Inspection on 19/12/05 for Ashdale

This inspection was carried out on 19th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ashdale 12/12/08

Ashdale 03/05/06

Ashdale 11/08/05

Ashdale 31/01/05

Ashdale 02/06/04

Ashdale 02/06/03

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

CARE HOME ADULTS 18-65 Ashdale 1 Rakemakers Holybourne Alton Hampshire GU34 4ED Lead Inspector Mrs Pat Hibberd Unannounced Inspection 19th December 2005 09:00 Ashdale DS0000012380.V272885.R01.S.doc Version 5.0 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 DS0000012380.V272885.R01.S.doc Version 5.0 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 DS0000012380.V272885.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ashdale Address 1 Rakemakers Holybourne Alton Hampshire GU34 4ED 01420 549048 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) ILIACE Limited Mrs Emily Tutton Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Ashdale DS0000012380.V272885.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users in the category LD are only to be accommodated between 18 and 55 years 11th August 2005 Date of last inspection Brief Description of the Service: Ashdale is one of six homes in the Alton area that is owned by ILIACE. Ashdale is a four bedroom detached property, which is situated in Holybourne, Alton, where there are a range of shopping, leisure and employment facilities available. The home was first registered in March 1999 and all four current service users moved there, from another home, in April 1999. ILIACE has currently another four homes in the Southampton area. Emily Tutton has worked for nearly ten years for the organisation and has managed Ashdale since March 2002. The service provides for four service users, between the age of eighteen and fifty-five years, who have a learning disability. Ashdale DS0000012380.V272885.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over two hours and was the second unannounced inspection of the 2005/2006-inspection programme. Due to all core standards having been inspected at the last inspection in August 2005 the objective of this inspection was to focus on care provided to service users, undertake discussions with staff and view any relevant documentation. However, following a number of areas of concern raised by staff and environmental issues observed three standards were inspected with nine requirements identified. One was completed on the day of the inspection. Due to the registered manager being on leave the inspector was supported throughout the inspection by Mr Michael Roberts a registered manager from one of the Organisation’s other homes. During the inspection discussions were held with Mr Roberts, the shift leader on duty, maintenance manager for the Organisation and a bank member of staff. Time was spent with three service users with a view to gaining an understanding of care provided and to observe staff interaction and support. What the service does well: Staff were observed communicating appropriately with service users using makaton/symbols, objects of reference and verbal communication. The Home is keen to ensure service users are encouraged and supported to identify and pursue individual interests with both in house and community activities provided. One staff member confirmed that they receive regular supervision and daily support from the manager of which they find to be of much benefit to their daily practice. Observations of staff interaction with service users indicated that they had a good understanding of their needs, provided choices and care in a respectful and dignified manner. Ashdale DS0000012380.V272885.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ashdale DS0000012380.V272885.R01.S.doc Version 5.0 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 DS0000012380.V272885.R01.S.doc Version 5.0 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): No standards were assessed on this occasion. EVIDENCE: Ashdale DS0000012380.V272885.R01.S.doc Version 5.0 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): No standards were assessed on this occasion. EVIDENCE: Ashdale DS0000012380.V272885.R01.S.doc Version 5.0 Page 10 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): No standards were assessed on this occasion. EVIDENCE: Ashdale DS0000012380.V272885.R01.S.doc Version 5.0 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 the following standard(s): No standards were assessed on this occasion. EVIDENCE: Ashdale DS0000012380.V272885.R01.S.doc Version 5.0 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 the following standard(s): No standards were assessed on this occasion. EVIDENCE: Ashdale DS0000012380.V272885.R01.S.doc Version 5.0 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 the following standard(s): 24 and 30. Some improvements are required to be undertaken to ensure the Home is clean, hygienic and homely. EVIDENCE: The core standards were fully inspected during the last inspection with no requirements. However, on this occasion six areas of improvement were identified. Carpets in the hall, on the stairs and landing were seen to be stained and marked. A discussion was held with the maintenance manager who was visiting the Home. He indicated that the carpets had been cleaned but the problem appeared to be with the floor that needs sealing to prevent what, in his opinion is a mould like substance reappearing in the carpets. He further indicated that the problem had been highlighted during a recent monthly audit undertaken by a manger of the organisation during a regulation 26 visit. Quotes have also been obtained to seal the floor and replace the carpets and forward to one of the Responsible Individual’s (RI) for the Organisation. However, the maintenance manager indicated that he has not had clarification that he can proceed with the work or purchase and replace the carpets. A requirement was made for this work to be completed 19/01/2006. One service user indicated that the carpets were “not nice” “ all dirty”. Ashdale DS0000012380.V272885.R01.S.doc Version 5.0 Page 14 Further areas of improvement related to the general cleanliness and hygiene in the Home. For example one of the bathrooms required the toilet to be thoroughly cleaned due to the personal hygiene needs of one service user in the Home. The bath also required a thorough clean. On inspection of the kitchen a number of cloths that were being used to wash dishes with were seen to have food particles stuck to the material and a sink used for hand washing had dried bits of food around the taps and basin. A discussion was held with a staff member who indicated that staff undertake cleaning duties and support service user’s to keep areas of the Home clean. When viewing the cleaning rota for the Home which is held in a file in the office the staff member indicated that the manager had not instructed them as to its content. The rota was dated 2001 and had been completed by the previous manager. Two further requirements were made. The first related to the Registered Manager ensuring a policy and procedure is in place in the Home and, shared with all staff with regards to the cleaning of all areas. The second related to the need for the care plan of the service user who has specific difficulties with their personal hygiene to be updated and shared with all staff to prevent the risk of infection. On inspection of the laundry room a clinical waste bag full to capacity was stored alongside dirty and freshly washed laundry. A further small bin was found to be full of clinical waste. The staff member explained that the Home did not have a clinical waste bin and, that once a yellow bag was full it was taken to another Home within the Organisation to be collected. A requirement was made for the Home to obtain a clinical waste bin and to ensure the safe storage and disposal of clinical waste. A further requirement related to the Home writing and implementing a clinical waste policy and procedure. This must be shared with all staff and kept under review. Records pertaining to water temperatures required by the Organisation to be maintained were not up to date. In discussion with a member of staff they expressed concern that some of the tap water in the Home was too hot to touch. Temperature recordings of the water from the hot tap in the bath in the downstairs bathroom were taken and recorded at 47.7oC. The staff member indicated that the water temperature felt cooler than earlier in the day and prior to three service users having a bath. Mr Roberts indicated that all taps in the Home have been fitted with water temperature restrictors to a maximum temperature of 43oC. The possibility of the temperature restrictor being faulty was discussed with Mr Roberts who indicated that he would discuss with the maintenance team manager. A requirement was made for the manager to ensure all water temperatures in the Home are regulated, based on the capabilities and needs of service users and, that water temperature restrictors are maintained in full working order. Risk assessments must be completed in the interim and instructions given to staff as to safety measures in place to prevent a risk of scalding. Ashdale DS0000012380.V272885.R01.S.doc Version 5.0 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 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): No standards were assessed on this occasion. EVIDENCE: Ashdale DS0000012380.V272885.R01.S.doc Version 5.0 Page 16 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): 42 The health and safety of service users must improve. EVIDENCE: This standard was inspected at the last inspection with no requirements identified. However, two areas of improvement were identified on this occasion. The first related to the front door that is the only fire exit at the front of the building. On arrival it was evident that the door could not be used as a fire exit as the latch had been disabled by means of a screw being fitted by the maintenance manager. It was explained by the maintenance manager that there had been an electrical failure of the release mechanism on the door five days earlier. The maintenance manager indicated that he had been endeavouring to obtain the relevant part and/or electrician to complete the work but was having some difficulties. As an interim measure a decision had been reached between the maintenance manager and the Home’s manager to disable the door by a screw being fitted. This was seen to prevent a security risk, as the door could not be locked due to Ashdale DS0000012380.V272885.R01.S.doc Version 5.0 Page 17 the mechanical failure. However, as a consequence there was no fire exit at the front of the building. In discussion with one staff member they indicated that they had been instructed by the manager to use the back door until the problem with the electrical failure of the release mechanism had been rectified. The staff member was unclear however, as to what they should do if there was a fire and the only means of escape was the front door that was not operational. The maintenance manager contacted Hampshire Fire and Rescue for advice during the inspection. Following a discussion with a fire officer the following safety measures were put in place in the Home; the screw was removed from the latch and a temporary bolt fitted. A notice was placed on the door instructing staff to undo the bolt in the event of a fire and the need to evacuate the building. The safety measures enabled the home to be secure at the same time ensuring the fire exit was operational albeit manually. The manager was required to notify the commission when the work is completed and, the bolt removed thus enabling the fire door to be independently and fully operational. A further area of improvement related to a fire notice on the wall in the hallway. The notice instructed staff as to the action they should take in the event of the fire alarm activating. However, one staff member indicated that it was confusing as the instructions differed to the Home’s policy and procedure and, guidance during training courses they had recently undertaken. The notice was not dated or signed. Mr Roberts agreed to rewrite the instructions in accordance with the Home’s policy and procedure and ensure staff were aware of the new procedure that day. This must be kept under review. Later in the day the commission received notification by telephone that Mr Roberts had rewritten the instructions and that staff had been instructed as to the procedures in place. A further requirement was made for the Registered Manager to ensure she is compliant and up to date with Fire Regulations and Legislation, its implications to service delivery and the health and safety of service users living and staff working in the Home. Ashdale DS0000012380.V272885.R01.S.doc Version 5.0 Page 18 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 X X X X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X X 2 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X X X X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Ashdale Score X X X X Standard No 37 38 39 40 41 42 43 Score X X X X X 2 X DS0000012380.V272885.R01.S.doc Version 5.0 Page 19 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. 1 Standard YA24 Regulation 23 Requirement The Registered Providers must ensure the carpets in the hall; stairs and landing are cleaned and replaced if necessary. The Registered Providers must ensure the care plan for one service user is updated to reflect their personal hygiene support needs. The Registered Providers must ensure a policy and procedure is in place in the Home and, shared with all staff with regards to the cleaning of all areas. The Registered Providers must ensure the safe storage and disposal of clinical waste. Timescale for action 19/01/06 2 YA6 15 22/12/05 3 YA30 23 22/12/06 4 YA30 13 28/12/05 5 YA30 13 The Registered Providers must 22/12/05 ensure a clinical waste policy and procedure is written and implemented in the Home. This must be shared with all staff and kept under review. The Registered Providers must ensure all water temperatures in the Home are regulated, based on the capabilities and needs of service users and, that water DS0000012380.V272885.R01.S.doc 6 YA30 13 22/12/05 Ashdale Version 5.0 Page 20 7 YA42 23 8 YA42 9 temperature restrictors are maintained in full working order. Risk assessments must be compiled in the interim. The Registered Providers must ensure the commission are notified as to when the front door fire exit is fully and independently operational. The Registered Providers must ensure the Registered Manager is compliant and up to date with Fire Regulations and Legislation, its implications to service delivery and the health and safety of service users living and staff working in the Home. 03/01/06 22/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Ashdale DS0000012380.V272885.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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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