Inspection on 05/04/07 for Ashcroft

This inspection was carried out on 5th April 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ashcroft 09/04/09

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

CARE HOME ADULTS 18-65 Ashcroft Milestone Lane Wicklewood Wymondham Norfolk NR18 9QL Lead Inspector Mrs Marilyn Fellingham Key Unannounced 5th April 2007 09:30 Ashcroft DS0000069868.V337410.R01.S.doc Version 5.2 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 DS0000069868.V337410.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 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 DS0000069868.V337410.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashcroft Address Milestone Lane Wicklewood Wymondham Norfolk NR18 9QL 01953 605191 01953 602732 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) www.break-charity.org BREAK Ms Julia Ann Allison Care Home 10 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (10), Physical disability (1) of places Ashcroft DS0000069868.V337410.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Ten (10) people with a mental disorder, excluding learning disability or dementia, may be accommodated. One (1) person with a physical disability may be accommodated. A maximum of two (2) mentally disordered people between the ages of 16 and 18 years may be accommodated within the overall total of the mentally disordered category. 5th April 2006 Date of last inspection Brief Description of the Service: Ashcroft is a residential home that is situated in the rural village of Wicklewood and comprises of a two-storey building with ten single bedrooms. Car parking is to the rear of the premises and there is a delightful secluded garden at the back of the house. The home accommodates up to ten women who have suffered severe enduring emotional distress and mental health problems. The home provides a rehabilitation programme that enables women to regain their independence and return to living in the community. It also offers respite care to those who require extra support from time to time that assists them to stay in the community. The home provides detailed information to prospective service users prior to admission. The range of fees charged by the home are £715 - £1575 per week, fees for women placed from outside of Norfolk are negotiated for each placement. Ashcroft DS0000069868.V337410.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection that took place unannounced over a period of nine and a half hours. The Inspector took the opportunity to interview the manager, her deputy members of staff on duty and a project leader. Only four service users were in residence on the day of inspection and the Inspector was able to speak with all four. Comment cards were received from all five service users. The Inspector was informed that the home had just changed ownership on the first of April. The focus of the inspection was to inspect all the key standards and to follow up the requirements that had been made at the last key inspection. What the service does well: An experienced team support the service users who feel safe in their hands. Ashcroft continues to provide a highly personal and therapeutic service to women with mental health needs. The staff team are very cohesive and are committed to providing a high standard of care and support to the women. This commitment allows the women to take control of their lives and be gradually supported to return to the community. The recent upheaval of change of ownership of the home has not impacted at all on the service and the staff are very positive about the changes being made. The home is committed to ensuring that it adheres to meeting the national Minimum Standards and has addressed all but one of the requirements made at the last key inspection. There is a good assessment process in place; care planning is good with appropriate use of all professional agencies. Ashcroft DS0000069868.V337410.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Ashcroft DS0000069868.V337410.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ashcroft DS0000069868.V337410.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is able to meet the assessed needs of sometimes very complex cases. EVIDENCE: Case tracking confirmed good practice; it also confirmed that the process for assessing the service user’s needs was done over a period of time. Five case files were sampled during the inspection, all three were found to contain a comprehensive needs assessment that had been completed prior to admission. Those service users who were spoken to felt that their needs were being met. Ashcroft DS0000069868.V337410.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users care plans reflect their assessed needs. They are encouraged to lead independent lifestyles. EVIDENCE: The Inspector examined five care plans; the assessment process had been used to formulate the plans of care that also covered other forms of intervention related to care. The care plans were detailed and related to the assessed needs of the service users. It was noted that there had been continued evaluation of care with updating according to the present health status of the individuals. There were very detailed daily notes and some data where appropriate had been entered on the plans of care. It was also noted that the service users were personally involved in the care planning process and this was confirmed by all four-service users that were in residence at the time of the inspection. Ashcroft DS0000069868.V337410.R01.S.doc Version 5.2 Page 10 Risk assessments were in place and the service users readily agreed that they were encouraged to take risks that were related to their move towards more independence. Ashcroft DS0000069868.V337410.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The service users are encouraged to be in control of their lives and enhance their social and educational skills whilst also developing personally. Meals are managed well. EVIDENCE: Discussion with the four service users confirmed that opportunities were given to encourage them in their personal development and educational needs. The home continues to offer numerous opportunities for their social and educational needs. The service users are also encouraged to make visits home and maintain links with friends. One service user was going to be visited by a friend on the day of inspection and another was being picked up by a bus to take them into the local town. The service users commented that the staff were very supportive and keen to help them in their personal development. Ashcroft DS0000069868.V337410.R01.S.doc Version 5.2 Page 12 Those staff spoken to are very aware of the service users needs and recognising the need for privacy and choice. The Inspector observed the interaction between all members of staff and noted it to be appropriate to the individuals and supportive in nature without being forceful. It was noted that the service users were offered a wide variety of food that appears nutritious; on the day of the inspection the service users were enjoying hot cross buns with their coffee that had been made by one of the service users. Ashcroft DS0000069868.V337410.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Medicines that enter the home are not recorded. EVIDENCE: Discussion with service users confirmed that they were well supported by the staff at all levels. Staff are aware of the policies and procedures for the handling and administration of medication and all have received training for giving medication. The Inspector was unable to do a spot check for medication to ensure that the amount of prescribed medication tallied with that, that had been recorded as given: however this could not be done because the home does not audit any medication that comes into the home. Regular meetings take place with the GP to discuss any medication issues and the local pharmacist continues to support the home. Ashcroft DS0000069868.V337410.R01.S.doc Version 5.2 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements for dealing with complaints is satisfactory. Service users are protected from abuse. EVIDENCE: The Inspector examined the records for complaints, these were detailed and contained notes on action taken in respect of all complaints. It was also noted that the responses to the complaints were dealt with, within the 28 days according to the home’s policy and procedures for making complaints. The Commission has not received any complaints since the last key inspection. Those staff spoken to were aware of the complaints procedure also all issues relating to the protection of vulnerable adults. Staff records confirmed that all staff members had attended training in the protection of vulnerable adults. The Inspector after discussion with the service users was satisfied that they felt that they could any concerns that they might have. Ashcroft DS0000069868.V337410.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users are provided with a homely and safe environment in which to live. EVIDENCE: A tour of the home took place both internally and externally. The Inspector found the external grounds most delightful with many areas for the service users to sit. A vegetable garden can be found to the rear of the house that produces vegetables that can be used by the home. As assessed during past inspections the facilities for the home remain unchanged and continue to offer a very homely and safe environment for the service users. Ashcroft DS0000069868.V337410.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The new change of ownership does not seem to have a negative effect on the staff or service users. A robust system is in place for recruitment. Service users benefit from the clarity of staff roles and responsibilities and also a cohesive staff team. They also benefit from staff support who are well supervised. EVIDENCE: Discussion with staff members confirmed that they felt very well supported and that they did not feel that the recent change of ownership of the home had impacted in any way on them or on the service users. The staff seen by the inspector felt that they had the necessary skills to meet the needs of the service users and that regular training continues to take place and records were seen for this. The staff felt that the provision of training opportunities in the home were good. Ashcroft DS0000069868.V337410.R01.S.doc Version 5.2 Page 17 Records for newly appointed staff were examined and were seen to contain appropriate proof of staff identity and reflected a robust checking system. One new staff member spoken to confirmed that they had had an induction and a record was seen for this. Staff appraisals have still not commenced and the manager explained that this was to the change of ownership of the home and hopefully would be commenced once all the new changes had taken place in relation to the provision of the new service. Although the appraisal system has not got off the ground the home has continued to provide formal supervision sessions and this was confirmed by the staff members who continued to find them useful. Ashcroft DS0000069868.V337410.R01.S.doc Version 5.2 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and staff benefit from a well managed home and continue to be safeguarded by its policies and procedures. EVIDENCE: Since the last key inspection the acting manger has been registered as the manager. The inspection process, discussion with staff and service users led the Inspector to form the opinion that the home is well run, the current manger is continually developing her skills in relation to the management of the home. Service users and staff have benefited from the leadership of the management and the manager and her deputy work well together. Ashcroft DS0000069868.V337410.R01.S.doc Version 5.2 Page 19 The manager has ensured that the home meets the National Minimum Standards and has recently put in place risk assessments for safe working practice and is hoping to appoint a new Health and Safety Officer for the home. It was noted by the Inspector that risk assessments are in place for falls and these are audited on a regular basis. Ashcroft DS0000069868.V337410.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 x LIFESTYLES Standard No Score 11 4 12 4 13 4 14 4 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 3 3 3 3 3 3 Ashcroft DS0000069868.V337410.R01.S.doc Version 5.2 Page 21 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 2 Standard YA20 YA36 Regulation 17 (1) (a) 18 Requirement All medicines that enter the home must be recorded. All staff must have an annual appraisal. This is a repeat requirement. Timescale for action 05/05/07 05/05/07 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 YA20 Good Practice Recommendations It is recommended for good practice that regular audits of medication takes place . Ashcroft DS0000069868.V337410.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 DS0000069868.V337410.R01.S.doc Version 5.2 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. 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