Inspection on 23/04/07 for Ashcroft

This inspection was carried out on 23rd April 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Ashcroft 10/12/08

Ashcroft 09/01/08

Ashcroft 03/07/06

Ashcroft 22/11/05

Ashcroft 18/07/05

Ashcroft 27/04/05

Ashcroft 31/08/04

Ashcroft 20/05/04

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Thorndene

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Southfields

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

CARE HOMES FOR OLDER PEOPLE Ashcroft Ashcroft 1 Wiggie Lane Redhill Surrey RH1 2HJ Lead Inspector Christine Bowman Unannounced Inspection 23rd April 2007 11:00 X10015.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.V333073.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 DS0000013557.V333073.R01.S.doc Version 5.2 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 (1), Learning disability over registration, with number 65 years of age (3), Mental disorder, excluding of places learning disability or dementia (1) Ashcroft DS0000013557.V333073.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The total maximum number of persons to be accommodated must not exceed five Persons accommodated in the category (LD) Learning Disability category must be aged over 40 years or over. 31st August 2006 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. The weekly fees range from £400-£500. Ashcroft DS0000013557.V333073.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit was conducted as part of a key inspection using the Commission’s ‘Inspecting for Better Lives’ (IBL) process. The site visit took place over six hours commencing at 11.00am and ending at 17.00pm and was undertaken by Ms Christine Bowman, regulation inspector. Mr Roopesh Ramful, the registered provider, was available in the morning and later in the day to assist in the inspection process. The registered manager, Mrs Aruna Ramful, was interviewed and all the residents were seen and spoken with as they came for their medication and to have lunch and went out to do the shopping. Two residents were interviewed and allowed the inspector to view their bedrooms. A tour of the shared accommodation was undertaken and the relative of one of the residents, who was visiting, gave their views. Since the previous key inspection, a random site visit had taken place to follow up on the requirements, which had been made, some of which had remained outstanding from the key inspection prior to that. At that time, a resident staying at the home on respite care did not have a care plan and the staffing numbers had not increased to accommodate them. The two new requirements made with respect to this situation no longer applied because the number of residents living at the home had returned to four. All the key standards for Older People were inspected with particular emphasis paid to the areas where requirements had been outstanding over two key inspection periods. An added category of need, included on the certificate, meant that some of the key standards for Younger Adults were also inspected. The Service User Guide, assessment documentation, care plans, risk assessments, medication records, and the complaints and compliments logs were viewed. A sample of staff personnel files was inspected including recruitment and individual induction, training records and rotas. Policies and procedures and a sample of health and safety records were viewed. Comment cards were left for residents and their relatives to complete. The inspector would like to thank the management, the staff and residents of Ashcroft for their assistance and hospitality on the day of the site visit and those who completed comment cards for their contribution to this report. Ashcroft DS0000013557.V333073.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The care planning process had improved. The residents had agreed and signed their care plans to ensure they were fully involved in the process. There had been improvement in respect of the administration of medication practises in the home. Secondary dispensing had ceased and the medication was obtained from a new chemist in blister packs. New medication administration cards had been implemented and the medication administered was now being signed for, indicating that the process was safer and all medication administered was recorded. The complaints procedure had been updated and was seen on display throughout the home to inform the residents and their relatives and representatives. The registered manager had attended the local authority safeguarding adults training to ensure that staff receive the appropriate knowledge and information to protect service users from abuse. Ashcroft DS0000013557.V333073.R01.S.doc Version 5.2 Page 7 Two members of staff were completing National Vocational Qualifications at Level 2, which means that the target of fifty percent of the care staff with a qualification will have been achieved and that the residents will be in safe hands. The shortfall in the recruitment procedure had been rectified and the missing reference supplied. This had been missing from the personnel file of a new member of the care staff at the last site visit and meant that the member of staff had taken up employment prior to the receipt of all the required checks, which are in place to protect the residents from harm. Two members of staff had accessed the safeguarding adults and moving and handling training to ensure they have the knowledge and skills to carry out the caring role. Policies and procedures had been reviewed to ensure the information with respect to the running of the home was up to date to inform the staff and the residents. Radiator covers had been supplied throughout the home to ensure the health and safety of the residents was protected. What they could do better: The lack of planning in the development of the service has led to the extending of the registration categories, which was reactive to a situation. The home did not have sufficient staff qualified and experienced in the original category of need or the new category to ensure the needs of the residents are met. The collection of pre-admission data should include information with respect to the cultural and spiritual needs and ethnicity of the resident to ensure the home is able to meet each individual’s needs. All resident’s individual needs must be assessed and the appropriate specialists should contribute to the care planning of those with mental health needs. There should be involvement from the Community Mental Health Team and a care programme approach to the planning of care should be used. The communal rooms should not be used for business purposes, restricting access to the residents who may wish to use them. Separate accommodation should be supplied for the staff for sleeping-in purposes and provision for confidential meetings and administration purposes to ensure confidential information is protected. Fire doors must not be wedged open because this is a safety hazard and could place residents in danger. Ashcroft DS0000013557.V333073.R01.S.doc Version 5.2 Page 8 A call bell system had not been installed although this requirement had been made at the key site visit, which took place on 27/04/06. This requirement was made with respect to bedrooms and bathrooms, particularly in relation to one individual who has mobility difficulties and likes to maintain their independence. The staffing arrangements were too flexible in favour of other responsibilities held by all the staff including the provider and the registered manager to offer the stability and commitment required in a registered care home. ‘All the staff employed at the home were part-time and were either mature students, or had other employment’, the provider stated. A requirement was made at the key site visit on 27/04/06 that an accurate record is maintained of all the hours worked by staff in the home. There were periods of time when staff members were working alone. The information on the staff rota must indicate the role and seniority of the staff members, the number of hours each staff member is employed to work, days off, holidays, sick leave and training days to ensure employment law is complied with and also to ensure that the needs of the residents are met as a priority. Responsibility for ensuring that the staff team has the training required to do the work rests with the registered persons. A training needs analysis should be undertaken and each staff member should have an individual development plan to ensure that the mandatory and specialist training has been accessed and is regularly updated. This also includes access to National Vocational Training. A requirement was made at the key site visit on 27/04/06 that fifty percent of the staff team should be completing National Vocational Qualifications at Level 2. The management must be proactive in this respect to ensure that care professionals care for the residents. The home should follow its own recruitment and selection policy to ensure that equal opportunity legislation is not breeched and so that the composition of the staff team is diverse and reflects the culture of the people who use the service. New staff must not be in post prior to the receipt of a clear Criminal Record Bureau (CRB) check unless a Protection of Vulnerable Adults First Check (POVA First) has already been carried out. Evidence must be provided to confirm that this check had been carried out if staff take up employment prior to the receipt of a CRB check. The application form must require staff to provide information with respect to former employment (a full employment history) and activities, gaps in employment and reasons for leaving posts where they were involved in caring for vulnerable people to protect the residents from harm. Ashcroft DS0000013557.V333073.R01.S.doc Version 5.2 Page 9 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ashcroft DS0000013557.V333073.R01.S.doc Version 5.2 Page 10 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 Outcomes Statutory Requirements Identified During the Inspection Ashcroft DS0000013557.V333073.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 3 & 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The emergency placement of a resident outside the category of need registered by the home and acceptance as a permanent resident with a change of certificate to include the new category has led to a wide spectrum of needs to be fulfilled by the home, with insufficient qualified and experienced staff. A pre-admission assessment form was in place for completion prior to the acceptance of new residents to provide information with respect to the prospective resident’s needs. The service does not provide intermediate care. EVIDENCE: An emergency placement taken by the home in the last year had increased the categories of need of the residents living in the home. There was no evidence to support the suitability of the placement for a resident with mental health needs and not assessed as having learning disabilities. Ashcroft DS0000013557.V333073.R01.S.doc Version 5.2 Page 12 The placement had become permanent which had led to the extending of the registration categories which was reactive to the situation and not a planned and considered development of the service with respect to the residents already living in the home or for prospective residents for whom the home could have provided appropriate services. The provider supplied evidence after the site visit to confirm that he had appropriate qualifications in mental health nursing and had recently attended training with respect to The Mental Health Act 1983 and one part-time support worker had also accessed some relevant training with regard to mental health needs through their other employment. There was no evidence that the staff had the qualifications or experience to work with people with learning disabilities or of the remainder of the staff understood mental health needs. The registered manager, when interviewed, did not have an understanding of the diagnosis, special needs or treatment plan of the resident with mental health needs. The pre-admission assessments viewed included the likes and dislikes of the prospective residents, social needs, activities, occupation and links with community as well as health and personal care needs. Ethnicity rather than nationality would be a more helpful category to include in the collection of pre-admission data and the cultural and spiritual needs of the residents had not been recorded to inform carers and to ensure the home is equipped to meet the individual’s needs. The provider stated that the home did not offer intermediate care placements. Ashcroft DS0000013557.V333073.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements had been made in ensuring residents and/or their representatives were fully involved in the care planning process, but omissions in the provision of specialist support and care planning with respect to mental health needs resulted in a shortfall in the fulfilment of residents’ needs. Residents are protected by the home’s medication policy and procedures and their privacy and dignity is respected. EVIDENCE: The care plans of two residents were sampled and both contained care plans, which had been kept under review and had been signed by the residents. This confirmed that the residents’ needs were being met and that the resident had been consulted with respect to the plan of care and had agreed its contents. A relative commented, ‘The home always meets the needs of my relative; when there was some concern about them managing the stairs in the past, the home was appropriately anxious that they were allocated a downstairs bedroom’. Ashcroft DS0000013557.V333073.R01.S.doc Version 5.2 Page 14 Residents’ files contained information with respect to the involvement of specialists such as the diabetes nurse and comprehensive advice including a full diabetes care plan to inform the care staff. Annual check-ups with general practitioners were recorded. Special dietary requirements were recorded on the care plan of one client with respect to their cultural and religious needs and wishes. The relative of one resident commented, ‘ My relative is encouraged in his involvement in the local church’. However, one resident, whose care plan restricted their access to the community with the exception of two afternoons per week when the second member of staff was allocated to support them, did not have specialist support from the Community Mental Health Team or a Care Programme Approach to the planning of their care. Since the site visit the provider had written to the General Practitioner with respect to specialist support for this resident and was awaiting the outcome. Some clients had undertaken risk assessments for the self-administration of medication and one resident stated that he, ‘takes care of his own medication.’ There had been improvement in respect of the administration of medication practises in the home. Secondary dispensing had ceased and the medication was obtained from a new chemist in blister packs. New medication administration cards had been implemented and the medication administered was now being signed for, indicating that the process was safer and all medication administered was recorded. Observations of the residents’ interactions with the manager and the provider, who were the only staff on duty at the time of the site visit, were respectful and polite. One resident stated, ‘they are the best people ever and they take good care of me.’ Ashcroft DS0000013557.V333073.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents choose their own lifestyles, maintain contacts in the community and are presented with a well-balanced diet, which meets their needs. EVIDENCE: ‘Would you like to see my photo album?’ one resident asked the inspector. The inspector was invited to view the photograph album in the resident’s bedroom, which was personalised, well furnished and comfortable. The provider had taken this resident on a holiday to his homeland of Mauritius and the resident had lots of photographs showing the good time they had experienced, staying in a hotel and having meals out in restaurants. This resident stated that they liked to travel and had aspirations to visit Canada also one day. Another resident also showed his photograph album to the inspector and shared some reminiscences of when they were able to maintain a garden. They also had pictures of trips to the seaside with the home. The provider confirmed that all residents have a holiday each year and Bognor Regis was the destination last year. One resident enjoyed art and showed his work to the inspector. Ashcroft DS0000013557.V333073.R01.S.doc Version 5.2 Page 16 Another resident stated that he liked to attend services at the church and was able to do this independently. The home was situated close to community facilities and shops and most of the residents were able to access these resources independently. The weekly activity plan of one resident included keeping their room clean and tidy, shopping, helping with cooking, watching the television and relaxation and two outings on weekday afternoons, accompanied by a staff member. Another resident attended a day centre for three days of the week and was supported to keep in contact with relatives. A relative was visiting on the day of the site visit and stated, ‘So far as I am aware the home supports the people to live the way they choose – My relative enjoys attending the local day centre and the home provides transport. Since he has been here my relative has been encouraged to learn some new skills, though his poor mobility means that he can’t use some of them now.’ One resident stated that, ‘the manager was a very good cook.’ A cooked meal was provided in the evening and at lunchtime residents were supported to access a variety of sandwiches and snacks. One resident stated, ‘the food is getting better’. The provider stated that the kitchen was locked when meals were not being prepared although the reason for this restriction was not recorded on the care plans viewed. The kitchen had been refurbished and was modern, well equipped and spacious. There was a separate dining room, where the residents could socialise whilst eating their meals. The home had acknowledged one resident’s cultural and religious needs with respect to diet. Ashcroft DS0000013557.V333073.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure, which has been updated to ensure that residents and their relatives/representatives have the appropriate information should they wish to raise a concern. Staff training in the protection of vulnerable adults has been accessed to ensure that the staff know how to protect the residents from abuse. EVIDENCE: The complaints procedure had been updated and was seen on display throughout the home to inform the residents and their relatives and representatives. A relative stated that, ‘the home has always responded appropriately when concerns had been raised. My relative developed mobility difficulties some years ago and the home responded and the concerns were resolved.’ There had been no recorded complaints since the previous key inspection. An invoice for the training of the registered manager in the local authority safeguarding adults training on 08/12/06 was shown to the inspector because there was no certificate in the file to confirm this training had taken place in order to ensure that the manager had received the appropriate knowledge and information to protect service users from abuse. Ashcroft DS0000013557.V333073.R01.S.doc Version 5.2 Page 18 The home had a copy of the local authority procedures to inform the staff of the action to take should a referral need to be made. Two members of staff had accessed training in the protection of vulnerable adults to ensure that they have the knowledge and skills to carry out their role in safeguarding the residents and protecting them from harm. There had been no referrals under the ‘Safeguarding Adults’ procedures since the previous key inspection. Ashcroft DS0000013557.V333073.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20, 24 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users live in a homely, pleasant, clean and hygienic environment, but shortfall in the installation of the call bell system, unsafe practices with respect to fire doors and the use of communal rooms for business could compromise the independence, safety and choice of the residents. EVIDENCE: A tour of the premises confirmed that this was a small family-scale home offering single rooms for up to five residents with access to shared bathroom facilities on both floors. The residents, whose bedrooms were viewed with their permission, stated they were happy with their bedrooms and had personalised them. There were only four residents at the time of the site visit and when the provider was asked to show the staff sleeping-in accommodation/office, the inspector was shown the bedroom that was not currently occupied by a resident. Ashcroft DS0000013557.V333073.R01.S.doc Version 5.2 Page 20 The provider stated that when the home was full, there would be waking night staff on duty because there was no place set aside for the staff to sleep. There was a small office attached to the laundry, which was detached from the home and confidential information was stored appropriately. The communal living accommodation consisted of a comfortable sitting room with television, video and DVD systems and a music centre, a dining room and a spacious, modern, well-equipped kitchen. The telephone used for the business was located in the sitting room and the fire doors leading to the entrance hall and to the other downstairs rooms were kept open with wedges. The provider removed them as soon as this was pointed out to him and he stated that a recent visit by the fire service had recommended the use of door guards, which he was in the process of ordering. The provider confirmed that supervision meetings took place in the office and that staff meetings were convened in the dining room, when the residents were not using it. Standard 22 was not fully inspected at this site visit, but the progress on a requirement, which had been ongoing since it was made at the site visit on 27/04/06, was assessed. On the day of the random inspection (31/08/06) the inspector was informed that a company had attended the home in respect of the call bells. However, a date for installation was to be confirmed. The manager was required to provide the Commission for Social Care Inspection (CSCI) with a date as to when this work was to be fully completed. This was to ensure that the residents have the specialist equipment they need to maximise their independence. The provider’s response to the improvement plan received by the CSCI on 17/01/07, was that ‘the call bell installation is still under progress. We were let down by a company who was meant to complete the installation of the call bell system in the home three months ago. Other quotations are being sought and it is hoped that the call bell installation will be done as soon as we get the compatible one for Ashcroft Home. In the meantime, although all the residents are independent, staff are encouraged to carry out routine checks on them at regular intervals’. This situation had still not been resolved by the present site visit, the provider stated that he had only been in touch with another company on the very morning of the site visit and was expecting a telephone call. The name of the company was confirmed, but no date was set to commence the work. The laundry was in a separate building with an independent door for access. The home was clean and fresh throughout. One resident took pride in keeping their bedroom clean and tidy and said they liked to, ‘vacuum the carpet and dust the furniture every day’. Ashcroft DS0000013557.V333073.R01.S.doc Version 5.2 Page 21 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 & 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Shortfalls in the resources available to support the staff and in the recruitment of a diverse and stable workforce, whose training needs are assessed to meet the needs of the residents and to complete the work required, leaves the residents unprotected and cared for by a workforce whose knowledge of their specialist needs is limited. EVIDENCE: ‘All the staff employed at the home were part-time and were either mature students, who were allowed to work 20 hours during term-time, or had other employment’, the provider stated. The situation was flexible and although a rota had been compiled, the provider stated that one staff member telephones him weekly to inform him of their shift availability. The provider also worked part-time for another agency, he stated, he completed administration work at the home, which was not recorded on the rota, and he also covered some shifts, which were. ‘The registered manager usually works in the home from 9.00am to 3.00pm during the week and sometimes stays a few extra hours to allow for providing social and recreational activities’, the provider stated, but she also had other responsibilities. There were periods of time when staff members were working alone. The information on the staff rota did not indicate the role and seniority of the staff members, the number of hours each staff member is employed to work, days off, holidays, sick leave and training days to ensure employment law is complied with and also to ensure that the needs of the residents are not just fitted around the needs of the staff. The Ashcroft DS0000013557.V333073.R01.S.doc Version 5.2 Page 22 provider confirmed that either the registered manager or himself were on call and would attend the home to deal with any emergencies. At the random site visit the inspector reported that two members of staff were completing National Vocational Qualifications at Level 2, which meant that the target of fifty percent of the care staff with a qualification would have been achieved and that the residents would be in safe hands. However, the letter in response to the improvement plan received by the CSCI on 17/01/07 stated, ‘I tried to get in touch with a training provider with a view to start NVQ 2 for staff members, unfortunately this training provider was fully booked. Have now liaised with training provider list from the Surrey Care Association. We are in the process of finalising whom to choose as the training provider and hopefully start the training as soon as possible’. The response of the provider when asked for an update with respect to the NVQ situation was that one member of staff, who is a college student, is completing the NVQ Level 2 as a student, and not as his employee. Another member of staff, who also has another occupation, will do the NVQ Level 2 with the other employer free of charge, a third member of staff, who does not work regularly at the home but completes occasional shifts, already has an NVQ at level 2 and a new member of staff, also a student, who, with the registered manager and the provider, makes up the full staff complement and works 20/25 hours, had not been enrolled yet because they were still on a six month trial period. The shortfall in the recruitment procedure, identified at the last key site visit, had been rectified and the missing reference supplied at the random visit. This had been missing from the personnel file of a new member of the care staff at the last site visit and meant that the member of staff had taken up employment prior to the receipt of all the required checks, which are in place to protect the residents from harm. At this site visit the most recently recruited member of staff had commenced employment prior to a Criminal Record Bureau (CRB) check having been returned. The provider stated that a Protection of Vulnerable Adults First (POVA First) check had been carried out, but there was no evidence to confirm this. He was advised to access the CRB website for advice on retaining and supplying evidence for inspection and on the storage and destruction of the CRB checks. The application form did not require a full employment history, so for someone who had only been in this country for two years, there was no evidence of a work permit, explanation of their activities, gaps in employment or reasons for leaving any posts held prior to that time. All this information is necessary to ensure that the residents are in safe hands. The home had a selection and recruitment policy and procedure and an equal opportunities policy but the provider stated that he did not need to advertise because potential staff approached him when vacancies arose. There was no evidence of interview notes held or of a selection process and there was little diversity in the staff team to reflect the culture of the residents. Ashcroft DS0000013557.V333073.R01.S.doc Version 5.2 Page 23 Two members of staff had accessed the safeguarding adults and moving and handling training to ensure that they have the knowledge and skills to carry out the caring role as confirmed by them at the random site visit and the provider wrote in his response to the improvement plan, ‘all the staff identified have now completed training on safeguarding adults and moving and handling. Personnel files inspected contained evidence that the mandatory training had taken place. The provider had accessed a course on The Mental Health Act and Capacity and was, himself, well-qualified and experienced in working with people with mental health and learning disability needs. Four staff members had received training on diabetes and attended a course on Death and Dying and Bereavement, but there was little evidence that the staff had the knowledge, experience or qualifications to deal with the specialist needs of the residents in terms of learning disability and mental health needs. However, one staff member had accessed some training with respect to mental health needs via their other employment. Personal development plans were not in place. There was no overall training plan recording the entire mandatory and specialist training requirements of the staff, showing when they received the training and dates recorded for updating to ensure that the staff team is trained to meet the collective needs of the residents. The personnel files were not in good order or bound to safeguard the confidential material contained in them and there was no audit sheet to indicate the contents. In order to professionalize the workforce, the provider must ensure that the staff team is equipped with the correct resources to do the work, including a private space for confidential meetings and for completing confidential documents, a private place to sleep for sleeping-in duties, secure storage for staff valuables and allocated time and resources to complete the National Vocational and other training. Since the site visit, the provider supplied copies of e-mails requesting information with respect to training for the staff to support residents with learning disability needs and NVQ at level 2. Ashcroft DS0000013557.V333073.R01.S.doc Version 5.2 Page 24 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 & 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The registered manager had not yet been enrolled on the required training to provide them with the knowledge and skill to discharge their duties and compliance dates had not been met with respect to some of the requirements made at the previous two key inspection site visits. Surveys confirmed that the residents thought the home was run in their best interests and their financial interests were safeguarded. The health, safety and welfare of the residents and staff was not always promoted. EVIDENCE: The inspector was not taken to view the small office on the tour of the premises. The provider later confirmed that it was attached to the laundry, which was a detached building in the garden. The provider stated that the office provided suitable accommodation for confidential supervision meetings and for the storage of confidential information with respect to the residents, Ashcroft DS0000013557.V333073.R01.S.doc Version 5.2 Page 25 the staff and the home. The resident’s dining room was used for staff meetings and other administrative purposes and books were stored there for the use of the staff. No IT equipment was provided in the home and the provider worked on documents at his home. The provider was asked if the staff had access to a computer to complete the required work for the National Vocational Award training and he stated that the local library could be used. The inspector had requested a space to work that would not intrude upon the day-to-day running of the home and where confidential documents could be viewed privately, and the provider stated that the sitting room could be used for these purposes. At the time both of the doors were wedged open and the room was effectively used as a corridor. The inspector was conscious of the fact that residents might want to access the sitting room, or that conversations of a confidential nature could be overheard. The business telephone was also located in this room. The provider stated that the residents preferred to remain in their bedrooms and closed the doors. There was also no lockable space provided for the staff to store their personal items whilst working in the home when a resident occupied the fifth bedroom. During the random inspection, which took place on 31/08/06, the inspector was informed that arrangements were in progress for the registered manager to recommence The Registered Manager’s Award in September 2006. This requirement had not been met from the previous site visit and another requirement was made that the CSCI must be informed when this training was to commence. This was to ensure that there is a qualified manager with the appropriate knowledge and skills to support the staff in the caring role and to manage the home in the best interests of the residents. The provider’s response to the improvement plan received by the CSCI on 17/01/07 stated, ‘I tried to get in touch with the training provider to continue with NVQ4 training for the registered person and with a view to start NVQ 2 for staff members. Unfortunately the training provider was fully booked. I have now liaised with training provider list provided by the Surrey Care Association. We are in the process of finalising whom to choose as the training provider and hopefully start the training as soon as possible’. This continued to be the case at the present site visit. Since the site visit, the provider sent copies of e-mails requesting RMA /NVQ 4 and NVQ 2 placements. The residents had completed quality assurance questionnaires, which confirmed that their views about the running of the home were sought. Standard 37 was not fully assessed but the progress on a requirement made at a previous key inspection was explored. Policies and procedures had an up to date review date, but they were not specific to the home and some policies referred to job titles, which did not exist in the home. Policies and procedures were not working documents containing local information to guide and instruct the staff of the actual working practice to be followed at Ashcroft. There was no record that the staff had read the policies and procedures. Ashcroft DS0000013557.V333073.R01.S.doc Version 5.2 Page 26 Radiator covers had been supplied throughout the home to ensure that the health and safety of the residents was protected. The certificate was viewed to confirm that legionella testing had taken place and a sample of health and safety checks viewed had been updated. The provider stated that the fire officer had visited and recommendations had been made, which he was in the process of attending to, including door guards for the doors leading from the sitting room, which had been wedged open. Ashcroft DS0000013557.V333073.R01.S.doc Version 5.2 Page 27 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X 2 X X X 3 STAFFING Standard No Score 27 1 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 3 3 X X 2 Ashcroft DS0000013557.V333073.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? Yes Ashcroft DS0000013557.V333073.R01.S.doc Version 5.2 Page 29 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 OP19 Regulation 23(3)(a) (i)(ii) (b) Requirement Suitable facilities, storage facilities, accommodation and sleeping accommodation must be supplied for the staff to enable them to carry out their duties. Call bells must be installed in all service users’ bedrooms. (Previous requirement 15/06/06 not met). (Previous requirement not met 03/09/06) The registered person must review the present staffing levels provided in the home based on the residential forum staffing guidance with the outcome to be submitted to the Commission for Social Care Inspection. Fifty percent of the staff team should be enrolled to complete the National Vocational Qualifications (Level 2). New staff must not take up employment until the results of satisfactory recruitment checks have been received to protect the residents. There must be sufficient, qualified, competent and DS0000013557.V333073.R01.S.doc Timescale for action 23/10/07 2. OP22 23(2)(n) 18/06/07 3. OP27 18(1)(a) 23/06/07 4. OP28 18(1) 23/06/07 5. OP29 19(4)(b) Schedule 2 25/04/07 6. OP30 18(1)(a)( b)(c)(i)(ii) 23/10/07 Ashcroft Version 5.2 Page 30 experienced staff employed at the home with respect to the assessed needs of the residents and in line with the Statement of Purpose. 7. OP38 10 (3) The registered person must complete the management National Vocational Qualification (Level 4) (previous requirement 03/08/06 not met) (previous requirement not met again 21/09/06) Admissions to the home should be through a planned process and prospective residents should be accepted according to the category of need the home is registered to provide care for. Proper provision must be made to ensure that the health and welfare of residents with a mental health need is met and community specialist support accessed. 23/06/07 8. YA2 14(1)(a)( d) 25/04/07 9. YA6 12(1)(a) 13(1)(b) 25/05/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP3 Good Practice Recommendations Pre-admission data should include information with respect to the cultural and spiritual needs and ethnicity of the resident. Ashcroft DS0000013557.V333073.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate Oxford Business Park South Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ashcroft DS0000013557.V333073.R01.S.doc Version 5.2 Page 32 - 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. 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