Inspection on 19/05/05 for Ashbridge Lodge

This inspection was carried out on 19th May 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Ashbridge Lodge 19/11/07

Ashbridge Lodge 14/09/06

Ashbridge Lodge 10/05/06

Ashbridge Lodge 22/09/05

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 Vivienne Patchett Announced Inspection 19th May 2005 at 10.00am 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 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 Stationary 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 G57 G06 S7276 Ashbridge Lodge V219227 190505 Stage 4.doc Version 1.30 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 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 Post vacant Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Ashbridge Lodge G57 G06 S7276 Ashbridge Lodge V219227 190505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 31st March 2005 Brief Description of the Service: Ashbridge Lodge is a residential home for five persons (currently 4 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 handbasins 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. Current charges are from £600 to £800 per week. Ashbridge Lodge G57 G06 S7276 Ashbridge Lodge V219227 190505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The announced inspection took place over a day in May 2005 from 10.00am to 6.00pm and found a clean, bright, freshly decorated and welcoming environment. One resident was in the home all day. The others arrived home from day centre about 3.30pm. The inspector spoke to all the residents alone. They were happy with the care they were receiving, although one wanted to discuss options for moving to another home. The previous manager had been in post for two years but had not been put forward by the proprietor for registration by the Commission until required to do so after the last announced inspection. This manager retired on 4th March. Meantime, one of the care staff has been made up to acting deputy manager and the proprietor is overseeing management of the home while he recruits to the post of manager. The acting deputy manager assisted at the inspection and had obviously put great efforts into the general running of the home and addressing the requirements of the last report of 31.3.05. Some had not yet reached the target dates for compliance and have been repeated. The inspector spoke to residents and staff, looked at the building, and examined various documents, such as care plans, menus, activities book, medication records, financial records etc. Comment cards were received from all residents (assisted by staff), some relatives and a placing authority, which were mostly positive. All of the residents expressed satisfaction with the care being offered although 2 wanted to be more involved in decision making within the home. Dissatisfactions from relatives related to sometimes not enough staff on duty; not always being consulted or informed about matters affecting their relative or decisions being made; the lack of stimulating activities or trips out and the lack of level access to the back garden. What the service does well: What has improved since the last inspection? Redecoration has taken place in most of the home over the last few months. The acting manager has been working hard to address the requirements from the last report and most of those whose target dates have been reached have Ashbridge Lodge G57 G06 S7276 Ashbridge Lodge V219227 190505 Stage 4.doc Version 1.30 Page 6 been met. The acting manager has re-organised some of the recordkeeping within the home. A good start has been made to increasing the opportunities for residents to make their views known - with the introduction of an independent advocate. 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 G57 G06 S7276 Ashbridge Lodge V219227 190505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Ashbridge Lodge G57 G06 S7276 Ashbridge Lodge V219227 190505 Stage 4.doc Version 1.30 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 standard(s) 1, 2, 3, 5 The lack of clarity in the homes Statement of Purpose, Service Users Guide contract may make it difficult for prospective service users or purchasers to know what services the home is able to offer or the costs involved. The Service User’s Guide is not currently available in a format suitable for the residents to understand. The limited amount of knowledge and recorded information regarding residents is hampering the Deputy manager and staff in understanding of the residents’ needs and how these can be met. EVIDENCE: The Statement of Purpose and Service Users Guide and Terms and conditions/ contract required some amendments e.g. for clarification and accuracy and to take account of the changes to the NMS standards made in February 2003 re the environment. See also standard 28 regarding a clear smoking policy. At the last announced inspection, it became evident that one of the residents had been admitted with care needs outside the category of registration. The proprietor has since made application for variation of registration conditions to accommodate someone with mental health needs as well as learning disability and the Commission is considering this. Care plans had been written but there was no record of the assessments carried out, prior to placement, of the longer-standing residents and limited information about the residents, their disabilities, their life histories or the Ashbridge Lodge G57 G06 S7276 Ashbridge Lodge V219227 190505 Stage 4.doc Version 1.30 Page 9 current assessment of their needs based on full background information. There was limited evidence as to how the needs and preferences of residents from specific ethnic or religious groups were being met. One resident told to the inspector that he wanted to discuss options for moving to another home. Ashbridge Lodge G57 G06 S7276 Ashbridge Lodge V219227 190505 Stage 4.doc Version 1.30 Page 10 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 standard(s) 6, 7, 8, 9 The acting manager has made improvements to the care plans but they need further development to ensure they are based on a full assessment of the service users’ abilities, disabilities and needs. A good start has been made to increasing the opportunities for residents to make their views known - with the introduction of an independent advocate. However, more could be done to introduce modern ideas of good practice relating to the care of people with learning disability or mental health history e.g. increasing choice, independence, decision-making, risk-taking etc. EVIDENCE: Care plans were in place and were fairly detailed with a helpful structure. However, these lacked some vital background information and would benefit from objectives being set, goals defined and agreed with residents and individual programmes instituted to guide staff and assess progress. Risk assessments had been done but should differentiate more clearly between health and safety and care practice issues and describe how the staff can maximise independence within a safe framework. An independent advocate has begun working in the home with the residents, which is good practice. The advocate has been involved in group discussions with residents and on an individual basis with one resident. The acting Ashbridge Lodge G57 G06 S7276 Ashbridge Lodge V219227 190505 Stage 4.doc Version 1.30 Page 11 manager has asked the advocate to provide her with an outline of how he sees his role and how he intends to carry this out to ensure collaborative working. Residents were able to meet prospective applicants for the managers post although it was not clear at how much their views have been taken into account in the recruitment process. Two residents indicated in their comment cards that they would like to be more involved in decision-making and the running of the home. Currently none of the service users manage their own finances independently. The proprietor acts as appointee for one resident and others are assisted by relatives. Service users’ finances were randomly sampled. Receipts were maintained for all expenditure from service users’ personal money. It was not clear, however, how much of which benefit each resident was due and how this was paid to the resident. This should be included in the care plan. Residents were paying a contribution to the home and details of this should be included in the Service Users Guide and contract. The residents’ contributions were being paid into the petty cash and used for shopping and the day-to-day running of the home. Monies handled on behalf of the residents should be kept separate from the day-to-day accounts of the home with a separate system and clear written procedures for the operation of petty cash. Ashbridge Lodge G57 G06 S7276 Ashbridge Lodge V219227 190505 Stage 4.doc Version 1.30 Page 12 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 standard(s) 12, 13, 14, 15, 16 The atmosphere in the house is relaxed and friendly and residents are able to choose to be alone or in company. Family members are welcomed to visit the home. More could be done to ensure that residents are able to take part in appropriate activities within the home and as part of the local community. EVIDENCE: All but one of the residents attends a work centre but it was not clear what service was being offered and how this met residents‘ needs. Feedback from relatives, the acting deputy manager and residents indicated that residents have not been going out so much recently and residents wish to take part in a wider range of fulfilling social and educational activities. None of the staff in the home can drive the minibus so, when they do go out, residents are taking taxis and are having to pay for these. The acting deputy manager should clarify what funds (e.g. DLA) the residents have to pay for travel and what this covers. Any extras that residents are expected to pay should be clearly described in the Statement of Purpose, Service Users Guide and contract. The acting deputy manager has registered the residents with dial-a-ride but had not yet taken advantage of this service. Ashbridge Lodge G57 G06 S7276 Ashbridge Lodge V219227 190505 Stage 4.doc Version 1.30 Page 13 Telephone points have been fitted in the bedrooms and a portable phone is also available for residents use to ensure privacy. Residents have been offered keys to their bedroom door but only one uses this. There are no lockable facilities in the bedrooms. Ashbridge Lodge G57 G06 S7276 Ashbridge Lodge V219227 190505 Stage 4.doc Version 1.30 Page 14 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 standard(s) 18, 19, 20 Residents are assisted appropriately with personal care. Arrangements were in place for meeting the health and personal care needs of the service users. However, more detail needs to be obtained of the residents’ health problems and disabilities to enable staff to understand these and respond appropriately. None of the residents are assessed as able to take responsibility for their own medication and this is administered by staff, following the policies and procedures of the home to ensure the safety of residents. EVIDENCE: See the section on ‘Individual Needs and Choices’ above regarding information on residents’ healthcare needs and care planning. The current residents are mostly self-caring with regard to personal care. Prompting, guidance and support are offered as required. Residents are able to choose their own clothes. The shower had been retiled and a handrail, which one of the residents said he needed, has not been replaced. A handrail has also not been replaced at the top of the stairs and residents were observed using the wall for support. The acting deputy manager should arrange for an occupational therapist to give advice in the safe positioning of the equipment and assess the needs of residents to assist them to maintain maximum independence. Ashbridge Lodge G57 G06 S7276 Ashbridge Lodge V219227 190505 Stage 4.doc Version 1.30 Page 15 There is a key worker system in place with named members of staff taking a special interest in each resident. The acting deputy manager had put in place a system for stock control of medication. Medication administration records inspected were generally satisfactory. However, at present staff take medication out of the Nomad measured dosage packs and put it in bottles for residents to take each day to the day centre. The Deputy should devise a method of recording amounts of medication handed over to the day centre for them to administer to avoid possible misunderstandings or errors. Ashbridge Lodge G57 G06 S7276 Ashbridge Lodge V219227 190505 Stage 4.doc Version 1.30 Page 16 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 standard(s) 22 Good personal relationships between the residents and deputy meant that residents felt able to voice their worries. More could be done, however, to ensure that all of the relatives know of the complaints procedure and that this is written in such a way to assist residents and relatives in understanding the process and staff in responding appropriately to any complaints. EVIDENCE: A written procedure for dealing with complaints was in place. The residents were clear that they would speak to the acting deputy manager if they had any concerns. However, comment cards indicated that not all relatives knew of the complaint procedure. A copy of the complaints procedure must be given to every service user and their representative and should be in an appropriate format for them to understand. The complaints procedure should be amended to clarify the following: how a potential complaint of abuse is linked to the adult protection procedure; the procedure if the complaint is about the manager and the role of the proprietor in the complaints process. The format of the complaint book had been revised and should be expanded further to include a record of the investigation, the action taken, the outcome, timescales etc. All complaints should be recorded whether they are made verbally or written. Ashbridge Lodge G57 G06 S7276 Ashbridge Lodge V219227 190505 Stage 4.doc Version 1.30 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 27, 28, 29, 30 The home was clean and generally homely, comfortable and safe, with residents’ bedrooms personalised according to their taste and interests. However, attention is required in some areas to ensure that the homes premises are suitable to meet residents individual and collective needs and ensure they have full and safe use of all of the facilities of the home. As a “pre-existing home” the premises meet the minimum standards for the physical environment with regard to bedroom sizes and sufficient sitting/dining rooms, bathrooms and lavatories to meet residents needs. EVIDENCE: Repainting, redecoration and replacement of furniture had taken place since the last inspection and a maintenance and renewal programme for the fabric and decoration of the premises showed continued planned improvements for the future. New armchairs and settees had been provided in the sitting room but these are too high for the comfort of the residents, staff or visitors. The armchairs in the small sitting room were rather low for one resident. A range of seating suitable to the individual needs of residents should be supplied. Ashbridge Lodge G57 G06 S7276 Ashbridge Lodge V219227 190505 Stage 4.doc Version 1.30 Page 18 All service users have their own bedrooms; two of which are on the ground floor. One of the bedrooms is 9 square metres plus ensuite toilet, 2 other rooms measure 10m2 plus ensuite. The other two rooms are larger and have wash handbasins but no ensuite toilets. Pre-existing care homes must set out in their Statement of Purpose and Service Users Guide information about the size of rooms. There is a shower room and toilet on the ground floor and a bathroom and toilet on the first floor, giving residents a choice of facilities. There is a communal lounge/diner, a kitchen and a good size back garden, which would benefit from the planting of flowers and shrubs etc. At present access to the garden is limited so cannot be used safely or independently by all residents. There are several steps down to the garden and the pathway is not suitable for the resident using a frame. There is currently no garden furniture. Most of the residents have good mobility, although some were unsteady on their feet. One of the residents uses a frame in the home and a wheelchair outside. Advice should be sought from an occupational therapist to ensure that suitable aids and adaptations are available to meet the needs of service users within the house and to provide access to the garden. See also standard 18. Arrangements for Infection control within the home were not inspected on this occasion. Ashbridge Lodge G57 G06 S7276 Ashbridge Lodge V219227 190505 Stage 4.doc Version 1.30 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 34, 35, 36 Staff appeared to be approachable and comfortable with residents and to be offering good basic day-to-day care. However, not all have had sufficient training in working with people with a learning disability or mental health problems to fully understand and meet resident’s needs. Significant input is therefore required to all aspects of training. Recruitment processes need to be sharpened to ensure effective protection for residents. The staff supervision system is at an early stage, needing further development. EVIDENCE: Two of the staff have obtained NVQ Level 2 in care, one is awaiting their certificate, one has started the training and one is waiting to start. Two have nursing qualifications in their own countries. Therefore more than 50 had achieved an NVQ 2 or equivalent qualification. Some induction and ongoing, in-house training had been supplied to staff but this did not appear to be to TOPSS specifications. There was no planned programme to ensure that staff had all the training required by the regulations. Staff had had mental health awareness training but some seemed to have limited understanding of mental illness. Staff had not received any training in learning disability or associated current good practice. Further information and advice can be gained from TOPSS and BILD websites. Staff regularly works 13-hour shifts during the day or at night with no break. Only one member of staff is on duty in the mornings to assist residents to get Ashbridge Lodge G57 G06 S7276 Ashbridge Lodge V219227 190505 Stage 4.doc Version 1.30 Page 20 up and get ready for going out to day centre. Otherwise the rota shows two staff on duty, including the acting deputy although it does not differentiate when the deputy manager or proprietor are engaged in management duties or care tasks. Although some of the residents are out at a work centre 4 days a week, there is always one resident in the home and no ancillary staff employed to do cooking or heavy cleaning. The Inspector continued to have some concerns that the total of care hours per week would not appear to be sufficient, particularly as some of the residents had quite complex care needs and occasional challenging behaviour. Sufficient staff must be on duty at all times to ensure the health and safety of both residents and staff and meet the needs of all residents. Also it is the policy of the Commission that staffing levels should not drop below the minimum levels set by the previous registration authority i.e. two members of staff on duty during the day, one care staff at night plus a second care staff available for support in case an emergency either on the premises or able to reach the home within 20 minutes. At the last inspection the staff records gave limited information to make a judgement of the applicants suitability prior to employment and did not provide evidence of the staff competencies, qualities and fitness to work in the home. The deputy manager has been working with staff to ensure that all the staffing information required is in staff files. No new staff have been recruited since the last inspection so it was not possible to check the current recruitment procedures. One member of staff currently on maternity leave had not had a CRB check returned. However, the Deputy manager is pursuing this and has meantime obtained a POVA First check. The acting deputy has been holding supervision sessions with staff, which are recorded. The inspector discussed how to build on this to cover all the aspects noted in standard 36. Staff should be able to put items on the agenda, any decisions made should be recorded and staff given a copy of the minute. Ashbridge Lodge G57 G06 S7276 Ashbridge Lodge V219227 190505 Stage 4.doc Version 1.30 Page 21 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 41, 43 The acting deputy manager has been doing a good job in covering the work of the manager but the service is generally suffering from the lack of a qualified, competent, registered manager, experienced and skilled in the care of people with a learning disability and a mental health history and knowledgeable about current good practice. EVIDENCE: The previous manager had been in post for two years but had not been put forward by the proprietor for registration by the Commission until required to do so after the last announced inspection. The inspector was concerned that the proprietor had allowed this situation to continue for such a long period. This manager retired on 4th March. Since then, one of the care staff has been made up to acting deputy manager and the proprietor is overseeing management of the home while he recruits to the post of manager. He has resumed his monthly visits to report on the conduct of the home after a gap of several months and has been supporting the acting deputy in her role. Ashbridge Lodge G57 G06 S7276 Ashbridge Lodge V219227 190505 Stage 4.doc Version 1.30 Page 22 The Deputy has NVQ level 2 and has started NVQ level 3. She is also due to start a three-month mental health training module. The job description drawn up by the proprietor to recruit the new manager shows a lack of knowledge on his part of the legal basis under which he and the manager operates and should be amended. A staff meeting had been held on 24th March and another was booked for the 27th May. The electricity installation has been checked since last inspection and was found be satisfactory. Noise activated, battery-operated doorstops have been fitted to some doors to allow the easy access of residents. However, other fire doors were not effectively self-closing, leading to a possible danger to staff and residents in the event of a fire. This was a requirement of the August 2004 CSCI report and the July 2004 report of the Environmental Health Officer (EHO) and must be remedied urgently. The proprietor should confirm to the Commission that all of the requirements of the EHO have been met. There was no business plan or financial plan for the home available for inspection. There was no record of accounts kept in the home as required by regulation 17 and no evidence of the systems in place to ensure the financial planning, budget monitoring and financial control of the home. The deputy manager did not have knowledge of or control over any budgets relating to the home. Ashbridge Lodge G57 G06 S7276 Ashbridge Lodge V219227 190505 Stage 4.doc Version 1.30 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 2 2 x 2 Standard No 22 23 ENVIRONMENT Score 2 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 2 2 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 2 3 2 2 2 Standard No 11 12 13 14 15 16 17 x 2 2 2 3 3 x Standard No 31 32 33 34 35 36 Score x 2 x 2 2 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Ashbridge Lodge Score 2 3 3 x Standard No 37 38 39 40 41 42 43 Score 2 x x x 2 2 2 G57 G06 S7276 Ashbridge Lodge V219227 190505 Stage 4.doc Version 1.30 Page 24 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 1 Regulation 4 Requirement The Statement of Purpose to be amended to meet regulation 4, include all of the information listed in schedule 1 and take into account the changes in the National Minimum Standards (NMS) made in February 2003. A copy to be sent to the Commission. (Outstanding since 18 August 2004, target date of 1 December 2004 not met.) The Service Users’ Guide to be amended to meet regulation 5 and take into account the changes in the National Minimum Standards made in February 2003. A copy to be sent to the Commission. (Outstanding since 18 August 2004, target date of 1 December 2004 not met.) The terms and conditions/ contract must be amended to include the amount charged, method of payment and any extras payable.(From the 31.3.05 report) Development of care plans to continue to ensure that goals are set, all care needs are addressed and to indicate, in detail, how G57 G06 S7276 Ashbridge Lodge V219227 190505 Stage 4.doc Timescale for action 1 July 2005 2. 1 5 1 July 2005 3. 5 5(b) 1 July 2005 4. 6, 19, 21 15 1 September 2005 Page 25 Ashbridge Lodge Version 1.30 5. 7, 8 12 6. 7 12 &17 staff will meet these. Care plans to: be based on a full written assessment; describe the services and facilities to be provided in the home and how these services will meet current and changing needs and aspirations and achieve goals; to include service users wishes on ageing, illness, death, religious and cultural customs. The daily recording to be more detailed and link to the care plans and how staff have been addressing these in their day to day work with residents. (From the 31.3.05 report) The registered person to demonstrate how service users are enabled to make decisions with respect to the care they receive and their health and welfare. The staff to provide service users with information, assistance, support and opportunities they need to make decisions about their lives. Staff must be able to demonstrate how individual choices have been made and must record instances when decisions are made by others and why. Clarification to be sought as to the input and any outcomes from the recent involvement of the advocacy service.(From the 31.3.05 report) All monies handled on behalf of residents to be recorded. The manager to ensure that residents receive their personal allowances and any other income to which they are entitled, details of which to be included in the care plans. Appropriate support and tuition for residents to manage their own finances to the best of their ability to be 1 September 2005 1 July 2005 Ashbridge Lodge G57 G06 S7276 Ashbridge Lodge V219227 190505 Stage 4.doc Version 1.30 Page 26 7. 9 12 & 13 8. 1, 16 5 9. 22 22 10. 24, 26 23 provided in line with their care plan, documented and reviewed. (From the 31.3.05 report) The manager to arrange training for service users regarding personal safety and using public and other transport to maximise their independence and ability to attend activities etc within a care planning and risk management framework. (Repeated from the August report) Rules on smoking and alcohol to be clearly stated in the contract and the Statement of Purpose. (Repeated from the August report, target date of 1 December 2004 not met) a) All complaints to be recorded whether they are made verbally or written. The record of complaints to include a sufficiently detailed record of the complaint, the investigation, the action taken, the outcome and timescales etc. The complaint procedure to be readily available in the home. b) A copy of the complaints procedure in an appropriate format for service users to understand to be given to every service user and their representative. (From the 31.3.05 report) c) The complaints procedure to clarify: how a potential complaint of abuse is linked to the adult protection procedure; the procedure if the complaint is about the manager and the role of the proprietor in the complaints process. A range of seating, suitable to the individual needs of residents, to be supplied in both sitting rooms and the garden. The bedrooms to contain the furniture and fittings included in 1 October 2005 1 July 2005 a) 1 July 2005 c) 1 August 2005 b) 1 April 2006 1 August 2005 Ashbridge Lodge G57 G06 S7276 Ashbridge Lodge V219227 190505 Stage 4.doc Version 1.30 Page 27 11. 33 18 12. 34 19 13. 35 18 & 19 this standard and listed in the residents contract/ statement of terms and conditions i.e. a table and 2 comfortable chairs, a lockable storage space, bedside tables and lamps. Suitable curtains to be provided in all rooms & the velcroed ones from a previous resident to be removed. If the space is not sufficient for provision of recommended facilities, this to be included in the Statement of Purpose, Contract and Service Users Guide and noted on the care plans. Sufficient staff must be on duty 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. The rota to specify when management tasks are being carried out and to include any hours worked in the home by the proprietor or any volunteers. The registered person to ensure staff have the breaks specified in the Working Time Regulations. (From the 31.3.05 report) The outstanding CRB to be obtained. The format of Job application forms to be reviewed to ensure that they seek appropriate information to form judgements. The registered person to ensure induction and foundation training is provided in all of the areas specified in the National Minimum Standards within the timescales set and be to specifications approved by TOPSS. (Outstanding from the August report, target date of 1 December 2004 not met). 1 July 2005 and ongoing 1 July 2005 1 October 2005 Ashbridge Lodge G57 G06 S7276 Ashbridge Lodge V219227 190505 Stage 4.doc Version 1.30 Page 28 14. 37 8&9 15. 37 10 16. 41 17 17. 42 13 Staff to have appropriate training in learning disability, mental health and associated current good practice. The proprietor to ensure that a suitable experienced and competent manager is appointed and an application for registration of manager is submitted to the Commission as a matter of urgency. (From the 31.3.05 report) The manager to have sufficient time and delegated overall responsibility, set out in a job description, to ensure: that she is able to carry out the duties of a registered manager; that written aims and objectives of the home are achieved; policies and procedures are implemented; the homes budget is properly managed; certificates and licences are obtained and displayed; the terms of service users contracts are fulfilled; the home complies with the Care Standards Act and Regulations, General social care Council codes of practice and other legal requirements. (Outstanding from the August report, target date of 15 October 2004 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 files, including recruitment and supervision records; medication records; accounts of the home; records of the monies handled on behalf of residents; Statement of Purpose and Service Users Guide etc. The registered person to ensure that fire doors consistently and effectively self-close and are 1 July 2005 1 July 2005 1 July 2005 1 July 2005 Ashbridge Lodge G57 G06 S7276 Ashbridge Lodge V219227 190505 Stage 4.doc Version 1.30 Page 29 18. 43 25 &17 19. 12,13,14 16 20. 18, 29 13, 23 21. 30, 42 13 22. 2 14 kept closed. (Outstanding from the August 2004 report, target date of 1 May 2005 not met. A record of accounts to be kept in the home as required by regulation 17. 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.A petty cash account to be available for the running of the home with clear budgets and separate finances available for the running of the home, separate from residents finances. (Outstanding from the August report target date of 1 November 2004 not met). The manager to ensure that residents are given appropriate assistance and encouragement to take the part in fulfilling social, educational and leisure activities in the home and within the community. An occupational therapist to assess the needs of residents to assist them to maintain maximum independence and give advice on the positioning of equipment e.g. handrails in the shower and at the top of the stairs and a ramp to give level access to the garden. The proprietor to confirm to the CSCI lead inspector that recommendations made by the Environmental Health Officer in July 2004 have been fully met. The placing authority to be asked to review the resident wanting to discuss options for moving to another home. 1 July 2005 1 July 2005 and ongoing 1 October 2005 1 August 2005 1 September 2005 Ashbridge Lodge G57 G06 S7276 Ashbridge Lodge V219227 190505 Stage 4.doc Version 1.30 Page 30 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 1 9 Good Practice Recommendations The proprietor and manager to make the Service Users Guide available in a format suitable for the residents to understand. The format for risk assessments to differentiate more clearly between practical health and safety issues and care practice issues and describe how the staff can maximise independence within a safe framework. A clear smoking policy to be developed which defines where the one resident who smokes and his visitors can smoke in the building. The smoking area should be separate from communal space used by other residents. The manager to visit the work centre to assess how well this provision is meeting residents’ needs and document how it fits into their care plans. It is recommended that the home have access to the Internet so that vital information and good practice guidance can be downloaded from appropriate government and allied web sites. A copy of the home’s business plan and financial plan to be forwarded to the CSCI. Residents should be provided with lockable facilities in their room. 3. 28 4. 5. 12 40 6. 7. 43 26 Ashbridge Lodge G57 G06 S7276 Ashbridge Lodge V219227 190505 Stage 4.doc Version 1.30 Page 31 Commission for Social Care Inspection Gredley House 1 - 11 Broadway London E11 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 G57 G06 S7276 Ashbridge Lodge V219227 190505 Stage 4.doc Version 1.30 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!