CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE
Ashcroft Ashcroft 1 Wiggie Lane Redhill Surrey RH1 2HJ Lead Inspector
Lisa Johnson Unannounced Inspection 22nd November 2005 1:30 X10029.doc Version 1.40 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 Ashcroft DS0000013557.V265506.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 Older People and 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. Ashcroft DS0000013557.V265506.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Ashcroft Address Ashcroft 1 Wiggie Lane Redhill Surrey RH1 2HJ 01737 789656 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) Mr Roopesh Ramful Mrs Aruna Devi Ramful Care Home 5 Category(ies) of Learning disability (5), Learning disability over registration, with number 65 years of age (5) of places Ashcroft DS0000013557.V265506.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. The total maximum number of persons to be accommodated must not exceed five Persons in the category (LD) Learning Disability must be aged over 40 years 18th July 2005 Date of last inspection 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 accommodation 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 DS0000013557.V265506.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the homes third inspection carried out in 2005/2006. One inspector carried out the unannounced inspection over three and half hours. A previous additional inspection had been carried out by the inspector to look at immediate requirements that had been made and copy of this report is available by contacting the Surrey Commission for Social Care Inspection office. The focus of this inspection was to review any requirements made at the last inspection and to look at other required standards. Care plans, policies and procedures and other required documents were sampled. The inspector spoke to three service users who live in the home and spoke to the responsible individual and registered manager. The inspector would like to thank the service users and staff for their hospitality and cooperation in carrying out this inspection. What the service does well: What has improved since the last inspection?
An immediate requirement was made at the previous inspection that one service user must not be left in the home without adequate staff support and risk assessment completed. Staff are now present in the home at all times which was confirmed by a service user spoken to. Requirements were made at the previous inspections in respect of staff recruitment and practices. One staff member required two references on her personal file, however this staff member is no longer employed in the home.
Ashcroft DS0000013557.V265506.R01.S.doc Version 5.0 Page 6 During the additional inspection visit an immediate requirement was made regarding two new members of staff employed in the in the home and it was clear from the duty rota that one staff member was working unsupervised without a returned police check and another staff member didn’t have all their references available. The police check has now been completed and was available for inspection. Two references were available for one person. A previous requirement was made that all changes to the duty rota and the hours worked by the sleep in staff must be recorded on the duty rota. This has now been completed. An updated copy of the local authority protection of vulnerable adult policy has been obtained. Fridge temperatures are now being recorded to ensure safe food storage practices. Medication records were examined and the registered manager has responded to the recommendation in respect of the medication cards being dated and signed when medication is transcribed on the records. What they could do better:
One reference was missing from one staff personal file and identification photographs were not present. A further requirement was made to ensure that this standard is fully met. This is to ensure that service users are protected by the homes recruitments policies and practices. A requirement was made that a photograph should be made available with each service users care plan and individuals should sign their care plans. This is to ensure that care plans are drawn up and agreed with the involvement with service users. A requirement was made that the registered manager should attend the local authority protection of vulnerable adult training. This is to ensure that knowledge is acquired to protect service users from abuse. A requirement was made that a broken window handle should be replaced in one bedroom and that some rubbish that was stored in the front garden. This is to ensure that service users have a safe, well-maintained home to live in. A further requirement was made that records must be kept up-to-date when alarm checks have taken place. This is to ensure the health, safety and welfare of service users is protected. Risk plans for service users were in place, however a recommendation was made that these should be updated.
Ashcroft DS0000013557.V265506.R01.S.doc Version 5.0 Page 7 The home is currently attempting to recruit staff and a strong recommendation was made that the present staffing levels should be reviewed before any more service users are admitted into to the home, as there are two vacancies. Training records were in place, however a recommendation was made that records are kept up-to-date Financial records were sampled and accounts were available but the most up to date records were with the responsible individuals accountant. A recommendation was made that the latest accounts should be made available to the Commission for Social Care Inspection for sampling. 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 DS0000013557.V265506.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Ashcroft DS0000013557.V265506.R01.S.doc Version 5.0 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed on this inspection EVIDENCE: For information on these standards please refer to the report 18th July 2005. Ashcroft DS0000013557.V265506.R01.S.doc Version 5.0 Page 10 Health and Personal Care
The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards to be inspected at least once during a 12 month period JUDGEMENT – we looked at outcomes for the following standard(s): 7&9 Each resident is provided with a completed care plan that is based on assessment. The home is able to demonstrate that goal plans are reviewed. The home needs to ensure that service users agree to their personal goals. EVIDENCE: Care plans were sampled and found to include personal goals for service users with regular reviews taking place. Care plans were detailed and risk assessments were completed. However a requirement was made that service users should agree and sign their plan and a photograph of each service user must be also be made available.
Ashcroft DS0000013557.V265506.R01.S.doc Version 5.0 Page 11 Risk assessments had been signed in consultation with service users but a recommendation was made that these plans must be updated. Medication and administration records were sampled and the manager has responded to the recommendation from the previous inspection ensuring that cards are signed and dated when prescriptions are transcribed on to the medication and administration records. Ashcroft DS0000013557.V265506.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) 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 & 14 The home supports service users to maintain independent living skills. Service users take part in fulfilling activities and participate in the local community. Service users engage in a range of leisure activities and are supported to exercise choice. EVIDENCE: It was clear that service users have a range of activities and interests. One service user spoken to has a job and another service user attends a daycentre fulltime. One service user stated that he goes to church.
Ashcroft DS0000013557.V265506.R01.S.doc Version 5.0 Page 13 All service users have been away on holiday this year. During the inspection service users were observed to be involved in tasks in the home such as laying the tables and clearing up. One service user said, “ I like to help with jobs in the house and I like to go shopping”. Two service users said they could choose their breakfast and go to the kitchen and make it. Choices of meals are provided based on individual preferences. One service user was seen to have facilities in his room for making drinks. Ashcroft DS0000013557.V265506.R01.S.doc Version 5.0 Page 14 Complaints and Protection
The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 17 & 18 The rights of service users are protected. Policies and procedures are in place that ensures that service users are protected from abuse. The home manager needs to attend training in respect of safeguarding vulnerable adults. EVIDENCE: Service users are on the electoral role and one service user spoken to chose not participate in the election process. Two service users have their own keys for their bedrooms. The home has acquired an updated copy of the local authority protection of vulnerable adults policy and a whistle blowing policy is available. The manager has attended training on the Protection of vulnerable adults. However a requirement was made that she attends the local authority protection of vulnerable adult training to ensure that all information is acquired. This is to ensure that service users are protected from abuse. Ashcroft DS0000013557.V265506.R01.S.doc Version 5.0 Page 15 Environment
The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25 & 26 The home is able to demonstrate that service users live in a pleasant and wellmaintained home. The home is clean and hygienic. Two minor matters were identified as requiring action in respect of the premesis. EVIDENCE: The home is in close proximity to redhill Town centre and externally the home is maintained in good decorative order, which is in keeping with the local community. However a requirement was made that some rubbish stored in the front garden needs to be removed.
Ashcroft DS0000013557.V265506.R01.S.doc Version 5.0 Page 16 The home provides service users with a homely place to live. The home is generally well decorated. However a requirement was made that a window handle is replaced in one bedroom so that the window can be shut properly. This is to ensure that service users have a comfortable and pleasant home to live in. Emergency lighting is provided and the home was adequately ventilated. The home was cleaned to a good standard and was hygienic. Ashcroft DS0000013557.V265506.R01.S.doc Version 5.0 Page 17 Staffing
The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 & 30 Adequate staffing levels are in place but the home should review its staffing levels before the occupancy of service users is increased. The home needs to ensure that all the required information is made available on staff files to ensure that service users are protected by the homes policies and practices. EVIDENCE: The duty rota was examined and now states the times that staff are working including the sleep-in duty. There are currently three service users in the house who are fairly independent and the home has two vacancies. Four staff are employed and the home is attempting to recruit additional staff. It is strongly recommended that the home should review its staffing levels and recruit staff before the homes occupancy is increased. This is to ensure that there are appropriate numbers of staff to meet the service users needs. Some progress has been made to complete the information required on staff files. However one file sampled still had one reference missing which the manager is currently pursuing and did not contain any means of identification.
Ashcroft DS0000013557.V265506.R01.S.doc Version 5.0 Page 18 A further requirement was made that this information is obtained to ensure that service users are protected by the homes recruitment practices. Training records were sampled and a recommendation was made that the training schedule be updated for all staff. Ashcroft DS0000013557.V265506.R01.S.doc Version 5.0 Page 19 Management and Administration
The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34,35 & 38 Service users are safeguarded by the accounting and financial procedures of the home. The home needs to ensure that records are maintained of all health and safety checks in the home. EVIDENCE: Ashcroft DS0000013557.V265506.R01.S.doc Version 5.0 Page 20 The responsible individual produces a business plan and accounts are maintained which were sampled. However a recommendation was made that the responsible individual makes the up-to-date plan for the current year available to the Commission for Social Care Inspection. At the time of the inspection the accountant was reviewing these. Adequate insurance cover is in place. Service users have their own bank accounts. One service user manages his own money. Records were sampled for one service users expenditure and balances were recorded appropriately. The homes accident book was sampled and no accidents have been recorded since the previous inspection. Maintenance records were examined such as emergency lighting and electrical testing. Fire records were sampled. Fire drills and equipment checks are up to date and all records were maintained appropriately. Fire alarms are checked weekly but there were some omissions in recording the dates. A requirement was made that these must be recorded in the fire book. This is to ensure the health, safety and welfare of service users. Ashcroft DS0000013557.V265506.R01.S.doc Version 5.0 Page 21 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 Standard No Score 1 X 2 X 3 X 4 X 5 X 6 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 ENVIRONMENT Standard No Score 19 2 20 X 21 X 22 X 23 X 24 X 25 3 26 3 STAFFING Standard No Score 27 3 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 X 32 X 33 X 34 3 35 3 36 X 37 X 38 2 Ashcroft DS0000013557.V265506.R01.S.doc Version 5.0 Page 22 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 OP7 Regulation 15 (2)(a)(b) Requirement A photograph must be made available with service users plans and where possible plans are to be signed by service users. This is to ensure that service users are consulted and agree their plan where a service user is unable to sign, this should be indicated in the plan. The registered manager must ensure that the rubbish in the front garden is removed. This is to ensure that service users have access to well maintained garden The manager must ensure that a broken window handle in one bedroom is repaired so that the window can be closed adequately. The registered manager must attend the local authority protection of vulnerable adult training. This is to ensure that information is acquired to protect service users from abuse. The registered manager must ensure that one missing reference for one staff member is obtained and that all staff files contain copies ofidentification
DS0000013557.V265506.R01.S.doc Timescale for action 22/12/05 2 OP19 23 (2)(b) 22/12/05 3 OP19 23(2)(b) 06/12/05 4 OP18 13 (6) 22/02/06 5 OP29 19 (5)(c) Schedule 2 06/12/05 Ashcroft Version 5.0 Page 23 6 38 23 (4) (a) such as a passport and birth certificate. The registered manager must ensure that up to date records are maintained when the fire alarm is tested. 29/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3. 4 Refer to Standard OP7 OP27 OP 30 OP34 Good Practice Recommendations The registered manager should consider updating service users risk assessments. It is strongly recommended that the registered manager should consider reviewing and recruiting more staff before the home increases its occupancy. The registered manager should consider updating the staff-training schedule The registered manager should supply the updated financial accounts of the home to the Commission for Social Care Inspection for sampling at the next inspection. Ashcroft DS0000013557.V265506.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Surrey Area Office 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 DS0000013557.V265506.R01.S.doc Version 5.0 Page 25 - 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!
