Inspection on 13/04/05 for Ashburnham Road, 95

This inspection was carried out on 13th April 2005.

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

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

Other inspections for this house

Ashburnham Road, 95 08/09/08

Ashburnham Road, 95 25/05/07

Ashburnham Road, 95 21/06/06

Ashburnham Road, 95 31/10/05

Ashburnham Road, 95 13/01/05

Ashburnham Road, 95 04/08/04

Ashburnham Road, 95 17/02/04

Ashburnham Road, 95 05/08/03

Similar services:

Chesham House

Argyll House

Dorset Lodge

Acacia House

Falcon House

Dial House Nursing Home

Cromwell Avenue (9)

Abbey Lodge

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

CARE HOME ADULTS 18-65 95 Ashburnham Road Luton Bedfordshire LU1 1JW Lead Inspector Ansuya Chudasama Unannounced 13 April 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 95 Ashburnham Road I51 S223662 95 ASHBURNHAM V223662 130405 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 95, Ashburnham Road Address Luton Beds LU1 1JW Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01582 481589 Advance Housing and Support Ltd Care Home 4 Category(ies) of MD - Mental Disorder (4) registration, with number of places 95 Ashburnham Road I51 S223662 95 ASHBURNHAM V223662 130405 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13Th January 2005 Brief Description of the Service: Advance Housing and Supported Living, a voluntary organisation, provides homes in the community for people with learning disabilities and mental health needs and owns 95 Ashburnham Road residential home, a three-storey building. The home is situated in Luton and provided care for four adults in the category of mental disorder. All the bedrooms are single and service users are encouraged to personalise their bedrooms. Service users bedrooms, a pay phone, bathroom and toilet are located on the second floor. The top floor is used for the staff sleeping-in room and is used by the service manager for an office. A call bell system is connected from the ground floor to the sleeping-in room, which the service user could use when required in emergency situations. The ground floor has a lounge/diner, toilet and a kitchen. The office is accessed via the kitchen and next to the utility room. Both the staff and service users use the pleasant garden, which is situated at the back of the home. The home is within walking distance of the park, shops, pub and a bus stop. The Town centre of Luton is three miles from the home. 95 Ashburnham Road I51 S223662 95 ASHBURNHAM V223662 130405 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken by two inspectors and started at 09.45am. It took place over 6 hours. The inspection was undertaken as a result of the concerns that were raised regarding poor care practices being carried out in the home. The inspection comprised of a tour of some of the communal areas, talking to staff, the service manager, and two service users. Three service users’ files and other records were also inspected. The service manager was unable to find a file of one service user who had passed away. This file was brought to the office a few days later and was examined and the information is included in the report. What the service does well: What has improved since the last inspection? What they could do better: 95 Ashburnham Road I51 S223662 95 ASHBURNHAM V223662 130405 Stage 4.doc Version 1.30 Page 6 The organisation needs to review their management structures to find out why the home is not being managed effectively. The home must have effective monitoring systems in place to check that the services offered are meeting the needs of service users. Any concerns raised by staff must be acknowledged and investigated by the organisation immediately. This was not the case of a member of staff who had used the whistle blowing procedures to expose poor care practices to the organisation. The manager must be supernumerary in order to be able to manage the home effectively. All service users admitted to the home must have assessments, care plans and risk assessments undertaken. They must also be reviewed on a regular basis and should involve the service user. Service users finances, medication and health care needs must be monitored and managed effectively at all times by management. Due to the number of requirements that were outstanding from the previous reports and in view of the concerns identified at this inspection, a meeting was held with the providers to discuss the action that they were going to take to meet these requirements. 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. 95 Ashburnham Road I51 S223662 95 ASHBURNHAM V223662 130405 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection 95 Ashburnham Road I51 S223662 95 ASHBURNHAM V223662 130405 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,23 No progress had been made to improve the assessment procedure to ensure that there is a proper assessment prior to people moving into the home. Without this there is no assurance that care needs will be met. EVIDENCE: One-service users’ file inspected stated that the person was admitted to the home on the 21st of October 1990. However records showed that the person was admitted to the home on the 8th January 2005. The admissions list contained all the names of the service users in this home and those who lived in the sister home near by. There was no evidence to show that an assessment had been undertaken for the two service users who had been admitted to the home recently or how their needs were going to be met by the home. The staff on duty was not aware where the service users’ guide was kept in the home. One service user spoken to had not seen this document. 95 Ashburnham Road I51 S223662 95 ASHBURNHAM V223662 130405 Stage 4.doc Version 1.30 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 standard(s) 6,7,9 No care plans or risk assessments were available for two new service users admitted to the home and so therefore these short falls have a potential to place service users at risk. One service users’ care plan was not detailed enough in order to identify how the service users needs would be fully met. EVIDENCE: Two out of three service users’ files inspected did not have any care plans or risk assessments or a new contract with the home. Their files had been transferred from one of the sister home where the service users came from. The information in both files was difficult to understand because the inspector was unable to distinguish information that belonged to this home, and information that was transferred from the other home. There was no information to state how the service users current and changing needs were going to be met by the home. There were no procedures seen for service users who were likely to cause harm to them selves. One of the service users stated that he wanted to move into a flat and asked the inspector to speak to the staff about this. The service users’ file inspected showed that his long-term goals had not been discussed. One service users’ file in abeyance could not be found and the service manager was asked to 95 Ashburnham Road I51 S223662 95 ASHBURNHAM V223662 130405 Stage 4.doc Version 1.30 Page 10 inform the CSCI when this file was found. The file was brought to the CSCI and the care plan inspected had not been reviewed and did not reflect the changing needs of the service user. Another service users’ file inspected had a care support plan dated 25.2.04. This had not been signed by the service user or staff and it had also not been reviewed. All plans inspected did not explain clearly how support was provided for service users to gain skills in the areas identified. There were lots of sheets of paperwork and this made it very difficult to see clearly what the needs of the service users were. Service users’ files inspected had a form that was devised by the organisation and this was given to service users to sign to give “permission for inspectors from National Care Standards Commission to have access to my files”. However this practice was not legal and the CSCI had a right to inspect all information held at the home. 95 Ashburnham Road I51 S223662 95 ASHBURNHAM V223662 130405 Stage 4.doc Version 1.30 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 standard(s) 12,13,14,15,17 There were no menus displayed for service users so therefore they do not get the opportunity to decide or know what is being offered. There were no appropriate leisure activities offered and there fore service users social care needs were not being met fully. EVIDENCE: The inspector was informed that a residents meeting was held last Saturday but the out come of the meeting was not available. In a residents meeting that was held in January 2005, a service user stated that in his care plan he was to have a day out with his key worker once a month but it was stated that this had had never happened. Another service user spoken to stated that he had not been out on any activities with the home because the home was short staffed. One service users file, inspected for activities showed that the service user attended day care three times a week and the other two days were spend undertaking household tasks. For example, emptying the dishwasher, emptying bins and walking to the local shops. No meaningful leisure activities were recorded for the last two months. A menu was seen displayed for four weeks but the inspectors were informed that this was not used. The inspector asked two service users in the home if 95 Ashburnham Road I51 S223662 95 ASHBURNHAM V223662 130405 Stage 4.doc Version 1.30 Page 12 they knew what they were having for their evening meal. They stated that they didn’t know. The inspectors were informed that the staff asked service users the night before what they wanted for their evening meal. The meal chosen was recorded in the menu sheet and this was kept in the office. The menu sheet showed that the meal chosen on Monday was not prepared on Tuesday. The service users asked for a menu to be displayed for the week in the kitchen so they were aware of what meals they were going to have for the week. The service users stated that the meals provided were nice. 95 Ashburnham Road I51 S223662 95 ASHBURNHAM V223662 130405 Stage 4.doc Version 1.30 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 standard(s) 18,19,20 Limited progress had been made on improving arrangements to ensure that the health care needs of service users were identified and met. These shortfalls have a potential to place service users at risk. EVIDENCE: One service user spoken to stated that he had only got one pair of shoes and he needed more trousers. His key worker session on the 22.2.05 stated that the service user had not had a new pair of shoes and the service user had discussed the issue of shoes on the 5.1.05 and in October 2004. The service user appeared to need help with shaving, as his beard growth was very uneven. The medication order book showed that there were no entries made between the 1.11.04 and 30.12.04. It appears that an entry was also not made for medication started in December 04. Medical records inspected for one service stated that the chiropodist had advised treatment for his feet but this was not recorded in the care plan. An eye test check up in October 2004 stated that the service user needed treatment and the home was to chase up for appointment if they had not heard by February 05. However there was no evidence recorded to show that this had been done. The communication book read for the 19.11.04 stated that a service user had cream for his feet and legs but entry of 4.12.04 showed that there were no sheets to demonstrate the 95 Ashburnham Road I51 S223662 95 ASHBURNHAM V223662 130405 Stage 4.doc Version 1.30 Page 14 creams had been applied. One-service users’ file inspected showed that he had seen a nurse about his diet in January 2005, and the outcome was to be reviewed in February 2005 but there was no evidence to show that this had happened. Another service users file inspected showed that the person’s health care needs had deteriorated and no preventative measures had been taken until the person was very ill. There were records of some health appointments recorded in service users files. The homes diary showed that appointments for service users living in the other sister home were also recorded in this book. The medication records showed that one service user was self-medicating but this was not the case since he was admitted to the home. The medication checked showed that some service users had extra tablets left over in the medication cabinet. However there were no written records to explain why this was the case. It was assumed that either the service users had not been given the medication or staff had not checked the medication when it was delivered to the home. The inspectors were informed that all staff had received the accredited medication training. 95 Ashburnham Road I51 S223662 95 ASHBURNHAM V223662 130405 Stage 4.doc Version 1.30 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 standard(s) 22,23 Concerns raised by a staff member regarding poor care practices were not acted upon in order to safe guard service users from abuse. There were no clear monitoring systems put in place by the home to ensure service users money was being managed appropriately and therefore this could put them at risk of financial abuse. EVIDENCE: Concerns were raised by a member of staff to the CSCI regarding poor care practices being carried out by the home. The staff member had raised these concerns to the organisation but felt that she was not listened to and nothing was done. The concerns raised were investigated at this inspection and all were up held. The staff member on duty stated that she was being victimised for raising issues of poor practice. She stated that she was also accused of refusing to have supervision but she had informed her manager that she could not have this because her complaint regarding breach of confidentiality in supervision had not been resolved. The service manager was asked about concerns raised by the member of staff regarding confidentiality and supervision and had the organisation considered an alternative option. The service manager stated that there were issues on both sides and the manager was aware that they needed to build the team. The service users’ spoken to at the home were not aware how much rent or benefits they were receiving and they stated that no one had explained this to them. There was no evidence in the service users care plans to state how they were being supported by staff to understand about their finances. One service users file inspected had not received any letters or printed statements of rent account from the organisation since July 2003. There were no records in the service users’ file of having a bank account or how and when his benefits were cashed or how his rent was paid. The service users’ meeting inspected for 95 Ashburnham Road I51 S223662 95 ASHBURNHAM V223662 130405 Stage 4.doc Version 1.30 Page 16 January 2005 stated that one service user wanted to know about his rent and if he was in credit. This information was asked a month ago. Several service users’ money checked was in correct. However there was no evidence to show that the management of the home had taken action to investigate these concerns. Two service users’ cashbook checked showed that there were a number of errors in the balance. None of the errors were identified by the manager’s checks. There was also documented evidence of money being short and staff finding money in the petty cash. It was noted that one-service user had no money for 13 days and therefore had to borrow money from the petty cash. One service users balance sheet showed that staff had forged a service users signature when giving out money to the person. The inspectors found several envelopes of money at the bottom draw of the cabinet where greeting cards were kept. There was no record in the service users’ files inspected or any other records seen to state why the money was kept in the envelopes. It was also stated to the inspectors that the filling cabinet was not always kept locked. 95 Ashburnham Road I51 S223662 95 ASHBURNHAM V223662 130405 Stage 4.doc Version 1.30 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25.26,27.28,30 The overall quality of the furnishings and fittings in the communal areas was good and met service users needs. The home did not keep adequate maintenance records, there fore the home was unable to demonstrate that the health and safety needs of the home were fully adhered to. EVIDENCE: The areas of the home seen were clean and well maintained. The service users smoked in the lounge/dinning area and the home did smell of tobacco smoke. The home had service users and staff who did not smoke and their needs were not being met. This issue was discussed at the last inspection visit. One of the service users showed his room to the inspector and stated that he liked his room. He stated that when his room was painted, some of it had spilled on his carpet and wanted the paint cleared from his carpet. Another service user stated that he also liked his room. However he stated that his mattress had cigarette burns and it was worn out. The home did not have a maintenance file. The diary read stated that Herts. Property visited on the 18th January 2005 to repair the central heating. There was no information 95 Ashburnham Road I51 S223662 95 ASHBURNHAM V223662 130405 Stage 4.doc Version 1.30 Page 18 recorded in the communication book to state when the system had broken down and what contingency plans had been put in place to meet the needs of service users. 95 Ashburnham Road I51 S223662 95 ASHBURNHAM V223662 130405 Stage 4.doc Version 1.30 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,34,36 The staff at the home worked at two homes and so therefore did not provide continuity of care to meet service users needs. EVIDENCE: The staff member on duty spoken to had not had an induction when she started working at the home. She stated that she was informed initially that she would not be working unsupervised at this home. However she was not informed why this was the case. The working rota showed that the staff worked on their own on shifts. The inspectors were informed that in the past the home had its own designated staff. However the staffing rota was changed by the operations manager for all staff to work at this and at another sister home near by. This was confirmed by inspecting the rota. The rotas were written in pencil. There were four versions of the rota weekending 11th of April 2005. Two rotas were for this home and another two were for the sister home. The rota also showed that many of the staff were working long hours in excess of 50 hours per week between the two homes, and had no days off in nine days. The manager was also seen to be working long hours and shifts at the two homes. The staff member on duty was not a key worker to any of the service users in the home but she was a key worker to two service users at the other home. The rota showed that the staff was only working one shift at the other home and the rest of her shifts were worked at this home. The member 95 Ashburnham Road I51 S223662 95 ASHBURNHAM V223662 130405 Stage 4.doc Version 1.30 Page 20 of staff stated that she enjoyed working with the service users and she was observed working well with the service users. The home had an induction list for agency staff. It was stated that these staff were given an induction for a few hours and then they were left to work the rest of the shift by themselves. There was no evidence to show who was responsible for checking that the agency staff had experience and CRB checks prior to starting work at the home. The service manager was asked when the manger was going to get registered. It was stated that a previous inspector had advised her that the manager should get registered after completing the registered managers award. However this was not the case as a requirement had been made in the previous inspection reports. The staff files seen had supervision notes, CRB checks, two references and contracts. However one file did not have a photo, or a copy of a passport or birth certificate. The Staff meetings were held on a regular basis for this home and the other sister home near by together. 95 Ashburnham Road I51 S223662 95 ASHBURNHAM V223662 130405 Stage 4.doc Version 1.30 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,38,42 The manager worked shifts on the rota and is therefore unable to manage the home effectively and unable to monitor the quality of care. EVIDENCE: The service manager was asked about the management of the home and why the home was not being managed properly. It was stated that the manager had a lot of learning to do and she was also a slow learner and staff management was stated not to be the manager’s strong point. The service manager was asked what support the manager was receiving regarding her role. She stated that she worked “hands on” in the past but now she was in background to help out when required. It was also stated that the manager was committed to developing services but there were too many ideas and this was being done too quickly. The service manager was informed that the inspectors were concerned that the manager did not have enough time to manage the services and she needed to be supernumerary on the rota. The inspectors were informed that the manager had lots of course work but she was going to discuss this with the operations manager. It was also stated by 95 Ashburnham Road I51 S223662 95 ASHBURNHAM V223662 130405 Stage 4.doc Version 1.30 Page 22 the service manager that they had to work within the budgets. The service manager was informed that there was no evidence to show that there were any formal monitoring methods put in place to observe what staff were doing. It was stated that the manager was unable to undertake this as she worked on shifts on her own. The service manager discussed her role and stated that her job description was out of date and this was going to be reviewed. It was also stated that the managers managed the home on a day-to-day basis and she was seen as the link person between the five homes that belonged to Advance in Bedfordshire. The service manager stated that she was at present managing two other Advance and Supported Living homes as the manager went off on early maternity leave in February 2005. However the CSCI had not been informed of this. The weekly hot water temperatures undertaken were very high. The fire logbook showed that the home had not had a fire drill/training since two new service users and a new member of staff had been appointed. The risk assessments on the environment had not been reviewed since July 03. There were no clear details to state what a risk was and action taken to minimise the risk. There was no entries in the communication book to state when the central heating was not working until the 22/12/04. Another entry stated that on the 14th of January 2005, Hearts property coming to see the heating. Another entry stated that on the 18th of January 05, heating fixed. The CSCI had not been informed of this as indicated in regulation 37. COSHH risk assessments had also not been reviewed. The emergency measures for lone working was to call the on call person, however it did not indicate how the on call would be contacted if the person was incapacitated or risks in relation to specific service users. 95 Ashburnham Road I51 S223662 95 ASHBURNHAM V223662 130405 Stage 4.doc Version 1.30 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 1 1 x x Standard No 22 23 ENVIRONMENT Score 1 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 1 2 x 1 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 2 3 3 x 2 Standard No 11 12 13 14 15 16 17 x 2 2 1 3 x 2 Standard No 31 32 33 34 35 36 Score x x 2 2 x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 95 Ashburnham Road Score 2 1 1 x Standard No 37 38 39 40 41 42 43 Score 1 1 x x x 2 x I51 S223662 95 ASHBURNHAM V223662 130405 Stage 4.doc Version 1.30 Page 24 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard Ya6 Regulation 18-(1)c Requirement The registered person must ensure staff receive training on how to implement the new care plans.This time scale of 01.11.2004 not met The registered person must ensure detailed risk assessments are provided for all service users. This time scale of 01.3.2005 not met. An immediate requirement was issued to have risk assessments in place for all service users by 4.5.2005 The registered provider must ensure that all complaints made to the organisation are fully investigated. The registered provider must provide a fire drill/instructions for new service users and staff. An immediate reguirement was issued on the day of the inspection to be complied by 18.4.2005 The registered provider must review the risk assessments on the environment. This time scale of 1.3.2005 not met The registered person must ensure all care plan documents Timescale for action 31/7/2005 2. Ya9 13 4.5.2005 3. Ya22 22-(3) 31.7.2005 4. Ya42 12(1) a 23(4) c 18.4.2005 5. Ya42 12(1) 31.7.2005 6. Ya6 15(1) 31.7.2005 Page 25 95 Ashburnham Road I51 S223662 95 ASHBURNHAM V223662 130405 Stage 4.doc Version 1.30 7. Ya42 13(4) 8. Ya37 9(1)(2) 9. Ya6 15(1) 10. Ya2 14(1) 11. Ya33 18 12. Ya23 16(2)l 13. Ya20 13(2) identifies service users needs and ensure these are reviewed on a regular basis. The registered person must provide a risk assessment based on an assessment of the capabilities and needs of service users from hot water/surfaces. The registered person must ensure that the manager applies for registration with the CSCI. This time scale of 22.10.2005 not met The registered person must ensure care plans are undertaken on all service users admitted to the home.This time scale of 20.2.2005 not met. An immediate requirement was issued on the day of the inspection for 4.5.2005 The registered person must undertake needs assessments on all service users admitted to the home. This time scale of 20.2.2005 not met. The registered person must ensure that the manager is supernumerary on the staffing rota to manage the two homes. The manager must be supported to undertake her role by management. This time scale of 28.3.2005 not met. The registered person must ensure service users money is kept secured and is properly accounted for. An immediate requirement was issued for this to be complied by at all times The registered person must ensure that all service users receive the prescribed medication and that accurate records are kept. An immediate requirement was issued for this to be complied by at all times 31.7.2005 31.6.2005 4.5.2005 31.6.2005 31.6.2005 15.4.2004 15.4.2005 95 Ashburnham Road I51 S223662 95 ASHBURNHAM V223662 130405 Stage 4.doc Version 1.30 Page 26 14. Ya19 12(1) The registered person must ensure that the health care needs of service users are monitored and problems are identified and dealth with at an early stage. 15.4.2005 15. 16. 17. 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 Ya18 Ya7 Ya18 Ya17 Ya7 Good Practice Recommendations The registered person should provide a strategy for recruiting and retaining staff to provide continuity for the service users. The registered person must explore ways of enabling and empowering service users to actively express their views. The registered person must ensure staffing levels are maintained, reviewed and increased to meet the changing needs of service users The registered person should provide weekly menus for the service users The registered person should provide service users information on how their rent and benefits are worked out and ensure service users are supported and consulted to manage their finances. The registered person should obtain all information required for recruiting staff. The registered person should consult service users about their social activities and make arrangements to enable them to engage in local, social and community activities. The registered person must review the adult abuse policy. The registered person should provide policies and procedures on aggression towards staff, bullying, and management of service users money. The registered person must fully implement the quality assurance programme, including seeking the views of staff. The registered person should replace service users worn out matress I51 S223662 95 ASHBURNHAM V223662 130405 Stage 4.doc Version 1.30 Page 27 6. 7. 8. 9. 10. 11. Ya34 Ya14 Ya23 Ya40 Ya39 Ya26 95 Ashburnham Road 12. Ya38 13. Ya38 The registered person should undertake a review of the role and responsibilities of the service manager and the registered manager. The roles and responsibilities must be clearly defined and differentiated. The registered person should ensure that the home is run as a seperate establishment and not combined with the sister home near by. 95 Ashburnham Road I51 S223662 95 ASHBURNHAM V223662 130405 Stage 4.doc Version 1.30 Page 28 Commission for Social Care Inspection Clifton House 4a Goldington Road Bedford MK40 3NF 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. 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