Inspection on 19/11/07 for Ashbridge Lodge

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 Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 19 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ashbridge Lodge 14/09/06

Ashbridge Lodge 10/05/06

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 Harbinder Ghir Unannounced Inspection 19th November 2007 10:15 Ashbridge Lodge DS0000007276.V355274.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 Ashbridge Lodge DS0000007276.V355274.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. Ashbridge Lodge DS0000007276.V355274.R01.S.doc Version 5.2 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) milly1963@tiscali.co.uk Mr Siddicq Yadallee Millicent Marjorie Tracey-Adejimola Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Ashbridge Lodge DS0000007276.V355274.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home can provide care for one named service user with a mental health needs. 14th September 2006 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. The most recent resident was admitted in February 2004. 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. 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 their rooms. There is a communal lounge/diner, a kitchen and a good size back garden accessible by a ramp. The office is on the first floor. Residents have a pet cat. As stated by the current Statement of Purpose the fees charged by the service range between £575.00- £850.00 per week. Ashbridge Lodge DS0000007276.V355274.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced inspection underdertaken by Regulation Inspector Harbinder Ghir on Monday 19TH November 2007 between 10am and 3.55pm. A second visit was undertaken on Thursday the 29th November 2007. The registered manager was available throughout both days of the inspection. During the inspection the inspector was able to talk to the residents residing at the home and staff. Professionals and relatives of residents were contacted by telephone for their views on the service. As part of the inspection the inspector toured the home and examined documents in relation to the management of the home. At the end of the inspection the inspector was able to provide feedback to the manager. A completed Annual Quality Assurance Assessment was received by the Commission for Social Care Inspection prior to the inspection. The inspector would like to thank everyone involved in the inspection process. What the service does well: What has improved since the last inspection? What they could do better: Ashbridge Lodge DS0000007276.V355274.R01.S.doc Version 5.2 Page 6 14 requirements were made at this inspection in the following areas: updating the Statement of Purpose; medication practices; pre-admission assessments; care planning; risk assessments; the management of resident’s finances; staffing; recruitment checks; staff supervision; healthcare; environment; menus; lack of social activities; quality assurance. Failure to act on requirements that relate to the care provided for the people living in the home may lead to the Commission taking enforcement action against the registered person, in order to secure compliance. The registered provider, the manager and the staff team may wish to refer to the Commission’s Key Lines of Regulatory Assessment (KLORA), to consider how they may additionally further enhance the overall quality of care in the home. 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. Ashbridge Lodge DS0000007276.V355274.R01.S.doc Version 5.2 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.V355274.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 People using the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The Statement of Purpose and Service User Guide must be updated to include the information required by the Care Homes Regulations, to ensure prospective residents have the information they need to make an informed choice about where to live. The registered persons must devise a pre-admission assessment form to complete for any new prospective residents, to ensure they can fully meet the needs of residents. Trial visits are offered to all prospective residents, to ensure residents have information on the services and facilities provided at the home. Each service user has an individual written contract of the statement of terms and conditions, to ensure they agree to the services provided at the home. EVIDENCE: The Statement of Purpose has been recently reviewed by the service provider. It is easy to follow. However the document did not include the admissions criteria used by the home. The document was also provided in text format, Ashbridge Lodge DS0000007276.V355274.R01.S.doc Version 5.2 Page 9 which would not allow residents who live at the home to understand the document due to their communication needs. The Service User Guide was also presented in text format. The document provided detailed information on the services provided at the home and how to contact external agencies involved with the service. However, the document did not include the service’s complaints procedure. A recommendation below has already been made that the documents are provided in formats suitable to the communication needs of residents living at the home. It is Requirement 1 that the Statement of Purpose and Service User Guide is updated to include the information required by the Care Homes Regulations. The pre-admission assessment process could not be fully tested at this inspection, as the service does not have any recently admitted residents. For new prospective residents, the service has a comprehensive pre-admission policy in place. However, the service does not have a pre-admission assessment form, which would need to be used for any new prospective residents admitted to the home to identify their needs and to ensure the service could meet those needs. To ensure prospective residents are admitted only on the basis of a full assessment, it is Requirement 2, that a preadmission assessment form is developed. New prospective residents would be able to visit the home as many times as they like and have an opportunity to stay overnight. Relatives and family are also invited to visit the home. On viewing care plan files of three residents; they all had a contract of terms and conditions. The contracts were also reviewed on a regular basis to reflect any changes. Each resident or their representative had signed the updated copies of the document. Unfortunately the documents were in text format and were not easy to understand and were also not provided in picture formats, which would have been more suitable to the communication needs of residents. It is therefore Recommendation 1 that documents are provided in formats suitable to the communication needs of residents living at the home. Ashbridge Lodge DS0000007276.V355274.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 People using the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There is a care planning system in place but needs to be more detailed and person centred to provide staff with personalised information to meet the needs of residents. The systems for residents to exercise choice and control can be further improved within the home, to ensure they are actively consulted on, and participate in, all aspects of life in the home. Risk assessments are undertaken routinely, but to ensure residents are supported to take risks as part of an independent lifestyle, they must be updated according to residents’ changing needs. Service users’ financial interests are not safeguarded, and systems need to be in place to ensure that records of residents’ outgoings and incomings of money are recorded promptly. Ashbridge Lodge DS0000007276.V355274.R01.S.doc Version 5.2 Page 11 EVIDENCE: Three care plans were closely examined. Care plans covered the health, personal care and emotional needs of residents. Each individual has a care plan but the practice of involving people who use the service in the development and review of the care plan is variable. The information necessary to deliver residents’ care was again variable in regards to detail and person centred care. Care plans did not state whether one required the assistance of one or two carers. However on one care plan there was sufficient detail in regards to the care tasks a resident could perform. Their care plan stated “ X is able to put her shoe on by themselves and dress themselves, but needs supervision to dress for the climate.” However, care plans did not provide information on residents likes and dislikes of food, their daily routines, what times they like to go to bed or get up, and were not personalised. Although the care plans had been reviewed on a regular basis there was limited evidence that this was done with residents or with their families or representatives. On speaking to relatives they highlighted that they were not always kept informed of staff changes at the home or of their relatives changing health needs. One relative stated “The home does not always keep you up to date on new members of staff working at the home. I don’t even know who the key worker is for my relative, as I haven’t seen her for ages. I visited the home, and I have had introduce myself to staff, as I have never seen them before.” Another relative stated “I have had to complain about the home not telling me about Y’s appointments. I have been to the home and Y has told me about his appointments, things have improved a bit.” Information could not be found through case recording or review documentation that residents or their families and representatives were actively encouraged to be involved in its review or development. Care plans were again in text format and included no pictures or photos to make the documents more suitable to the communication needs of residents. It is Requirement 3 that care plans are developed and reviewed with the involvement of the resident and their relatives and representatives and include sufficient detailed information to meet the needs of residents. The North East London Advocacy service currently represents and works with two residents at the home. Three remainining residents do not have access to an advocate. To ensure residents have representation and that there views are listened to, it is Recommendation 3 that all residents have an advocate. Care plans seen had completed risk assessments in areas which included environmental risks, falling, the risk of a fire and risks in relation to taking medication. One resident chose to smoke in his bedroom and an appropriate risk assessment had been completed. A behaviour assessment for another resident who presented challenging behaviour had been completed and guidelines and strategies were in place to inform staff of how to manage these risks presented to them. However, for one resident their care plan stated that they are at risk of “isolating themselves, severe self neglect, a short temper, Ashbridge Lodge DS0000007276.V355274.R01.S.doc Version 5.2 Page 12 swearing, shouting and inappropriate in conversation.” A risk assessment had not been completed for the resident to identify strategies and actions on how to minimise these risks, ensuring the safety of staff and people using the service. A requirement will be stated as Requirement 4 in relation to these findings. Two residents were at home during the day of the inspection and a further three residents joined them in the evening when returning from their day centres. Residents were seen to be involved in the running of the home, as they were seen clearing away after their tea. Residents were also encouraged to express their views in resident meetings on the running of the home and changes they would like made, which were held once a month. Minutes evidenced that staff took responsibility for actioning the issues raised by residents and recorded timescales within which these would be done by. The service has also introduced key worker meetings to take place on a regular basis between the resident and their key worker to discuss any issues or concerns the resident may have. The service is responsible for managing the daily personal finances of four residents. The Commission for Social Care Inspection was concerned to observe that all residents’ money was kept together. When family gave money to the manager for their loved ones for personal expenditure, it was not recorded straight away. The manager informed that she also kept a log of residents’ fares when paying for transport in her notebook, which was impossible to make sense of. Receipts were kept individually for residents. As the records for residents’ in-goings and out goings were not recorded on a day-to-day basis, it was not possible to complete an audit of residents’ finances. The Registered Persons must check the recordings of expenditure to ensure they are correct and all incomings and outgoings of money are recorded straight away and residents’ monies are kept individually. This is Requirement 15. Ashbridge Lodge DS0000007276.V355274.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): 11, 12, 13, 14, 15, 16, 17 People using the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are not provided with support to maintain their independence and in areas of personal development according to their needs and wishes. Residents are not encouraged to be engaged in community life, promoting their opportunities to be part of the local community. Daily routines respect the rights of residents ensuring their needs are met the way they prefer. Residents are not offered meals that promote their choices and respect their individual preferences. Residents are supported to maintain family links and relationships inside and outside the home. Ashbridge Lodge DS0000007276.V355274.R01.S.doc Version 5.2 Page 14 EVIDENCE: Residents do attend day centres during the week and one resident attends a paid employment centre five days a week, whilst another resident works at a garden centre once a week. Residents’ religious needs were identified in their care plan and one resident was supported to attend a local church every Sunday. However little evidence was seen of residents being involved in community activities during the evenings or at the weekends. On the day of the inspection two residents were at home, as they informed that it was not their day to attend their centres. No plans were made for residents to go out with their involvement, and they were seen to be watching T.V for the most part of the day. On viewing a log of the activity book, where all residents activity involvement is recorded, the registered manager pointed out that two residents had visited McDonalds restaurant a couple of times in the last few months but no further recording could be found of residents going out on a daily basis. On speaking to a relative they commented very negatively about the lack of outdoor activities offered to residents. She stated “When I visit the residents are always just sitting there watching television, some of them are not even watching and are just sitting there, they really need to do more for them.” A social care professional spoken to as part of the inspection stated “ There is a fair bit of sitting around when I go to the home. When I talk to the residents, they don’t know what activities are going on at the home.” A resident spoken to during the second visit, when asked about what he planned for the day stated “not a lot”. The registered manager recognised this and plans to make some changes. It is Requirement 5 that residents are actively involved and encouraged to participate in community activities of their choice to ensure social inclusion. Daily routines were flexible and residents could go to bed and get up at whatever times they liked. The inspector arrived at the premises late morning at 10.15am; one resident was just being assisted to get up and supported with personal care tasks. Daily case recording also evidences flexible daily routines. A resident spoken to stated, “We can go to bed and get up what time we want. I watch my own telly and go to sleep late.” Individuals living at the home have the opportunity to develop and maintain important family relationships. Some service users visited their family household on a weekly basis while others had family visit them at their home. On viewing the homes menu, it was identified that residents are only offered a choice of one meal at suppertime and at lunchtime. There was a selection of foods to choose from at breakfast. The menu was devised by staff and on viewing the daily case recording all residents were eating the same meals as each other, further evidencing the lack of choice offered at meal times. Residents were not actively supported to help plan, prepare and serve meals. There was little evidence as discussed above of residents going out to eat or of Ashbridge Lodge DS0000007276.V355274.R01.S.doc Version 5.2 Page 15 foods being prepared of their choice. The service must provide food, which is varied, and a choice of meals to meet the preferred dietary needs of residents and ensures their rights to choice and autonomy are promoted. This will be stated as Requirement 6. Ashbridge Lodge DS0000007276.V355274.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 People using the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents do receive health care support but systems to ensure healthcare professionals are contacted promptly need to be improved, to ensure their healthcare needs are met efficiently. Medication practices when residents take medicine home for the weekend do not always ensure the safety of people who use the service. The ageing, illness and death of service users are handled with respect and as the individual would wish. EVIDENCE: On examining three care plans it was evident that people who use the service have access to health care services both within the home and in the local community. There was evidence of involvement of multi-disciplinary healthcare professionals where required, and visits were made to dentists, GP’s and community psychiatric nurses. However, evidence was found of healthcare Ashbridge Lodge DS0000007276.V355274.R01.S.doc Version 5.2 Page 17 professionals not being contacted promptly. One resident’s care plan stated, “Y is to be provided with nutritious and healthy food in the home and to monitor his weight.” The residents care plan identified that the resident liked to eat sweet foods, which was affecting his weight. On checking the resident’s weight checks, the only weight check made was in January 2007 no further weight checks had been made. This was discussed with the registered manager who informed that the resident refused to have his weight checked by staff. The manager did not make any further contact with the resident’s GP to inform them of this or enquired about making a referral to a Dietician. Another resident’s care plan stated, “Z is to be supported in active activities, e.g. going for walks and have his weight checked monthly.” The last weight check was on September 2007 and no evidence in the care plan or the daily case recording notes could be found of the resident being supported to go out for walks or encouraged to participate in active activities. A requirement in relation to these findings will be stated as Requirement 7. There are policies and procedures for the handling and recording of medicines. Each resident has a medication care plan file, including information on the residents’ current medication. A random sample of Medication Administration Records (MAR) charts were examined. The following concerns were found and discussed with the registered manager. All medication was stored in a lockable kitchen cabinet with other documentation such as care plans. Medication was secondary dispensed into containers that the manager had kept of previous medications, by staff for residents when leaving the home. If the home fills medicine containers or compliance devises then a written policy is required that includes the procedure to be followed and the precautions to be taken, including a witness to the transfer. A fully documented record of the transfer would need to be retained and signed by staff involved. The procedure would need to include the staff trained as being authorised to transfer medication and they will require contacting their pharmacist for advice before transferring medication as the transfer of some medicines from the manufacturer’s packaging is contraindicated. A signature of the person accepting receipt and return is required. Medication leaving the home for each resident was all transferred into one container for the individual when attending their day centres. The manager informed that currently they only need to dispense 1 tablet for the day for some residents. However if more than one tablet was dispensed it would be impossible to identify which tablet is which and what time it should be administered. - Ashbridge Lodge DS0000007276.V355274.R01.S.doc Version 5.2 Page 18 - On examining the staff signature list, which is to identify staff authorised to administer medication, one signature was missing. It is Requirement 8 that medication practices are reviewed to ensure the safety of residents. Ashbridge Lodge DS0000007276.V355274.R01.S.doc Version 5.2 Page 19 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 People using the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The service has a complaints procedure in place, but needs to be amended to meet the requirements of the Care Homes Regulations. Residents can be assured that their views are listened to and acted on. All staff have attended training in Safeguarding Adults, to ensure they are provided with the knowledge to ensure the safety of residents. EVIDENCE: The complaints procedure was seen which was provided in text format and was included in the Statement of Purpose. The home has a clear complaints procedure, but needs amending to state that the Commission for Social Care Inspection can be contacted at any stage of a complaint being made. This will be stated as Requirement 9.The service also has a concerns books, to record all concerns expressed by residents and records how they are actioned. Two formal complaints have been made regarding the practices at the home. The first complaint received by the Commission for Social Care inspection was made by a resident against a member of staff alleging physical abuse. The registered manager informed that the Safeguarding Adults investigation has been closed by the London Borough of Waltham Forest who are the host authority of the service, as the findings were not substantiated and the resident has retracted their statement. The member of staff’s suspension has Ashbridge Lodge DS0000007276.V355274.R01.S.doc Version 5.2 Page 20 been lifted. The Commission for Social Care Inspection has received details of the Registered Providers investigation. The second complaint descended from the first complaint and referred to health professionals not being contacted promptly, which has further been discussed under standard 19 of this report. The London Borough of Waltham Forest completed an investigation and the allegations were substantiated. A risk management and protocol plan has been devised by the authority, which the service implemented, and the Safeguarding Adults Investigation was closed on the 31st October 2001. All staff have received training in Safeguarding Adults, and the service has clear procedures and protocols for staff to follow. Procedures have also been obtained by the London Borough of Waltham Forest. Ashbridge Lodge DS0000007276.V355274.R01.S.doc Version 5.2 Page 21 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 28, 29, 30. People using the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents live in a comfortable environment and décor is of a good standard and provides a homely and pleasant living environment enhancing residents’ comfort. But further environmental safety checks would improve the environment of the home. EVIDENCE: The premises were comfortable, clean and free from offensive odours. Furnishings and fittings in communal areas were domestic and unobtrusive. However, communal areas of the home looked tired and worn out. Service User’s would greatly benefit from a re-decoration programme. The home provides a homely environment to meet the needs of residents. The home provides a main lounge, kitchen, shower room and two bedrooms on the ground floor and a further three bedrooms and shower room are situated on Ashbridge Lodge DS0000007276.V355274.R01.S.doc Version 5.2 Page 22 the first floor. Three rooms are en suite. Residents’ rooms were viewed during the inspection, all residents had personalised their rooms according to their individual taste. One resident liked the colour pink and therefore had her room painted pink and had pink carpet. Residents had further personalised their rooms with pictures and ornaments, TV’s and music players. Bedrooms were made very warm and welcoming. All rooms were lockable and can be overridden by staff in an emergency During a tour of the home a packet of razors were found in a unlocked bathroom cabinet. A log of fridge, freezer and food temperatures was seen, which staff did not consistently complete and no recordings were found for some days. The garden area was well maintained and adequate garden furniture was provided. However, the garden shed which stored sharp gardening tools was not kept locked. All parts of the home to which residents have access to must be so far reasonably practicable made free from hazards to their safety and unnecessary risks to residents are identified and so far as possible eliminated, this is Requirement 10. Ashbridge Lodge DS0000007276.V355274.R01.S.doc Version 5.2 Page 23 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): 31, 32, 33, 34, 35, 36 People using the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Recruitment vetting procedures are in place but need to be further improved to ensure residents are in safe hands at all times. Staff are not supervised on a regular basis and therefore, residents cannot be confident that the staff team who care for them benefit from regular supervision. The service has a good skill mix of staff, but needs to review it staffing levels at night, to ensure adequate numbers of staff are on duty to meet the needs of residents. EVIDENCE: Three staff files were closely examined two of which were of recently recruited members of staff. Two files were found to be in good order with all the required checks and documentation being in place. However for one member Ashbridge Lodge DS0000007276.V355274.R01.S.doc Version 5.2 Page 24 of staff the application form was incomplete, which did not include a full employment history and two references received by the service did not include company stamps which the service did not seek further confirmation, to ensure they were provided by the people the applicant had named on her application form. To ensure the protection of residents and staff the service must complete robust recruitment checks before the applicant is employed. This will be stated as Requirement 11. On viewing staff files, staff certificates evidenced that staff had attended training in infection control; administration of medication; safeguarding adults; food hygiene; fire training. Although training is provided to staff in mandatory areas, it is recommended that the service considers providing further training to staff in understanding and managing challenging behaviour, person centred care and mental health to provide them with the skills and information to meet the needs of residents. This will be stated as Recommendation 2. On viewing the staff rota it was identified that the there are one to two members of staff on from 9am-4pm, two members of staff on duty from 4pm to 10pm and at night from 10pm to 9am there is one waking member of staff on duty. The home provides services to residents who can present challenging behaviour and one resident who has complex mental health needs. One member of staff and on duty and may be placed at risk if they are working alone as well as other residents, which does not ensure their protection. Appropriate risk assessments must be put in place for staff to identify the level of risks they may be exposed to and residents and that staffing levels are reviewed to ensure members of staff are protected at all times. This will be stated as Requirement 12. On viewing three staff files, two members of staff had been supervised regularly this year, but the remaining member of staff had only been supervised three times this year. All staff must be supervised at least six times a year, ensuring staff are provided with the skills, training and knowledge to perform the tasks required by their employment role. This will be stated as Requirement 13. During the inspection staff were observed to interact positively with residents. Residents were observed to be very comfortable with staff members when speaking or interacting with them. Relatives were also contacted as part of the inspection who also commented positively about the staff team at the home. One relative stated “The staff are very nice at the home, they are very welcoming, they always offer me a cup of tea when I’m there, X seems to be happy there.” Another relative spoken to informed, “On the whole we are satisfied with the care, the staff always listen, they are friendly.” Ashbridge Lodge DS0000007276.V355274.R01.S.doc Version 5.2 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 People using the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users or their relatives and representatives do not benefit from systems that involve them in the running of the home. The systems for service user consultation are in place, but must also include views from stakeholders to ensure the home is run in the best interests of residents. The welfare of staff and residents is promoted by the home’s policies and procedures. EVIDENCE: The registered manager has been in post for a year at the home. She was previously the deputy manager of the home and has past experience of Ashbridge Lodge DS0000007276.V355274.R01.S.doc Version 5.2 Page 26 working in residential settings. She is currently in the process of completing her NVQ level 4 qualification in health and social care. Staff spoken to on duty during the inspection spoke positively about the manager and commented that she was “Supportive and that enough training was provided at the home.” However, on speaking to relatives they highlighted that they were not always kept informed of staff changes at the home or of their relatives changing health needs. One relative stated “The home does not always keep you up to date on new members of staff working at the home. I don’t even know who the key worker is for my relative, as I haven’t seen her for ages. I visited the home, and I have had introduce myself to staff, as I have never seen them before”. Another relative stated “I have had to complain about the home not telling me about Y’s appointments. I have been to the home and Y has told me about his appointments, things have improved a bit.” Keeping relatives involved with care of their loved ones has been discussed under standard 6 and a requirement has been made. Quality assurance systems are in place and surveys completed by relatives and staff were seen. Residents had also completed surveys with the assistance of their advocate. The registered manager informed that the surveys were completed in January this year. However, no evidence was seen of where there was a dissatisfaction with the service, the service had taken action to address the concern. The results had not been compiled or collated or communicated back to all those who had completed them. Health professionals, social services and any other stakeholders in contact with the home also had not been involved in quality assurance surveys, to ensure their views are sought on how the home is achieving goals for residents. The results must be communicated to residents, family and stakeholders must be included in the process and a copy of the results must be made available to the Commission for Social Care Inspection. This will be stated as Requirement 13. Health and Safety records were inspected. All documentation was in order and appropriately completed. Fire drills were completed regularly. The registered persons has completed monthly regulation 26 visits and reports, which the Commission for Social Care Inspection has received copies of. However, the reports are very brief and do not provide enough detail of the findings of the visit or the views of service users during the visit. It is Recommendation 4, that the report format is reviewed to ensure the reports reflect the above information. Ashbridge Lodge DS0000007276.V355274.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 2 3 2 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 2 33 2 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 2 2 x LIFESTYLES Standard No Score 11 3 12 3 13 1 14 1 15 3 16 3 17 1 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 1 x 2 x 2 x x 3 x Ashbridge Lodge DS0000007276.V355274.R01.S.doc Version 5.2 Page 28 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation Schedule 1 Requirement The Registered Persons must ensure the Statement of Purpose and Service User Guide is updated to provide the correct information on the service. The Registered Persons must ensure that a pre-admission assessment form is developed. The Registered Persons must ensure that care plans are developed and reviewed with involvement of the resident and their relatives and representatives; and include sufficient detail to meet the needs of residents. The Registered Persons must ensure that risk assessments are completed to ensure the protection of people who use the service. The Registered Persons must ensure that residents are actively involved and encouraged to participate in community activities of their choice to ensure social inclusion. The Registered Persons must ensure that the service must provide food, which is varied, DS0000007276.V355274.R01.S.doc Timescale for action 31/01/08 2 3 YA2 YA3 YA6 YA8 14 15 28/02/08 28/02/08 4 YA9 13 14 31/01/08 5 YA13 YA14 16 (m) (n) 31/01/08 6 YA17 16 (i) 31/01/08 Ashbridge Lodge Version 5.2 Page 29 7 YA19 12 (1) (a) 8 YA20 13 9 YA22 22 10 YA24 16 11 YA34 18 (1) (a) 12 YA33 18 (1) (a) 13 YA36 18 (a) and a choice of meals to meet the preferred dietary needs of residents and ensures their rights to choice and autonomy are promoted. The Registered Persons must ensure that proper provision to meet the healthcare needs of residents is made and that prompt referrals are made to health care professionals. The Registered Persons must ensure medication practices are reviewed to ensure the safety of residents. The Registered Persons must amend the complaints procedure to include that the Commission for Social Care Inspection can be contacted at any stage of a complaint being made. The Registered Persons must ensure all parts of the home to which residents have access to are so far reasonably practicable made free from hazards to their safety and unnecessary risks to residents are identified and so far as possible eliminated. The Registered Persons must ensure the protection of residents and staff by the service completing robust recruitment checks before the applicant is employed The Registered Persons must ensure that appropriate risk assessments are put in place for staff to identify the level of risks they may be exposed to when working alone at night and that staffing levels are reviewed to ensure members of staff are protected at all times. The Registered Persons must ensure that all staff must be supervised at six times a year, ensuring staff are provided with DS0000007276.V355274.R01.S.doc 31/01/08 31/01/08 31/12/07 31/01/08 28/02/08 31/01/08 28/02/08 Ashbridge Lodge Version 5.2 Page 30 14 YA39 YA37 24 15 YA7 16 (l) 17 3 (a) the skills, training and knowledge to perform the tasks required by their employment role. The Registered Persons must ensure that the results of quality assurance surveys are communicated to residents and family. Stakeholders must also be included in the process. The Registered Persons must check the recordings of expenditure to ensure they are correct and all incomings and outgoings of money are recorded straight away and residents’ monies are kept individually 31/01/08 15/12/07 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 Refer to Standard YA1 YA8 Good Practice Recommendations It is recommended that information and documents such as the Statement of Purpose, care plans, the contract of terms and the complaints procedure should be considered to be made available in formats such as Braille, appropriate languages, pictures, and video, audio that are suitable for the people who use the service. It is recommended that the service provider considers providing further training to staff in understanding and managing challenging behaviour, person centred care and mental health to provide them with the skills and information to meet the needs of residents. It is recommended that the service provider ensures residents have an advocate to ensure their views are listened to. It is recommended that regulation 26 visit reports provide enough detail on the findings of the visit and the views of service users during the visit. 2 YA35 YA32 3 4 YA7 YA39 Ashbridge Lodge DS0000007276.V355274.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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 Ashbridge Lodge DS0000007276.V355274.R01.S.doc Version 5.2 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. 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