Inspection on 18/07/05 for Ashcroft

This inspection was carried out on 18th July 2005.

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

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

Other inspections for this house

Ashcroft 10/12/08

Ashcroft 09/01/08

Ashcroft 23/04/07

Ashcroft 03/07/06

Ashcroft 22/11/05

Ashcroft 27/04/05

Ashcroft 31/08/04

Ashcroft 20/05/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

1 Marten Road

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

CARE HOMES FOR OLDER PEOPLE Ashcroft 1 Wiggie Lane Redhill Surrey RH1 2HJ Lead Inspector Lisa Johnson Unannounced 18 July 2005 11:45 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. 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. Ashcroft H58 s13557 Ashcroft v221149 180705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Ashcroft Address 1 Wiggie Lane Redhill Surrey RH1 2HJ 01737 789656 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Roopesh Ramful Mrs Aruna Devi Ramful Care Home 5 Category(ies) of LD(E) Learning Disability - over 65 (5) registration, with number of places Ashcroft H58 s13557 Ashcroft v221149 180705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The total number of persons to be accommodated must not exceed five. 2. Persons in the category (LD) Learning Disability must be aged over 40 years. Date of last inspection 31 August 2004 Brief Description of the Service: Ashcroft is a semi detached house situated in a residential area in Redhill Surrey and is close to local amenities. The service provides accomodation to five adults with learning disabilities. All the service users have single occupancy bedrooms, which are arranged over two floors. The home has a communal sitting room, separate dining room and large kitchen with a breakfast bar. There is a small garden to the rear of the house and parking is available at the front. Ashcroft H58 s13557 Ashcroft v221149 180705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes first inspection carried out in 2005/2006. One inspector carried out the unannounced inspection over three and half hours. The main focus of the inspection was to review requirements made at the last inspection. A tour of the premises took place and care plans, policies and procedures and other required documents were sampled. The inspector spoke to three service users who live in the home and also spoke to the responsible Individual and registered manager. The inspector would like to thank the service users and staff for their cooperation in carrying out this inspection. What the service does well: What has improved since the last inspection? At the last inspection a requirement was made that police checks were made available on staff personnel files and this has now been completed. Ashcroft H58 s13557 Ashcroft v221149 180705 Stage 4.doc Version 1.40 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ashcroft H58 s13557 Ashcroft v221149 180705 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Ashcroft H58 s13557 Ashcroft v221149 180705 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 4, & 5 The home provides adequate information to enable prospective service users that decide whether they wish to live there. Individual contracts were in place. Pre admission assessments are completed and the home is able to accommodate visits and trial stays in the home. EVIDENCE: The home has a comprehensive Statement of purpose, which clearly states the services and facilities that the home is able to offer. A service user guide is made available to all of the service users. Pre admission assessments were undertaken and the home is able to accommodate visits and trial visits to assess the suitability of the home. Individual contracts were in place in the form of a statement of terms and conditions. Ashcroft H58 s13557 Ashcroft v221149 180705 Stage 4.doc Version 1.40 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 &10 The health, personal and social needs of service users were set out in an individual plan based on assessment. Risk assessments need to be implemented for residents left unsupervised in the home for any period of time to ensure that their welfare and safety is protected. Outcomes of risk assessments should be agreed with the service user, their representatives and significant others and recorded in the individuals care plan. Service users where appropriate are responsible for their own medication and policies and procedures are implemented. EVIDENCE: Each individual has a care plan in place and a key worker system is facilitated. Health, personal and the social care needs of service users were recorded. It was evident that care plans are reviewed on a regular basis. Each individual is registered with a local GP and dentist and one service user visits the doctor independently with monitoring. Although there were risk assessments in place, one had not been implemented for one service user who was left alone in the home at lunchtime. On the day of the inspection an immediate requirement was made that adequate staffing levels be maintained across the twenty-four hour period and that any proposals to leave a service user unsupervised in the home be reviewed urgently. This must be completed Ashcroft H58 s13557 Ashcroft v221149 180705 Stage 4.doc Version 1.40 Page 10 immediately in consultation with the service user, representative and care manager to promote and protect the welfare of service users. The outcome of this assessment must be recorded in the individuals care plan and this to be made available to the Commission for Social Care Inspection. A medication policy is available and records were sampled. A recommendation was made in respect of one medication card that was found to have a date and signature missing when it was transcribed on to the medication and administration record. One service user administers his own medication and appropriate records were implemented. Service users confirmed that their privacy is maintained when in their rooms. An accident /incident book is in place and no accidents were recorde since the previous inspection. Ashcroft H58 s13557 Ashcroft v221149 180705 Stage 4.doc Version 1.40 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 Service users were offered a range of recreational activities and are supported to exercise choice and control over their lives. Residents were able to maintain links with the local community as they so wish. EVIDENCE: All service users plans included an activity programme based on the needs and wishes of individual preferences. One service user holds a job in a charity shop and one service user attends a local day centre full-time. One service user attends the local church and one service user spoke about his pending holiday to Butlins. Service users were observed to have a range of interests and had televisions and collections of videos and CDs. It was clear that the home supports service users to make choices and to maintain maximum independence. Two service users spoken to go out and about in the local community and use the local buses to go out shopping. Service users were observed to be helping themselves to drinks in the kitchen and were undertaking household tasks. One service user was undertaking ironing in his room, which he said that he enjoyed. Another service user stated that he likes watering the garden. Service users are supported to take care of their bedrooms and keep them clean. Ashcroft H58 s13557 Ashcroft v221149 180705 Stage 4.doc Version 1.40 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18 The home is able to demonstrate that it has an accessible complaints procedure in place. Policies and procedures were in place to ensure that service users are protected from abuse. EVIDENCE: An adequate complaint procedure was in place and is accessible and a copy is maintained in the homes statement of purpose. There have been no complaints received since the last inspection. Evidence was available that staff receive adult protection training and the responsible individual and manager have attended the local authority training. However the home needs to obtain the updated version of the local authority protection of vulnerable adult procedure. This will ensure that the safety of service users will be promoted and protected. Ashcroft H58 s13557 Ashcroft v221149 180705 Stage 4.doc Version 1.40 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20,21, 23,24,25 & 26 Service users live in a well maintained home that is clean and hygienic. Service users live in well furnished and comfortable bedrooms with their own possessions around them. EVIDENCE: The home presents a homely atmosphere and was clean and hygienic. There is a comfortable lounge and separate dining room which were decorated and well furnished to a good standard. The kitchen was well maintained, hygienic and food was found to be stored adequately. There are ample bathrooms and toilets which are accessible to service users. Bedrooms were spacious, decorated and well furnished. Service users had a range of personal possessions around them, which reflected their individual interests and tastes. Lockable facilities were in place. There are small garden areas to the front and rear of the house which were adequately maintained. Ashcroft H58 s13557 Ashcroft v221149 180705 Stage 4.doc Version 1.40 Page 14 Ashcroft H58 s13557 Ashcroft v221149 180705 Stage 4.doc Version 1.40 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 & 30 The home needs to ensure that adequate staff are on duty and that an accurate record is maintained of the working hours of staff to ensure that the numbers of staff on duty meets service users needs. The home provides adequate training and development for staff to ensure that they are competent to carry out their job. The service needs to ensure that all information is available on staff files to ensure that service users are protected by the homes policies and procedures. EVIDENCE: On arrival, the inspector noted that there was no staff on duty in the building and that one service user was at the home unsupervised. It was later reported that the member of staff was out collecting another service user from an activity and that it was practice to leave one individual in the home unsupervised for a short period at lunchtime. Requirements have been made in respect of this matter. It was reported that in general as well as the responsible individual and registered manager the home employs three other part time staff. The registered individual stated that as there are three service users living in the home at the present time one staff is available during the day and one sleep in staff at night time with an on call system in place. If the home admits two other service users then the level is increased to two staff during the day and one waking night staff at nighttime. The duty rota was sampled and did not indicate as to what time the sleep in member of staff begins and ends their shift. An immediate requirement was made that shift times and any changes to shifts must be recorded on the rota. Ashcroft H58 s13557 Ashcroft v221149 180705 Stage 4.doc Version 1.40 Page 16 Two staff personnel files were sampled and required documentation was in place except that one staff member had only one reference in place. The registered individual stated that he had requested that he had obtained a verbal reference in the interim but this could not be located. An immediate requirement was made that two references should be made available to ensure that service users are protected by the homes recruitment policy and practices. Staff training records were sampled. Mandatory training has been completed including fire prevention, health and safety, food hygiene, infection control and protection of vulnerable adults. An induction programme is in place for new staff and this was sampled with new staff receiving appropriate training to meet TOPPS specifications. Ashcroft H58 s13557 Ashcroft v221149 180705 Stage 4.doc Version 1.40 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 36, 37 & 38 The manager has adequate experience and appropriate training to manage the home. A quality assurance system is in place based on feedback from service users to ensure that the home is run in the best interest of service users. Regular staff supervision is taking place. Policies and procedures are in place, but the home needs to adhere to food hygiene legislation to protect the health, safety and welfare of service users. EVIDENCE: The home manager has experience of working with adults who have learning disabilities and is currently completing the Registered Managers Award and has undertaken training to update her knowledge. The home has implemented a quality assurance system by the way of questionnaires to obtain feedback. The questionnaires were sampled and were satisfactory and evidence was seen that these have been updated. Ashcroft H58 s13557 Ashcroft v221149 180705 Stage 4.doc Version 1.40 Page 18 Formal staff supervision was implemented and evidence was sampled which showed that regular supervision was taking place. Records were maintained safely and adequately and a procedure for confidentiality was in place. Other policies and procedures were sampled including fire safety, health and safety, accident, moving and handling and control of harmful substances, which were satisfactory. The responsible individual and manager are currently in the process of updating all of the policies and procedures. However an immediate requirement was made that fridge temperatures should be recorded daily as some gaps in records were observed, to adhere to food hygiene legislation and to promote the health, safety and welfare of service users. Ashcroft H58 s13557 Ashcroft v221149 180705 Stage 4.doc Version 1.40 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 x 3 3 3 3 STAFFING Standard No Score 27 1 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 3 x 3 x x 3 3 2 Ashcroft H58 s13557 Ashcroft v221149 180705 Stage 4.doc Version 1.40 Page 20 No 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 27 Regulation 13 (4)(b)(c) Requirement Timescale for action Immediate 18/7/05 2. 7 3. 27 4. 29 The registered manager must ensure thatadequate staffing levels are maintained in the home across twenty four hourperiod at all times. 13(4)(b)(c The registered manager must ) ensure that any proposals to leave a service user unsupervised for a short period of time are urgently reviewed in conjuction with the service user, their representative, care manager and significant others. Any decisions agreed must be recorded on the care plan and signed by those involved. A risk assessment must also be completed with respect to this matter. 18 (a) The start and finish times of all staff working in the home must be recorded on the duty rota to ensure that service users needs are met by the numbers of staff on duty. 17 (2) The registered manager must ensure that two references are available on staff personnel files in order that residents are protected by the homes recruitment policies and H58 s13557 Ashcroft v221149 180705 Stage 4.doc immediate 18/7/05 immediate 18/7/05 immediate 18/7/05 Ashcroft Version 1.40 Page 21 practices. 5. 6. 38 18 13 (3) 13 (6) The temperature of the fridge must be recorded daily to adhere to food hygeine regulations The registered manager must obtain the updated version of the local authority protection of vulnerable adult policy to ensure that the safety and welfare of service users is protected. immediate 18/7/05 1 month 18/8/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 9 Good Practice Recommendations It is recommended that the registered manager sign and date the medication administration record when prescriptions are transcribed on to medication records. Ashcroft H58 s13557 Ashcroft v221149 180705 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Ashcroft H58 s13557 Ashcroft v221149 180705 Stage 4.doc Version 1.40 Page 23 - 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!