Inspection on 27/10/05 for Ashchurch House

This inspection was carried out on 27th October 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 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 26/02/07

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 Harbinder Ghir Unannounced Inspection 27 October 2005 10:00 Ashchurch House DS0000027831.V261692.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 Ashchurch House DS0000027831.V261692.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. Ashchurch House DS0000027831.V261692.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ashchurch House Address 6 Chase House Gardens Emerson Park Hornchurch RM11 2PJ 01708 473202 01708 472279 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 Mr Barry Marc Jacobs Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Ashchurch House DS0000027831.V261692.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. To include one named service user over the age of 65. Date of last inspection 30th September 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 three storey house, with five ground floor bedrooms and five on the first floor. The third floor is used for staff training. The building is maintained and decorated and has car parking facilities to the front of the building. The home is located in a residential area of Emerson Park, close to shops, public transport and the M25, A127 and the A12. At present there are eight residents living in the home. The home employs staff working a roster, which gives 24-hour cover. Currently there is no registered manager in post. The deputy manager has undertaken the role of acting manager until the newly recruited manager comes into post on 1st November. Ashchurch House DS0000027831.V261692.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Harbinder Ghir, Regulatory Inspector, undertook this unannounced inspection on the 27th October 2005 and was at the premises from 10.35am to 12.35pm. The visit included talking with residents and staff. Some judgements about quality of life within the home were taken from direct conversation with staff and observation. In addition a tour of the premises was undertaken and some records were looked at. During the inspection 8 residents were at the home. Due to the profound level of learning disabilities, residents at the home were not able to verbally communicate to the inspector. 5 Requirements were made at the time of the last inspection, the home has time to meet the timescales set and therefore have been re-stated at this inspection. For 1 Requirement made at the time of the last inspection, the timescale has not yet been reached, so this has been re-stated with a new timescale. Further information about unmet requirements can be found in the relevant standard. Unmet requirements impact upon the welfare and safety of service users. Failure to comply by the revised timescale will lead to the Commission for Social Care Inspection considering enforcement action to secure compliance. They were not tested at this inspection and will be tested at the next inspection. This was the second statutory inspection for 2005/6, and across the two visits all core standards have been assessed. What the service does well: What has improved since the last inspection? What they could do better: The homes does not have its own account or a business plan so it was not possible to establish that the business was viable or that appropriate financial planning was in place. Ashchurch House DS0000027831.V261692.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. Ashchurch House DS0000027831.V261692.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 Ashchurch House DS0000027831.V261692.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): Standards 2, 3 4, 5 were not tested on this visit. However evidence from the last inspection was that: Service users needs are fully assessed prior to admission. Service users have access to specialist services if they need them. Admissions procedures are tailored to the individual needs of the person. Each resident does not have an individual written contract, including the statement of terms and conditions of the service. EVIDENCE: The above standards were not specifically tested on this visit. The home has time to reach the timescale of 30/12/05 for the outstanding requirement in relation to standard 5 set at the last inspection and will be tested at the next inspection. At the time of the last inspection, all of the outcomes for standards 2,3,4,5 were assessed as met. These standards will be re-tested at a future inspection. Ashchurch House DS0000027831.V261692.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): Standards 6, 7, 8, 9, 10 were not tested on this visit. However evidence from the last inspection was that: There is a clear and consistent care planning system in place, which provided staff with the information they needed to meet the needs of residents. Residents are supported to make active choices and decisions throughout their daily living and areas of risk are assessed. Information about service users is kept confidential. EVIDENCE: The above standards were not specifically tested on this visit, as there were no outstanding requirements in relation to the 5 standards. At the time of the last inspection, all of the outcome standards were assessed as met. These standards will be re-tested at a future inspection. Ashchurch House DS0000027831.V261692.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): Standards 11,12, 13, 14,15, 16, 17 were not tested on this visit. However evidence from the last inspection was that: Residents are provided with the support to maintain their independence and in areas of personal development according to their needs and wishes. Residents are engaged in community life; enjoy a range of leisure activities and a varied and nutritious diet. EVIDENCE: The above standards were not specifically tested on this visit, as there were no outstanding requirements in relation to the 7 standards. At the time of the last inspection, all of the outcome standards were assessed as met. These standards will be re-tested at a future inspection. Ashchurch House DS0000027831.V261692.R01.S.doc Version 5.0 Page 11 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 clear and comprehensive arrangements for the administration of medication. Standards 18,19, 21 were not tested on this visit. However evidence from the last inspection was that: Personal, physical and emotional healthcare is provided that meets residents’ need. Residents’ wishes in the event of death are established through liaison with their representatives and are handled with respect and as the individual would wish. EVIDENCE: Medication is managed well by the home. At present none of the residents at the home are able to self medicate. The home has an appropriate medication policy and procedure in place, which protects all service users and ensures the safety of those who can self-medicate by using risk assessments where necessary. Standards 18, 19, 21 were not specifically tested on this visit, as there were no outstanding requirements in relation to standards. At the time of the last inspection, all of the outcome standards were assessed as met. These standards will be re-tested at a future inspection. Ashchurch House DS0000027831.V261692.R01.S.doc Version 5.0 Page 12 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): Standards 22, 23 were not tested on this visit. However evidence from the last inspection was that: The home’s complaints procedure must be updated to include timescales within complaints will be responded to. Policies, procedures and staff training were provided that protected residents from abuse. EVIDENCE: The above standards were not specifically tested on this visit. The home has time to reach the timescale of 30/11/05 for the outstanding requirement in relation to standard 22 set at the last inspection and will be tested at the next inspection. At the time of the last inspection, the outcome for standard 23 was assessed as met. These standards will be re-tested at a future inspection. Ashchurch House DS0000027831.V261692.R01.S.doc Version 5.0 Page 13 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): Standards 24, 25, 26, 27, 28, 29, 30 were not tested on this visit. However evidence from the last inspection was that: Residents’ benefited from living in a safe, well-maintained and clean environment. Décor, furnishings and fittings were of a good standard and provide a homely and pleasant living environment. EVIDENCE: The above standards were not specifically tested on this visit, as there were no outstanding requirements in relation to the 7 standards. At the time of the last inspection, all of the outcome standards were assessed as met. These standards will be re-tested at a future inspection. Ashchurch House DS0000027831.V261692.R01.S.doc Version 5.0 Page 14 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): Standards 31, 32, 33, 34, 35, 36 were not tested on this visit. However evidence from the last inspection was that: Staff were aware of their and other’s job roles and responsibilities, although. there was no record on the staff files that job descriptions were provided to all staff. There is a good match of qualified staff offering consistency within the home. Staff morale is high resulting in an enthusiastic workforce that works positively with service users to improve their quality of life. Recruitment processes are not robust enough to ensure the protection of people living at the home. The staff group receive adequate training to meet the needs of residents. Staff supervision needs to be prioritised by the home. EVIDENCE: The above standards were not specifically tested on this visit. The home has time to reach the timescale of 30/12/05 for the outstanding requirements in relation to standard 34 and 36 set at the last inspection and will be tested at the next inspection. At the time of the last inspection, all of the outcomes for standards 31, 32, 33, 35, were assessed as met. These standards will be retested at a future inspection. Ashchurch House DS0000027831.V261692.R01.S.doc Version 5.0 Page 15 Ashchurch House DS0000027831.V261692.R01.S.doc Version 5.0 Page 16 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): 42, 43 The welfare of staff and service users are promoted by the homes policies and procedures at all times. The home does not have its own account or a business plan in place to ensure financial viability of the home. Standards 38, 39, 40, 41 were not tested on this visit. However evidence from the last inspection was that: The home does not have a registered manager in post. There are no formal methods of quality assurance in place. Residents are safeguarded by the home’s record keeping policies. EVIDENCE: The acting manager and staff take overall responsibility for ensuring relevant maintenance checks are carried out throughout the home. It is clear from the records seen that all relevant legislation is complied with and reportable incidents are reported to the appropriate authorities. Fire signs and safety Ashchurch House DS0000027831.V261692.R01.S.doc Version 5.0 Page 17 posters are evident throughout the home. All members of staff have health and safety training as part of the induction process. The home does not have its own account or a business plan so it was not possible to establish that the business was viable or that appropriate financial planning was in place. The registered provider must put in place a business plan for the home. This has not been actioned from the last inspection, so has been re-stated as requirement 1 with a new timescale. Insurance certificates for the home were displayed in the main reception area and showed that the required cover was provided. Standards 38, 39, 40, 41 were not specifically tested on this visit. The home has time to reach the timescale for the outstanding requirement in relation to standard 39 set at the last inspection and will be tested at the next inspection. At the time of the last inspection, all of the outcomes for standards 37, 38, 40, 41 were assessed as met. These standards will be re-tested at a future inspection. Ashchurch House DS0000027831.V261692.R01.S.doc Version 5.0 Page 18 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 X X 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 X X X X X x x LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X X X X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Ashchurch House Score X X 3 x Standard No 37 38 39 40 41 42 43 Score X X X X X 3 2 DS0000027831.V261692.R01.S.doc Version 5.0 Page 19 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA5 Regulation Requirement Timescale for action 30/12/05 2 YA22 3 YA34 4 5 YA36YA39 YA39 (5) (1) (b) A contract/ statement of terms and conditions must be provided to all residents admitted to the home, or to their representatives. 22 (7) (a) The complaints procedure must be updated with contact details for the CSCI, timescales within which a complaint is to be investigated and that CSCI can be contacted at any time of the complaint being made or investigated. (Previous timescale of 01/05/05 not met) 19 Sch 2 Criminal Records Bureau check (7) (b) must be obtained for all staff employed at the home. (Previous timescale of 01/05/05 not met) 18 (2) All staff must be supervised at least 6 times a year. 24 Quality assurance and monitoring systems must be developed to include the outcome of the quality audit, an annual development plan and results of any surveys/ audits, which are used to monitor the performance of the home and overall quality of care. (Previous DS0000027831.V261692.R01.S.doc 30/11/05 30/12/05 30/12/05 30/12/04 Ashchurch House Version 5.0 Page 20 timescale of 01/05/05 not met) 6 YA43 25 (1) (2) (a) The registered provider must ensure that accounts for the home are in place to demonstrate the homes financial viability and must put in place a business plan for the home. (Previous timescale of 01/06/05 not met). 27/01/06 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 YA21 YA31 YA40 Good Practice Recommendations It is recommended that the wishes of residents in the events of dying are identified in their care plan. It is recommended all staff employed at the home receive job descriptions and a copy is placed on their file. It is recommended all policies and procedures should be signed and dated. This recommendation is restated from the last inspection. Ashchurch House DS0000027831.V261692.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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 Ashchurch House DS0000027831.V261692.R01.S.doc Version 5.0 Page 22 - 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!