Inspection on 18/09/06 for Ashburnham House

This inspection was carried out on 18th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Ashburnham House 01/12/08

Ashburnham House 31/01/06

Ashburnham House 04/08/05

Ashburnham House 03/02/05

Ashburnham House 19/08/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Ashburnham House 33/35 Westminster Road Morecambe Lancashire LA4 4JA Lead Inspector Mrs Joy Howson-Booth Unannounced Inspection 18th September 2006 10:30 X10015.doc Version 1.40 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 Ashburnham House DS0000056670.V302966.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 Older People. 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. Ashburnham House DS0000056670.V302966.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashburnham House Address 33/35 Westminster Road Morecambe Lancashire LA4 4JA 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) 01524 413508 Mr Nashir Kasmani Care Home 11 Category(ies) of Dementia (7), Old age, not falling within any registration, with number other category (4) of places Ashburnham House DS0000056670.V302966.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home shall at all times employ a suitably qualified and experienced manager who is registered with the National Care Standards Commission. 31st January 2006 Date of last inspection Brief Description of the Service: Ashburnham House is a small, family type environment providing residential care for up to 11 people of either sex. At present, the home is registered to accommodate up to 7 people with dementia and up to 4 older persons. The home comprises of two terraced houses which have been developed into one large property and it is situated in the West End of Morecambe, close to local shops, amenities and the promenade. In early 2004, the home had a change of Proprietor and is now owned and managed by Mr Nashir Kasmani. Mr Kasmani continues to develop and improve both the care provided and the fabric of the building. The current range of fees is £350.00 per week. Further details over fees can be obtained from the registered provider of the home. Ashburnham House DS0000056670.V302966.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first site visit and was unannounced so the registered provider, assistant manager, staff and service users were not aware of the visit. The site visit forms part of the overall inspection for the home which makes sure people are being cared for properly and to make sure the home is a safe place for people to live in. As well as the site visit, judgements have been made about the service based on information supplied by the registered provider and from comment cards received from both relatives and service users. The site visit took place over one day and included taking time to sit and speak with service users, observing staff on duty performing the day-to-day routines, speaking with staff, examining documents held in the home and speaking with the registered provider and assistant manager. The inspector looked around the home, including communal rooms, bathrooms and toilets. The tour also provided an opportunity to find out about any improvements made and to see if the home was a comfortable, clean and safe for people to live in. Of the comment cards sent out for distribution by the home, a good number were returned and all spoke very highly of their satisfaction with the care provided by the registered provider and staff at the home. Additional information was also supplied from a pre-inspection questionnaire completed by the manager. The site visit was positive with everyone welcoming, friendly and co-operative during the visit. Ashburnham House has been assessed as a good home, although a small number of standards have shown shortfalls during this inspection. The registered provider has provided assurance that these will be addressed as it is the aim of the home to improve from being a good service to one which provides an excellent service to the service users accommodated. What the service does well: Ashburnham House provides a relaxed and family based environment which is unhurried and restful and service users are encouraged to take life at their own pace. The registered provider of the home considers that the home works with the service user, relatives, healthcare and other professionals as “Partners in Care” working to provide an excellent service to the service users in the home. Ashburnham House DS0000056670.V302966.R01.S.doc Version 5.2 Page 6 Information supplied by the home confirms that there are a range of policies and procedures which ensure service users are provided with the care they need and respects their rights irrespective of their race, gender, disability, sexuality, age, religion or beliefs. The home is well maintained and homely with communal rooms being accessible to the service users. For the bedrooms upstairs there is both a stair lift and a passenger lift for the service users to use, although not all floors are accessible by these means and service users may have to use a small flight of stairs to the top floor. The corridors in the home are fitted with handrails and there are a range of aids and adaptations to help service users maintain their independence. Service users own rooms are well maintained and in the process of being refurnished by the registered provider. It is the intention to redecorate individual rooms and the registered provider has already said that he consults with the service user and their relatives over their preferred choice of colours. Service Users are also encouraged to bring in treasured personal items to personalise their rooms. Communal rooms are well decorated and provide a homely and comfortable environment for the service users to use. During the site visit, a number of residents were seen and spoken with and all appeared to be well cared for and content. Communication between service users and staff were heard to be very respectful and friendly and there was much good humour and affection between both service users and staff on duty. Comment cards received from relatives were all very positive and expressed their high level of satisfaction with the home. Comments included – “I can’t recommend the home too highly. All the staff are caring and the Kasmani family who own it couldn’t be kinder”; “the care and support given by the staff and owner of Ashburnham House is amazing. Nothing is too much trouble”; “we consider ourselves very lucky to have our relative in Ashburnham House. We know she is safe but not institutionalised. The home has a relaxed and welcoming feel”; “The owner is available to discuss any queries. He always keeps you up to date with what is happening. He is easy to talk to”; “I think the home is well run and the staff are very kind”. Two visiting relatives were also spoken with and both confirmed they are very happy with the care provided to their relative, they are made welcome at any time when the visit and the registered owner is “very conscientious and makes sure everyone is well cared for”. Training continues to be provided, with all staff having now started the National Vocational Qualification (NVQ) Level II, and one member of staff starting NVQ Level III. This means that the service users are looked after by suitably trained staff. Ashburnham House DS0000056670.V302966.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: Information to be given to prospective service users and their relatives needs to be improved as it currently does not provide all the necessary information the Commission feels is needed. There is also the opportunity for the information to be provided to any prospective service user in a user-friendlier format as many people with dementia may not be able to recognize written information. When information is being gained about a possible service user it would be helpful for the home to find out the type of dementia the person has been diagnosed with so that staff can be provided with information over how best to support the person concerned. When staff have done training or when training needs have been identified, each member of staff should have their own training record kept by the home. Staff must be provided with the opportunity to review their care practices and training needs by talking to the registered provider on a one to one basis. Ashburnham House DS0000056670.V302966.R01.S.doc Version 5.2 Page 8 When the home holds personal monies for the service users this money must be kept separately for each person and not together. Other recommendations have been made which can be found at the end of this report. 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. Ashburnham House DS0000056670.V302966.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ashburnham House DS0000056670.V302966.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home ensures enough information is obtained on prospective service users to ensure their needs can be met. Satisfactory information is provided to service users to enable them to make an informed choice. EVIDENCE: It was found that the home does not have a separate Statement of Purpose and information is generally included in the Service User Guide. However, this latter document does not provide all the information required that is required for a Statement of Purpose and the outstanding requirements have been discussed with the provider. It was also suggested that this might provide an excellent opportunity to review the Service User Guide to make it more user friendly for the people who may access the service. The home has a new assessment procedure in place which includes the completion of a written assessment form, home or hospital visit by the Ashburnham House DS0000056670.V302966.R01.S.doc Version 5.2 Page 11 provider and senior member of staff, involvement of the service user, relatives and other professionals to enable an all-round picture to be built up of presenting needs. It would be during this assessment period that any specific cultural, religious, disability or sex needs would be highlighted and the home would then be able to make the necessary arrangements to ensure these would be met. The provider also encourages short visits – for example for lunch and afternoon stay, overnight stay and weekend stays to enable the service user to make an informed judgement. Once admitted, there is a fourweek trial period to enable more in-depth information to be gained and to enable the service user to see first hand the care provided. Discussions with staff members on duty confirmed that prior to admission information is given to them about the prospective service user and they have access to the care plan. Staff confirmed that following admission, they are included in getting to know the service user and spend time talking and listening to them to find out about their needs. Staff also talk with relatives who visit for further information or for clarification over any queries. A comment card received confirmed that the owner and senior carer visited the prospective service user prior to admission. Discussion with two visiting relatives also confirmed the admission procedure outlined above was followed and written information was provided by the home. The home does not provide an intermediate care facility. Ashburnham House DS0000056670.V302966.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care plans provide good information over the needs of the service users and how these are to be met by staff at the home. EVIDENCE: The provider confirmed that prior to admission information is sought from both healthcare professionals and relatives over the needs of the person concerned. This is in line with the home’s philosophy of care which seeks to be “partners in care”. Whilst this provides information about presenting needs it was recommended that the home should try to find out what the specific type of dementia has been diagnosed. For example, Lewy Body, Vascular or multi-infarct dementia, Alzheimer’s disease, etc. This would mean that the staff could be provided with information to enable them to better understand the way the diagnosis may affect the individual service user and how they can best offer support. Ashburnham House DS0000056670.V302966.R01.S.doc Version 5.2 Page 13 The home has recently purchased a new computerised package for their care plan records which provides prompts and sections for every area of care. The computerised care plans are currently being completed and hard copies are printed off and made available as working documents to the care staff. Reviews are held when needed or monthly and additional update sheets are printed off so that specific changes can be noted by the staff team. These additional sheets are signed by the members of staff to confirm they have read and understood the changes. The provider confirmed that the computer programme is “backed up” and also conforms to the Data Protection Act. It is hoped the new care plan system will enable a pen picture to be built up for each individual service user which provides information on their social and employment history so that staff can use this for activities, discussion and understanding of some behaviours. Discussions with staff confirmed that they have access to the care plans and update information is provided both in written form and at handovers (at the start of each shift). Care staff indicated that individual needs would be met by the home and would take into account any religious, cultural, disability, healthcare or sexual needs. Healthcare records were also seen on the computer records and, again, any changes are noted on an additional update sheet for staff. Weight monitoring of the service users is carried out by a designated member of staff and records were seen to be done on a monthly basis. Two care plans were examined during this site visit and found to contain comprehensive information over the care needs of the individual service users. The care files were well organised and tidy and divided into sections for ease of reference. Staff record daily records for each of the service users at the end of each shift. The provider was made aware that some healthcare notes in the home’s diary were personal and should be written in the service users’ individual record sheets. The medication stocks were seen and found to be kept in an well-ordered and clean manner. The medication records were generally accurately kept, although one omission was noted. There are no controlled drugs in the home. Observations during this site visit confirmed that the residents are treated well with dignity and respect being paramount within the care home. The Service User Guide that the home’s philosophy is to promote and respect privacy and dignity. This document, as well as discussions with the provider, also confirmed that the home’s approach is to consider themselves as “partners in care” along with the service users, relatives and other professionals. Discussions with two visiting relatives confirmed that they are very happy with the care provided by the home and that they have always heard and seen staff speak and provide care with kindness and patience. Comment was made “you would have to go a long way to find anywhere better than this home”. Comment cards included the following comments “I can’t recommend the Ashburnham House DS0000056670.V302966.R01.S.doc Version 5.2 Page 14 home too highly. All the staff are caring and the Kasmani family who own it couldn’t be kinder”; “we consider ourselves very lucky to have our relative in Ashburnham House”; “the care and support given by the staff and owner of Ashburnham House is amazing – nothing is too much trouble”. Ashburnham House DS0000056670.V302966.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above 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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home enables the service users to follow an good standard of lifestyle, with individual routines being respected and family/friend contacts being maintained. EVIDENCE: The care plans reflect individual routines and preferences and that care is provided equally. Care is taken to ensure that cultural and religious needs are met, for example, staff had highlighted that one service user’s religious needs were not being met so the home arranged for a Priest to visit the home and provide Holy Communion on a regular basis. The home has a part-time Activities Organiser. The provider has recognised the benefits provided by this person and is looking to increase this by having an additional member of staff designated to develop activities within the home. The home has a range of activities, including homely tasks, provided which are enjoyed by the service users. Other activities include – music, singing, bingo, games, craftwork and going out to local shops and cafes. Ashburnham House DS0000056670.V302966.R01.S.doc Version 5.2 Page 16 Confirmation was received from staff, two visitors to the home and comment cards that service user are able to see their visitors in private. The visitors also confirmed they have visited at different times, although the Service User guide asks for visitors to avoid mealtimes. Discussions with staff confirmed that there is a good understanding of what it means to offer choice and examples were given. Importantly, staff felt that service users preferences could be gained by getting to know the service user, talking and listening to them, speaking with their relatives and by observation. Advocacy information is included in the Service User guide, although few service users would be able to access this service independently. The Service User guide also confirms that service users can bring in items of furniture or treasured personal items. The provider has already confirmed that records are kept in accordance with the Data Protection Act 1998. From the menu book examined there appears to be a range of home-cooked food available to service users. Staff confirmed that individual choices and dislikes are known and respected and specialist diets would be catered for if needed. Generally comment cards confirmed that service users enjoyed the food provided, although two comment cards indicated only sometimes they enjoyed what was on offer. This was discussed with the provider who is to remind staff to ensure service users know there are choices available to them. The idea of providing photographs of the menu of the day was discussed and something that may be of use for service users in the home. The dining room is a pleasant and homely environment. Ashburnham House DS0000056670.V302966.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users know how to voice their feelings and who to go to if they are unhappy. Service users are safeguarded by staff at the home EVIDENCE: The home has a formal complaints procedure which provides all the required information. This is included in the Service User guide and is also on display. There have been no complaints, either to the home or to the Commission for Social Care Inspection. Comment cards received and discussion with two visitors confirmed all know about the complaints procedure for the home. The majority of service users would not be able to use the complaints procedure but the provider and staff speak with the service users on a day-to-day basis and use this opportunity to check out if there are any issues of concern. From observation, there is a very good rapport between the service users, provider and staff at the home and most are able to make their feelings known. Staff spoken with also confirmed they knew of the home’s complaints procedure and would ensure any concerns or complaints were passed on to the provider. Ashburnham House DS0000056670.V302966.R01.S.doc Version 5.2 Page 18 Information supplied by the home confirmed that there is a policy and procedure for adult abuse awareness and whistle blowing. Staff spoken with confirmed they were aware of these procedures. Staff confirmed that adult abuse awareness has been covered in their Skills for Care Induction training undertaken. Ashburnham House DS0000056670.V302966.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable and homely environment for the service users which is well maintained. EVIDENCE: There have been no physical changes to the environment of the home, although the refurbishment and upgrading work continues. The provider outlined a number of improvements he is hoping to make over the next 12 months which will mean an improvement in the facilities provided. A tour of the home confirmed that the home is well maintained and provides a pleasant and homely environment for the service users. The two lounges are very homely, with open fires and the addition of service user photographs, birthday cards, ornaments and flowers make this an environment where the service users can feel relaxed and very much at home. Individual service users rooms are clean and well maintained, with new furniture and evidence of Ashburnham House DS0000056670.V302966.R01.S.doc Version 5.2 Page 20 service users’ personal and treasured items in place. The use of larger signs on toilet doors appears to be helpful for the service users in the home. Most areas of the home are accessible to the service users, although those who are accommodated on the top floor must be able to use the upper staircase. The home has a passenger lift and stair lift in place. There are some aids and adaptations in place which enable service users to maintain some independence. Comment cards received made positive comments about the home, including “the home never smells like an institution. Everywhere is just like a real home.” Discussions with two visitors also confirmed they felt the environment was homely, clean and tidy. Information provided by the provider confirmed the home has an infection control policy in place. The provider confirmed there have been no changes to the existing hygiene and infection control systems in place which previously met the requirements. Ashburnham House DS0000056670.V302966.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing is at a good level, with support and training provided to improve knowledge and skills. A thorough recruitment procedure is being followed which safeguards the service users. EVIDENCE: Information supplied by the home confirms that there is an equal opportunities and ethnic minorities employment policy in place. Discussions with the provider confirms that staff would be employed on their attitude and ability to care and not on their age. The staffing rota reflected that both male and female staff, including an overseas carer, are employed at the home. In addition, the rota now includes the management hours worked in the home. Confirmation was also received that there is are separate domestic hours for the home. Care staff deal with anything outside of this. The shifts worked by staff have been changed so that during the day there are only two shifts instead of three. The provider feels that this more continuity for service users and more time for staff to undertake the care tasks. Discussions with staff confirmed they are much happier with the new shifts. Ashburnham House DS0000056670.V302966.R01.S.doc Version 5.2 Page 22 The duty rota confirmed that there are enough staff to take care of the service users and this was also confirmed in comment cards received and from discussions with two visitors. Comments included – “the care and support given by the staff and owner of Ashburnham House is amazing. Nothing is too much trouble”; “the staff listen and always try to understand what my relative says and needs”; “the staff are always available, pleasant and cheerful. The often anticipate what my relative needs”. All the staff at the home have commenced National Vocational Qualification (NVQ) Level II, with one member of staff now undertaking NVQ Level III. Currently the home does not have the required 50 of staff trained but, on completion of the NVQ Level II, the home will have certainly achieved this target. Staff spoken with confirmed they are enjoying the NVQ training and, whilst early days, feel that it is giving them more knowledge and skills in their dayto-day care roles. Discussion also took place over the need to provide the staff with some specific training in the care of people with dementia. Staff commented that they would very much welcome such training. The provider is to source out a suitable training provider. Staff files for three recently recruited members of staff were examined and found to contain all the required information, including POVA first and Criminal Records Bureau checks in place. The provider confirmed that all staff have undertaken the Skills for Care Induction training and induction training. Certificates were seen on files. As mentioned earlier, all staff are currently undertaking NVQ training. Discussion took place with the provider that whilst verbal confirmation had been received over induction training provided by the home there were no completed induction training records on staff files. This must be addressed. Although a range of certificates were seen on file there did not appear to be any cohesive record of training undertaken, planned, etc. which means the home cannot be certain what training staff have undertaken. The provider confirmed that the staff files are in need of some reorganisation which would provide a good opportunity to ensure that all staff have completed the required mandatory training and certificates are on files. It was also suggested that a training matrix be set up so that training needs can be identified, planned and updated as needed. Ashburnham House DS0000056670.V302966.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management of the home is good which means service users live in a safe and well-managed home. EVIDENCE: The registered provider has now achieved the Registered Managers Award and, in addition, has accessed other pertinent training. The home is managed as a family concern with the day-to-day management being covered by the registered provider and his immediate family. Comment cards received were all very positive about the management of the home and included – “the owner is available to discuss any queries. He always keeps you up to date with what is happening. He is easy to talk to”; “the home is well run and the staff are very kind”. Discussions with two visitors also confirmed they are very happy indeed with the way the home is managed. Ashburnham House DS0000056670.V302966.R01.S.doc Version 5.2 Page 24 Staff spoken with also confirmed that they are very happy with the way the home is managed and that the registered provider is a “very good boss”. Information supplied by the home confirms there is a formal quality system in place – ISO 9001. The manager and staff speak with the residents on t daily basis to ensure they are happy and, importantly, takes steps to address any concerns promptly. It was confirmed that external professionals are asked for feedback over the home and the service provided at review meetings which are held. One example given was a recent review meeting with the Continence Advisor. The home’s policies and procedures was discussed with the provider and it was confirmed these have remained the same since the current provider purchased the home. It was advised that all policies and procedures should be reviewed to ensure they reflect current practices and to ensure they reflect what the current provider wishes to happen in any given situation. Staff spoken with confirmed they have access to the policies and procedures if needed. Financial records were seen for personal monies held and signed by the service user on receipt. Personal monies held for service users were seen but are kept secure in one envelope. The provider was advised that these should be kept individually and separately and this must be attended to. Charges and payments are maintained on the home’s computer system and the owner was advised to ensure these are accessible to the Commission at all times. The home has a safe for keeping items deposited and monies held safe and secure. No supervision records were available for staff and the provider confirmed that whilst supervision is provided during care tasks there are no formal supervision sessions in place at the home. The provider was reminded of the requirements of the regulations and is to address this shortfall. Information supplied by the home confirmed that all the required maintenance and safety checks are carried out and regular fire drills take place. Discussions with staff on duty confirmed they were aware of the fire procedure for the home. Staff also confirmed that should a safety or maintenance issue be raised it is attended to promptly by the provider. The home’s accident book was seen and one anomaly pointed out to the provider. The provider is to remind staff to ensure accuracy when recording. Ashburnham House DS0000056670.V302966.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 3 Ashburnham House DS0000056670.V302966.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO 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 OP1 Regulation 4 Requirement Timescale for action 31/10/06 2. OP30 18(1)(c) The home must produce a Statement of Purpose which provides all the required information as outlined in Schedule 1 of the Care Homes Regulations 2001 Individual training records must 30/11/06 be set up for members of staff so that training undertaken can be recorded, training identified and update training planned Induction and mandatory training undertaken must be evidenced within the training records Formal supervision must be set up for staff as outlined in the National Minimum Standard 36 Personal allowance monies held by the home must be kept separately for each individual service user 3. 4. OP36 OP35 18(2) 12(4) 30/11/06 30/09/06 Ashburnham House DS0000056670.V302966.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP12 OP19 Good Practice Recommendations Activities enjoyed and provided to residents should continue to be developed The redecoration and refurbishment programme should continue as this is having a positive effect on the environment The Service User Guide could be developed in to a more user friendly document for the people who will live at this home During assessment the type of dementia should be ascertained so that staff can be given specific guidance over how the service user may be affected and the specific support that may be required The home’s application form should enable any prospective employee to provide a full employment history. A recruitment checklist may be of help to ensure all the required documents have been returned The provider to remind staff to ensure choices are made known to service users at mealtimes. The use of photographs may be helpful for service users to make a choice. Staff should continue with the National Vocational Qualification training so that the home achieves 50 of staff trained to Level II. A training matrix may be helpful to identify training needed, training undertaken and update training identified The provider to remind staff to ensure the accident book is accurately completed 3. 4. OP1 OP7 5. 6. 7. OP29 OP29 OP15 8. OP30 9. OP38 Ashburnham House DS0000056670.V302966.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1, Tustin Court Port Way Preston PR2 2YQ 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 Ashburnham House DS0000056670.V302966.R01.S.doc Version 5.2 Page 29 - 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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