Inspection on 29/09/05 for Ashbury

This inspection was carried out on 29th September 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Ashbury 23/08/06

Ashbury 13/02/06

Ashbury 21/07/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Ashbury Six Acres Close Roman Road Taunton Somerset TA1 2BD Lead Inspector Sally Murphy Unannounced 29 September 2005 th 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. Ashbury D53 - D02 S35366 Ashbury V235905 290905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Ashbury Address Six Acres Close Roman Road Taunton Somerset TA1 2BD 01823 423126 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) Somerset County Council (LD Services) Mrs Heather Davies Personal Care Home Only 9 Category(ies) of Learning Disability (9) registration, with number of places Ashbury D53 - D02 S35366 Ashbury V235905 290905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Two named service users with a physical disability. Date of last inspection 16th December 2004 Brief Description of the Service: Ashbury is a single storey building situated close to Taunton town centre. There is a large lounge, dining room, two assisted bathrooms and two shower rooms at the home. Building work has recently taken place to increase the size of four service user bedrooms. The home is set in pleasant gardens that are accessible to service users. Ashbury is registered with the Commission for Social Care Inspection to provide care for up to nine people with learning disabilities, including two people who also have physical disabilities. The home is run by Somerset Social Services. The Registered Manager is Mrs Heather Davies and the Responsible Individual is Mr David Dick. Ashbury D53 - D02 S35366 Ashbury V235905 290905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out as part of the planned annual programme of inspection. The inspection was unannounced and carried out by one inspector over one day. The previous inspection was also unannounced and took place on 16th December 2004. On the day of the inspection there were nine service users residing at the home. During the course of the inspection service users, staff and the Registered Manager were spoken with. Care practice was also observed, records examined and a tour of the premises was made. What the service does well: What has improved since the last inspection? Since the last inspection, building work has been completed to increase the size of four service users bedrooms. One service user room now also has en suite toilet facilities. A large summerhouse and further seating areas have been erected in the garden. A second assisted bath has been installed at the home. During the period of building work four service users moved into the respite unit located close to Ashbury. Staff continued to support service users during this period and have worked to help service users settle back into their rooms. Ashbury D53 - D02 S35366 Ashbury V235905 290905 Stage 4.doc Version 1.40 Page 6 What they could do better: 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. Ashbury D53 - D02 S35366 Ashbury V235905 290905 Stage 4.doc Version 1.40 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 Ashbury D53 - D02 S35366 Ashbury V235905 290905 Stage 4.doc Version 1.40 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, 2 & 5. Service users and their families are provided with appropriate information regarding the home. Service users are provided with a written contract stating the terms and conditions of the home. EVIDENCE: The home has a Statement of Purpose and Service User Guide that provide details of the services and facilities offered at Ashbury. The current service users have been resident at the home for many years. An assessment of need would be completed prior to any new service user being admitted to the home. A contract is provided for each service user setting out the terms and conditions of the home. Ashbury D53 - D02 S35366 Ashbury V235905 290905 Stage 4.doc Version 1.40 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, 8, 9 & 10. The home has developed an appropriate care plan for each service user. Service users are supported in exercising choice. Care plans are regularly reviewed and updated. Records relating to service users are stored securely. EVIDENCE: Care plans are maintained for each service user. These follow the standard model used by Somerset Social Services. Two care plans were examined in detail. Care plans provided information regarding service users needs, daily routines and preferences. Risk assessments had been completed where required. Care plans had been regularly reviewed and updated appropriately. Service users are encouraged to exercise choice regarding their daily routines. Each service user is supported by a key worker group, who work to ensure that the care provided continues to appropriately meet their needs. One service user has an advocate. A board in the hallway displays which members of staff will be on duty. The home will keep money securely for those service users who wish them to. Records are maintained of all transactions involving service user finances. Ashbury D53 - D02 S35366 Ashbury V235905 290905 Stage 4.doc Version 1.40 Page 10 These are audited on a weekly basis. Service user monies were examined, and all seen tallied with records kept. Ashbury D53 - D02 S35366 Ashbury V235905 290905 Stage 4.doc Version 1.40 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) 11, 12, 13, 14, 15, 16 & 17. Service users are provided with a range of activities and are supported in accessing the local community. Service users are provided with a well-balanced diet and appropriate action is taken to meet their individual dietary needs. EVIDENCE: Service users are able to participate in a wide range of activities. At the time of inspection service users were enjoying watching videos and listening to music within the home. One service user was attending a course at SCAT and two people had gone for a walk on the Quantock Hills. Service users each have a ‘My Day’ plan. These are displayed on notice boards in some service users’ bedrooms. Service users are provided with regular opportunities to access the local community. Service users currently enjoy aromatherapy, hydrotherapy and attending Harmony. Ashbury D53 - D02 S35366 Ashbury V235905 290905 Stage 4.doc Version 1.40 Page 12 Service users are provided with a holiday away from the home or quality days out dependent upon their individual needs. Some service users at the home have enjoyed a week away earlier this year. There is a further holiday planned this year and additional days out. Staff support service users in maintaining contact with friends and family members. Dietary guidelines are provided for each service user. A cook is employed at the home on a part-time basis. The menu is regularly reviewed to ensure that it continues to meet service user’s dietary preferences and needs. There is a spacious dining room at the home. A notice board in the dining room displays the meals planned for that day. Ashbury D53 - D02 S35366 Ashbury V235905 290905 Stage 4.doc Version 1.40 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. Service users are provided with appropriate assistance to meet their personal care needs. The home supports service users in accessing healthcare services. Staff receive medications training. The home must take further action to ensure that the recording of medications follows good practice. EVIDENCE: Service users are provided with assistance to undertake personal care tasks. Personal care is provided in private. Staff support service users in accessing health care services and ensure that specialist advice is sought as required. Pressure-relieving equipment had been provided for one service user. Care plans included details of epilepsy and behavioural guidelines. Risk assessments had been completed in relation to the use of bed rails. Staff at the home receive medications training. All medications are stored securely. Medication Administration Records were examined. A record is maintained of all medications entering the home. All hand transcribed entries had been accompanied by two staff signatures. Where ‘F’ is recorded to represent ‘other’ the reason for non-administration must be defined. A Ashbury D53 - D02 S35366 Ashbury V235905 290905 Stage 4.doc Version 1.40 Page 14 signature must be recorded for all medications given or a definition used as appropriate. Ashbury D53 - D02 S35366 Ashbury V235905 290905 Stage 4.doc Version 1.40 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. The home has a comprehensive complaints procedure and appropriate policies relating to the Protection of Vulnerable Adults. EVIDENCE: The home has a complaints procedure displayed, which includes the photographs of people that may be contacted, including the Inspector from CSCI. Somerset Social Services Department has also produced a video providing details of how to make a complaint. A copy of the Somerset Social Services document entitled ‘Our Promise to You’ and details of the Advocacy Service are displayed in the hallway. The Registered Manager has also ensured that the family of each service user has received a copy of the complaints procedure. There has been one complaint received by the home since the last inspection regarding noise levels within the garden of the home. This has been responded to appropriately. The home has appropriate policies relating to the Protection of Vulnerable Adults and Whistle blowing. Ashbury D53 - D02 S35366 Ashbury V235905 290905 Stage 4.doc Version 1.40 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 standard(s) 24, 25, 26, 27, 28, 29 & 30. The home has been decorated and furnished to a good standard. The home has sufficient communal areas and bathrooms to meet service users’ needs. Adaptations have been provided as required. Further action should be taken to ensure that unguarded hot water pipes do not pose a risk to service users. The home must ensure that appropriate good practice is followed with regard to infection control. The home was found to have a high standard of cleanliness. EVIDENCE: As previously mentioned building work has taken place at the home to extend four service user rooms. This has provided additional space for service users who have a physical disability, and has included the provision of an en suite toilet facility for one service user. Communal facilities comprise of a lounge, dining room and additional seating areas throughout the home. There is also a light room at the home. Service user rooms have been decorated to reflect individuals’ tastes and needs. There is clear signage throughout the home. Adaptations have been provided Ashbury D53 - D02 S35366 Ashbury V235905 290905 Stage 4.doc Version 1.40 Page 17 as required. An en suite sleeping-in room is provided for staff members. The home is set in a spacious garden that is accessible to service users. There are two bathrooms and two shower rooms available. A new assisted bath is being installed at the home. Hot water temperature outlets were tested and found to be within appropriate limits. The home must ensure that hot water pipes are guarded in any areas that may pose a risk to service users. The radiator cover in one bathroom, and the grab rails surrounding a toilet have become rusty and require replacement. The laundry was tidy and well organised. The washing machine has the facility to meet disinfectant standards. In order to reduce the risk of cross infection, hand washing facilities consisting of liquid soap and papers towels must be provided for staff members in bathrooms, toilets and all bedrooms where service users may require assistance with personal care. Ashbury D53 - D02 S35366 Ashbury V235905 290905 Stage 4.doc Version 1.40 Page 18 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) 31, 32, 33, 34, 35 & 36. Staffing levels are appropriate to meet service users’ needs. Staff are provided with appropriate training to undertake their role. The home operates a robust recruitment procedure. Staff are provided with appropriate support and supervision. EVIDENCE: Duty rotas are maintained. There are generally four staff on duty during the day and one waking, and one sleeping-in member of staff at night. A parttime cook and domestic assistant are also employed. Staff are encouraged to attend training. Newly appointed staff receive a thorough Induction Program. Nearly 50 of the staff employed have obtained the NVQ level 2 qualification. Staff are provided with regular updates in mandatory training and receive further training in relation to individual service users’ needs. Recruitment files were examined for two recently employed members of staff. Each was found to contain the documentation required under Schedule 2 of the Care Home Regulations 2001. Ashbury D53 - D02 S35366 Ashbury V235905 290905 Stage 4.doc Version 1.40 Page 19 Staff meetings are held on a monthly basis. Staff receive regular supervision, and appropriate records are maintained. Ashbury D53 - D02 S35366 Ashbury V235905 290905 Stage 4.doc Version 1.40 Page 20 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, 39, 40, 41 & 42. The Registered Manager provides effective leadership to the staff team. There is a relaxed and open atmosphere within the home. Records relating to service users are stored securely. Equipment servicing records have been appropriately maintained. EVIDENCE: The Registered Manager is Heather Davies. She is an experienced manager and has obtained the NVQ level 4 qualification in Management and Care. Due to the dependency levels of the service user group, it is not appropriate to hold residents meetings, therefore staff obtain feedback on the service provided through regular reviews and from service users on an individual basis. The home has appropriate policies and procedures in place to safeguard vulnerable service users. All records relating to service users are stored securely in accordance with the Data Protection Act 1998. Ashbury D53 - D02 S35366 Ashbury V235905 290905 Stage 4.doc Version 1.40 Page 21 Fire safety records were examined. Fire equipment is serviced and tested as required. Appropriate action is being taken to address the fire door that is failing to close properly during alarm tests. There are notices displayed in each room in Somerset Total Communication that provide details of the actions to be taken in the event of a fire. Staff are provided with regular fire safety training. Hazardous substances had been stored securely and were not accessible to service users. Accidents have been reported and recorded as required. Ashbury D53 - D02 S35366 Ashbury V235905 290905 Stage 4.doc Version 1.40 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 x x 3 Standard No 22 23 ENVIRONMENT Score 3 4 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 2 3 3 2 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Ashbury Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 3 3 D53 - D02 S35366 Ashbury V235905 290905 Stage 4.doc Version 1.40 Page 23 Are there any outstanding requirements from the last inspection? na. 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 YA 20 Regulation 13(2) Requirement Where ‘F’ is recorded on Medication Administration Records to represent ‘other’ the reason for non-administration must be defined. A signature must be recorded for all medications given or a definition used as appropriate. The home must ensure that hot water pipes are guarded in any areas that may pose a risk to service users. The radiator cover in one bathroom, and the grab rails surrounding a toilet have become rusty and require replacement. In order to reduce the risk of cross infection, hand washing facilities consisting of liquid soap and papers towels must be provided for staff members in bathrooms, toilets and all bedrooms where service users may require assistance with personal care. Timescale for action 29.09.05 2. YA 24 13(4c) 7.11.05 3. YA 27 23(2c) 31.1.06 (radiator) 7.11.05 (grab rails) 24.10.05 4. YA 30 13(3) Ashbury D53 - D02 S35366 Ashbury V235905 290905 Stage 4.doc Version 1.40 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Ashbury D53 - D02 S35366 Ashbury V235905 290905 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection Riverside Chambers Castle Street Tangier Taunton TA1 4AL 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 Ashbury D53 - D02 S35366 Ashbury V235905 290905 Stage 4.doc Version 1.40 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!