Inspection on 20/06/05 for Ashcroft House

This inspection was carried out on 20th June 2005.

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

Other inspections for this house

Ashcroft House 14/11/06

Ashcroft House 03/02/06

Ashcroft House 15/09/04

Ashcroft House 22/04/04

Ashcroft House 25/06/02

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Thorndene

Sutton Lodge Nursing Home

Insight - Eastchurch

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Dovedale Court

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

CARE HOME ADULTS 18-65 Ashcroft House 11 Elmstead Road Bexhill On Sea East Sussex TN40 2HP Lead Inspector James Houston Unannounced 20 June 2005 10:00 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 House H59-H10 S21452 Ashcroft House V229740 200605 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Ashcroft House Address 11 Elmstead Road Bexhill On Sea East Sussex TN40 2HP Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Amjid Faqir Vacant Care Home 8 Category(ies) of Learning disability (LD), 8 registration, with number Physical disability (PD), 3 of places Ashcroft House H59-H10 S21452 Ashcroft House V229740 200605 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The maximum number of residents to be accommodated will be eight (8) 2. Residents should be aged under fifty five (55) years on admission 3. All residents will have a learning disability 4. There will be a maximum of three (3) people who may also have a physical disability Date of last inspection Brief Description of the Service: Ashcroft is a detached house located in a residential area of Bexhill. There is a range of amenities in the area and good access to public transport. It is one of a group of homes owned by the Beacon Care Group of companies for adults with a learning disability. The home is registered for adults between 18 and 55 and includes registration for up to three service users also have a physical disability. The home has no lift and therefore residents who might require wheelchair support have to be housed on the ground floor. The home has a rear garden which is mostly laid to lawn. The home aims to enable its residents to lead a fulfilled life, which builds on their abilities through individually developed day care programmes that provide stimulation and access to the wider community. Ashcroft House H59-H10 S21452 Ashcroft House V229740 200605 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place during the morning and early afternoon of the twentieth of June 2005. Before the inspection the inspector read records held on the home held by the Commission for Social Care Inspection and prepared to inspect those sections of the standards to be covered at that visit. The inspection in the home took 5.9 hours. The inspector made a tour of the whole premises, and read a variety of policies, procedures and records and two care plans. The inspector spoke with the acting manager, three staff and four residents. Seven residents were living in the home on the day of the inspection. What the service does well: 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. Ashcroft House H59-H10 S21452 Ashcroft House V229740 200605 Stage 4.doc Version 1.40 Page 6 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 Standards Statutory Requirements Identified During the Inspection Ashcroft House H59-H10 S21452 Ashcroft House V229740 200605 Stage 4.doc Version 1.40 Page 7 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2 and 3. The home provides full information to prospective residents and their representatives to inform the decision about coming to live in the home. A full assessment is undertaken on prospective residents. The home meets the needs of those living there. EVIDENCE: The home has a statement of purpose and service users guide which give full information. An illustrated service users’ guide has also been prepared and is on display in the house. Minor amendments to these documents were made during the inspection. The acting manager said that no new resident has been admitted for some time, but that it is the home’s practice to undertake a full assessment prior to admission-she took part in the preparation for the last admission. Care management assessments are obtained if available. From discussion with the acting manager and staff and examination of records it is clear that staff individually and collectively have the skills and experience to meet the needs of residents. Observation confirmed that staff are able to communicate with residents. The acting manager said that the home would not admit any resident whose needs they could not meet. Ashcroft House H59-H10 S21452 Ashcroft House V229740 200605 Stage 4.doc Version 1.40 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6and 9. Comprehensive care plans and risk assessments are drawn up and regularly reviewed. EVIDENCE: The home has drawn up good care plans. Staff said that they have read them and are familiar with them. Staff are now familiarising themselves with a new form of monthly review and daily recording. Risk assessments are undertaken and records inspected showed they are updated regularly. Staff said that they give guidance and training to residents as needed. Ashcroft House H59-H10 S21452 Ashcroft House V229740 200605 Stage 4.doc Version 1.40 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11,15,16 and 17. Residents are enabled to maintain and develop social and communication skills. Visitors are made welcome. The daily routines of the house promote independence. Meals and mealtimes promote the health and well being of residents. EVIDENCE: The staff have a programme for each resident, and were seen to able to spend time with each, to assist them with social and independent living skills appropriate to their needs and abilities. Most residents have a placement at a local school or college. Staff regularly take residents out for outings or to go shopping. Staff said they see making visitors welcome as an important part of their role and that they are offered hospitality. Ashcroft House H59-H10 S21452 Ashcroft House V229740 200605 Stage 4.doc Version 1.40 Page 10 Staff said that they only enter residents’ bedrooms after knocking. They bring mail to residents and ask the resident to open it, before giving assistance as needed to deal with it. Residents can choose the name by which they are called and staff were observed to address a resident by their surname in accordance with expressed preference. The kitchen was observed to be clean and tidy. The home caters as necessary for medical and therapeutic diets. The home keeps a record of food served and of alternatives. Residents’ likes and dislikes are recorded. Nutritional advice is obtained where needed and residents are weighed monthly. The manager said that giving assistance to residents with food is a very important part of the staff role. Ashcroft House H59-H10 S21452 Ashcroft House V229740 200605 Stage 4.doc Version 1.40 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 and 20. The home makes effective arrangements to meet the healthcare needs of residents. Medicine administration systems need review. EVIDENCE: Records inspected showed that arrangements to meet the healthcare needs of residents are thorough. Staff said that that they take residents for appointments and go in with them to the health practitioner as appropriate. The acting manager said that no controlled drugs are currently held on behalf of residents. No residents self-administer. Drugs are securely held. The acting manager said that the home uses a monitored dosage system from a local chemist who visits regularly and leaves a written report. No matters are outstanding. Only senior staff administer medication and some need to complete a new signature sheet in the medicine record. Relevant staff said that they have had medication training. The medicine administration record contained an unexplained gap. Ashcroft House H59-H10 S21452 Ashcroft House V229740 200605 Stage 4.doc Version 1.40 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 The home has a suitable complaints procedure. EVIDENCE: An illustrated and text version of the complaints procedure is displayed in the hall. The home has a complaints log, and this was inspected. The home was seen to have a suitable system for dealing with matters raised about its services. The Commission for Social Care Inspection has received no complaints about the home in the last year. Ashcroft House H59-H10 S21452 Ashcroft House V229740 200605 Stage 4.doc Version 1.40 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25,26 and 28. The home offers a comfortable environment. Some maintenance items need attention. Communal areas are well appointed and bedrooms are well personalised. EVIDENCE: The home has been gradually upgraded to a good standard. There are two good-sized communal rooms on the ground floor together with three ground floor bedrooms. Some items needing attention were raised at the inspection. They include some areas of paintwork externally and internally, hanging sash cords, and a cracked pane. A fire extinguisher appeared not to have been serviced at the same time as the others, and a key to a fire escape door on the first floor was not in the right place. The acting manager was advised to seek appropriate advice. Bedrooms are suitably personalised, and contain residents’ possessions. Residents’ rooms are lockable and have an override device. The acting manager said that at present residents do not hold keys. Ashcroft House H59-H10 S21452 Ashcroft House V229740 200605 Stage 4.doc Version 1.40 Page 14 The home has a domestic style kitchen and laundry. The home has no private areas available within the home for visitors, consultations or treatment. The rear garden would be improved by a paved area for the benefit of wheelchair users. Ashcroft House H59-H10 S21452 Ashcroft House V229740 200605 Stage 4.doc Version 1.40 Page 15 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,33,34 and 36 The recommended proportion of the home’s staff hold at least NVQ level 2 in care. The home has a competent staff team capable of meeting the needs of residents. The home has a generally thorough recruitment procedure but not all the required records were in place. Staff are supervised regularly to assist them to continue to meet the needs of residents. The acting manager should receive training in supervision. EVIDENCE: Nine of the staff hold NVQ in care with four at level 3. Several other staff plan to start level 3 later in the year. There were sufficient staff on duty to meet the needs of residents during this unannounced inspection. Staff said that the home had had significant turnover of staff in recent years but added that the team is now stable with low levels of sickness and no need to use agency cover. One staff member left in charge at times is not quite 21. Staff said that regular staff meetings are held and the minutes of these were made available to the inspector. The acting manager said that she is on call to staff. Staff said that the manager is supportive. Ashcroft House H59-H10 S21452 Ashcroft House V229740 200605 Stage 4.doc Version 1.40 Page 16 Recruitment records inspected showed that not quite all the required records – references in the case of one staff member-were to hand. The acting manager said that she was aware of this and was seeking to obtain them. Staff said that they have been given job descriptions and contracts of employment and records inspected confirmed this. Staff records inspected showed that supervision is given regularly to staff at the recommended frequency. The acting manager has not yet been given supervision training, but has a date set of 20th July 2005 for this. The acting manager plans to introduce annual appraisals at an early date. Ashcroft House H59-H10 S21452 Ashcroft House V229740 200605 Stage 4.doc Version 1.40 Page 17 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,39,40, and 43. The acting manager appears to have the necessary experience and skills to run the home. The home’s registered manager should hold or obtain the recommended qualifications. The home’s quality assurance mechanisms are appropriate. The procedures are thorough and comprehensive. Management systems are good. EVIDENCE: Since the last inspection Ms B Rowley has been appointed acting manager by the provider. She has been in post for two months. She has suitable relevant experience and is undertaking the registered managers award. She undertakes periodic training to update her knowledge and skills. She has a suitable job description. An application to the Commission for Social Care Inspection in respect of a registered manager is needed over time. Ashcroft House H59-H10 S21452 Ashcroft House V229740 200605 Stage 4.doc Version 1.40 Page 18 The home has undertaken recent surveys of residents, staff, family friends and advocates and outside professionals and these were made available to the inspector. The acting manager said that the results are discussed and used to inform practice. Regular reports from the providers’ representative on their monthly visits to the home were made available to the inspector. The home has a procedure manual which the acting manager had recently signed and dated. Staff said that they are familiar with the manual and records showed that there is a system for them to sign that they have read it. The home has a suitable current certificate of insurance on display. The acting manager said that the company head office carries much of the responsibility for administration and finance. The acting manager considers that lines of accountability are clear. Ashcroft House H59-H10 S21452 Ashcroft House V229740 200605 Stage 4.doc Version 1.40 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 x x Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 x 2 x x Standard No 11 12 13 14 15 16 17 3 x x x 3 3 3 Standard No 31 32 33 34 35 36 Score x 3 3 2 x 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Ashcroft House Score x 3 2 x Standard No 37 38 39 40 41 42 43 Score 2 x 3 3 3 x 3 H59-H10 S21452 Ashcroft House V229740 200605 Stage 4.doc Version 1.40 Page 20 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. 4. Standard 20 24 34 36 Regulation 17(1)a &Sch3.3.i 23(2) (b)&(d) 19(1)(b) 18(1)(c) (i) Requirement Keep a full record of all drugs administered Address maintenance items identified Obtain references on all staff employed. Staff involved in providing supervision to others must undertake relevant training (Previous timescale of 30/10/04 not met) Timescale for action Immediate 31 October 2005 31 July 2005 31 July 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard 6 28 36 37 Good Practice Recommendations Ongoing attention to implementing the care planning system is recommended. Consider providing an area which could be used for private consultations and a paved area in the rear grden for the benefit of residents in wheelchairs. Staff have annual appraisals. The manager obtains the recommended qualifications. Ashcroft House H59-H10 S21452 Ashcroft House V229740 200605 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection Ivy House, 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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