Inspection on 03/02/06 for Ashcroft House

This inspection was carried out on 3rd February 2006.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ashcroft House 14/11/06

Ashcroft House 20/06/05

Ashcroft House 15/09/04

Ashcroft House 22/04/04

Ashcroft House 25/06/02

Similar services:

Thorndene

Sutton Lodge Nursing Home

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

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 Jon Wheeler Unannounced Inspection 3rd February 2006 08:30 Ashcroft House DS0000021452.V252058.R01.S.doc Version 5.1 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 House DS0000021452.V252058.R01.S.doc Version 5.1 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 House DS0000021452.V252058.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Ashcroft House Address 11 Elmstead Road Bexhill On Sea East Sussex TN40 2HP 01424 736020 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) Ashcroft House Limited (part of Beacon Care Holdings PLC) Mrs Tanya Pannett Care Home 8 Category(ies) of Learning disability (8), Physical disability (3) registration, with number of places Ashcroft House DS0000021452.V252058.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The maximum number of residents to be accommodated will be eight (8) Residents should be aged under fifty five (55) years on admission All residents will have a learning disability There will be a maximum of three (3) people who may also have a physical disability 20th June 2005 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 who 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 DS0000021452.V252058.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection started at 8.30am and lasted for four and a quarter hours. The inspection involved talking to the manager and deputy manager, two members of staff and three of the service users. Because of their learning disabilities, some service users were not able to clearly communicate their views about the home during the inspection. However, service users and staff were observed working together. The process also included a brief tour of the premises; reading care plans, policies and records; checking the administration and recording of medication. Those key standards not assessed at this inspection were assessed at the inspection of 20 June 2005. What the service does well: What has improved since the last inspection? What they could do better: Where medication is not routinely administered, written guidelines should be available to ensure the health and safety of the service user affected. Ashcroft House DS0000021452.V252058.R01.S.doc Version 5.1 Page 6 The statement of purpose should accurately reflect the services and facilities provided, including where service user bedrooms are under the size stipulated in the national minimum standards. All radiators should be covered to ensure the health and safety of service users. 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 DS0000021452.V252058.R01.S.doc Version 5.1 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 House DS0000021452.V252058.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4. The statement of purpose did not accurately reflect the whole range of services and facilities provided in the home. There were comprehensive policies and procedures for admission of new service users. Prospective service users are able to visit the home prior to moving in. EVIDENCE: The service has a statement of purpose, which is in accessible form using pictures, providing clear and concise information. However, some of the required information was not present, including that some of the bedrooms may be under the size stated in the national minimum standards. It was discussed that this information should be freely available in the statement of purpose to enable service users and their representatives to make an informed choice about services and facilities provided in the home. There was documentary evidence of a clear policy and procedure for the assessment of and opportunities for visits for prospective service users. The manager and deputy manager were able to describe in detail how the process of assessing prospective new service users occurs. The service uses community care assessments and information from a range of professionals and services as part of their pre-admission process. Ashcroft House DS0000021452.V252058.R01.S.doc Version 5.1 Page 9 Service users, with their families and representatives are encouraged to visit the home to meet the staff and the service users before choosing whether or not to move in. Ashcroft House DS0000021452.V252058.R01.S.doc Version 5.1 Page 10 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 the following standard(s): 6, 7, 8, 9. Care plans clearly identify the needs, preferences and support required for each service user. Service users are supported to make decisions, where possible, in all aspects of their lives and are consulted about issues affecting the home. A range of risk assessments protects Service users. EVIDENCE: Each service user has a comprehensive care plan, which included background information, communication details, daily routines and personal care support. There was evidence that the care plans had been reviewed with clear indication where the needs of the service users had changed and how the staff team should support those changes. Staff were observed supporting service users to make decisions, where they were able to do so. Two service users said they were able to choose their activities. Service users were observed being asked what they wanted to eat and drink for breakfast. Staff were able to describe a variety of ways they use observation of body language and reactions of service users who are not able to clearly express their opinions and choices. Ashcroft House DS0000021452.V252058.R01.S.doc Version 5.1 Page 11 Service users are able to spend one to one time with their key worker, where they identify their issues and preferences. Service users play a role in cooking, cleaning their rooms and helping with their personal laundry. There were risk assessments where service user’s rights or freedom were limited to ensure their health and safety. The risk assessments viewed had been reviewed and in some cases updated to reflect the support needed to meet any changing needs. Ashcroft House DS0000021452.V252058.R01.S.doc Version 5.1 Page 12 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 the following standard(s): 11, 12, 13, 14, 15. Service users are supported to access a range of activities, in the home and in the community. Service users are supported to maintain relationships with their families and friends EVIDENCE: There was documentary evidence that service users are supported to access a range of educational, vocational and leisure activities throughout the week, which reflect their needs, preferences and age. Staff were able to describe which activities service users enjoy, and the support they require to undertake them. Activities are tailored to meet the individual needs of each service user and include day care services, college, bowling, sensory room sessions, swimming, walks, arts and crafts and music. Service users also access other facilities in the community such as the cinema, pubs and shops. All the service users have an annual holiday. Service users had been to Euro Disney, Butlins, Blackpool or Centre Parks. Ashcroft House DS0000021452.V252058.R01.S.doc Version 5.1 Page 13 Two of the service users spoken with said they enjoyed their activities and were able to choose what they did. Where possible, staff support service users to keep in regular contact with their families with visits and by telephone. Ashcroft House DS0000021452.V252058.R01.S.doc Version 5.1 Page 14 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 the following standard(s): 18, 20. Service users receive dignified and sensitive support to meet their personal, emotional and health needs. The system for the recording and administration of medication does not ensure the health and safety of the service users. EVIDENCE: Staff were observed providing dignified and sensitive support to service users. Staff spoken with were knowledgeable about the specific needs of each service user and how those needs are appropriately and consistently met. Medication is kept securely and is dispensed by senior staff, all of whom have been appropriately trained. The home uses a monitored dosage system and has a full record of all medication dispensed. It was found that one service user routinely did not take his medication whilst he was at his day centre. There were no clear written guidelines to indicate that this practice was safe for the service user. Ashcroft House DS0000021452.V252058.R01.S.doc Version 5.1 Page 15 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 the following standard(s): 22, 23. An effective complaints procedure and appropriate adult protection policies and training for staff protect the rights and interests of the service users. EVIDENCE: There is a complaints policy and procedure for the home. No complaints had been received recently. Two of the service users said they felt able to complain, or raise anything concerning them. They said they would talk to the manager or staff if they were unhappy with anything in the home. All staff had completed adult protection training. Staff spoken with were able to describe how they would raise any concerns about the protection and wellbeing of service users. There was documentary evidence that any accidents were recorded, with appropriate details and actions. Ashcroft House DS0000021452.V252058.R01.S.doc Version 5.1 Page 16 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 the following standard(s): 24, 30. Service users live in a clean, comfortable and homely environment, which generally meets their needs. Some uncovered radiators did not guarantee the health and safety of the service users. EVIDENCE: The home was clean, tidy and hygienic at the time of the unannounced inspection. There is a homely and relaxed atmosphere, where service users have their own bedrooms and access to a range of communal spaces. Each service user’s bedroom meets their individual needs and preferences, with their own possessions and pictures personalising the room. There is a spacious lounge and a large dining area providing communal space. The home has a garden to the rear, which service users are able to access. There was evidence of an on-going maintenance programme, such as the shower being mended and the fitting of a new bath chair. However, some radiators posed a risk to service users as they were not covered and were very hot to the touch. Ashcroft House DS0000021452.V252058.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36. An enthusiastic, knowledgeable and well trained staff team provide good quality care to meet the needs of the service users. Regular supervision and support enable staff to provide consistent and caring support. Robust employment procedures ensure the protection of the service users. EVIDENCE: Staff were able to describe their roles and responsibilities and confirmed that they had been issued with a job description. Staff were able to describe the specific needs of the individual service users and were able to identify how those needs are consistently met. Staff were knowledgeable about the likes and dislikes of each service user. Staff were observed working with service users in a friendly and professional manner. There was evidence that there are sufficient staff on duty to meet the needs of the service users and enable them to access their chosen activities. It was reported that at the time of the inspection, there were no staff vacancies in the home. There was documentary evidence of the service following robust employment procedures. A sample of staff recruitment files contained two references each, photographic identification, application forms, interview questions and Criminal Bureau Records checks. Ashcroft House DS0000021452.V252058.R01.S.doc Version 5.1 Page 18 There was documentary evidence of on-going training for all staff, including induction training and foundation training for new staff. There was evidence of a range of other training courses for staff, including fire safety, first aid, health and safety and moving and handling. The service is proactive in ensuring staff are able to undertake relevant NVQ courses. Staff reported that they were able to access a range of courses to ensure they are able to meet the needs of the service users. There was evidence that the manager and deputy had completed training in supervision and had instigated regular supervision and appraisal for all staff. Ashcroft House DS0000021452.V252058.R01.S.doc Version 5.1 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 40, 42. The manager ensures a clear ethos and values of the home enable staff to provide good quality care to the service users. Policies and records within the home protect Service users rights and choices. Whilst there are a range of regular health and safety checks, some uncovered radiators did not ensure the health and welfare of the service users and staff. EVIDENCE: The manager is in the process of applying for registration with the Commission. Staff and service users spoken with confirmed that the manager is open, approachable and supportive. The manager and deputy were able to describe in detail their roles, responsibilities and systems for managing the service. A sample of policies for the service were found to be in place and had all been recently reviewed. Staff were able to describe how the policies worked in practice, to ensure effective and consistent support for service users. Ashcroft House DS0000021452.V252058.R01.S.doc Version 5.1 Page 20 There was documentary evidence of a range of health and safety checks within the home. Temperatures of the fridge and freezer are taken daily. Fire doors had been fitted with automatic closing devices and fire safety equipment had been recently serviced. Some radiators in the home had not been covered, were very hot to the touch and posed a risk to the health and safety of the service users. Ashcroft House DS0000021452.V252058.R01.S.doc Version 5.1 Page 21 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 2 2 3 3 X 4 3 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 2 25 X 26 X 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 3 12 3 13 3 14 3 15 3 16 X 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 X 2 X 2 3 X 3 X 2 X Ashcroft House DS0000021452.V252058.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? Yes 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 YA1 Regulation 4(1)(c) & Schedule 1 17(1)a &Sch3.3.i Requirement Update the statement of purpose to accurately reflect the range of services and facilities provided in the home. Keep a full record of all drugs administered and have clear written guidance where medication is routinely not administered. Ensure all radiators are fitted with appropriate covers. Timescale for action 03/03/06 2. YA20 10/02/06 3. YA24 13 (4) 03/04/06 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 YA6 YA28 YA36 YA37 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 DS0000021452.V252058.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection East Sussex Area Office 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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