Inspection on 15/05/06 for Ashdale

This inspection was carried out on 15th May 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ashdale 26/01/06

Ashdale 31/08/05

Ashdale 01/12/04

Ashdale 26/05/04

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

1 Lanark Close

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

CARE HOME ADULTS 18-65 Ashdale Ashdale Byerley Road Shildon Durham DL4 1HN Lead Inspector Mr Leonard Hird Unannounced Inspection 15th May 2006 09:30 Ashdale DS0000007450.V294243.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ashdale DS0000007450.V294243.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ashdale DS0000007450.V294243.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashdale Address Ashdale Byerley Road Shildon Durham DL4 1HN 01388 777693 01388 777693 graham.spencer1@ntlworld.com None United Response 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 Graham Conway Spencer Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Ashdale DS0000007450.V294243.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. PD LD (5 persons) Date of last inspection 26th January 2006 Brief Description of the Service: Ashdale is a long established care home providing care for 5 younger adults with profound physical and learning disabilities. The home is a large bungalow with all accommodation and facilities on ground floor level. All bedrooms are single occupancy and are decorated and furnished to a high standard. Each bedroom has been fitted with aids and equipment to suit the specific needs of individual service users. There is good access throughout and it is situated in the community of Shildon close to all amenities and good public transport links. The home is surrounded by well kept easily accessible gardens. Ashdale DS0000007450.V294243.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection of Ashdale House took place on the 15th May between 0930 and 1430 hrs and the 26th May between 930 and 1100 hrs. The inspection process considered all of the Key standard areas as identified by the Commission for Social Care Inspection within the Care Homes for Younger Adults National Minimum Standards. These Key standards are: Choice of Home (NMS2), Individual Needs and Choices (NMS 6,7 and 9), Lifestyle (NMS 12, 13, 15,16 and 17) Personal and Healthcare Support (NMS 18,19 and 20), Concerns Complaints and Protection (NMS 22 and 23), Environment (NMS24 and 30) Staffing (NMS 32, 34 and 35) Conduct and Management of the Home (NMS 37,39 and 42). The Commission for Social Care Inspection received 2 written comment cards from relatives. Comments were also received from the registered manager and members of the care staff team. What the service does well: What has improved since the last inspection? The home has acted on the recommendation of the previous inspection report to develop a quality assurance document that takes account of the views of all interested parties. Ashdale DS0000007450.V294243.R01.S.doc Version 5.2 Page 6 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. Ashdale DS0000007450.V294243.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ashdale DS0000007450.V294243.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The homes management team had ensured that prior to the admission of a resident to the home both the local authorities social care and health team as well as the home’s registered manager had carried out anl assessment of need. EVIDENCE: From a review of individual residents care plans it was noted that comprehensive assessments of need had been carried out prior to admission. The local authorities social care and health team and the home had undertaken these assessments of need separately. Resident’s representatives had signed this assessment documentation on behalf of their relative and this information was being maintained on the individual residents file. Ashdale DS0000007450.V294243.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 6 NMS 7 NMS 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The system for care planning in the home is adequate and provides staff with the information required to assist them in meeting the needs of the individual resident. Residents were being actively encouraged and supported to participate in the decision-making and risk taking process that affected their lives. EVIDENCE: Each resident had a comprehensive care plan in place that contained information about differing aspects of their personal and social well-being, their physical and mental health care requirements and their other specialist needs. Also contained within these care plans was information regarding any restrictions on individual residents choice and freedom and how this was to be managed. Ashdale DS0000007450.V294243.R01.S.doc Version 5.2 Page 10 Individual residents care plans contained information about the different methods of communicating with and responding to the resident by the care staff. Where there was an involvement of specialist staff in the care of the resident from outside of the home this had been recorded and any instructions had been acted upon. Care plans were being reviewed on a monthly basis at the home and on a yearly basis by the local authorities social care and health team. Records were being maintained of the daily life of the individual resident within the home and these included information on the different activities that the resident had taken part in. A parent commented in writing that, ‘their relative had recently undergone major surgery and the help and understanding they had received from the manager and staff was tremendous’ Ashdale DS0000007450.V294243.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 12 NMS 13 NMS 15 NMS 16 NMS 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The routines of daily living and activities available at Ashdale were varied and flexible and meeting the needs of the residents. The independence and personal choices of residents at Ashdale were being actively promoted by the home. The dietary needs of residents were well catered for with a balanced and varied selection of food being provided. EVIDENCE: Residents had individually planned programs of weekly activities that had been developed to take account of the residents own likes and dislikes. Activities ranged from walks, visits to local public houses, swimming sessions and listening to music. Ashdale DS0000007450.V294243.R01.S.doc Version 5.2 Page 12 On an accompanied visit as part of the inspection process to a local public house for lunch it was observed that the resident had really enjoyed the experience of being in the community and that the staff member involved in this activity had sensitively supported the resident in the activity. Residents were attending during the week a day placement where they engaged in different activities with their peer group. Families were encouraged by the home to spend time with their relatives either at the parental home or by taking them out to different places. Ashdale DS0000007450.V294243.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 18 NMS 19 NMS 20 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. The health needs of residents were being well met with evidence of very good multidisciplinary working taking place on a regular basis. No resident currently can self-administer medication. EVIDENCE: A review of residents care plans confirmed that residents were receiving support and advice from the appropriate health professionals as and when required. Individual residents care plans included detailed information about the involvement of doctors, dentists and other healthcare professionals who were contributing to the well being of the resident. The home had appropriate policies and procedures in how to administer medication to residents for care staff to refer to. Those staff involved in the administration of medication had undergone an appropriate course in the Safe Handling and Administration of Medication. Ashdale DS0000007450.V294243.R01.S.doc Version 5.2 Page 14 Records of this training were been maintained on the individual members of staffs personnel file. Staff were observed during the inspection process to be providing sensitive, dignified and flexible support to the residents. Ashdale DS0000007450.V294243.R01.S.doc Version 5.2 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): NMS 22 NMS 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The complaints and adult protection policies and procedures currently being used in Ashdale provide for a safe environment for residents to live in. Care staff had been trained in different ways to communicate with residents who had great difficulty in expressing their views and were able to act on their behalf. EVIDENCE: Ashdale had appropriate policies and procedures in place for the Protection of Vulnerable Adults. Staff had received training on how to deal with the Protection of Vulnerable Adults and records were being maintained of this training. Staff had also received specialist training in how to communicate with residents who had special needs and communication difficulties. In discussions with staff they confirmed that they were fully aware of the importance of acting quickly in cases of suspected abuse and that they would follow the homes policy and procedures if the situation arose. The home had appropriate policies and procedures in place for residents and their families on how and who to complain to if they needed. Ashdale DS0000007450.V294243.R01.S.doc Version 5.2 Page 16 There had been no formal complaints recorded. The manager confirmed that any concerns or issues that might be raised with staff were recorded in the service users’ daily records or in the diary. There was also a compliments and complaints book for people visiting the home to make their views known. Ashdale DS0000007450.V294243.R01.S.doc Version 5.2 Page 17 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): NMS 24 NMS 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Ashdale is clean, pleasant and hygienic and provides a safe, homely comfortable environment for its residents to live in. EVIDENCE: Ashdale is clean, tidy and free from unpleasant odours. Individual residents rooms been decorated and furnished to a pleasant and homely standard. The communal living areas were well decorated, furnished to a pleasing standard and well maintained. Maintenance work undertaken on the homes equipment and facilities had been recorded appropriately. There were appropriate systems in place for infection control. The homes infection control policies and procedures were written in accordance with relevant legislation and professional guidance. Ashdale DS0000007450.V294243.R01.S.doc Version 5.2 Page 18 and It was confirmed by staff that they had received appropriate training in infection control and a record of this had been kept on their personnel file Ashdale DS0000007450.V294243.R01.S.doc Version 5.2 Page 19 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): NMS 32 NMS 34 NMS 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Ashdale through its recruitment, employment and training procedures were ensuring that only suitably qualified care staff were employed the home. Staffing levels at the home were sufficient to meet the current assessed needs of the residents. EVIDENCE: From a review of the staff rota provided it was noted that staff were being deployed in sufficient numbers as to ensure the current needs of the residents were being met. There was a commitment to training for all staff at the home and currently over 60 of the homes care staff were qualified at NVQ level 2 or above. Staff had received appropriate induction training and there was also a rolling training programme operating in the home providing training for staff in moving and handling, first aid training and the Protection of Vulnerable Adults. Records of training undertaken and completed were being maintained on individual members of staffs personnel file. Ashdale DS0000007450.V294243.R01.S.doc Version 5.2 Page 20 All staff employed at the home had being recruited in accordance with the homes policies procedures and that of the parent company. All of the appropriate employment checks prior to starting to work at the home had been undertaken and recorded accordingly. Personnel files were generally being maintained well though some files did not contain a photograph of the staff member. Ashdale DS0000007450.V294243.R01.S.doc Version 5.2 Page 21 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): NMS 37 NMS 39 NMS and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Ashdale has a well-established management structure ensuring that the home promotes the health, safety and welfare and rights of residents. EVIDENCE: Records of individual staff supervision sessions were being maintained safely and staff confirmed that they had received copies. From discussions with staff it was confirmed that they were aware of the management structure within the home as well as that of the parent company. A written comment received from a family member stated, “the staff were caring and understanding and their relative was very happy living there” Records were being maintained of when equipment had been serviced and who had undertaken and completed the work. Ashdale DS0000007450.V294243.R01.S.doc Version 5.2 Page 22 Feedback was available from a questionnaires sent by the home to the parents and a health professional of the residents in regard to the quality of service being delivered at Ashdale. Records were being maintained safely and where necessary kept in a locked filing cabinet. Ashdale DS0000007450.V294243.R01.S.doc Version 5.2 Page 23 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 4 4 X 4 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 3 16 3 17 3 X 3 3 X 3 X 3 3 X 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 3 x 4 X X 3 X 3 X 4 X X 3 X Ashdale DS0000007450.V294243.R01.S.doc Version 5.2 Page 24 No 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. Standard YA34 Regulation Requirement Timescale for action 31/08/06 Regulation The home must ensure that all 19 staff personnel files contain a Schedule2 photograph of the individual member of staff RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP20 Good Practice Recommendations It is recommended that the home purchases a small medication fridge for the storage of medication. Ashdale DS0000007450.V294243.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS 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. Extracts may not be used or reproduced without the express permission of CSCI Ashdale DS0000007450.V294243.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!