Inspection on 30/11/05 for Ashbrook House

This inspection was carried out on 30th November 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ashbrook House 13/07/06

Ashbrook House 23/05/05

Ashbrook House 13/09/04

Ashbrook House 20/04/04

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 Ashbrook House 20 St Hellier Avenue Morden Surrey SM4 6LF Lead Inspector Liz O`Reilly Unannounced Inspection 30th November 2005 1pm Ashbrook House DS0000027206.V272337.R01.S.doc Version 5.0 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 Ashbrook House DS0000027206.V272337.R01.S.doc Version 5.0 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. Ashbrook House DS0000027206.V272337.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ashbrook House Address 20 St Hellier Avenue Morden Surrey SM4 6LF 0208 646 3096 0208 646 3096 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) Ashbrook House Limited Jenny Hamilton Care Home 9 Category(ies) of Learning disability (9), Physical disability (4) registration, with number of places Ashbrook House DS0000027206.V272337.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd May 2005 Brief Description of the Service: Ashbrook House is owned and managed by Allied Care, a private organisation. The home is situated on a busy road in Morden close to local shopping, entertainment and public transport amenities. The home opened in 1999 and provides care and accommodation for up to nine residents with learning disabilities, some of whom also have physical disabilities. The home is staffed twenty four hours a day with staff awake in the home throughout the night. Allied Care own a significant number of care homes across the South East of England. Ashbrook House DS0000027206.V272337.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by one regulation inspector over six hours on 30th November 2005. The inspector had the opportunity to meet with all of the residents and the acting manager and a sample of records were examined. What the service does well: What has improved since the last inspection? What they could do better: Further work needs to be done to complete the quality assurance and monitoring systems. Residents must be supplied with clear information on how much money is held on their behalf at the head office of the organisation. Any furnishings in the home should be of an appropriate height for residents. Ashbrook House DS0000027206.V272337.R01.S.doc Version 5.0 Page 6 Staff must take care to record the temperature of the water before they assist any resident into the bath or shower. The vehicle for the home must be kept in good working order. 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. Ashbrook House DS0000027206.V272337.R01.S.doc Version 5.0 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 Ashbrook House DS0000027206.V272337.R01.S.doc Version 5.0 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&2 Prospective and present residents are provided with good information on the home through the Service User Guide and Statement of Purpose. Before any resident is admitted to the home assessments of individual need are carried out. EVIDENCE: The home has a Statement of Purpose which sets out the aims and objectives of the service. Staff have produced a Service User Guide in a written, pictorial and photographic form which gives present and prospective residents information on the home. These variations make sure that the Service User Guide is more accessible to residents. To make sure that staff are well informed of the needs of any new resident the home gets copies of the care management assessment and also carry out their own assessment of needs and strengths. Ashbrook House DS0000027206.V272337.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 8 Each resident is supplied with a care plan which sets out individual needs, strengths and preferences. Staff support residents to make decisions about their lives. EVIDENCE: Staff have made very good progress in producing individualised care plans and documentation. Files contain good information on the daily living needs of each person along with how these needs will be met by staff. The preferences of residents are documented. A support plan sets out “what is happening now” with what residents would like to achieve and how staff will support them to reach their goals. Residents confirmed they are supported and encouraged to make their own decisions about their day to day activities. Where residents have difficulty in communicating staff involve families and or social services. All residents are registered with Advocacy Partners who will be visiting in the near future. This will allow residents to have independent support should they wish or need to. Two residents manage their own day to day money. Ashbrook House DS0000027206.V272337.R01.S.doc Version 5.0 Page 10 Staff are working towards increasing the accessibility of key policies and procedures for residents by making them available in different formats. Information on making a complaint was seen to be on display for residents. Monthly meetings are held where residents can discuss any issues they have with the home and plan future events. Minutes are taken at each meeting which assist in making sure that any suggestions are carried forward. Ashbrook House DS0000027206.V272337.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17 Residents take part in range of activities in line with their individual interests. Staff work to expand the opportunities for residents to take part in new activities. Residents attend a variety of colleges and day centres. Residents were happy with the food provided in the home. EVIDENCE: Residents confirmed they make their own choices about what activities to join both inside and outside the home. An activities organiser is employed in the home three days a week. Residents said they enjoyed the pottery classes in the home. An aromatherapist visits the home on a regular basis. Residents attend colleges, day centres and clubs on a weekly basis. Staff have made good progress in seeking out appropriate day centres for some residents who were not able to attend the local authority provision. Two residents were to commence drama therapy in the near future. Residents enjoy going out shopping, bowling and going to the cinema. Residents who wish to are supported to attend religious services of their choice. Ashbrook House DS0000027206.V272337.R01.S.doc Version 5.0 Page 12 All residents are registered with the Dial a Ride service. Staff support residents to use public transport and the home has its own vehicle. It was noted that the homes’ vehicle had a long standing problem with one of the windows. The registered persons must ensure that action is taken for the vehicle to be repaired of replaced. Residents confirmed they can have visitors at any reasonable times. Residents can meet with visitors in the communal areas of the home or in the privacy of their own room. Residents can invite friends to the home for a meal and staff will support residents who wish to go out with friends. The home has a policy on intimate personal relationships and residents are free to meet with boy or girlfriends within or outside the home. Individual risk assessments are carried out on freedom of access and exit of the building. The manager stated that keys for bedrooms had been ordered and that all residents would be offered a key. Residents were seen to enjoy the food and those who could provide verbal comments said they were very happy with the meals in the home. Certain residents will assist with the preparation of meals and snacks. The home produces a four week menu with alternatives available at each meal time. In addition residents can get snacks and drinks at any time. To ensure that all residents are receiving a well balanced diet the home keeps a record of food for each person. Staff also monitor the weight of residents and seek advice if anyone is gaining or loosing a significant amount of weight. One resident requires assistance with eating meals. Ashbrook House DS0000027206.V272337.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 & 20 Staff provide personal support in line with residents wishes and needs. Medication is well managed which assists in ensuring the health and welfare of residents. EVIDENCE: Residents confirmed that times for getting up, baths and other daily living activities are flexible. Residents also confirmed and staff were observed to provide personal care in a sensitive and discreet manner which respects the privacy and dignity of individuals. Staff have access to good information on the personal needs and wishes of all residents. Staff consult with health care professionals to ensure that individual residents have any aids or adaptations they need to promote health and independence. Should any resident require general nursing input this is provided by the local district nursing team. Staff from the community learning disabilities team visit the home and are available to give advice to staff. Each residents has an allocated keyworker from the staff group. Two residents informed the inspector that they were happy with their keyworker and felt well supported. The manager confirmed that residents can request a change of keyworker if they wished. Ashbrook House DS0000027206.V272337.R01.S.doc Version 5.0 Page 14 Residents confirmed they wear their own clothing at all times, make their own choices of hairstyle and appearance. The home keeps good records of all medication administered, received into the home and returned to the pharmacy. Medication was seen to be safely stored. All staff who administer medication have received appropriate training. Staff are provided with clear guidance on the administration of medication prescribed to be taken when required. Staff can call on the local pharmacist for advice on medication. Ashbrook House DS0000027206.V272337.R01.S.doc Version 5.0 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 The home has a complaints procedure. Clear information needs to be available on the right to approach the CSCI with a complaint. Information and training has been provided on the protection of vulnerable adults. Further work needs to be done to ensure that residents are aware of how much money they have available at the head office. EVIDENCE: None of the residents spoken to had any complaints about the home. There are systems in place for the recording of any complaint received. Staff have made the complaints procedure more accessible by displaying “speaking out” forms in the home. Staff will assist residents to complete these forms should they be unhappy with anything in the home. The complaints process is described in the Service User Guides. The information provided in these documents needs to be amended to include the right to approach the CSCI at any point with a complaint. All staff have been provided with training on the protection of vulnerable adults. The home has procedures in place as well as copies of the local authority procedures for the reporting of any suspected abuse of a resident. Booklets on protecting residents from abuse are on display in the home. Staff have been provided with guidance on spending money on behalf of any resident. At the time of the last inspection a requirement was made for regular, clear information to be provided to residents who have money held on their behalf at the head office of the organisation. Statements have been produced but these do not make clear to residents how much money they have available to spend. The registered persons must ensure that a clear, easily understood statement of money held on behalf of any resident is provided to Ashbrook House DS0000027206.V272337.R01.S.doc Version 5.0 Page 16 the resident on a regular basis. This will enable residents to plan their spending and keep up to date on what funds they have available to them. Ashbrook House DS0000027206.V272337.R01.S.doc Version 5.0 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 the following standard(s): 24, 29 & 30 Residents live in a well maintained environment. The maintenance of the home has been improved. An assessment of the premises has been carried out by a qualified occupational therapist. The home was found to be clean and tidy. EVIDENCE: Residents have been supplied with new lounge furniture, a new microwave and a computer for their use since the last inspection of the home. The manager informed the inspector that internal redecoration of the home was to commence in the near future. It was noted that the new seating in the lounge was low. One person who uses a wheelchair was seen to have some difficulty in transferring from the seating to their wheelchair. Action should be taken to raise or change this seating. The manager reported that an assessment of the premises had been carried out by a qualified occupational therapist to ensure that the appropriate aids and adaptations are in place. The home had not at the time of this visit received a copy of the report. The manager must ensure that a copy of the Ashbrook House DS0000027206.V272337.R01.S.doc Version 5.0 Page 18 report with confirmation that any recommendations made have been complied with is sent to the CSCI. A small laundry room fitted with appropriate equipment is available in the home. Residents are supported to assist with their own laundry. Staff are well informed on the safe disposal of clinical waste and the safeguarding of residents from cross infection. Ashbrook House DS0000027206.V272337.R01.S.doc Version 5.0 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 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): 33, 35 & 36 Sufficient staff were seen to be available to meet the needs of the present resident group. Staff are provided with good opportunities to develop their knowledge and skills through regular training. All staff are provided with one to one supervision which ensures they are well supported and work in line with the homes’ aims and objectives. EVIDENCE: Four staff plus the acting manager are available on duty during the day. Two staff are awake on the premises at night. There are no staff vacancies and agency staff are not used. The home has its own “bank” which ensures continuity of care for residents. No trainees are employed and all staff are over the age of 21. Additional staff are made available if required to support residents in activities outside the home. All staff are in the process of completing NVQ training. All senior staff are completing level three training with support workers carrying out level two training. All staff have completed training in the protection of vulnerable adults, first aid, food hygiene and infection control. Staff are clearly committed to improving their skills and knowledge which will ensure that residents are supported by a well informed staff group. Ashbrook House DS0000027206.V272337.R01.S.doc Version 5.0 Page 20 All staff are provided with an annual appraisal and regular one to one supervision from a more senior staff member. At the time of this visit the manager stated they were working towards all staff receiving supervision at least six times a year in line with national minimum standards. Ashbrook House DS0000027206.V272337.R01.S.doc Version 5.0 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 The acting manager and staff have made significant progress in meeting requirements and recommendations. An application for the registration of the manager should be made to the CSCI. Further work needs to be done to complete the quality assurance and monitoring systems. Staff carry out regular checks on the building and equipment to ensure the health and safety of residents, visitors and staff. Staff must ensure that the temperature of the water is taken and recorded before any resident uses the bath or shower. EVIDENCE: The acting manager is in the process of NVQ level four training and is planning to continue with further training once this is completed. The Registered Persons should ensure that an application for the registration of the manager is made to the CSCI. Ashbrook House DS0000027206.V272337.R01.S.doc Version 5.0 Page 22 Work has commenced on the quality assurance and monitoring system. The results of residents questionnaires should be published and made available to present and prospective residents. The Registered Persons must ensure that an annual review of the service is carried out with a copy of any resulting report supplied to the CSCI. Staff make regular checks on the equipment in the home to ensure the health and safety of residents. Records showed weekly testing of the fire alarm system, regular fire drills, annual testing of electrical equipment, recording of fridge and freezer temperatures, monthly checks on the homes’ vehicle and regular maintenance checks on hoists. The manager must ensure that staff record the temperature of the water prior to any resident being assisted into a bath or shower. Ashbrook House DS0000027206.V272337.R01.S.doc Version 5.0 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 3 3 x x x Standard No 22 23 Score 2 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 x x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x 2 3 LIFESTYLES Standard No Score 11 x 12 3 13 2 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score x x 3 x 3 2 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Ashbrook House Score 3 x 3 x Standard No 37 38 39 40 41 42 43 Score 2 x 2 x x 2 x DS0000027206.V272337.R01.S.doc Version 5.0 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 YA13 Regulation 23(2)(c) Requirement The Registered Persons must ensure that the vehicle for the home is maintained in full working order or replaced. The Registered Persons must ensure that the complaints procedure supplied to residents and their representatives includes information on their right to approach the CSCI at any stage and the contact details of the CSCI. 3. YA23 17(2) Sch 4(9) 4(3) 01/04/06 The Registered Persons must ensure that residents are supplied with regular clearly understandable information on the amount of money held on their behalf at the company head office. 01/04/06 The Registered Persons must supply to the CSCI a copy of the assessment of the premises carried out by a qualified occupational therapist. Ashbrook House DS0000027206.V272337.R01.S.doc Version 5.0 Page 25 Timescale for action 01/04/06 2. YA22 22(7) 01/04/06 4. YA29 23(1) 5. YA42 13(4) The registered persons must ensure that checks are carried out on the temperature of hot water supplied prior to any service user using the bath or shower in the home. A record of these temperatures must be retained. 01/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA24 Good Practice Recommendations The Registered Persons should ensure that any seating supplied is at an appropriate height for residents. Ashbrook House DS0000027206.V272337.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG 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 Ashbrook House DS0000027206.V272337.R01.S.doc Version 5.0 Page 27 - 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!