Inspection on 23/03/06 for Ashbridge Road (22)

This inspection was carried out on 23rd March 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ashbridge Road (22) 02/12/09

Ashbridge Road (22) 02/10/07

Ashbridge Road (22) 17/08/06

Ashbridge Road (22) 02/02/05

Ashbridge Road (22) 05/10/04

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 Road (22) 22 Ashbridge Road Leytonstone London E11 1NH Lead Inspector Sarah Greaves Unannounced Inspection 23rd March 2006 11:00 Ashbridge Road (22) DS0000007277.V287467.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ashbridge Road (22) DS0000007277.V287467.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ashbridge Road (22) DS0000007277.V287467.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Ashbridge Road (22) Address 22 Ashbridge Road Leytonstone London E11 1NH 020 8989 1170 020 8530 5339 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) Mrs Shirlene Hasmat-Ali Ms Claire Thorne Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Ashbridge Road (22) DS0000007277.V287467.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th July 2005 Brief Description of the Service: Sable Care is part of Sherico Care Homes group and provides care, support and accommodation for four adults with a learning disability (inclusive of services for people with challenging behaviour and autism). The home is a four bedded, Victorian style house situated in a residential road in Leytonstone within easy reach of an underground station, bus routes, local shops and amenities. The home has two upper floors, containing four bedrooms, two bathrooms and an office. There is a lounge with an adjacent visitors room/quiet room, a kitchen/dining area and a laundry room on the ground floor. Ashbridge Road (22) DS0000007277.V287467.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home had not received a report relating to the last inspection on the 4th July 2005, for which the Commission for Social Care Inspection apologises. The present inspection therefore reviewed compliance with the 13 requirements and 3 recommendations made at the inspection on the 2nd February 2005. This unannounced inspection was conducted in one day. The inspector met all of the service users, and also discussed care issues and practices with staff and the registered manager. There were no personal or professional visitors at the time of this inspection. The inspector read two care plans, reviewed policies and procedures and checked the premises (inclusive of the medication cabinet and medical refrigerator). What the service does well: What has improved since the last inspection? Thirteen requirements and three recommendations were issued in the previous inspection report. The inspector found that nine requirements and three recommendations had been met. The specific improvements noted were (1) Quality assurance monitoring (2) Improvement in practices relating to laundry/infection control and (3) Procedures for recording service users finances. Ashbridge Road (22) DS0000007277.V287467.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ashbridge Road (22) DS0000007277.V287467.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ashbridge Road (22) DS0000007277.V287467.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 5 Service users (and prospective service users/representatives) were provided with information about the home; however, the home needs to develop more pictorial style information. EVIDENCE: A recommendation was issued in the previous inspection report for the home to ensure that the Statement of Purpose and the Service Users Guide contained information regarding the arrangements for trial stays for prospective service users. The inspector found that this recommendation had been met. It was noted that the Statement of Purpose incorrectly referred to the Registered Homes Act 1984. At the time of this inspection, service users were provided with a pictorial Service Users Guide. A recommendation has been issued in this report for the home to develop pictorial contracts to promote service users understanding of their residential rights, responsibilities and entitlements. Ashbridge Road (22) DS0000007277.V287467.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 and 9 The care plans and risk assessments were of a good standard; however, the home needs to work towards developing “person centred planning” care plans. EVIDENCE: The inspector read two care plans. These care plans were found to be up-todate, relevant and satisfactorily written. The inspector found that the home had not implemented Person Centred Planning. The benefits of working with a care planning system that actively promotes the on-going participation of service users and their representatives was discussed with the registered manager. The registered manager was unable to confirm if the home was working towards the introduction of Person Centred Planning; a recommendation has been issued in this report. The risk assessments for service users were found to be comprehensive and valid. Ashbridge Road (22) DS0000007277.V287467.R01.S.doc Version 5.1 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,16 and 17 Service users are supported to access fulfilling activities. The home demonstrated an active approach to promoting service users independence and choice; however, risk assessments to address service users access to personal keys are needed. The food service was very good. EVIDENCE: The inspector spoke to the registered manager and to service users about the type of interests and hobbies pursued by the service users. The service users went to a holiday centre in Norfolk last year and had regular trips to local restaurants, pubs and shops. Service users were consulted about their choice of leisure activities via monthly meetings; the minutes for these meetings were shown to the inspector. Service users attended a local resource for adults with a learning disability, managed by a voluntary sector provider. This organisation offered a wide range of daytime, evening and weekend sports and social groups, including gardening, football and discos. Service users were observed to retire to their rooms to listen to music or engage in artwork with staff in the main lounge. A requirement was issued in the previous inspection report for the home to assess whether service users were able to manage keys to their room; the results of these assessments must be reflected in the care plans and subject to Ashbridge Road (22) DS0000007277.V287467.R01.S.doc Version 5.1 Page 11 periodic review. The inspector noted that this requirement was not met; it has therefore been repeated for action within a specified limited timescale. The menu was varied, healthy and balanced. The meals reflected the cultural and individual preferences of the service users. The inspector observed that there was fresh fruit available and the menu plan promoted vegetables, fruit and other healthy options. The inspector noted that the menu plan stated that yoghurts were served approximately six days per week; however, the registered manager stated that other healthy desserts were offered; it was advised that the menu should reflect this. Ashbridge Road (22) DS0000007277.V287467.R01.S.doc Version 5.1 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 and 21 The home needs to improve upon its disposal of surplus medications. The last wishes of service users must be recorded. EVIDENCE: A requirement was issued in the previous inspection report in regard to the home’s management of medication. It was noted at the previous inspection that the home had accumulated an excessive amount of medications. The inspector found at this inspection that service users possessed several months’ supplies of topical medications in their bedrooms (for example, prescribed skin creams) and there were too many respiratory inhalers stocked in the medicine cupboard within the registered manager’s office. The importance of regularly auditing medication supplies, returning surplus supplies to the pharmacist and liaising with the General Practitioner was discussed during this inspection. It was noted that an eye ointment was appropriately refrigerated and marked by staff with the date of opening (in accordance to the manufacturer’s instructions); the inspector advised that it would be beneficial to also mark the date for disposal. A requirement was issued in the previous inspection report for the home to ensure that the ‘last wishes’ of service users was recorded, via discussion with service users and/or their representatives. The registered manager presented a verbal account of these wishes; however, this information had not been recorded in the files of the service users, as stipulated by the requirement. Ashbridge Road (22) DS0000007277.V287467.R01.S.doc Version 5.1 Page 13 The home had developed policies to address how the needs of service users would be met in accordance to changing needs (such as ageing, chronic illnesses related to the ageing process, terminal illnesses and death). Ashbridge Road (22) DS0000007277.V287467.R01.S.doc Version 5.1 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Satisfactory written information about how to make a complaint was provided; however, additional pictorial guidance needs to be provided for the service users. Appropriate procedures for Adult Protection were produced; however, the home needs to ensure valid staff training and a comprehensive guidance relating to whistle blowing. EVIDENCE: A requirement was issued in the previous inspection report for the home to ensure that the complaints procedure referred to the role of the Commission for Social Care Inspection and provided timescales for responding to complaints. The inspector viewed the home’s complaints procedure and noted that this requirement had been met. The inspector recommended that the home should produce a pictorial version of the complaints procedure so that staff and/or advocates can undertake individual work with service users to promote the service users knowledge of how to make a complaint. The registered manager stated that the home had already identified the need to produce a pictorial complaints procedure to accompany the existing pictorial version of the service user guide. The inspector looked at the home’s Adult Protection procedure, which was found to be satisfactorily written in accordance with current Department of Health guidelines. The home possessed an up-to-date copy of the local social services (Waltham Forest) Adult Protection procedure. The home’s Adult Protection procedure had not been reviewed since 2003; the inspector recommended that the home’s procedure should be amended to state that it must be read in conjunction with the local social services procedure. Discussions with registered manager and staff demonstrated that this practice was already occurring. The registered manager stated that she had recently notified the proprietor of the need for staff to update their Adult Protection Ashbridge Road (22) DS0000007277.V287467.R01.S.doc Version 5.1 Page 15 training. The home’s whistle-blowing policy did not inform staff of organisations that they could approach to whistle-blow to (for example, the Commission for Social Care Inspection); a recommendation has been issued in this report for the inclusion of this information. There had not been any issues since the past twelve months relating to the protection of the service users. A requirement was issued in the previous report for the home to ensure a more rigorous approach to the recording of service users personal finances; a check of these practices was found to be satisfactory at this inspection visit. Ashbridge Road (22) DS0000007277.V287467.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. The home provided a pleasant and well-maintained environment for service users. EVIDENCE: Three requirements were issued in the previous inspection report in regard to the maintenance and safety of the environment; these requirements were found to have been satisfactorily met at this inspection visit. The home was observed to be clean, comfortable, pleasantly maintained and free from any offensive odours. The inspector noted that some metal gates had been discarded at the rear end of the back garden and the garden fence needed to be repaired. Ashbridge Road (22) DS0000007277.V287467.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 36 Staff received appropriate supervision linked to the needs of the service users. EVIDENCE: The inspector looked at the supervision records for care staff, the deputy manager and the registered manager. It was noted that the supervision records for the staff were up-to-date. The registered manager demonstrated that regular staff meetings were conducted. Ashbridge Road (22) DS0000007277.V287467.R01.S.doc Version 5.1 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39, 42 and 43 The home had improved upon its undertaking of quality assurance monitoring. Some issues relating to health and safety must be promptly addressed. EVIDENCE: A requirement was issued in the previous inspection report for the home to arrange for periodic satisfaction surveys to be carried out. The registered manager stated that the she had sent out survey forms to the parents of the service users and to relevant social workers (a copy of the survey form was shown to the inspector) but the home had not received any replies. The inspector contacted the placing authorities for two of the service users but was not able to secure any feedback at the time of writing this report; however, the statutory reviews conducted by the placing authorities evidenced a positive account of the care and support provided by the home. A requirement was issued in the previous inspection report for the responsible person (proprietor) to ensure that monthly- unannounced visits are carried out, and copies of the reports to be forwarded to the home and to the Commission. The inspector found that the home possessed eleven out of a Ashbridge Road (22) DS0000007277.V287467.R01.S.doc Version 5.1 Page 19 possible twelve reports for the past year; July 05 was missing. The registered manager stated that the proprietor was on leave in July 05; a requirement has been issued in this report for the responsible person to ensure that alternative arrangements are established to cover any absences. A requirement was issued in the previous inspection report for the home to ensure that the electric wiring certificate is up-to-date; this requirement had been satisfactorily met. The inspector found that the annual portable electrical appliances testing and the professional maintenance of the emergency lighting and fire alarm systems were overdue. Other health and safety checks (fire alarm points testing, food temperature probes, refrigerator and freezer temperatures and fire drills) had been satisfactorily maintained. The inspector found one item in the refrigerator that did not have a date of opening or date of expiry. The first aid box was found to contain some equipment that was out of date. The registered manager identified that not all staff possessed a valid first aid certificate and that training had been requested. A requirement has been issued in this report, taking into account that there must be a member of staff with current first aid training available at the premises at all times. The home’s public liability insurance was up-to-date; however, the business plan shown to the inspector did not have any projections beyond 2004. Ashbridge Road (22) DS0000007277.V287467.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 X 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 X 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 X X X 3 X X 1 2 Ashbridge Road (22) DS0000007277.V287467.R01.S.doc Version 5.1 Page 21 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA16 Regulation 13,14 and 15 Requirement The registered manager must ensure that service users care plans and risk assessments reflect whether they can be issued with keys for their bedroom. This is a repeated requirement. The registered manager must ensure that surplus supplies of medication are promptly returned to the pharmacist. This is a repeated requirement. The registered manager must ensure that the service users’ and relatives’ wishes in the event of death are recorded in their individual files. This is a repeated requirement. The registered manager must ensure the provision of a pictorial complaints procedure that is appropriate to the assessed needs of the service users. The responsible person and the registered manager must ensure that all staff possess valid Adult DS0000007277.V287467.R01.S.doc Timescale for action 15/05/06 2. YA20 13(2) 15/05/06 3. YA21 12 15/05/06 4. YA22 22 30/06/06 5. YA23 18 31/08/06 Ashbridge Road (22) Version 5.1 Page 22 Protection training. 6. YA23 21 The registered manager must ensure that the whistle-blowing policy is amended to advise staff of organisations that they can whistle blow to. The registered manager must ensure that the discarded gates are removed and the fence is repaired. The responsible individual must implement arrangements to ensure that the monthlyunannounced visits are conducted every month. The registered person must ensure that the following actions are taken: 1) Portable electrical appliances test 2) Annual professional maintenance of emergency lighting and fire alarm system The registered person must ensure that the first aid equipment is maintained within valid dates. The registered person must ensure that all food is labelled with the date of opening. This is a repeated requirement. The registered manager must ensure that all staff possess valid first aid training. 15/05/06 7. YA24 23 31/05/06 8. YA39 37 15/04/06 9. YA42 13 (4) 30/04/06 10. YA42 13(4) 30/04/06 11. YA42 13(4) 30/04/06 12. YA42 18 30/06/06 Ashbridge Road (22) DS0000007277.V287467.R01.S.doc Version 5.1 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard YA1 YA5 YA6 YA17 YA43 Good Practice Recommendations The reference to the Registered Homes Act within the Statement of Purpose needs to be deleted. The contracts for service users should be presented in a pictorial format. The home needs to develop the care- planning model towards “person centred planning”. The menu plan should demonstrate that different healthy desserts are provided. The business plan needs to be updated. Ashbridge Road (22) DS0000007277.V287467.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection East London Area Office Gredley House 1-11 Broadway Stratford London E15 4BQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ashbridge Road (22) DS0000007277.V287467.R01.S.doc Version 5.1 Page 25 - 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. 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