reviewed indicated that work had began to address some of the recording deficiencies noted at the previous inspection, namely that care plans and risk assessments were generally more specific and detailed. Managers informed the inspector that all service user files were to be reorganised to make access and reading easier. All existing policies and procedures were being reviewed. Ashbridge Lodge DS0000007276.V293412.R01.S.doc Version 5.1 Page 6 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. Ashbridge Lodge DS0000007276.V293412.R01.S.doc Version 5.1 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 Ashbridge Lodge DS0000007276.V293412.R01.S.doc Version 5.1 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): 1&5 The home’s ability on promote choice of home is in need of improvement. EVIDENCE: Since the last inspection, no new service users had been admitted to the home. The inspector saw newly devised contracts for each service user these were considered satisfactory. The previous inspection had highlighted the need for the home to revise both its Statement of Purpose and Service User Guide. The inspector reviewed the home’s Statement of Purpose document, which still failed to include all information as required. Noticeably missing was information pertaining to key contract conditions, the range of fees and information regarding smoking and alcohol use by service users. The inspector also asked to review the home’s Service User guide, but this document was not produced. Managers told the inspector that this document was still being amended. Ashbridge Lodge DS0000007276.V293412.R01.S.doc Version 5.1 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 The individual needs of service users are generally well met and service users are given choices. EVIDENCE: The inspector saw on the two service user files reviewed good evidence to suggest work had begun to improve on previous service user assessments and care plans. Documentation seen was more concise containing relevant information. This development needs to be extended to all files. Managers informed the inspector that increasingly service users were encouraged to make decisions for themselves; this was demonstrated in choices around meals, recreational activities, domestic chores and the home’s environment. Service users who spoke with the inspector indicated that they did enjoy choice and were able to make decisions for themselves. One service user told the inspector of his refusal to have a broken wardrobe in his room removed as it held significant sentimental value as the wardrobe previously belonged to his mother. The inspector also observed the bedroom of one service user that was painted and accessorised in the colour pink. This was at the expressed wish of the service user. The inspector felt that evidence of decision making could be made more explicit in case recordings. Ashbridge Lodge DS0000007276.V293412.R01.S.doc Version 5.1 Page 10 The inspector reviewed the home’s residents meeting book, which detailed issues discussed. There appears to be a set agenda that explored complaints, the home’s environment, activities, key working, health and safety, menus and issues of abuse. The inspector felt that an open meeting agenda or one that explored other issues would prove useful. Newly devised risk assessments were seen on one of the files reviewed by the inspector, but not for the second. The risk assessment seen was clear and relevant to the service user in question. The deputy manager informed the inspector that at the time of the inspection she was working on updating this service users risk assessment. Ashbridge Lodge DS0000007276.V293412.R01.S.doc Version 5.1 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 Service users’ lifestyles are of fair quality. EVIDENCE: All service users attended local day centres four times a week. Service users who spoke to the inspector indicated that they enjoyed attending allocated day centres. There was some evidence of activities service users participated with while at the home. No service user attends day centre facilities on a Wednesday and as the inspection took place on a Wednesday, the inspector was able to observe activities. On the day of the inspection, service users generally remained seated in the lounge area watching television or completing colouring or sorting magazine cuttings. While service users seem content participating in these activities, the inspector felt perhaps more creative activities could be introduced. Managers explained that staff had attempted to encourage service users to go out on Wednesdays and at the weekends but that most service users were reluctant to do so particularly when the weather was poor. Attempts to encourage service users to access public transport had proved unsuccessful and distressed some service users. The home has access to a mini van that is Ashbridge Lodge DS0000007276.V293412.R01.S.doc Version 5.1 Page 12 also used by another home owned by the proprietor; the inspector was informed that the mini van is used by the other home on Wednesdays to complete weekly shopping. The home’s current registered manager is also the only staff member who holds a valid driving license. The inspector was of the opinion that service users quality of life would be significantly improved if more creative activities were provided. Managers were clear that another hindrance to this was the lack of support staff, which was not available due to apparent funding restrictions. This is unacceptable. The inspector saw on file an organised trip to the cinema and was informed that last years holiday had been well received by service users. The home must explore offering greater choice of local resources to service users and involve them more in the local community. The proactive encouragement of staff and service user responses must be clearly documented. Adequate staff cover must be provided. Managers informed the inspector of the very good contact most service users had with family and friends, there was also good documentation on file to support this view. One service user spoke about his very large family who were in close contact with him, his brother in particular visited weekly while at the day centre. As part of the inspection process the inspector shared a lunchtime meal with service users. Service users commented that the deputy manager “was a good cook” and that they enjoyed all meals prepared. Service users have a choice of menu and participate in meal planning. Two service users resident at the time of the inspection were African/Caribbean in origin; managers informed the inspector that traditional Caribbean meals were frequently offered. These two service users also attended a Caribbean run day centre that met their cultural and religious needs. Ashbridge Lodge DS0000007276.V293412.R01.S.doc Version 5.1 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 The personal and healthcare needs of service users are well generally met. EVIDENCE: Service users who spoke with the inspector indicated that staff supported them in a manner they preferred, however, there were no explicit written guidelines to staff around this. The inspector acknowledged that service users needs were well known to the home’s current staff, but with the imminent extended leave of the registered manager and the recent recruitment of new staff, the inspector felt clear documentation was required. Service users files reviewed contained very comprehensive information regarding the healthcare needs of service users. The development of newly structured assessments had contributed to this. Medical appointments were well documented, as were outcomes of such appointments. Appropriate medical and mental health referrals were initiated by staff as required and followed up. The inspector reviewed in detail the medicines and medication information for two service users and was satisfied that staff’s administration of service user medication was sound. Ashbridge Lodge DS0000007276.V293412.R01.S.doc Version 5.1 Page 14 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 The home’s management of complaints and adult protection issues are in need of improvement EVIDENCE: The inspector reviewed the home’s information regarding its complaints procedure, which is also available on tape. The procedure identified the home’s manager as the person solely responsible for the management of complaints. No information was available about who would be responsible for the investigation of any complaint made against the home’s manager. This issue was compounded by the fact that the home’s one documented complaint had been made against the home’s current registered manager. Documentation regarding this complaint was comprehensive, however, the complaint was of an adult protection nature and should have triggered the use of relevant adult protection procedures. The inspector reviewed the home’s ‘Adult Abuse and Protection’ policy, which is in need of revision to ensure the home’s policies and procedures are in accordance with the local authority’s adult protection procedures. At the time of the inspection, managers could not produce a copy of local adult protection procedures on site, which is required. In reviewing the documented complaint/allegation of abuse, it was clear that managers had not followed appropriate procedures in that they failed to alert social services or indeed notify CSCI of the allegation. There was clearly a need for staff to receive training around adult protection. Ashbridge Lodge DS0000007276.V293412.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 29 & 30 The home’s environment is generally fair. EVIDENCE: The inspector participated in an accompanied tour of the home’s premises. In general the home’s décor and maintenance is good. The previously noted issued regarding the lounge furniture had been resolved following an assessment by an occupational therapist late last year. The OT’s assessment however highlighted the need for the home to put in place an access ramp both at the front and to the entrance of the rear garden to facilitate easy access for one service user who experienced mobility difficulties and was an occasional wheelchair user in the house. Additionally, the OT recommended an extension to the shower area to facilitate service user ease and comfort. The home was generally clean and hygienic, although the inspector noted an unsightly (bleach) stain in one service users bedroom. This carpet must be replaced. The inspector also noted that in another service users bedroom the window was heavily stained. Managers commented that they felt the obstruction to view was not stained glass, but moreover was ill fitting doubleglazing that had given rise to continual condensation. This had occurred to another service users window in the house, which was subsequently replaced. Ashbridge Lodge DS0000007276.V293412.R01.S.doc Version 5.1 Page 16 The inspector noted fridge and freezer temperatures were consistently recorded, however, perishable goods in the communal fridge was not labelled with the date first opened. This is poor food hygiene practice. Staff must also participate in food safety training. Ashbridge Lodge DS0000007276.V293412.R01.S.doc Version 5.1 Page 17 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, 34, 35 & 36 The home’s management of staff and staffing issues are poor. EVIDENCE: Service users who spoke with the inspector said they were happy with the way staff were working with them. Of concern however were the vetting and recruitment practices of the home, which had been highlighted as being problematic on previous inspections. The inspector reviewed the personnel files for six members of staff and found a number of required information to be missing. Two staff files seen contained a CRB disclosure forms dated after the staff members had started working at the home. Another staff file contained limited documented work history and no CV. The home must amend its current application form to allow applicants to provide complete work histories. Most staff files reviewed contained limited or no record of formal 1:1 supervision having taken place and there was no evidence of an annual appraisal for staff or completed induction process for new staff. The inspector was very concerned for the lack of training opportunities available to staff. While many of the home’s staff had completed or were in the process of completing NVQ awards, staff themselves apparently funded such training. Managers commented that there were no funds available for external training, and so any staff training conducted is either financed by the staff group themselves or conducted internally by managers. This is an Ashbridge Lodge DS0000007276.V293412.R01.S.doc Version 5.1 Page 18 unacceptable situation, particularly since elsewhere in this report issues around adult protection, food hygiene, health and safety and case recording has been highlighted as areas in need of improvement. The situation is further compounded by the lack of consistent formal supervision and appraisal of staff training needs. Staffing issues as outlined here must be addressed as a matter of urgency. Ashbridge Lodge DS0000007276.V293412.R01.S.doc Version 5.1 Page 19 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 & 42 The conduct and management of the home is poor. EVIDENCE: Based on the inspection findings, the inspector was of the opinion that while service users were generally well cared for, the management of the home was in need of improvement. Managers were clearly struggling to improve services on a limited budget; managers informed the inspector that they did not have access to petty cash on site, which proved problematic at times. Issues of record keeping, (detailed elsewhere in this report) is also of concern. The home’s quality assurance systems need to be effective and consistent to ensure service improvement. The inspector reviewed records of the home’s monthly monitoring visits, which are conducted by the proprietor. Records revealed that only two visits had been completed since June 2005. This is unacceptable. The registered provider will need to submit an application for registration for any manager (either permanently employed or employed on a temporary basis) due to past and ongoing issues regarding the poor management of the home. Ashbridge Lodge DS0000007276.V293412.R01.S.doc Version 5.1 Page 20 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 1 2 X 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 2 23 1 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 2 30 2 STAFFING Standard No Score 31 X 32 2 33 2 34 1 35 1 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 3 2 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 X 2 X 2 X 1 2 2 Ashbridge Lodge DS0000007276.V293412.R01.S.doc Version 5.1 Page 21 YES 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 YA1 Regulation 4 Requirement The registered person must ensure that the Statement of Purpose is amended to include all of the information listed in Schedule 1 of the Care Homes Regulations. A copy to be sent to the Commission. (Outstanding since 18 August 2004, previous dates for compliance of 1 December 2004, 1 July 2005 & December 1 2005 not met). The registered person must ensure that the service users guide to be amended to meet Regulation 5 of the Care Homes regulations. (Outstanding since 18 August 2004, previous dates for compliance of 1 December 2004, 1 July 2005 & December 1 2005 not met.) The registered person must ensure that staff demonstrate via case recording how service users are enabled to make decisions with respect to the care they receive and their health and welfare. Timescale for action 31/08/06 2. YA1 5 31/08/06 3. YA7 12 31/08/06 Ashbridge Lodge DS0000007276.V293412.R01.S.doc Version 5.1 Page 22 4. YA9 12 5. YA13 16 6. YA14 18 7. YA18 12 8 YA22 22 9 YA23 13(6) 10. YA23 13(6) 11. YA23 13(6) 12. YA24 23 The registered person must ensure that all risk assessments are completed and evidenced on service user files The registered person must ensure that staff pro actively encourages service users to participate in the local community and recreational activities. All efforts and decisions must be clearly documented. (Previous timescale of July 1 2005 & December 1 2005 not met) The registered person must ensure that adequate staffing is made available to the home to facilitate recreational activities outside the home. The registered person must ensure that staff ascertain and record the specific individual preference of service users regarding personal care tasks. The registered person must ensure that the home’s complaint procedure is revised to identify who is responsible for investigations of complaints against the home’s managers. The registered person must revise the home’s adult protection policy to ensure it offers staff guidance that is in accordance to local authority protocols The registered person must ensure that local authority adult protection protocols are available to staff on site. The registered person must ensure that all staff receive comprehensive training in adult protection issues. The registered person must ensure that range of seating, suitable to the individual needs of residents, to be supplied in DS0000007276.V293412.R01.S.doc 31/08/06 31/08/06 31/08/06 30/09/06 31/08/06 31/08/06 31/08/06 15/09/06 01/07/06 Ashbridge Lodge Version 5.1 Page 23 13. YA24 23 14 YA29 23(2)(n) 15 YA29 23(2)(n) 16 YA30 23 17 YA33 18 18. YA32 18 19. A34 19 the garden (Previous timescale of 01/12/05 not met) The registered person must ensure that window in service users bedrooms are appropriately maintained. All damaged windows must be replaced The registered person must ensure that an access ramp is placed both at the front and rear of the home’s premises The registered person must extend the shower area as recommended by the OT assessment to ensure service user safety and comfort while showering. The registered person must ensure that the stained carpet seen in one service users bedroom is replaced. The registered person must ensure that sufficient staff are employed at all times to ensure the health and safety of both residents and staff, fulfil the aims and objectives in the Statement of Purpose and meet the needs of all residents. (Previous timescale of 01/11/05 not met) The registered person must ensure that all staff have NVQ Level 2 or 3 qualification in care or be working to obtain one by an agreed date (Previous timescale of 01/01/06 not met) The registered person must ensure that staff are not employed until CRB and POVA or POVA First checks and adequate, verified references have been obtained. (Previous timescale of 01/11/05 not met) 30/09/06 30/09/06 30/09/06 30/09/06 01/08/06 01/09/06 01/07/06 Ashbridge Lodge DS0000007276.V293412.R01.S.doc Version 5.1 Page 24 20. YA34 19 21. YA35 18 (2) (a)(b) 22. YA35 18 & 19 The registered person must 01/08/06 ensure that the format of Job application forms and references are revised to ensure that they provide appropriate information to form a basis for judgements of fitness of applicants, particularly employment histories. (Previous timescale of 01/12/05 not met) The registered person must 01/08/06 ensure that all newly appointed staff have structured induction training to Skills for Care (ex TOPSS) specifications, covering all of the areas specified in the National Minimum Standards, within 6 weeks of employment and to be supervised during the period of induction by a designated member of staff on duty at the same time. (Outstanding from the August 2004 report, date for compliance of 1 December 2004 and 1 November 2005 not met). The registered person must 01/09/06 ensure: foundation training is provided to staff within 6 months of employment. Such training to cover all of the areas specified in the National Minimum Standards and be to Skills for Care (TOPSS) specifications (Outstanding from the August 2004 report, dates for compliance of 01/12/2004, 1/10/05 & 01/03/06 not met) Staff to have appropriate training in learning disability, mental health and associated current good practice. The registered person must ensure that a schedule of planned and structured supervision sessions to be DS0000007276.V293412.R01.S.doc 23. YA36 18 01/08/06 Ashbridge Lodge Version 5.1 Page 25 24. YA37 8&9 25. YA39 26 26. YA41 17 implemented for all staff - to start as part of the induction process, through the probationary period and then establish a regular pattern of supervision at least six times a year. All supervision sessions are to be documented. A supervision contract to form part of the supervision procedure, defining the length and frequency of sessions and the areas to be included. (Outstanding from previous reports. Timescale for compliance of 1 November 2004, 1 July 2005 & 1 December 2005 not met) The registered person must ensure that an application for registration of any appointed manager (temporary or otherwise) is promptly submitted to the CSCI. The registered provider must consistently visit the care home at least once a month, unannounced, and: interview service users, representatives and staff in order to form an opinion of the standard of care provided in the home; inspect the premises, its records of events and any complaints and prepare a written report on the conduct of the care home. The registered provider must supply a copy of the report to the Commission and a copy must be kept in the home. (Previous timescale of 01/11/05 not met) The registered person must ensure that all the records required by regulation are in place within the home, kept in sufficient detail and up-to-date. E.g. staff supervision records; DS0000007276.V293412.R01.S.doc 01/07/06 01/07/06 01/08/06 Ashbridge Lodge Version 5.1 Page 26 27. YA43 25 & 17 accounts of the home; Statement of Purpose and Service Users Guide etc. (Outstanding from the May 2005 report, date for compliance of 1 July 2005 & 1 November 2005 not met.) The registered person must ensure that clear budgets are available for the running of the home and petty cash account, separate from residents finances. Appropriate systems to be in place to ensure the financial planning, budget monitoring and financial control of the home, including the manager having access to budgets relating to the home. Lines of accountability within the home to be clarified. (Outstanding from the August report. Dates for compliance of 1 November 2004, 1 July 2005 & 1 December 2005 not met). 01/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA8 YA142 Good Practice Recommendations It is recommended that the agenda for residents meetings are varied and offer opportunity for service users you decided what issues are to be discussed. It is recommended that the organisations mini bus be made available to the home on Wednesdays, when all service users are at home to facilitate trips out Ashbridge Lodge DS0000007276.V293412.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection East London Area Office Gredley House 1-11 Broadway Stratford London E15 4BQ 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 Ashbridge Lodge DS0000007276.V293412.R01.S.doc Version 5.1 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. 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