Inspection on 17/10/05 for Ashby House

This inspection was carried out on 17th 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Ashby House 27/06/06

Ashby House 27/06/05

Ashby House 03/02/05

Ashby House 04/06/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Ashby House 40 Richmond Avenue Bognor Regis West Sussex PO21 2YE Lead Inspector Unannounced Inspection 17th October 2005 12:30 Ashby House DS0000014370.V258414.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 Ashby House DS0000014370.V258414.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. Ashby House DS0000014370.V258414.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ashby House Address 40 Richmond Avenue Bognor Regis West Sussex PO21 2YE 01243 822145 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) Emeraldpoint Limited Mr Alan Shepherd Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Ashby House DS0000014370.V258414.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th June 2005 Brief Description of the Service: Ashby House is a spacious house located in a quiet residential road on the Western outskirts of Bognor Regis. The home is registered to provide care for up to six adults with learning disabilities. The town centre of Bognor Regis is approximately fifteen minutes walk away. There are cinemas, a theatre, pubs, cafes, restaurants, and amusements within the town centre. There are local shops, other amenities and the seafront is close to the home. The railway station is in the centre of Bognor and main bus routes pass by. Ashby House DS0000014370.V258414.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this unannounced inspection, which started at 12.30 pm and lasted for two and a half hours. Four clients were at home for the inspection and two were out at day centres. One feedback card was returned from a placing authority care manager in July 2005 with positive comments. The inspector spoke with four residents, staff on duty and the manager, observed staff and residents interacting, walked around the home and read some paperwork. What the service does well: What has improved since the last inspection? What they could do better: Incorporate information about POVA into the adult protection policy. Ensure there is written evidence as proof of making any referrals to POVA. Commence the proposed NVQ training programme for staff. The manager needs to obtain the NVQ Level 4 qualification in care. Amend residents’ contracts to include rules on smoking, alcohol and drugs. Offer residents a key to their own bedroom, or risk assessments to be completed if not appropriate. Ashby House DS0000014370.V258414.R01.S.doc Version 5.0 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. Ashby House DS0000014370.V258414.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 Ashby House DS0000014370.V258414.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): EVIDENCE: Ashby House DS0000014370.V258414.R01.S.doc Version 5.0 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 the following standard(s): EVIDENCE: Ashby House DS0000014370.V258414.R01.S.doc Version 5.0 Page 10 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): 11, 12, 15, 16 Residents have opportunities for personal development, education and occupation. Residents are supported to maintain family links and friendships. Daily routines and house rules ensure residents’ rights are respected. EVIDENCE: The daily activity schedules were discussed with the manager. Some residents have in-house activities provided. Appropriate employment and college courses have been accessed for the other residents. After lunch, one resident was observed to enjoy completing a jigsaw puzzle with staff. Another resident was seen to gain great pleasure playing dominoes with staff. Staff were observed to interact well with clients and appeared happy in their work. One resident was looking through a catalogue with staff to give her preferences about which new games and activities to buy. Ashby House DS0000014370.V258414.R01.S.doc Version 5.0 Page 11 None of the bedrooms have door locks. The manager said that this would not apply to the current residents. It is recommended that residents are offered a key to their own bedroom, or risk assessments completed if door locks are not thought appropriate. There is a keypad on the front door and the side gate is kept locked, to ensure the security and safety of residents. The residents are encouraged to open their own mail, and are assisted by staff as necessary. An example was noted during the inspection whereby staff used the preferred name of a resident. Residents are able to have visitors to the home. The manager said he had noticed that visiting relatives make an effort to speak with all the residents when they come to the home. Residents can see their visitors in private in their own rooms, or in communal areas of the home. Residents have opportunities to meet people and make friends, e.g. by attending local clubs and community events. Each resident contributes to daily life in the home. Daily housekeeping tasks are suited to their individual capabilities and include helping with the laundry, cleaning, laying the table for dinner etc. The manager checked to see if residents’ contracts included rules on smoking, alcohol and drugs. Contracts do not cover these topics and therefore need to be amended. Ashby House DS0000014370.V258414.R01.S.doc Version 5.0 Page 12 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): 20 Residents are protected by the home’s policies and procedures for dealing with medication. EVIDENCE: The medication records and medication in the medication cupboard were checked at the inspection and found to be in order. All staff have attended medication training run by a local pharmacy and have also done in-house training on this matter. There are no controlled drugs in use and no residents self administer medication. Ashby House DS0000014370.V258414.R01.S.doc Version 5.0 Page 13 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, 23 Residents are listened to and a satisfactory complaints procedure is in place. Failure to include details about POVA into the abuse guidance policy and a lack of evidence regarding a referral to the POVA register could indicate that residents are not fully protected from abuse. EVIDENCE: Policies and procedures are held regarding the protection of clients. Training is also held on this matter. It was noted at the last inspection that the abuse guidance policy needed to be updated to include the Protection Of Vulnerable Adults (POVA). This remains outstanding, but the manager said that it would be dealt with centrally by the organization. All staff receives in-house training in conflict management, gentle restraint and breakaway techniques. The manager confirmed that no restraints have been used on any of the current clients. Care plans indicate how to respond to any changes in behaviour. The manager talked about how the clients can be verbally aggressive and described strategies for dealing with this behaviour. At an adult protection meeting in April 2005, the manager confirmed that a member of staff had been referred in accordance with the Care Standards Act 2000 for consideration for inclusion on the Protection of Vulnerable Adult register (POVA). The inspector was unable to find any evidence in support of this at this inspection or at the June inspection. The manager said he had rereferred the person to POVA in September 2005. Although this person no longer works at the home, the Commission require written evidence that the referral to POVA was undertaken. Ashby House DS0000014370.V258414.R01.S.doc Version 5.0 Page 14 There have been no complaints made to the home or to the Commission since the last inspection. A complaints policy and procedures are in place at the home. Ashby House DS0000014370.V258414.R01.S.doc Version 5.0 Page 15 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 Ashby House is a homely, clean and safe environment. EVIDENCE: The inspector found the home to be safe, comfortable, airy and clean. Since the last inspection, the kitchen ceiling has been repainted and a wash hand basin has been installed in the kitchen. The freezer was previously kept in the shed, but has now been brought in to the home. These changes were as a result of an environmental health officer’s visit in September 2005. The manager said that the company have appointed an efficient maintenance man who has repainted the outside of the house. The home has a separate laundry area. This was seen to be clean and hygienic. The manager said the tumble dryer was not working, but that a replacement part had been ordered. Ashby House DS0000014370.V258414.R01.S.doc Version 5.0 Page 16 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): 33, 34, 35 Residents’ benefit from being supported by a caring staff team. To ensure that residents’ needs are met appropriately, staff need to commence the NVQ training. EVIDENCE: The manager confirmed that no staff had left or joined the home since the last inspection. As per the last inspection, of the current staff team, excluding the manager, only two care staff have obtained the NVQ in Care Level 2, and one of these has also completed the NVQ 3. The manager confirmed that half of the remaining staff team would be starting their NVQ training before the end of 2005. All staff files were read at the last inspection and two members of staff were noted to only have Standard CRB checks carried out. The manager confirmed that the required Enhanced Level checks have been applied for. The members of staff concerned expressed some dissatisfaction over having to do this. The company do not pay for checks, so these staff have paid twice for their checks (once for the Standard and once for the Enhanced level checks). Ashby House DS0000014370.V258414.R01.S.doc Version 5.0 Page 17 There was an appropriate number of staff working with residents during the inspection. Staff were observed to communicate appropriately with residents and have knowledge about their individual needs. Ashby House DS0000014370.V258414.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): 37, 39, 42 The manager needs to undertake further training in order that he may run the home effectively. Quality assurance systems are in place to ensure residents, family, advocates and friends views are taken into account about any review and development by the home. In order to ensure the health, safety and welfare of residents are promoted and protected, staff need to undertake the forthcoming training on moving and handling. EVIDENCE: At the last inspection, it was identified that staff would benefit from attending moving and handling training. The manager confirmed that all staff would be attending this training in November 2005. Ashby House DS0000014370.V258414.R01.S.doc Version 5.0 Page 19 Mr Shepherd said that he intends to start the NVQ Level 4 qualification in Care before the end of 2005. He also confirmed he would be attending the moving and handling course with the staff team in November 2005. He has expressed an interest in attending a course about the supervision of staff. The gas boiler and portable electric appliances are routinely checked every year to ensure their safety. In January 2005, a fixed wiring electricity test was carried out with some identified work carried out. Risk assessments were seen to be in place, e.g. on COSHH (Control Of Substances Hazardous To Health), the kitchen, the laundry room and the side gate. Regular visits are undertaken by a representative from the company to ensure the home is running as it should. Reports are then completed, with a copy for the manager and a copy sent to the Commission. In addition, quality audits are completed which involve seeking the views of residents, families, representatives, staff and stakeholders. The last one was completed in 2004, but so far there has not been one completed during 2005. Ashby House DS0000014370.V258414.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 X X X X X Standard No 22 23 Score 3 1 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X 3 LIFESTYLES Standard No Score 11 3 12 3 13 X 14 X 15 3 16 2 17 Standard No 31 32 33 34 35 36 Score X 3 3 2 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Ashby House Score X X 3 X Standard No 37 38 39 40 41 42 43 Score 3 X 3 X X 2 X DS0000014370.V258414.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? Yes 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 42 Regulation 19 Requirement All staff need to receive training appropriate to the work they are to perform, e.g. training on moving and handling. (Previous timescale of 27/9/05 not met). All staff should be CRB checked at the Enhanced Level. (Previous timescale of 27/7/05 not met). The registered manager shall maintain in the care home the records specified in Schedule 4. (Evidence is needed of referring a previous member of staff to POVA) Timescale for action 17/12/05 2 3 34 23 19 17 (2) 17/12/05 17/12/05 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 Refer to Standard 23 32 37 Good Practice Recommendations Include details about POVA in the adult abuse policies and procedures. Continue with the NVQ staff training programme. The manager is advised to undertake the NVQ level 4 training course in care. DS0000014370.V258414.R01.S.doc Version 5.0 Page 22 Ashby House 4 5 16 16 Offer residents a key to their own bedroom, or risk assessments to be completed if not appropriate. Residents’ contracts need to include rules on smoking, alcohol and drugs. Ashby House DS0000014370.V258414.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Worthing LO 2nd Floor, Ridgeworth House Liverpool Gardens Worthing West Sussex BN11 1RY 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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