Inspection on 26/02/07 for Ashchurch House

This inspection was carried out on 26th February 2007.

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

Other inspections for this house

Ashchurch House 19/05/08

Ashchurch House 07/06/07

Ashchurch House 27/10/05

Ashchurch House 24/03/05

Ashchurch House 20/01/05

Ashchurch House 12/02/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Ashchurch House 6 Chase House Gardens Emerson Park Hornchurch RM11 2PJ Lead Inspector Mrs Sandra Parnell-Hopkinson Unannounced Inspection 26 February 2007 09:15 th Ashchurch House DS0000027831.V328729.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 Ashchurch House DS0000027831.V328729.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. Ashchurch House DS0000027831.V328729.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashchurch House Address 6 Chase House Gardens Emerson Park Hornchurch RM11 2PJ 01708 473202 01708 456559 ashchurchhouse@fsmail.net 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) Ashchurch House Limited Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Ashchurch House DS0000027831.V328729.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To include one named service user over the age of 65. Date of last inspection 27th October 2005 Brief Description of the Service: Ashchurch House is a care home registered to provide care, support and accommodation to 10 adults of both sexes aged between 18-65 with physical and learning disabilities. Ashchurch House is a detached three storey house, with five ground floor bedrooms and five on the first floor. There is a kitchen/diner and large lounge on the ground floor and a kitchen/diner on the first floor. The home does not have a lift and, therefore, residents would need to be able to negotiate stairs if their bedrooms are located on the first floor. The second floor is used for staff training and the manager’s office. There are car parking facilities to the front of the building. The home is located in a residential area of Emerson Park, (off Wingletye Lane) close to shops, public transport and the M25, A127 and the A12. Currently there is no registered manager in post, but his application has been submitted to the Commission. The statement of purpose and last inspection report was available at the home on the day of the inspection, and a copy of the statement of purpose can be obtained by applying to the manager. At the time of this inspection the fees ranged from £800. to £1500. per week. Ashchurch House DS0000027831.V328729.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection which took place on the 26th February, 2007 from 09.15 hours. The manager and the deputy manager were present during the inspection, and both were available for the feedback at the end of the inspection. The home was clean and bright and well maintained. Some of the bedrooms had been recently re-decorated and all those occupied had been furnished and personalised according to the wishes of the individual resident. At the time of the inspection there were 8 permanent residents with two vacant rooms. The home does not have a lift and the installation of a list is something which the organisation would need to consider for the future as the current residents become more immobile and dependent. The care plans were very comprehensive but needed some minor adjustments as did the risk assessments. The residents are highly dependent and two are also registered as blind. It was not possible for the inspector to have a meaningful conversation with any of the residents due to their inability to verbally communicate, and the inspector is not conversant with maketon or other sign language. However, it was apparent from observation that the staff team were able to communicate with the residents for example by means of facial expressions and sounds. Some residents were still in bed at the start of the inspection, and staff respected their wishes not to be disturbed. During the visit the inspector introduced herself to 5 of the residents who were sitting in the lounge. The residents appeared to accept the presence of the inspector and made her feel welcome. The visit included observing residents and staff, talking to staff, the manager and the deputy manager, inspecting maintenance records, staff files, training schedules and case tracking. Some judgements about quality of life within the home were taken from direct conversation with and observation of staff and residents. In addition a tour of the premises was undertaken. At this inspection no visitors were present. Additional information relevant to this inspection has been gained from a questionnaire, monthly Regulation 26 reports and regulation 37 notifications. Since the last inspection there have been two adult protection notifications and following investigations no referrals have been made to the Protection of Vulnerable Adults list. However, this has meant some staff retraining and some adjustments to the policies and procedures. The manager is newly appointed and has submitted his application form to the Commission for registration as the manager at Ashchurch House. Ashchurch House DS0000027831.V328729.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: As the majority of residents are not able to actually participate in cooking, cleaning and undertaking other activities of daily living such as hoovering and laundry, it is essential that the organisation employs additional staff to undertake the ancillary functions at the home. Staffing levels need to be reviewed to ensure that care support staff are more actively engaged in interacting with, and engaging in activities with residents who have extremely high and complex needs and require this input for stimulation and motivation. Ashchurch House DS0000027831.V328729.R01.S.doc Version 5.2 Page 7 The small room where the medication is kept would benefit from the installation of a fan or other such method of cooling the atmosphere, because in warm weather this room has the potential for becoming very hot. This would have a detrimental effect on medicines, creams and gels. The organisation must review the current arrangements whereby the manager is an appointee for 5 residents. The Care Home Regulations 2001 require that the registered person shall ensure so far as practicable that persons working at the care home do not act as the agency of a service user. This should be done in consultation with the resident, relatives, commissioners of the service for the individual resident and his/her social worker. 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. Ashchurch House DS0000027831.V328729.R01.S.doc Version 5.2 Page 8 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 Ashchurch House DS0000027831.V328729.R01.S.doc Version 5.2 Page 9 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): 1, 2, 4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management ensures that all prospective service users have an individual needs assessment, are given the opportunity to visit the home and are provided with a written contract or statement of terms and conditions, so that they are able to make an informed choice about where to live. EVIDENCE: The files of 4 residents were viewed and both showed evidence of a comprehensive pre-admission assessment and a statement of terms and conditions, together with a service user guide. The service user guide has been produced in a pictorial format for the benefit of some residents, although quite clearly several of the residents would not be able to benefit from even the pictorial service user guide due to the level of disability. The statement of purpose sets out the admission criteria, the needs that can be met and the support that can be offered. Trial visits to the home are encouraged for potential residents and their family to identify how appropriate the home is for them in meeting their needs. This also gives an opportunity for the prospective resident to meet the current residents, and to become familiar with the environment. The admissions procedures are tailored to the needs of the prospective resident. Ashchurch House DS0000027831.V328729.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The assessed and changing needs and goals of service users are reflected in their individual plans, and they are enabled to make decisions about their lives, where possible, with the necessary assistance. Service users are consulted on, and can participate in some aspects of life in the home and are supported to take risks as part of their independent lifestyle. EVIDENCE: There are currently 8 residents at the home, and the files of 4 of these residents were inspected. All files showed clear evidence of a comprehensive assessment of need, and personal goals for each of the residents had been reflected in their individual plan. As far as is possible the care plans are drawn up with the involvement of the residents, together with family and other relevant agencies where possible. Care plans are not in a pictorial format or in any other format which could possibly be understood by any of the residents. The residents have very diverse and complex needs around communication, Ashchurch House DS0000027831.V328729.R01.S.doc Version 5.2 Page 11 but the manager and the organisation must make more effort in producing the care plans in differring formats so that residents can have a greater influence on their care. There is a key worker system and perhaps this could be implemented to a greater effect in the care planning process. It was clear from observation that residents were enabled to be as independent as possible within a risk management framework. It was evident that staff help service users to make decisions about their own lives, and certainly with regard to community visits, personal care and choice of clothes. Residents are members of the Havering Learning Disabilities Society and enjoy visits to the centre on Monday evenings for social events, and other outings organised by it. All residents have a taxicard, although the home does have its’ own minibus. Advocacy services are provided to residents through Mencap. The current residents are generally not able to manage their own finances, but wherever possible they are enabled to be involved in the decision making with the support and assistance of staff. Although the manager and staff endeavour to ensure that residents are offered opportunities to participate in the day to day running of the home, this is not always possible due to the high level of disabilities of the residents. Also because there are no ancillary staff to undertake duties such as cleaning, laundry and the main cooking, some of the time of some care support staff is taken up with these duties. It was not apparent that residents are enabled to contribute to the development and review of policies, procedures and services, and perhaps the manager and the organisation could investigate ways and methods as to how this could be achieved, even if to a limited degree, having regard to the complex disabilities of the residents. Risk is assessed prior to admission according to health and social services protocols and in discussions with residents, family and other agencies. Risk management strategies are agreed and recorded in the individual care plans, which are reviewed. Ashchurch House DS0000027831.V328729.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 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. Service users are able to take part in age, peer and culturally appropriate activities and are encouraged to participate in community and leisure activities. Service users are enabled to maintain appropriate personal and family relationships, and generally their rights are respected. They are offered a healthy diet in congenial surroundings. EVIDENCE: The home has now employed an activities co-ordinator who works at the home 4 days each week. Whilst this has improved the range of activities available to residents, it is still obvious that even more improvements can be made with the assistance of the care support staff. Such staff are often not able to assist with the activities because they are involved in the undertaking of cleaning, cooking and laundry tasks. Ashchurch House DS0000027831.V328729.R01.S.doc Version 5.2 Page 13 The manager and other staff actively assist residents with regards to benefits and finance problems, and involve other agencies as appropriate. From discussions with staff, viewing care plans and other records it was obvious that all residents are supported to become part of, and participate in, the local community. All are members of the Havering Learning Disability Society and attend functions organised by them. Residents also make use of services, facilities and activities in the general local community such as visiting shops, pubs and restaurants. However, residents are not generally enabled to visit places of worship nor do ministers of religion visit the home. This is an area which may be of importance to some of the residents, and the manager must ensure that this area of daily living is explored with each resident so that the individual needs can be met. Again the culture and ethnicity of the staff team is not generally reflective of that of the residents at the home. It is therefore, essential that the organisation ensures that the cultural and religious needs of the residents are met, and this may need addressing through staff training and supervision. This was discussed with the manager and the deputy manager at the time of inspection, and they were very keen to take this on board. It was very apparent from documentation, from talking to the manager and also to staff that all residents are enabled to enjoy annual holidays. Residents are involved as much as is possible to choose the venue, and the organisation contributes towards the cost of these holidays. Family and friends are encouraged to visit the home, and residents are supported by staff to maintain these relationships. The daily routines endeavour to promote as much independence, choice and freedom of movement and staff were observed to treat residents with respect. However, there was an adult protection issue around the inappropriateness of a resident’s dress when being taken through a communal area. It is essential, therefore, that these issues are dealt with through training and supervision, and that staff involved realise what was being done wrongly without any repercussions on other staff. Staff on duty on the day of the inspection were observed to treat residents with respect, and were sometimes seen actively interacting with them. Generally residents have unrestricted access to the ground floor communal rooms and the gardens, but the absence of a lift does restrict access to the communal areas on the first floor. The statement of purpose does state that residents would be involved in the general housekeeping task, but in reality this is not a realistic expectation for the current residents because of their profound and complex disabilities. Ashchurch House DS0000027831.V328729.R01.S.doc Version 5.2 Page 14 The inspector was satisfied that the health and wellbeing of residents is promoted by the supply of nutritious, varied, balanced and attractively presented meals in congenial surroundings, and at flexible times. Residents have at least two cooked meals daily, and there is always a range of drinks and snacks available for individuals at all times. However, the staff must ensure that the residents are able to choose what they eat, and that it is not the staff making the ultimate decisions. Ashchurch House DS0000027831.V328729.R01.S.doc Version 5.2 Page 15 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 adequate. This judgement has been made using available evidence including a visit to this service. Service users generally can be assured that they will receive personal support according to their wishes and that their physical, emotional and health needs will be met by the involvement of appropriate professionals where necessary. Where appropriate service users will be able to retain, administer and control their own medication within the protection of the home’s medication policies and procedures. EVIDENCE: Four files were inspected and it was evident that all had a detailed plan of care for their daily routines including the support required. Generally the care plans were up to date but there were a few areas which required updating and these were discussed with the manager at the time of the inspection. Currently all service users have a degree of mobility with the assistance of a member of staff, but the organisation must give consideration to the changing and increasing needs of residents with regard to the future provision of necessary equipment. For instance the alarm system for one resident needs Ashchurch House DS0000027831.V328729.R01.S.doc Version 5.2 Page 16 reviewing, and this would be the responsibility of the provider and not that of the commissioning authority. Times for getting up and going to bed, baths and meals are flexible and at the beginning of the inspection some residents were still in bed in accordance with their choice. Residents are supported in choosing their own clothes, but personal care is not always provided in a respectful manner as indicated by a recent adult protection referral. However, it was apparent that generally residents do not visit the hairdressers, and neither does a hairdresser visit the home. This was discussed with the manager as hair care is very important to residents, and the cutting and styling of hair must be given the importance it deserves. Staff should not be expected to cut hair when not qualified to do so, and hopefully this practice will cease. It was evident from the files and from discussions with the manager and staff that residents receive additional specialist support and advice as needed from physiotherapists and occupational therapists. Two residents are under the Orthotic Dept. at the local hospital. Residents are seen regularly by the chiropodist, dentist and optician and the GP as necessary. However, staff shortages within the local PCT (Primary Care Trust) means that access to a speech therapist is entailing a long waiting time. A member of staff always accompanies a resident to health care appointments. It was evident from the files that the weights of residents are being monitored on a regular basis, and any areas of concern are addressed with the GP and dietician. All of the residents attend the GP’s surgery on a regular basis and undergo the necessary health screenings. At the present time none of the current residents are able to administer and control their own medication. However, the medication administration records (MAR) and the medications were inspected and found to be in good order and in accordance with the home’s policies and procedures. There is regular pharmacist input at the home and arrangements are in place for the return of unused medicines. An area which needs addressing is the small room where the medicines are stored. This area does have the potential for becoming very hot during the summer months, and there is no fan or other means of cooling the atmosphere. Medicines and ointments should be stored in an appropriate environment and this was discussed with the manager at the inspection who will be addressing this matter. Ashchurch House DS0000027831.V328729.R01.S.doc Version 5.2 Page 17 Ashchurch House DS0000027831.V328729.R01.S.doc Version 5.2 Page 18 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 adequate. This judgement has been made using available evidence including a visit to this service. The service has a complaints procedure that meets the National Minimum Standards and the Regulations. However, although the complaints procedure is available within the home, this could not be readily understood by the current residents. Generally residents are protected from abuse, neglect and self-harm, but more staff awareness in this area is required through training and ongoing supervision. EVIDENCE: Although there is a clear complaints procedure in accordance with the NMS and regulations, the inspector was not satisfied that residents understood the procedure and who to complain to. It is important that the method of communication for each resident is clearly understood by each member of staff, so that if a resident exhibits unusual behaviour, or pushes something away, staff would question as to why this was happening. It could be that the resident is unhappy for example with the food, the activity or the environment. It is therefore, essential that the manager develops a complaints process which is clear to both residents (as far as his/her disability will allow), but also to staff members, and it actively enables residents to be able to complain. There have been two recent adult protection investigations where it was evident that either through the lack of appropriate training or supervision that the protection of residents was not at the forefront of the minds of the Ashchurch House DS0000027831.V328729.R01.S.doc Version 5.2 Page 19 members of staff. However, the inspector is confident that the home does have a robust and effective whistle blowing policy and that members of staff are very aware of this. The manager is advised to obtain a copy of the adult protection procedures for the London Borough of Havering since it is the local authority that would take the lead on an adult protection investigation. The home does have policies and practices regarding residents’ money and financial affairs and these ensure for example that service users can access their personal financial records, and preclude staff involvement in making or benefiting from residents’ wills. Records were inspected and found to be in order and the necessary receipts are retained. Ashchurch House DS0000027831.V328729.R01.S.doc Version 5.2 Page 20 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, 25 and 30 Quality in this outcome area is good.. This judgement has been made using available evidence including a visit to this service. Service users live in a homely, comfortable and safe environment and bedrooms suite their individual needs, although bedrooms do not have en suite facilities.. However, there are sufficient shared bathrooms and toilets. The home was clean and hygienic with no offensive odours. EVIDENCE: A tour of the premises was undertaken and the home provides a physical environment that is currently appropriate to the specific needs of the residents who are living there. All of the bedrooms are single, and the bedrooms have been personalised in accordance with the wishes of the residents. Some bedrooms have recently been redecorated in colours that the residents have chosen, and some bedrooms have sensory equipment and mobiles, which are often used by the residents in their leisure time, with the support of staff. Ashchurch House DS0000027831.V328729.R01.S.doc Version 5.2 Page 21 The home was well lit, clean and tidy and had no offensive odours, and currently the bathrooms and toilets have minimum aids and adaptations which currently meet the needs of the residents. However, the organisation must give consideration to the future changing needs of residents when other equipment such as hoists, bath aids and a lift may be required. Without these some of the residents may not be able to stay at this home in the future. This would be a great shame since they view Ashchurch as their home, and should be able to stay their as long as their needs can still be met. Staff showed an understanding of the need for furniture not to be moved because of the need of the residents who are registered as blind, and there are handrails along the corridors which aid these residents with their mobility. The communal areas were well furnished and bright. The control of infection procedures were appropriate and there were no offensive smells anywhere in the home. There is an external rear garden which is well maintained, and used by the residents when the weather permits. Ashchurch House DS0000027831.V328729.R01.S.doc Version 5.2 Page 22 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, 33, 34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are generally supported by competent and qualified staff, but there are some gaps in training. The staff team is reasonably effective but could be more so with the addition of ancillary staff. The home’s recruitment policy and practices are robust, but staff must implement the home’s policies and procedures to ensure that residents are protected at all times. EVIDENCE: From viewing staff files it was evident that the necessary references and criminal records bureau disclosure are obtained prior to the employment of a member of staff. The interview process appears robust and staff do undertake induction training, but this should be done within the first six weeks of appointment. All staff are given a copy of the General Social Care Council’s standards of conduct and practice, and staff must ensure that they adhere to this. It is essential that all staff know and support the main aims and values of the home and understand, and implement the home’s policies and procedures. It Ashchurch House DS0000027831.V328729.R01.S.doc Version 5.2 Page 23 was apparent from the recent adult protection issues that this was not necessarily the case. Staff are encouraged to obtain qualifications and the organisation works towards the Learning Disability Assessment Framework. Generally the inspector was satisfied that the home has an effective staff team, but has concerns around the ability of this team to always be as effective as they should because of the lack of ancillary staff. The current residents have high levels of dependency and are not able to effectively undertake cooking, cleaning and laundry, and these duties are therefore done by support staff to the detriment of time spent with the residents on an individual or group basis. The current staff team is not reflective of the cultural composition of the residents, and it is essential that staff undertake equality and diversity training so that they will understand the religious, cultural and other needs of residents. The inspector would wish to add that all members of staff spoken to and observed interacting with residents expressed an understanding of the needs of people with a learning disability, and were very kind and caring in their approach and attitudes. It was apparent from discussions and from viewing records that not all staff have undertaken training in adult protection, and this was discussed with the manager who will be addressing this issue. Staff meetings take place on a regular basis as does supervision which is recorded and acknowledged by the staff members. However, it is essential that staff also have supervision on day to day practice which will also monitor the work with individual residents, and also give support and professional guidance. Ashchurch House DS0000027831.V328729.R01.S.doc Version 5.2 Page 24 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, 38, 39 41 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a manager in post, not yet registered, and his approach creates an open, positive and inclusive atmosphere to the benefit of service users. The organisation does have a quality assurance system which seeks the views of service users, relatives and friends. Currently the manager is acting as the appointee for 5 residents, and the Commission does not view this as acceptable practice as per the Care Home Regulations 2001. However, the resident’s rights and best interests are safeguarded by the home’s record keeping, policies and procedures. EVIDENCE: There is a new manager in post and he has submitted his application for registration to the Commission, and is now awaiting this to be processed. His management style is to create an open, positive and inclusive atmosphere and this is to the benefit of residents. Ashchurch House DS0000027831.V328729.R01.S.doc Version 5.2 Page 25 Since his appointment he has worked hard to ensure that the residents’ have been redecorated and some rooms now have sensory equipment installed. The manager is improving and developing systems that monitor practice and compliance and he is aware that more work is still needed in this area. As there is now a deputy manager in post hopefully this work will progress at an increasing rate. Staff spoken to spoke highly of the manager and said that “he is very supportive, friendly and approachable.” The manager ensures, so far as is reasonably practicable the health, safety and welfare of service users and staff. Staff have undertaken fire safety training and are aware of the procedures to be adopted in the event of a fire alarm being raised. Residents’ finances were inspected and it was apparent that the manager is the appointee for 5 residents. Whilst all records were in order, this was discussed with the manager who, himself, is not happy at being the appointee. The organisation must discuss this arrangement with the residents, where possible, commissioning authorities, families, social workers and the manager to ensure that appropriate alternative arrangements for appointees are made as soon as is possible. Maintenance records for insurance, wheelchairs, gas, electric, PAT testing, fire safety and water were inspected and found to be in good order, and the organisation regularly reviews the policies and procedures. Regulation 26 visits are undertaken by the responsible individual and copies of the reports are available at the home. Some regulation 37 notification are being sent but the manager must ensure that this is consistently done when there are any issues/incidents which adversely affect residents. Ashchurch House DS0000027831.V328729.R01.S.doc Version 5.2 Page 26 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 3 2 3 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 2 12 3 13 3 14 3 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 X 3 3 3 X 3 2 3 Ashchurch House DS0000027831.V328729.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No 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 YA11 Regulation 16(3) Requirement The registered persons must ensure that so far as practicable service users have the opportunity to attend religious services of their choice. The registered persons must ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users. The registered persons must ensure, for the purpose of providing care to service users, and making proper provision for their health and welfare, so far as practicable ascertain and take into account their wishes and feelings, this should include hairdressing by a qualified and competent person The registered persons must establish a complaints procedure appropriate to the needs of service users. The registered person shall ensure so far as practicable that persons working at the care DS0000027831.V328729.R01.S.doc Timescale for action 31/03/07 2. YA16 18(1)(a) 30/04/07 3. YA18 12(3) 31/03/07 4. YA22 22 (2) 30/04/07 5 YA23 20(3) 30/04/07 Ashchurch House Version 5.2 Page 28 6. YA32 YA35 18(1)©(i) 7 YA33 16(2)(n) 18(1)(a) 8. YA42 16(2)© home do not act as the agent of a service user The registered persons must ensure that the persons employed to work at the care home receive training appropriate to the work they are to perform, and this must include adult protection training and equality and diversity training The registered persons must ensure that activities are provided to meet the needs of the service users, and that staff are employed in sufficient numbers and mix as are appropriate for the health and welfare of service users. This will include a review of the tasks to be undertaken by ancillary staff as residents are unable to contribute to cleaning, cooking and laundry. The registered persons shall provide equipment suitable to meet the needs of service users, this includes emergency call alarms where necessary 30/04/07 31/03/07 31/03/07 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 Ashchurch House DS0000027831.V328729.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU 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. Extracts may not be used or reproduced without the express permission of CSCI Ashchurch House DS0000027831.V328729.R01.S.doc Version 5.2 Page 30 - 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. 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