Inspection on 09/01/08 for Ashcroft

This inspection was carried out on 9th January 2008.

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

Other inspections for this house

Ashcroft 10/12/08

Ashcroft 23/04/07

Ashcroft 03/07/06

Ashcroft 22/11/05

Ashcroft 18/07/05

Ashcroft 27/04/05

Ashcroft 31/08/04

Ashcroft 20/05/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

1 Marten Road

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

CARE HOMES FOR OLDER PEOPLE Ashcroft Ashcroft 1 Wiggie Lane Redhill Surrey RH1 2HJ Lead Inspector Jane Jewell Unannounced Inspection 12:00a 9 January 2008 th 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.V344043.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.V344043.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.V344043.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. 23rd April 2007 Date of last inspection Brief Description of the Service: Ashcroft is a semi-detached domestic house situated in a residential area half a mile from Redhill town centre. The home provides care and accommodation for up to five people who have a learning disabilities or mental health past or present condition. Currently all residents are male and the majority are over sixty five years old. The home is presented across two floors with stairs providing access to the first floor. Resident’s accommodation consists of five single occupancy bedrooms. Communal space consists of a Kitchen, lounge and separate dinning room. There is a small rear garden. The homes literature states that it aims “to provide the highest quality of care to all service users and support them to lead a normal life as much as possible” The fees for residential care are currently £435 to £780 per week, depending on the services and facilities provided. Extra such as: newspapers, hairdressing, chiropody, transport , toiletries are additional costs. Ashcroft DS0000013557.V344043.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The information contained in this report has been assembled from an unannounced inspection undertaken over six and half hours and information gathered about the home including discussion with relatives. As part of the inspection process the manager had been asked to complete a Annual Quality Assurance Assessment form. This has not been completed and the manager will be required in future to complete this form as part of their statutory obligations under the Care Standards Act 2001 and amended regulations. The inspection was facilitated by Mr R Ramful (Registered Manager) and in part, by the deputy manager. The inspection involved a tour of the premises, observation, examination of records and discussion with residents and staff. There were five residents living at the home at the time of the inspection and all were consulted. The focus of the inspection was to look at the experiences of life at the home for people living there, this involved observing residents and their interactions with staff and examination of the homes facilities and documentation and the progress made towards meeting the outstanding requirements from the previous inspection. All of the key standards for Older People were inspected, as the primary support needs of most residents is due to older age. However, due to additional learning disabilities and mental health needs of the resident group some of the key standards for Younger adults were also inspected. These were standards 7 (Decision making ) 9 (Risk taking) 12 (Education and Occupation ) 13( community links and social inclusion) 14 (Leisure) and 15 (Relationships) which were discussed with the manager at the time of the inspection. In order that a balanced and thorough view of the home is obtained, this inspection report should be read in conjunction with the previous inspection reports. The Inspector would like to thank the residents and staff for their assistance and hospitality during the visit. What the service does well: Residents live in a clean and homely environment, which is decorated and maintained to a good standard. Resident’s private accommodation is personalised, safe and comfortable. Comments received regarding the environment include: “perfectly nice”; “comfortable”; “not exactly new furniture but comfortable” and “Very homely”. Resident’s lives are enriched by the promotion of independence, choice and being enabled to live their chosen lifestyle and by personal and health care Ashcroft DS0000013557.V344043.R01.S.doc Version 5.2 Page 6 support that is individual and which respects their privacy and dignity. Resident’s are supported to maintain relationships with their families and friends. The home balances the rights of residents to take reasonable risks as part of an independent lifestyle. Residents spoke positively about their experiences at the home and a sample of their comments include: “alright no complaints”; “ best bit about the home is that they look after me”. Relatives consulted with also spoke positively about the home with particular reference to the improvements in personal development their relatives had made since the current owners had managed the home. A sample of comments made by relatives included: “I knew the minute we visited that it was the home he needed” and “he is more at ease at this home and has the freedom to move around and they do encourage him to do things around the home” Resident’s spoke positively about the food and how they are provided with choices, a resident commented “alright if you don’t like something they get you something else” . Residents’ benefit from a stable, and enthusiastic staff team that know them. A sample of comments from residents about staff include: “always someone here, very helpful”; “very caring very professional live by the book”; “they are very patient with the more confused residents” and “Staff outstanding patient skilled and compassionate”. The home is very relaxed and quiet which suites the lifestyles of the current residents. What has improved since the last inspection? What they could do better: Prospective residents need to have access to a range of up to date information about the home. This is in order to help them make informed choices about whether to live at the home and their rights and responsibilities whilst residing at the home. Ashcroft DS0000013557.V344043.R01.S.doc Version 5.2 Page 7 Staff need to have clear guidance on the specialist needs of some residents in order to ensure that their needs are being met in a consistent manner in accordance with their preferences and wishes. Staff training must be better organised to ensure that staff all receive the mandatory and specialist training necessary to meet the needs of residents and for staff to be able to work safely with residents. Staffing levels at the weekend must be reviewed to ensure that there is sufficient staff on duty to enable residents who are not able to go out independently to have the opportunity to go out with the support of staff. There needs to be a system in place for the home to receive feedback on the quality of its services. This is so the home is able to critically evaluate its own performance in order to identify any areas for service improvement or to inform future service developments. Residents, staff and visitors health and safety needs to be further supported by ensuring that all of the necessary health and safety checks are undertaken. The management of the home needs to provider a clearer sense of leadership and direction in order to ensure standards are consistently maintained and their legal responsibilities met. 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.V344043.R01.S.doc Version 5.2 Page 8 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.V344043.R01.S.doc Version 5.2 Page 9 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): 1 2 3 4 and 5 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Prospective residents do not have access to a range of up to date information about the home to help them make informed choices about whether to live at the home. Prospective residents are assessed to help ensure that the home admits only those residents who’s needs can be safely met at the home. EVIDENCE: There is some information about the home and the services it provides, this includes a statement of purpose and service user guide, which were reported to be made available to prospective residents and their families. There is a need to include in this information details on the range of needs the home is able to meet and the terms and conditions of residency. This is to ensure that prospective residents and their representatives have the information they need to make an informed choice about whether to move to the home and existing Ashcroft DS0000013557.V344043.R01.S.doc Version 5.2 Page 10 residents are aware of their rights, roles and responsibilities whilst staying at the home. The manager agreed to review the service user guide to ensure that it is also in a more suitable format for ease of understanding. The manager said that residents are provided with a written contract of terms and conditions of residency with the home, which they or their representatives have signed. The manager said that due to the confidential nature of these they are not stored at the home but stated that all residents or their representatives had signed a copy. A blank copy was instead examined and it was discussed that it must be updated to include all of the additional areas stated in the National Minimum standards. This is to ensure residents and their representatives are aware of the placement arrangements and to clarify mutual expectations around rights and responsibilities. Pre-admission documentation was viewed for a recent admission and information about the prospective residents needs had been gathered from a range of people including relevant health care professionals. This enabled the manager to collate much information about the resident in order to decide whether their needs could be met at the home. The manager stated that on this occasion they had not used the homes formal assessment documentation but instead made hand written notes. They agreed that in future it would be beneficial to use the formal assessment tool to ensure that all of the necessary information is collected. The manager demonstrated an understanding of the range of residents needs that could be safely met at the home and had in past declined referrals where it was assessed that needs could not be met. There is a range of residents needs being accommodated this includes some residents who have learning disabilities, and some residents who have mental health needs, with the majority of residents aged over 65years. The evidence seen indicates that although most needs of residents are being met, further minor work is needed to the care planning process and staff training to ensure that the full range of residents needs can be identified and met. This is discussed further on in this report. Residents spoke positively about their general experiences at the home and a sample of their comments include: “alright no complaints”; “really look after me well” and “ best bit about the home is that they look after me”. All relatives consulted with spoke positively about the home with particular reference to the improvements in personal development their relatives had made since the current owners had managed the home. A sample of comments made by relatives include: “Very homely”; “I knew the minute we visited that it was the home he needed” and “he is more at ease at this home and has the freedom to move around and they do encourage him to do things around the home” A newly admitted residents spoke of being provided with the opportunity to visit the home in advance to assess the quality, facilities and suitability of the home with their family and stayed for meals, and spoke of their admission to the home being relaxed. Ashcroft DS0000013557.V344043.R01.S.doc Version 5.2 Page 11 Intermediate care is not offered at the home therefore this standard is not assessed. Ashcroft DS0000013557.V344043.R01.S.doc Version 5.2 Page 12 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): 7 8 9 and 10 (Younger Adults standard 9- Risk taking and standard 7 -Decision making) Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Resident’s benefit from a care planning process, which provides staff with guidance on how to support them, further minor work is needed to them to ensure any specialist needs are identified and that they are being regularly updated. The homes practices promote choice for residents. The home balances well the rights of residents to take reasonable risks as part of an independent lifestyle. Residents receive input form health care professionals to help meet their health care needs. The system for the administration of medications are good with clear and comprehensive arrangement in place to ensure residents safety. Ashcroft DS0000013557.V344043.R01.S.doc Version 5.2 Page 13 EVIDENCE: Residents were encouraged to make decisions in their daily lives and were heard to be given choices by staff about where they wanted to go, what they wanted to eat and drink, and how they wanted to spend their day. Four individual plans of care were inspected and were found to contain guidance for staff to follow on the individual needs and preferred routines of each resident. Good practices were noted in the guidance provided on managing the anxieties for one resident. However, additional work has been required to the care planning process in order to ensure that there is a clear record of when care plans are being reviewed and that staff have the appropriate guidance to following on supporting residents mental health needs. Staff did demonstrated a good understanding of each residents needs and preferences. This knowledge must be supported by clear documentation in order to promote continuity. The standard of daily recording was noted to be good with a clear account of actions and events that had occurred. Residents consulted with expressed little or no interest in the development and review of their care plans, but felt that they could ask to see what is recorded about them at any time. The home tries to balance the rights of residents to take reasonable risk as part of an independent lifestyle against the risks faced and posed by themselves or others. This is supported through the written assessment of risks, however an example was noted whereby not all of the risks faced by a resident had been assessed with particular reference to them going out independently. The manager agreed to address this immediately. Records of medical intervention showed that residents receive input from a range of health care professionals including GP’s, district and specialist nurses. All residents consulted with felt that when they have requested medical intervention this has been sought promptly. A resident spoke of the support they receive from a specialist nurse in order that they can continue to manage independently a medical condition. The medicine administration practices observed were seen to be safe and the records demonstrated that systems have been established to ensure staff are appropriately trained and records are accurate and provide a history of what was given by who and when. However, in order to fully eliminate the associated risk when copying prescribed instructions onto medication administration records, it is recommended that these records should be checked and countersigned for accuracy by a second member of staff. During the inspection staff were seen to be respectful and considerate to residents and visitors. Staff were observed using residents preferred forms of Ashcroft DS0000013557.V344043.R01.S.doc Version 5.2 Page 14 address and knocking on bedroom doors prior to entering. Staff consulted with showed an understanding of good practices in preserving resident’s rights to privacy and dignity and were able to give examples of how they promote these rights in their every day care practices. A resident spoke of how staff helped them to maintain their dignity by gently encouraging them to wash and change clothes. Another resident said that “staff always knock on my door and they don’t talk about other residents in front of me” Ashcroft DS0000013557.V344043.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): 12 13 14 and 15 (Younger Adults standards: 12 -Education and occupation, Standard 14 Leisure, Standard 13- Community links and social inclusion, Standard 15 -Relationships) Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. Resident’s lives are enriched by the promotion of independence, choice and being enabled to live their chosen lifestyle. Staffing levels at the weekend do not always enable residents to go out with the support of staff. Resident’s benefit by being supported to maintain relationships with their families and friends. Resident’s spoke positively about the food and how they are provided with choices. EVIDENCE: Residents in the main make their own arrangements for occupation and stimulation as part of maintaining an independent lifestyle. Residents spoke of the support they received from staff to maintain their chosen lifestyles and interests. A resident said; “Culturally the staff are very knowledgeable about Ashcroft DS0000013557.V344043.R01.S.doc Version 5.2 Page 16 my background and are respectful”. A relative spoke of how supportive the home were in enabling their relative to visit their friends and the social/religious groups that they like to attend. Residents spoke of visiting day centres, church events and a local market where they undertook some voluntary work. All the residents consulted with felt that they were suitable occupied with a resident commenting: “I have enough things to do to keep me occupied I like going out by myself”. Another resident liked to watch TV and had sky television installed and said: “quite happy staying in my own room”. A resident spoke of an overseas holiday that they want on with the manager, while other residents went on holiday in the UK. The home has its own mini bus, which is used for individual and group activities. Currently it is only the manager and deputy who are able to use this. The manager spoke of extending this to the staff team to enable more outings to occur. The staffing structure at the weekends did not always enable sufficient staff on duty to be able to support those residents to go out who cannot do so independently. This is further discussed under standard 27. A relative spoke of the improvements in their relatives personal development and how much more talkative and expressive they are since living at the home. Visitors commented upon how welcomed they are made to feel during their stay, this included being offered beverages or meals and staff being friendly and approachable. A resident spoke of the importance of keeping in touch with family and friends through their mobile phone. The homes phone is currently located in the lounge and it was discussed with the manager ways of ensuring that residents privacy when using it or maintaining confidentiality when discussing other residents on the phone. The manager said that they would provide a portable phone to enable calls to be taken in private. Relatives consulted with all said that the home was good at keeping in touch with them and informing them of any changes in their relatives needs. Observation of the daily routines and discussion with residents confirm that staff accommodate resident’s personal wishes with regard to meal times, going to bed, rising and bathing. Staff were knowledgeable about the cultural, religious needs of residents. During the inspection residents were observed to move around the home choosing which room to be in and what level of company they wanted to enjoy with a residents saying: “ I can go to bed whenever I want and get myself a cup of tea”. Residents spoke positively about the food, a sample of their comments include: “alright if you don’t like something they get you something else” “not bad I am a bit fussy I make my own drinks”; “the kitchen is sometimes locked Ashcroft DS0000013557.V344043.R01.S.doc Version 5.2 Page 17 as another resident eats all the food but if I want to go in I just ask a member of staff for the key”; “very well taken care off with the food they always cater for what you want”. A resident spoke of cooking meals for some of the other residents. The record of resident’s food intake was very limited and therefore it could not be clearly established whether specialist’s diets were being catered for appropriately. The manager agreed to address this immediately to ensure that the records provided sufficient detail to determine whether diets are satisfactory, in relation to nutrition and variety. The provider/managers young children often visit the home and often stay for several hours at a time. All of the residents spoke of how much they enjoyed having the children at the home and that they never entered their private accommodation without their permission. Ashcroft DS0000013557.V344043.R01.S.doc Version 5.2 Page 18 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): 16 and 18 Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. An effective complaints procedure and appropriate adult protection policies protects the rights and interests of residents. EVIDENCE: There is a written accessible complaints procedure in place for residents, their representative and staff to follow should they be unhappy with any aspects of the service. All residents and relatives consulted with said that they were aware of how to raise any concerns and felt comfortable to do so and that where that have done so their concerns have been addressed promptly. The manager reported that there have no formal complaints made since the previous inspection. Residents have however raised minor concerns relating to some of the difficulties of communal living and these were reported by a resident to have been sorted out quickly. There are written policies covering safeguarding adults and whistle blowing. These make clear the vulnerability of people in residential care, and the duty of staff to report any concerns they may have to a responsible authority for investigation. The staff member consulted with, although had not yet undertaken safeguarding adult training demonstrated a good understanding of their roles and responsibilities in this area. Ashcroft DS0000013557.V344043.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): 19 20 21 22 24 25 and 26 Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. Residents live in a clean and homely environment, which is decorated and maintained to a good standard. Resident’s private accommodation is personalised, safe and comfortable. EVIDENCE: The home comprises of a converted domestic dwelling in a residential area on the outskirts of Redhill. Standards of maintenance were good with the manager reporting that the home is undergoing a gradual refurbishment. Since the previous inspection some bedrooms have been decorated and a bathroom which has been completed to a good standard. Much effort is made throughout the home to promote a domestic and homely feel. A sample of comments made about the environment included: “environment perfectly nice”; Ashcroft DS0000013557.V344043.R01.S.doc Version 5.2 Page 20 “comfortable”; homely”. “not exactly new furniture but comfortable” and “Very Communal space consists of a kitchen, lounge and separate dining room. The dinning room is used as an office/meeting/storage area. The manager was aware of the restricted communal space at the home and spoke of their plans to build a conservatory in the near future. There is a rear small garden, which was currently being used to store old furniture and was not inviting or safe for residents to use. Residents said that they only use the garden in the summer when it is usually clear of items. The manager agreed to ensure that the garden was safe and ready for use in warmer weather. It was previously required that the home provided suitable facilities for staff. Storage lockers have now been provided with the plan to make the conservatory a more private sleep-in are for staff. All residents consulted with liked their bedrooms. One resident spoke of their bedroom being due for redecoration and what colours they were choosing. Bedrooms were seen to be personalised in accordance with the individuals taste and preferences. Bedroom doors had been fitted with locks but none of the residents said they wanted a key. There are sufficient number of toilets and bathrooms located around the building, this includes two standard baths/showers, which all residents are assessed as able to use. The type of lock used on the down stairs bathroom did not support residents being able to maintain their privacy whilst also ensuring their safety by enabling the lock to be overridden in the event of an emergency. This is particularly important as several residents bath independently. The manager agreed to address this as a matter of priority. The home is not registered to admit residents with physical disabilities and the stairs and other access arrangements would make it unsuitable for people with significantly restricted mobility. In line with the previous requirement a call system has been installed throughout the home. This enables assistance to be summoned when pressed. A resident said : “not had to press it but I know what to do if I needed help” The home was found to be warm and comfortable, with good levels of light and ventilation. All parts of the home visited were observed to be cleaned to a high standard. A resident spoke of being responsible for cleaning his own room and how important this was to him. Ashcroft DS0000013557.V344043.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): 27 28 29 and 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents’ benefit from a stable, and enthusiastic staff team that know them. However further work is needed to improve the management of training to ensure that staff are suitable trained to work safely with residents. There is not always sufficient staff on duty at the weekend to ensure that residents who are not able to go out independently have regular opportunities to do go out. EVIDENCE: Staff, visitors and residents felt that there were sufficient numbers of staff on duty during the week for staff to undertake their roles in a timely manner and for residents to receive the support they needed, when they wanted it. However at weekends there is not always a cross over period where two staff are on duty at the same time, to enable those residents who are not able to go out independently to do so with staff. The manager has been required to ensure that the staffing levels at the weekend are reviewed to ensure that there is always sufficient staff on duty to meet the needs of residents. A sample of comments from residents about staff include: “not bad, a bit silly sometimes as they try and make me laugh”; “always someone here, staff very Ashcroft DS0000013557.V344043.R01.S.doc Version 5.2 Page 22 helpful”; “very caring very professional live by the book”; “they are very patient with the more confused residents” and “Staff outstanding patient skilled and compassionate”. Relatives spoke positively about the staff and their comments included: “always very nice and sensitive to his needs”; “very attentive” and “welcoming”. The staff on duty had a good rapport with residents, which promoted a relaxed atmosphere in the home and were knowledgeable on the individual needs and preferences of residents. The manager reported that staff who had previously undertaken a National Vocational Qualification (NVQ) had now left. Two staff out of the four employed are currently in the process of undertaking it, but this is on hold while their assessor is on long term leave. A new member of staff spoke about the local induction they had and how residents were actively involved in showing them where everything was. They had not yet undertaken the industry recommended minimum inductions standards “skills for care”. This is designed to help ensure that all new staff entering into the care industry have a minimum level of initial training. The manager said that they are in the process of obtaining copies of this ready for new staff to complete it within the recommended time scales. The majority of training is undertaken in house by the manager using a training guide, which involves videos, questionnaires and competency tests. In addition some external courses have recently been provided on mental health in addition to the mandatory areas of training. The records of training were disorganised and inaccurate and therefore it could not be clearly established that all staff had received the necessary training in order to work safely with residents. Furthermore there was no training and development plan for the home to identified the training needs of staff. In the absence of any clear evidence of the level and type of training undertaken by staff it has been required that staff receive the necessary training in order for them to be able to meet the needs of residents. It has also been recommended that a training and development plan be developed and that training records be better organised. The personal files of newly appointed staff were inspected and these showed that a recruitment process is followed which includes the use of an application form, interviews, Criminal Records Bureau (CRB) checks and written references prior to employment commencing. Copies of documents regarding staffs eligibility to work in the UK had not always been retained once seen as part of the recruitment process. The manager stated that although some copies had been taken, which staff confirmed, they could not be located at the time of inspection and that they would locate the copies taken. Ashcroft DS0000013557.V344043.R01.S.doc Version 5.2 Page 23 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): 31 33 35 36 and 38 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The manager is clearly well liked and respected, however they must provide a clearer sense of leadership and direction to ensure that standards are consistently maintained and their legal responsibilities met. There is currently not a system in place for the home to receive feedback on the quality of its services and to be able to critically evaluate its own performance The health, safety and welfare of residents and staff are generally promoted and protected however this must be further supported by ensuring that all of the necessary health and safety checks and documentation is undertaken. Ashcroft DS0000013557.V344043.R01.S.doc Version 5.2 Page 24 EVIDENCE: The management team consists of the provider/manager and his wife who is the deputy manager. The manager has been required since August 2006 to complete the recommended management qualification. They reported that they have commenced this and plan to finish this by the end of 2008. All persons consulted about the home spoke positively about the manager with particular reference to the manager’s friendliness and laid back approach. Comments about the manager included: “amiable”; “shows a keen interests in residents”; “decent bloke”; “alright” and “very nice”. Throughout the course of the inspection it was evident that the standards of administration for which the manager was directly responsible for were variable. The manager stated that due to personal circumstance they have not been as attentive to this side of their role and as a consequence some standards had dropped. This included the manager’s failure to complete an Annual Quality Assurance Assessment form as required by the Commission. The manager stated that informal mechanisms are the most successful tool for residents to affect the way the service is delivered, through regular discussions and consultations. However this must be supported by a more systematic process of obtaining feedback from residents and other stakeholders involved in residents care on the standards of the services and facilities provided. This is necessary in order for the home to be able to self-monitoring and review of its own practices and identify any shortfalls or to help inform future service development. A staff member spoke of attending staff meetings where staff are encouraged to put forward their view points. Staff are in the main supervised by the manager or deputy working along side them each shift and staff consulted with felt well supported and said that there was a good standard of communication between the manager and staff. Residents are encouraged to retain control of their own finances as part of an independent lifestyle. Where the home does manage a resident’s money the manager stated that records were not kept at the home due to the lack of storage space. The manager confirmed that records are kept of any expenditure along with any receipts, as there was no concern regarding finances these records were not requested to be seen on this occasion. The residents confirmed that they could access their money at any time and had never been denied access to funds. Systems are in place to support fire safety, which include: regular fire alarms and emergency lighting checks, staff training and maintenance of fire equipment and fire drills were reported to have been undertaken or due to be serviced. The manager reported that a fire risk assessment had been Ashcroft DS0000013557.V344043.R01.S.doc Version 5.2 Page 25 undertaken. This records significant findings and the actions taken to ensure adequate fire safety precautions in the home. Not all of the required health and safety documentation had been completed, and a sample of the required information to be kept on the premise identified that the home did not have an up to date electrical fixed wiring installation certificate or the appropriate documentation under the Control of Substance Hazardous to Health (COSHH). This have been required and the manager agreed to check that all of the health and safety documentation necessary is up to date and accessible. Ashcroft DS0000013557.V344043.R01.S.doc Version 5.2 Page 26 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 2 2 3 2 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 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 3 3 3 3 x 3 3 3 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 3 3 x x Ashcroft DS0000013557.V344043.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? NO 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 OP1 Regulation 4(1-2) &Sch 1 & 5(1)(a-f) Requirement Timescale for action 30/03/08 2 OP2 5(1)(b) (ba) (bb) (bc) (bd) 3 OP7 15 (1) That the Statement of Purpose includes the range of needs the home is intended to meet and that the service users guide includes the terms and conditions of residency, is reviewed regularly and made available, in order to inform prospective residents and their representatives about the homes services and facilities. 30/03/08 That for service users admitted since the 1/09/06 the terms and conditions of residency include a description of the services offered, the arrangements for charging and paying of additional services and a statement whether any of the above conditions are different where a service users care is being funded by another party other than the service user. That care plans detail the actions 30/03/08 needed to ensure that all aspects of the health and social care needs of the service users are identified and which make explicit the actions needed to meet these needs and which is DS0000013557.V344043.R01.S.doc Version 5.2 Ashcroft Page 28 4 OP27 18(1)(a) reviewed regularly. That there are adequate staffing levels during the weekend as is appropriate for to be able to meet the needs of service users. That staff receive the necessary training in accordance with the needs of the service users accommodated, in order that they can provide the appropriate support to people with learning disabilities and mental health needs. That a system be established and maintained for monitoring the quality of the care provided, which includes a system for obtaining feedback from service users their representatives and other stakeholders on the services provided and the performance of the home. That an up to date electrical fixed wiring installation check has been undertaken and certificated. That hazardous cleaning chemicals are managed and handled in accordance with Control of Substances Hazardous to Health COSHH regulations 1988. 30/03/08 30/05/08 5 OP30 18(1)(c) (i) 6 OP33 24(1) 30/03/08 7 OP38 12(1)(a) & 13(4)(c) 13(4)(c) 30/03/08 8 OP38 30/03/08 Ashcroft DS0000013557.V344043.R01.S.doc Version 5.2 Page 29 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 Refer to Standard OP9 OP30 Good Practice Recommendations That hand written Medication Administration Records (MAR) are checked and countersigned by a second member of staff for accuracy. That individual training records, or evidence of attendance be maintained so that a profile of the training undertaken by staff is available and outstanding training is easily identified. That a training and development plan be developed which identifies the training necessary to meet the homes Statement of Purpose, service aims and service users needs and individual plans. 3 OP30 Ashcroft DS0000013557.V344043.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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.V344043.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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