Inspection on 03/05/06 for Ashclyst

This inspection was carried out on 3rd May 2006.

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

Ashclyst 15/12/08

Ashclyst 23/06/08

Ashclyst 25/06/07

Ashclyst 16/11/05

Ashclyst 04/05/05

Ashclyst 25/10/04

Ashclyst 22/04/04

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 Ashclyst 23 Park Lane Winterbourne South Glos BS36 1AT Lead Inspector Paula Cordell Key Unannounced Inspection 3rd May 2006 09:30 Ashclyst DS0000003390.V291405.R01.S.doc Version 5.1 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 Ashclyst DS0000003390.V291405.R01.S.doc Version 5.1 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. Ashclyst DS0000003390.V291405.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Ashclyst Address 23 Park Lane Winterbourne South Glos BS36 1AT 01454 250946 0117 970 9301 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) admin@aspectsandmilestones.org.uk Aspects and Milestones Trust Mr Ian John Knowles Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Ashclyst DS0000003390.V291405.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 4 residents aged 19 - 64 years Date of last inspection 16th November 2005 Brief Description of the Service: Ashclyst is situated in South Gloucestershire in a somewhat remote, almost rural position on the outskirts of Bristol. The home is registered with the Commission for Social Care Inspection to provide accommodation and personal care to four people with a learning disability aged between 19-65 years of age. It is a modern 4 bedroom detached bungalow. Accommodation is on two floors. Residents have access to two bathrooms. The communal areas consist of a lounge and an open planned dining room and kitchen. Residents have access to a minibus in addition to public transport to enable them to access the local community. The home is managed by Mr Knowles. The fees at the time of publication of this report were £1250. Presently there is no Email address for the home. Ashclyst DS0000003390.V291405.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection. The purpose of the visit was to monitor the progress to the requirements from the last inspection in November 2005 and review the standard of the care provided to the residents living at Ashclyst. The inspection was planned using the new methodology looking at the evidence received since the last inspection including the reports from the provider in respect of regulation 26 visits, the completed pre-inspection questionnaire, regulation 37 notices detailing any occurrence that affects the residents and the running of the care home and the last inspection report. An opportunity was taken to view care documentation, speak with staff, the deputy manager and the registered manager. The inspection provided good opportunities to observe residents in their home. However, residents were unable to fully participate in the inspection process due to limited verbal communication. The visit to the home was conducted over a period of five hours. Two of the residents were in the home during the inspection. What the service does well: What has improved since the last inspection? Residents can now be assured that the home has stability in relation to the management, direction and leadership of the home. Residents can be assured that there is now a duty rota that reflects how the home is staffed. Ashclyst DS0000003390.V291405.R01.S.doc Version 5.1 Page 6 Residents now benefit from replacement beds ensuring their comfort and their safety. There has been considerable work completed in the home on the management of continence and this is noticeable in the lack of unpleasant odour and clear guidelines for staff to follow and the changes to the flooring in rooms of concern. Whilst there has been improvement in the record of fire safety tests, which assures the safety of residents, it remains outstanding that staff do not attend regular drills assessing their practical competence of their fire evacuation procedures. Whilst there has been some improvement on the storage of medication ensuring the safety of the residents. A further requirement was made relating to the recording of medication. What they could do better: There remain outstanding, requirements relating to the environment. Residents would benefit from a complete refurbishment of the home both internally and externally. Further requirements remain outstanding relating to the refurbishment of the laundry and the installation of a sluicing facility. The deadline for achieving this has been extended to enable the home to comply. An action plan has been requested of the Trust, which addresses these shortfalls over a twelve-month period. Further non-compliance could lead to enforcement action being taken. Information available to residents relating to the home must be a true reflection of the home in relation to the legislation that governs the running of a care home. Residents should be assured that care information is duly signed and dated to demonstrate that it is current and relevant. Residents must be assured that a varied and nutritious diet is provided. Residents must be assured that medication is administered as per the doctor’s instructions ensuring their safety. Residents must be protected in the event of a fire by competent staff. Residents must be assured that Ashclyst is a homely environment to live, which is kept clean and well decorated. Ashclyst DS0000003390.V291405.R01.S.doc Version 5.1 Page 7 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. Ashclyst DS0000003390.V291405.R01.S.doc Version 5.1 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 Ashclyst DS0000003390.V291405.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 Quality in this outcome area is good. This judgement has been made using available evidence including a site visit. Residents have information to make an informed choice about where to live. However, this would be enhanced if a minor amendment were made to the documentation. Residents assessed care needs are being met and routinely being reviewed. EVIDENCE: Residents have a service user guide that is accessible and in picture format. This had been laminated for ease of reading and was readily available to individuals living in the home. However, the documentation whilst in most part included details as per the standard and the Care Homes Regulations, it made reference to previous legislation. It was evident that this had been an oversight as the manager had a good understanding of the National Minimum Standards. The documentation was being reviewed at regular intervals and copies had been sent to the Commission for Social Care Inspection. Evidence was provided that residents care needs were being continually assessed involving other professionals, care staff and the placing authorities. This information was evidenced in conversations with the manager, the deputy manager, and observation and care documentation. Ashclyst DS0000003390.V291405.R01.S.doc Version 5.1 Page 10 The home has full occupancy and many of the residents have been living in the home for a number of years. There was evidence that the home liaised with placing authorities prior to making a decision for an individual to be admitted to the home. There are policies and procedures to guide the staff on the process of admission. It was evident that the home would complete an assessment of need prior to the individual moving to the home. Examples were given where a resident had been hospitalised for a period of time, staff were collating information to inform the plan of care and training was planned to ensure that the home could meet the changing care needs of the individuals. This is good practice. Staff had clearly signed up to the principle of meeting the changing care needs of the individual. Ashclyst DS0000003390.V291405.R01.S.doc Version 5.1 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good. This judgement has been made using available evidence including a site visit. Residents can be assured that their individual care needs are being met. There is good culture in the home for resident led services. Communication needs of residents are being continually reviewed to enable them to participate in all aspects of their care. Residents are supported to take risks as part of an independent lifestyle. EVIDENCE: As part of the planning for the inspection two individuals were identified to randomly review in respect of the service provided to them. Due to communication issues it was difficult to establish whether individuals consented to this appraisal of their care service. Residents had a care file containing information pertinent to them. Plans were person centred and fully described a spectrum of care support needs covering all aspects of daily living. There was evidence of reviews involving the individual, care staff and other professionals involved in the care of the individual. It was evident from talking with staff that plans are tested and Ashclyst DS0000003390.V291405.R01.S.doc Version 5.1 Page 12 residents are observed to ensure that it is appropriate. It was evident from conversations with staff and care documentation that residents would assertively say if they were unhappy with any aspect of their care. It was evident that a core group of staff had a good understanding of the communication needs of the residents. This knowledge was being transferred to a communication dictionary for less experienced staff. This is good practice. Methods of communication are an important part of the role of staff since each individual residents needs and abilities vary and are particularly intricate. Care plans included how individuals are supported to make choices including where actions are taken by staff. This demonstrated an open approach to the planning of care. Clear information was included in the plans of care on personal mail and the role staff play in supporting individuals with their finances ensuring a consistent approach. Staff training records further demonstrated the commitment to meeting the communication needs of residents with attendance at regular makaton updates and other means of communication with individuals who use non-verbal communication. Risk assessments were in place and covered activities both in the home and the local community ensuring the safety of the resident, staff and others. These did not curtail residents who were encouraged to lead full and active lifestyles. It was pleasing to see that residents were not excluded due to their behaviours but safe practice guidelines put in place to ensure the safety of all concerned. Risk assessments were kept under review. Staff meeting minutes demonstrated that the whole team had been involved in the development of new risk assessments and informed the process to ensure that it reflects practice and the individual needs of the residents. Care plan documentation included plans for supporting individuals with their behaviours that challenge staff including the triggers, diversion strategies and positive guidelines for staff to follow. Staff records and conversations with staff confirmed that training is given to support individuals that can be challenging and this is refreshed periodically. A number of staff had attended training in “person centred planning” and “record keeping in a care home”. This was reflected in the quality of the care plans. Whilst there was evidence of care reviews not all care documentation was signed and dated, making it difficult to determine how current the documentation was. Ashclyst DS0000003390.V291405.R01.S.doc Version 5.1 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a site visit. Residents are enabled to maintain appropriate and fulfilling lifestyles in and outside of the home maintaining contact with friends and family. However the home has failed to demonstrate that the home is providing residents with a wholesome, nutritious and varied diet. Residents can be assured that their rights are respected and take an active part in the planning of their daily lifestyles taking into the account their varying abilities and individual needs. EVIDENCE: In line with previous inspection findings the home was able to demonstrate that residents are encouraged to participate in a range of activities. This was clearly documented in the plan of care, daily records and further evidenced from observations and discussions with staff. Ashclyst DS0000003390.V291405.R01.S.doc Version 5.1 Page 14 Care documentation focused on individual’s strengths in addition to building on areas of need. All the residents attended a day centre and had access to an individual plan of structured activity. Activities included in-house activities, for example involvement in household chores, listening to music, aromatherapy and arts and crafts and then activities in the community. It was evident that residents were supported to attend and visit places of interest and were not discriminated against due to their learning disability or their behaviours that challenge. Staff spoke positively about individuals and care records further demonstrated that residents were treated in a respectful and dignified manner. Photographs situated around the home provided further evidence of the wide spectrum of activities that were available including an annual holiday. Care plans included information relating to the contact with relatives and friends. It was evident that relatives were asked to reviews and informed of changes to the plans of care. A completed questionnaire by a relative further evidenced that relatives were kept informed and consulted in respect of an individuals planned care and were made welcome when they visited the home. The statement of purpose and the service user guide clearly described the rights of the individuals and the manager and the staff spoken with during the inspection process echoed these. The home has a policy on equalities and it was evident that residents were treated as individuals and their individual preferences were respected and documented in the plan of care. Finances were checked for a random sample of residents. Amounts held in the home corresponded with the records held in all but one case. However, this was resolved at the time of the inspection to the satisfaction of the inspector. Individuals had their own bank account. Agreements were in place for the funding of the vehicle and signed by the individual’s representative. In addition there was a contract detailing different scales of return should that individual move from the home over a period of time. This is good practice and demonstrated a transparent system for the funding of the vehicle, which was equitable. Menu planning was explored as part of the site visit. Concerns were raised about the information recorded on the menu record as this lacked sufficient detail on how the home was ensuring that residents had available to them a nutritious and varied diet. It was not evident that residents were having access to sufficient fruit and vegetables. Whilst the home is commended on the format of the record which allows for each individual dietary intake to be recorded and where a variation has been offered in respect of choice. It was not clear that residents were being offered at least five portions of fruit and vegetables per day. A member of staff stated that a dietician was visiting the week after the inspection to look specifically at menu planning. This was confirmed with the service manager responsible for completing the regulation 26 visits on behalf of the registered provider and the manager who had already identified this as Ashclyst DS0000003390.V291405.R01.S.doc Version 5.1 Page 15 an issue. A requirement was made for the home to review the menu to ensure that a nutritious diet is available to residents. Ashclyst DS0000003390.V291405.R01.S.doc Version 5.1 Page 16 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): 18,19,20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a site visit. Residents can be assured that their personal and health care needs are being met. However, resident’s safety in relation to medication is being compromised and staff need to ensure that they are following the directions as detailed by the prescribing doctor. EVIDENCE: Care plans included an individual approach to the delivery of personal care. It was evident that personal support was delivered flexibly to suit the individual. Residents are allocated a key member of staff who relates closely to the individual and offers support in maintaining as much independence as possible. Care plans and daily records provided evidence that residents health care was continually monitored with appropriate health professionals involved. Residents seen had a distinctive style in clothes and haircut. Residents seen on the day of the inspection had the appearance of being well cared for. An opportunity was taken to speak with a visiting health care professional who stated that the staff were always welcome in their approach and evidently Ashclyst DS0000003390.V291405.R01.S.doc Version 5.1 Page 17 wanted to ensure that the residents had the best care and sought guidance and acted upon that guidance. The statement of purpose clarifies which therapeutic techniques are on offer at Ashclyst. These include access to the Community Learning Disability Team and consultant psychiatry and psychology. In addition there is access to aromatherapy. Behaviour strategies were in place detailing triggers, de-escalating strategies and the interventions. These were personalised to the individual. There were clear records of incidents of behaviour for monitoring purposes. Training was in place for staff as seen in records and further evidenced in discussion with staff, on supporting staff with individuals that can be challenging. This was updated annually. This is good practice. Since the last inspection the home has sought guidance on the management of continence. Care plans included information on individual support needs. It was evident that this has been a useful process as previous odours were not apparent. As part of this process the home has explored alternative flooring again this has had a positive effect on the aroma of the home. Medication was satisfactory. The home has responded to a previous requirement to ensure that all medication is stored securely. This was evidenced via observation, discussion with the manager and in addition had been a topic of conversation for staff via staff meetings and supervisions. The home has an organisational and a local policy to guide staff this was seen on the previous inspection and was assessed to meet the needs of the home. There were clear medication records of stock entering and leaving the home. A competent person signed medication records. The manager was periodically reviewing competency of staff. In addition staff had attended medication training as evidenced via staff training records and conversation with a member of staff. A concern was raised where a prescribed topical medication was being given not in accordance with the instructions on the medication record and this did not follow the in-house guidance, which lacked real information on when to administer. This must be addressed immediately and will be subject to a follow up visit. Ashclyst DS0000003390.V291405.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a site visit. Residents can be assured that there are robust systems for enabling them to make a complaint or in the event of an allegation of abuse. EVIDENCE: This standard was fully assessed at the last inspection and found to be sound and robust. Evidence provided at this inspection demonstrates that this continues to be the case. Conversations with the manager and staff clearly detailed how they would support residents to complain. Due to the residents using non-verbal communication this was mainly from staff knowing the individual well, for many years and from observation. To assist new staff, communication dictionaries have been developed to enable staff to interpret body language and noises that are pertinent to the individual. This is good practice. There was no record of a complaint in the home’s complaint book and the Commission for Social Care Inspection have not received any. A completed relative’s questionnaire stated that they were aware of how to make a complaint but in the time the individual had lived in the home they had no cause for concern. Policies and procedures were in place to guide staff both on the protection of residents and enabling individuals to make a complaint. Training for staff had been undertaken in protection of vulnerable adults. The manager Ashclyst DS0000003390.V291405.R01.S.doc Version 5.1 Page 19 demonstrated a good understanding of underlying principles of the protection of vulnerable adults policy and the involvement of social services in taking the lead in an allegation of abuse. Ashclyst DS0000003390.V291405.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29,30 Quality in this outcome area is poor. This judgement has been made using available evidence including a site visit. The home does not provide a pleasant, well-maintained and clean environment for individuals to live. EVIDENCE: Ashclyst is situated in a rural area on the outskirts of Bristol. The home has a minibus to enable residents to access the local community. Ashclyst is a detached dorma-bungalow. Consistent with the findings from the last two inspections the home fails to achieve some of the basic environmental standards. Whilst the home has met some of the requirements namely the replacement of the beds, which had been worn, or sub standard, replacing flooring to two of the bedrooms and the offensive odour, it still remains that this home is in need of a refurbishment programme. The new sluice and laundry facility remains outstanding from the last inspection, which is to be sited away from the kitchen facility. However, the Ashclyst DS0000003390.V291405.R01.S.doc Version 5.1 Page 21 manager contacted the appropriate person and it has been agreed to extend the timescale for achieving this to the 20th June 2006. The Trust and the home must develop a refurbishment programme. This must include replacement of the kitchen, the bathrooms, decoration work undertaken both internally and externally. The home must address these serious issues of concern by submitting a refurbishment plan addressing all the above works with timescales, which will form the requirement for the home and be monitored closely by the Commission for Social Care Inspection. All works must be carried out within a twelve-month period. There were areas of concern raised further from this inspection that the home was found to be unclean deep staining was seen on walls and cobwebs were found in most rooms in the home. Staff stated that cleaning was completed on a daily basis however; there was no schedule of works completed. An immediate requirement was left with the home and will be subject to a follow up visit. From the tour of the home it was evident that little pride was taken over the environment, continence pads and gloves were evident throughout the home, which detracted from the homely appearance. Communal areas and bedrooms were quite empty and void of personality and the touches that can make the difference from an institutionalised feel to a homely environment. Staff talked about the concerns that they have of walking from the front of the house to the rear with laundry late at night. This was in response to a previous requirement. The inspector advised that the home consult with environmental health and that it could be seen as more appropriate to walk through the dining area when not being used for the purpose of eating and when cooking is not taken place as long as washing is in a closed container. This must be fully documented in a risk assessment with the agreement of environmental health. These serious concerns should not detract from the standard of care that the residents are afforded in relation to living fulfilling lifestyles. These are organisational issues and for the team to address the balance to ensure that Ashclyst is a pleasant place to live. Ashclyst DS0000003390.V291405.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,24,35,36 Quality in this outcome area is good. This judgement has been made using available evidence including a site visit. Residents are assured that there are sufficient and competent staff working in the home. There is a commitment to ensure that staff receive appropriate training and support. However, the residents must be assured that staff are aware of their day-to-day responsibilities in respect of domestic chores. EVIDENCE: There was information recorded on the duty rota that demonstrated that there was sufficient staff to meet the social, personal and health care needs of residents. However, there were concerns raised about the standards of cleanliness in the home. Whilst staff have clear roles and responsibilities there was no guidance available on the routine household cleaning – there was no cleaning schedule in place. The manager and the deputy stated that this was an issue that was being addressed by the home and a request has been made to the Trust for additional funding to the staffing budget to recruit a domestic which would relieve the care staff of some of the responsibility. As yet no decision has been made. A member of stated that it was difficult to complete all the domestic Ashclyst DS0000003390.V291405.R01.S.doc Version 5.1 Page 23 chores and ensure that residents are supported with both their personal care and daily activities and the challenges that can be exhibited by the individuals. This will be followed up at the next inspection and within the next seven days to ensure that the home is clean. The home has demonstrated compliance to a previous requirement to ensure that there is a rota that clearly records who is working in the home. The manager now has a system where he informs staff when he is not available in the home and taking on additional management responsibilities for the Trust. It was noted that the home remains adequately staffed with two persons working in the home during the day and one member of staff providing sleeping in cover at night. It was evident that the team were stable and staff talked of a cohesive approach to providing care. As already mentioned staff described a good understanding of the aims and objectives of the home and a commitment to meeting the diversity of care needs via a person centred approach. From conversations with the manager the home follows clear and robust recruitment procedures. Evidence was provided that copies of the recruitment information was held in the home as part of the staff record as seen for the most recently recruited member of staff. Staff records demonstrated that staff are supported to attend periodic training including statutory training. There was a rolling programme in place. In addition there was evidence of attendance of specific training to the needs of the residents including mental health, supporting individuals that challenge, person centred planning, record keeping, autism and communication courses. This is good practice. A member of staff commended the manager and the Trust on the commitment to ensuring a trained and competent workforce. Evidence was provided that all staff have either completed an NVQ in care at level 3 or were in the process of completing. The home has two assessors the deputy and the manager. New staff complete the Learning Disability Award Framework as part of a comprehensive induction. The home is commended on the commitment to ensure that staff receive regular supervision and support. The home exceeds the standard relating to supervision, which is given to staff monthly. In addition there are regular team meetings. Staff were evidently committed to meeting the care needs of the residents. A training session was organised on the day of the inspection specific to one individual – not all staff were rostered to work but there was a 100 attendance and bank staff that regularly work in the home were also present. Ashclyst DS0000003390.V291405.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a site visit. Residents can be assured that the home is managed well and there is clear direction and leadership given to the staff. Quality assurance was in place. Residents’ health and safety was being compromised due to the lack of staff participation in drills. EVIDENCE: Mr Knowles is the registered manager. He has returned from a secondment of acting on behalf of the Service Manager. Previous inspections have highlighted concerns about the aims and purpose, leadership and direction of the home. With the manager now working in the home it was evident that this is now not the case. There was good evidence that the home was well managed and staff were clear on the direction and the aims and objectives of the home which runs parallel to the aims of the Trust. The home has good quality assurance initiatives including the development of a business plan focusing on service user outcomes. In addition the provider Ashclyst DS0000003390.V291405.R01.S.doc Version 5.1 Page 25 completes a monthly report appraising the service. The Commission is receiving copies. The Trust has a number of policies and procedures, which have been developed and reviewed over time. They cover all aspects of running a care home and are relevant to the individuals’ that the home supports. Policies and procedures were kept in the main office. These were accessible to staff. Staff confirmed that these were covered during the induction and periodically with them as new policies are introduced. It was clear from policies and procedures that the home and the Trust was committed to being both a service for individuals and a place to work where individual rights, equalities and diversities were recognised. There were good systems in place to ensure the safety of residents and staff. Information was accessible to staff and included policies and procedures, risk assessments. Routine checks on the premises were being completed including the testing of the gas and electrical appliances. These systems also included checks on the home’s vehicles. Logs were maintained of the checks. This is good practice. As evidenced from the pre-inspection questionnaire, records held in the home and discussions with the manager and the deputy. Since the last inspection staff have undertaken training in the storage of chemical hazardous to health this was addressed via supervisions and through a staff meeting. The home has demonstrated compliance to a previous requirement. Staff confirmed that this was discussed with them. All chemicals hazardous to health were stored in accordance with the home’s risk assessment. An opportunity was taken to view the fire logbook. Whilst it was clear that routine testing was being completed on the fire equipment and periodic training was in place, information was lacking to demonstrate that staff attend a fire drill every six months. All staff attended an annual fire-training lecture. Ashclyst DS0000003390.V291405.R01.S.doc Version 5.1 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 2 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 1 25 2 26 2 27 2 28 2 29 2 30 1 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 3 3 2 X Ashclyst DS0000003390.V291405.R01.S.doc Version 5.1 Page 27 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 YA1 Regulation 5 Schedule 1 16 (2) (i) 13 (2) 23 (2) (b) Requirement To amend the service user guide to ensure that information relating to the legislation is clear in relation to the Care Home’s Regulations. To ensure residents are provided with a nutritious and varied meal. To ensure that all staff follow the instructions as detailed by the prescribing doctor. To provide the CSCI a plan to ensure that a complete refurbishment of the fabric of the building is undertaken both internally and externally within the next twelve months. (Outstanding Requirement 01/03/06) The home needs better continence management relating to laundry and sluicing facilities. (Outstanding requirement from 01/03/06) The home must be kept clean at all times. To ensure that all staff attend a fire drill within seven days and thereafter once in a six month period. DS0000003390.V291405.R01.S.doc Timescale for action 03/08/06 2 3 4 YA17 YA20 YA24 03/05/06 03/05/06 03/06/06 5 YA30 23 (2) (k) 20/06/06 6 7 YA30 YA42 23 (2) (d) 23 (4) (e) 03/05/06 10/05/06 Ashclyst Version 5.1 Page 28 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 YA6 YA24 YA30 Good Practice Recommendations For all care documentation to be dated and signed by a member of staff. For the staff team to re-evaluate the environment to provide a more homely atmosphere. For the home to re-introduce cleaning schedules which balance meeting the needs of the residents, consideration to be taken to employ a domestic so as not to detract from the range of activities that are available to the residents. Ashclyst DS0000003390.V291405.R01.S.doc Version 5.1 Page 29 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 Ashclyst DS0000003390.V291405.R01.S.doc Version 5.1 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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