Inspection on 25/05/07 for Ashburnham Road, 95

This inspection was carried out on 25th May 2007.

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 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ashburnham Road, 95 08/09/08

Ashburnham Road, 95 21/06/06

Ashburnham Road, 95 31/10/05

Ashburnham Road, 95 13/04/05

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 Ashburnham Road, 95 Luton LU1 1JW Lead Inspector Mr Pursotamraj Hirekar Unannounced Inspection 25th May 2007 02:10 Ashburnham Road, 95 DS0000014989.V337685.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ashburnham Road, 95 DS0000014989.V337685.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ashburnham Road, 95 DS0000014989.V337685.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashburnham Road, 95 Address Luton LU1 1JW 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) 01582 481589 F/P 01582 481589 Advance Support Ltd Vacant Care Home 4 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (4) of places Ashburnham Road, 95 DS0000014989.V337685.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Complete Registered Manager`s Award in 6 months of becoming Registered Manager The role undertaken by the manager must not include working on the rotas on a day-to-day basis except in emergencies. 21st June 2006 Date of last inspection 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. The minimum fee charged per service user was £540/- per week and the maximum was £ 580/- per week. Ashburnham Road, 95 DS0000014989.V337685.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the report of the unannounced key inspection carried out on 21/06/06 from 2.10pm to 6.35pm by pursotamraj hirekar. The method of inspection included review of outstanding requirements and recommendations, study of care plans, risk assessments, discussion with the service users’, staffs on duty, conversation on phone with the acting locality manager, and partial tour of the premises. The pre-inspection questionnaire and the service users’ survey forms responses are also considered in this report. What the service does well: What has improved since the last inspection? What they could do better: The home must review the care plans of all the service users at least every six months and updated to reflect changing needs; and changes are recorded and actioned. The home must consult all service users’ individually and collectively and develop individual specific activities that stimulate and engage service users’ to achieve assessed needs and aspirations. The home must ensure that each staff member training and development plan was implemented as scheduled. The home must appoint an individual to manage the home and ensure that the manager makes an application for registered manager. Ashburnham Road, 95 DS0000014989.V337685.R01.S.doc Version 5.2 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ashburnham Road, 95 DS0000014989.V337685.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ashburnham Road, 95 DS0000014989.V337685.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had updated statement of purpose and service user guide that enabled potential service users to make informed decisions. EVIDENCE: The home had reviewed and updated the statement of purpose in May 2006, which was comprehensive and includes key information of services offered, staff details, organisational structure, category of service users, admission criteria and details of premises. The statement of purpose would enable the potential service users to make an informed choice. Alongside the service users’ guide was reviewed and updated with details regarding qualification and experiences of staffs, description of accommodation, support services and facilities, terms and conditions in respect of accommodation and a copy of latest inspection report. No new service users had been admitted since the last inspection. Therefore this standard could not be fully assessed. However there was evidence included within the records of the service users whose lives were tracked, which supported that the home had undertaken a full assessment of needs for each of them. The home had developed a service user care plan from the assessment of needs. Ashburnham Road, 95 DS0000014989.V337685.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home had made arrangements for staff to support service user lead independent lifestyles. However, the care plan reveiews needed reugalirisation and the outcomes reflected in the individual care plans. EVIDENCE: On this inspection 2 service users’ care plans and their reviews were seen, the 2 service users’ summary details are as follows: Service user –1 had a review on the 16/04/07; service user, acting deputy manager, link worker and acting locality manager participated. The review included link worker report, service users report, plan for the next 6 months, and long-term plan. The areas covered were medication, daily activities, smoking, GP appointments, DLA, and friendship. On the basis of the review care plan was produced that covered therapy, medication, social activities, daily living skills, and money management signed by the link worker and the service user. The latest monthly link worker session held was on 03/03/07, need to be regularised on a monthly basis. Ashburnham Road, 95 DS0000014989.V337685.R01.S.doc Version 5.2 Page 10 Service user – 2, review was carried out in January 2007, unfortunately as the then manger was unavailable immediately following the review due to ill health her notes were not provided to allow the recording to be completed. Subsequently, in May 2007 a draft care plan was produced which had incorrect dates and names. A date of 3rd July 2007 had been set for the review to take place and review invites have been issued. The draft care plan covered areas such as mental health, physical health, dental/optician, death and dying, activities/hobbies, relationships, life skills, religious and cultural needs, nutritional needs, financial, communication, work and leisure, personal care, illness, safety, and agreed actions in the above areas. Link worker session with the service user has been regular. Ashburnham Road, 95 DS0000014989.V337685.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home need to further consult individually, all service users’ and develop activites that meet the individual service users’ needs and aspirations to achieve quality of life goals. EVIDENCE: The home had made plans to engage service users’ in meaningful activities that stimulate independent living. Which included, newspaper, DVD, board games, local shop, local cinema, local pub, local meal out, maintain relationships with family and friends and annual holiday. However, The home need to further consult individually, all service users’ and develop activites that meet the individual service users’ needs and aspirations to achieve quality of life goals. For example: Service user –1 enjoyed shopping with staff and helps with the garden and admin jobs in the home. He had stopped going to the day centre because the NHS stopped the £3.00 a day for dinners, which he enjoyed. Ashburnham Road, 95 DS0000014989.V337685.R01.S.doc Version 5.2 Page 12 Service user –2 the personal care record for the week starting 19/05/07 was seen on this inspection and found that the service user has had bath/wash, hair wash, shave and dressing regularly. The service user appeared clean and well dressed. It was noted by the then manager that the service user needed support to reduce his capital savings to avoid encountering disqualification of benefits entitlement. The home had planned for a personal summer holiday to Jersey with staff support in consultation with the service user and the social worker. The personal summer holiday is in addition to the holidays organised by the home. However, the personal summer holiday for the service user would incur costs for two staffs during the holiday in addition to service user’s own holiday costs. The care plan under the restrictions on choices or freedom regarding personal monies mentioned that ‘the service user has limited knowledge of money matters. Has no understanding of costs of items or their meaning’. The licence agreement referred to ‘changing the residential fee’, which was not written to cover service user’s personal holiday costs and staffs’ costs. Following the feedback on the inspection, the acting locality manager had written to the Senior Housing Officer and Manager of the Quality Unit asking for their views as to the need to amend or add to the existing agreement to cover the situation regarding the service user’s holiday. And now intend placing the issue of the service user needed the services of an Advocate upon the agenda for the service user’s forthcoming review. The menu’s choices were in a suitable format for service users to make an informed choice and decide what they would like to eat. Ashburnham Road, 95 DS0000014989.V337685.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had made appropriate arrangements to provide personal and health care support for service users’. EVIDENCE: The home had made arrangements to provide personal and health care services in response to the outcomes of the assessed needs of the service users’ through accessing support from GP, CPN, district nurse, pharmaceutical service, dentist, and optician. For example: Service user –1 Visited GP for regular blood tests and the CPN visit to give his injection fortnightly. The service user has been advised to stop smoking but chooses not to do so – smoking 30 a day. The service user is going to try to get sponsorship for giving up though as a result of discussion in the review. The service user is on selfmedication. Service user –2 does not accept that he has mental illness. However, know that he must take his medication and will come to office at the correct time and ask to be given his tablets. The inspector observed staff administering medication to the service user, which was polite and good. The draft care plan covered areas such as mental health, physical health, Ashburnham Road, 95 DS0000014989.V337685.R01.S.doc Version 5.2 Page 14 dental/optician, death and dying, activities/hobbies, relationships, life skills, religious and cultural needs, nutritional needs, financial, communication, work and leisure, personal care, illness, safety, and agreed actions in the above areas. Link worker session with the service user has been regular. Ashburnham Road, 95 DS0000014989.V337685.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had made appropriate arrangements with regard the complaints policy and procedures. EVIDENCE: The home had a comprehensive complaints policy and procedures. There were no complaints recorded since the previous inspection. The staff and the service users’ were aware of the complaints procedure. Ashburnham Road, 95 DS0000014989.V337685.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was clean and had maintained comfortable enevironment with the help of service users’. EVIDENCE: The home was clean and free from offensive odours. Service users spoken to were happy with their individual bedrooms and they had free access to them and were encouraged to take responsibility to maintain their cleanliness. The home had maintained record of health and safety checks of fridge, freezer, and water temperatures, and then requests made with description of fault if any for their maintenance. The home had a maintenance log, which was used to get the repair work fixed by using the company hotline number. Fridge in the kitchen has been replaced, bath on the first floor enamelled, sink on the first floor toilet replaced. In the pre-inspection questionnaire the home had mentioned that the fire equipment, fire training, fire alarm, gas installation, central heating system and emergency lighting were checked and records maintained. Ashburnham Road, 95 DS0000014989.V337685.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staff had good working raelations with the service users and work as a team, the home need to sustain the morale of the staffs in the best interest of the service users’ and implement the planned staff training schedule. EVIDENCE: The home had a robust recruitment policy and practice. The staffs on duty were having good working relations with the service users’ and were making efforts to work as a good team. Staffs support service users in decision making regarding their choices and lifestyles. The service users spoken to have confirmed that the staffs were supportive and enable them to lead independent life and were available when needed. The home had carried out staff training needs assessment and has planned to provide staffs training for the year 2007 in the areas of violence & aggression, first aid, manual handling, effective communication, POVA, fire safety, personal safety, medication, managing risks, supervision/appraisals, food hygiene, care planning, health & safety, diversity equality, professional boundaries and mental capacity act. Staff supervisions have been carried out as a regular practice. However, 2 staff members’ supervision notes were not recorded onto the computer system due to illness of the then manager. Ashburnham Road, 95 DS0000014989.V337685.R01.S.doc Version 5.2 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. Currently, the home is in transistion as the registered manager’s position is vacant and a senior staff member is working in the capacity of a team leader. The home had made interim arrangements and was in the process of filling up the vacancy. EVIDENCE: The home had service users’ meeting on the 02/05/07 and has discussed matters arising from the previous meeting, holiday, staffing, and service users’ duties. The service users and the staff participated. Service users’ meetings appeared a good platform for airing views, opinions, and community living by the service users, which further enabled them to have good working relations with the staff and lead an independent life of their choice. The commission had received a written communication from the operations manager on the 02/05/07 that the registered manager had died on 19/04/07. However, the commission had not received notice of absence regarding the Ashburnham Road, 95 DS0000014989.V337685.R01.S.doc Version 5.2 Page 19 then registered manager’s absence on sick leave from 18th January 2007. Currently, the home had made an interim arrangement with on e of the senior staff has been working in the capacity of a team leader, a management consultant providing one day a week and the registered manager of a sister home supporting with daily issues and more general issues including on-call requirements and the covering of rota’s. The home had also planned for advertising the now vacant post with a view to filling in June/July 2007. Ashburnham Road, 95 DS0000014989.V337685.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 3 X X 3 X Ashburnham Road, 95 DS0000014989.V337685.R01.S.doc Version 5.2 Page 21 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 (2) Requirement Timescale for action 15/07/07 2. YA12 16 (2)(m)(n) The home must review the care plans of all the service users at least every six months and updated to reflect changing needs; and changes are recorded and actioned. The home must consult all 15/07/07 service users’ individually and collectively and develop individual specific activities that stimulate and engage service users’ to achieve assessed needs and aspirations. (Partly met previous time scale 31/07/06) The home must ensure that each staff member training and development plan was implemented as scheduled. The home must appoint an individual to manage the home and ensure that the manager makes an application for registered manager. 31/07/07 3. YA35 18 (1) (c) 4. YA37 8 (1) 31/07/07 Ashburnham Road, 95 DS0000014989.V337685.R01.S.doc Version 5.2 Page 22 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Ashburnham Road, 95 DS0000014989.V337685.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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