Inspection on 31/10/05 for Ashburnham Road, 95

This inspection was carried out on 31st October 2005.

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

The inspector found no outstanding requirements from the previous inspection report, but made 11 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 25/05/07

Ashburnham Road, 95 21/06/06

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 95 Ashburnham Road Luton LU1 1JW Lead Inspector Ansuya Chudasama Unannounced Inspection 31st October 2005 13:30 95 Ashburnham Road DS0000014989.V258837.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 95 Ashburnham Road DS0000014989.V258837.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 95 Ashburnham Road DS0000014989.V258837.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 95 Ashburnham Road 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 01582 481589 Advance Support Ltd Care Home 4 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (4) of places 95 Ashburnham Road DS0000014989.V258837.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th April 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 DS0000014989.V258837.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken by two inspectors and started at 13.30pm. It took place over 3 hours. The manager was present at the inspection. The inspection comprised of a tour of some of the communal areas, talking to staff, the service manager, and three service users. The home had one vacancy due to one service user had recently moved into an independent flat. . What the service does well: What has improved since the last inspection? What they could do better: The care plans and risk assessments needed to be further developed. The registered person must ensure that the home is run as a separate establishment and not combined with the sister home near by. This recommendation was not met from the last inspection. The manager needs to 95 Ashburnham Road DS0000014989.V258837.R01.S.doc Version 5.0 Page 6 be supernumerary on the staffing rota to manage the two homes and manage her legal duties. The home needs to develop a quality assurance system and an annual development plan. The registered person must find a solution to meet the needs of service users who smoke and those staff and service users who don’t smoke in the home. This standard was not met since the last inspection. 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 DS0000014989.V258837.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 95 Ashburnham Road DS0000014989.V258837.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,5. The home had a statement of purpose and a service users guide but the documents needed to include information that was accurate and user friendly to help prospective service users to make an informed choice of choosing the home. EVIDENCE: The home had a statement of purpose and a service users guide. However the information on staffing levels at the home was incorrect. The information on the age range and sex of service users was not recorded. Also the information recorded on this is incorrect. Information on the range of needs that the care home is intended to meet was not explained. The information on the home receiving additional inspections from the local operations manager is misleading. The information should be discussing regulation 26 visits. The hours worked by the manager at the home are incorrect. The manager works at two homes on a supernumerary basis and her hours worked at each home needs to be recorded in the documents. The information talks about a service manager visiting a service user but the staffing structure does not mention this position. The information on whether nursing care is provided needs to be explained further. The service users guide needs to be available in an easy to understand language. Some of the information needs to be accurate as stated in the statement of purpose. The information in both documents also needs to be made clearer to understand. The files inspected showed that the service users had a contract with the home. The information on fees charged needed to be included. 95 Ashburnham Road DS0000014989.V258837.R01.S.doc Version 5.0 Page 9 The home had not admitted any new service users since the last inspection. 95 Ashburnham Road DS0000014989.V258837.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,9 Service users care plans needed expanding to include all assessed needs to adequately provide staff with the information they need to satisfactorily meet service users needs. Risk assessments needed expanding and made clear, and easy for staff and service users to understand. EVIDENCE: Two service users care plans were inspected in detail. However their files needed to be better filed. The format for the care plans was good. The two plans seen had three objectives set. For example one service users objectives in the care plan were focussed on saving money to visit the pub as and when possible. However the plans did not contain information on all aspects of personal and social support and healthcare needs as set out in standard two. The care plans had dates recorded when the objectives set in the plan had been reviewed. However there was no information recorded to show what the outcome of the review. The time scales for some objectives had three years. This was quite concerning as for example the objectives set did not require three years to achieve. Information added to the care plan was not signed or dated by staff. Information on blood pressure test did not explain why this 95 Ashburnham Road DS0000014989.V258837.R01.S.doc Version 5.0 Page 11 was being undertaken. There was no information to state how the service user was supported to manage his finances by the home. The finances checked for one service user were satisfactory. The care plan did not have any information about the service users physical health needs, poor diet, which could affect the service users diabetes, social activities, helping with cooking, Risk assessments were available in the service users file. However, most of the information recorded in the risks identified, needed to be in the hazards section. The risk assessments needed to be developed further to make them more clear and user friendly. They should be signed by the service users to state that they understand the risks. Some of the risks identified in the assessment information were not recorded in the care plan. There were other areas of assessments that needed undertaking for example, managing service users finances, cooking, using the kitchen equipment and the office. 95 Ashburnham Road DS0000014989.V258837.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,14,15,17. The meals in this home are good offering both choice and variety. EVIDENCE: The care plan seen for one service user stated that the service user was to visit his mother and this would take up to a year. This was recorded on the 18th of June 2005. However evidence showed that nothing had been done by the home. However evidence showed that nothing had been done by the home to organise this visit. The service users spoken to stated that they went on holiday with the home and enjoyed this. One service user attended day care five days a week. Service users had monthly meetings and these were recorded and signed by service users and staff. The service users spoken to stated that the food was very nice and they choose the meals. One service user was observed helping staff with cooking the evening meal. The protocol for expenditure for petty cash stated that each home has a “maximum of £150-00 per week, which needs to cover all expenditure including stationary etc where possible retain some money to enable saving for outings”. It was confirmed by the manager that the service users food money also came from this budget. The manager stated that she decided how much money was given per person for food. The money for food should be ring fenced and this 95 Ashburnham Road DS0000014989.V258837.R01.S.doc Version 5.0 Page 13 budget should be kept separate from other expenditure. Concerns were raised that the food budget was not the same each week. 95 Ashburnham Road DS0000014989.V258837.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20. The service users health care needs were being met by the home. EVIDENCE: The service user visits to health professionals was recorded well. Service users spoken to stated that they visited the chiropodist, GP, the psychiatrist, and other health professionals. The staff and manger also understood the needs of the service well. The home had a medication policy. All the staff had received the accredited training in administering medication. The manager needs to ensure that the extra medication received medication not taken is recorded. 95 Ashburnham Road DS0000014989.V258837.R01.S.doc Version 5.0 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 The home had a satisfactory complaints policy. EVIDENCE: The service users files inspected showed that the staff had discussed the complaints policy with the service users. This was confirmed by talking to the service users who stated that they knew who to talk to if they were not happy. The complaints procedure seen was satisfactory. 95 Ashburnham Road DS0000014989.V258837.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30. The needs of service users and staff who did not smoke were not being met and therefore put them at risk. EVIDENCE: The home was clean but smelled of tobacco smoke. The communal lounge was used as a smoking area. The lounge was very smokey. The home had two service users who smoked and one service user and most of the staff did not smoke. This issue was discussed with the manager who stated that this was the service users home. The inspector agreed that this was the service user home but the needs of the service users who did not smoke were not being met. The manager was also informed that the last service user who left did not like tobacco smoke. The service user therefore stayed in his room most of the time. However the home failed to meet his needs. This was discussed in the previous inspection reports. The manager must find a solution to ensure the needs of those people who do not smoke are also met. 95 Ashburnham Road DS0000014989.V258837.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33,35,36 The staff rotas were combined with another sister home and the information was difficult to understand about staffing for the home. The staff have a good understanding of the service users support needs. EVIDENCE: The manager stated that the home was not fully staffed and they had a vacancy for one full time care staff position. It was stated that the recruitment process was slow from the organisation. The home had the vacancy since June 05. Agency staff, permanent staff and the manager covered the hours. The staff spoken enjoyed working at the home. The staff member was doing NVQ level 3 in care. She had many years experience of working with client group. The staff was observed working well with the service user. The rotas inspected showed that the rota for the home was combined with the sister home. The staff stated that they had supervision on a monthly basis and staff meetings were held regularly with the other sister home. 95 Ashburnham Road DS0000014989.V258837.R01.S.doc Version 5.0 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 38,39,42. The health and safety systems in the home are good and protect staff and service users from potential risks. The management style of this home does not promote good working relationships with staff. EVIDENCE: The service users spoken to stated that they were involved in fire drills and knew what to do if there was a fire. The fire book showed that fire alarm testing, emergency lighting and fire drills were carried out regularly. The environmental risk assessments were difficult to understand. Information on what is a risk and a hazard was missing. The staff spoken to had received training on safe working practices. The CSCI were informed that the manager was going to be supernumerary on the staffing rota. However the rota showed that the manager undertook sleepin duties and also worked shifts. The manager must spend more time at undertaking her legal duties. Concerns had been raised to the CSCI regarding the manager’s style of management. The concerns were that the manager was not trustworthy as she did not keep confidentiality about things and this 95 Ashburnham Road DS0000014989.V258837.R01.S.doc Version 5.0 Page 19 was causing conflict with staff. It was sated that the home would only improve if the manager was professional and worked supernumerary on the rota. The manager stated that she needed a computer to manage her duties. It was stated that she used her own computer to type the care plans in her own time. It was also stated that she wanted the staff to type the care plans but this was not possible, as she does not have a computer for the two homes that she managed. The home did not have a quality assurance system in place or an annual development plan. 95 Ashburnham Road DS0000014989.V258837.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 x x x 3 Standard No 22 23 Score 3 x ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 x x 2 x Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x 2 x 3 LIFESTYLES Standard No Score 11 x 12 3 13 x 14 3 15 2 16 x 17 Standard No 31 32 33 34 35 36 Score x 3 3 x 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 95 Ashburnham Road Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score x 1 1 x x x 3 DS0000014989.V258837.R01.S.doc Version 5.0 Page 21 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 Requirement The registered person must expand the service users care plans to include all areas of assessed need, which makes clear the type and level of support to be provided by staff. The out come of the review of the service users care plans must be recorded in their files. The risk assessments on service users need to be clear and easy to understand as discussed at the inspection. The registered person must ensure that the home is run as a separate establishment and not combined with the sister home near by. This recommendation was not met from the last inspection. The registered person must fully implement the quality assurance programme, including seeking the views of staff. This recommendation was not met since the last inspection. The registered person must ensure that the statement of DS0000014989.V258837.R01.S.doc Timescale for action 12/01/06 2. YA9 13 22/12/06 3. YA38 10 22/12/05 4. YA39 4 23/01/05 5. YA1 4 22/12/05 95 Ashburnham Road Version 5.0 Page 22 6 YA38 10,18 7. 8. YA24 YA38 16 10,24 purpose and service user guide is updated with accurate information about the services and facilities provided by the home. The registered person must 30/11/05 ensure that the manager handles confidential information appropriately and within the homes written policies and procedures. The registered person must 22/12/05 ensure that the home is kept free from offensive odours 30/11/05 The responsible individual must ensure that the manager is supernumerary on the staffing rota to manage the two homes and undertake her legal duties as stated in the standard. The managers working hours worked at the two homes must be recorded on the two rotas. This requirement was not met from the last inspection. 28.3. The registered person must ensure that all extra medication received is recorded in the medication book. The registered person must find a solution to meet the needs of service users who smoke and those staff and service users who don’t smoke in the home. This standard was not met since the last inspection The registered person must ensure that the home helps service users to maintain contact with their families. 9 YA20 13(2) 30/11/05 10 YA28 12 22/12/05 11 YA15 14,15 31/12/05 95 Ashburnham Road DS0000014989.V258837.R01.S.doc Version 5.0 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 3 4 Refer to Standard YA18 YA1 YA6 YA17 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 should ensure that the fees charged are recorded in the service users contract. The registered person needs to ensure that service users files are better organised. The registered person needs to ensure that service users food budget is separated from other petty cash expenditure. 95 Ashburnham Road DS0000014989.V258837.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Bedfordshire & Luton Area Office 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. Extracts may not be used or reproduced without the express permission of CSCI 95 Ashburnham Road DS0000014989.V258837.R01.S.doc Version 5.0 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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