Inspection on 21/05/07 for Ashdene House

This inspection was carried out on 21st May 2007.

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 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 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ashdene House 13/05/08

Ashdene House 19/07/06

Ashdene House 22/11/05

Ashdene House 01/06/05

Ashdene House 10/08/04

Ashdene House 02/06/04

Similar services:

Insight - Eastchurch

Southfields

Thorndene

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Ashdene House 50 St Mildreds Road Ramsgate Kent CT11 8EF Lead Inspector Lois Tozer Key Unannounced Inspection 21st May 2007 10:00 Ashdene House DS0000023721.V341526.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 Ashdene House DS0000023721.V341526.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. Ashdene House DS0000023721.V341526.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashdene House Address 50 St Mildreds Road Ramsgate Kent CT11 8EF 01843 592045 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) Ashdene House Limited Post Vacant Care Home 18 Category(ies) of Learning disability (18), Physical disability (18) registration, with number of places Ashdene House DS0000023721.V341526.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th July 2006 Brief Description of the Service: Ashdene House is registered to provide residential care for up to eighteen adults with learning disabilities. Some people may have additional physical disabilities. The home is situated in a residential area of the seaside town of Ramsgate, within walking distance of most local amenities. It has its own transport, which is regularly used. Ashdene is split into two buildings. The main house has 15 bedrooms, with one large open plan dining/sitting/conservatory area. There is no lift to the first floor, limiting people who have mobility difficulties to the bedrooms on the ground floor. The Cottage, a self contained property at the back of the big house, accommodates 3 people, and is only suitable for people who can manage stairs. Staff are provided to give supervision and support to the residents on a twenty-four hour basis, including wake and sleep-in cover at night. The majority of staff have training at or above NVQ 2. The local primary health care team meet the health care needs of the residents. Fees are: £980.00 to £1900.00 per week. Previous inspection reports can be obtained from the home, as can their improvement plan and statement of purpose. Ashdene House DS0000023721.V341526.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key site visit took place on 21 May 2007 between 10.00am and 5.15pm. The manager, Barbara Watkins, has been in post since March 2007. She, service users and staff assisted with the inspection process. Twelve people currently live at the home, six gave face-to-face feedback. Service user, family and care manager surveys were sent out after the site visit, and that feedback is not included in this report. Some organised activities were taking place during the visit, and observations formed part of the evidence collected. The communal areas of the main house and most of the cottage was seen during this visit. The inspection process consisted of information collected before and during the visit to the home. Other information seen included assessment and care plans, medication records, duty rota and service users finances paperwork. We had discussion about the improvement in recruitment practices and confirmed that the home now obtain correct work permits. What the service does well: What has improved since the last inspection? Most staff have finished NVQ training. Staff have the right checks before working at the home. There are clear records of meals eaten. Ashdene House DS0000023721.V341526.R01.S.doc Version 5.2 Page 6 Staff make sure any medication that is given away from the home done so safely. People can see how much money they have in their own account. The company help people look after their money, but everyone has their own account. Some new furniture and redecoration has taken place. Over 50 of the staff have got their NVQ training. All hot water that service users use is restricted to a safe temperature. What they could do better: The manager is new to the home. There are a lot of improvements needed. We discussed this, and the manager agreed to have a very close look at the findings from this key inspection. The big house is not at all homely. There are locks on most doors, and most residents cant move freely around their own home. There are locks on the hallway doors leading to the first floor, and at the top of the stairs to get back down. People in the cottage have keys, but these open each other’s doors, which does not give anyone privacy. Some bathrooms are locked, so people cant’ get in independently, but once they are in, cant lock the door for privacy. Some toilets do not have locks at all. Bedrooms are locked. No-one can choose to keep their room unlocked because the bit to hold the lock up has been removed. The type of lock being used needs fine motor skills, which might limit some people from having a key. The kitchen is out of bounds to residents. There is a ‘training kitchen’, but it is not used very often and is in an outbuilding. The laundry is also locked. People are not developing ordinary life skills. They have to rely on staff to do everything. The manager must make sure people have opportunities to develop, rather than being contained within the home. Some decoration and storage needs improvement, especially in the bathrooms, toilets and sluice room. Care plans are being reviewed, but very little has been done to discuss this with the persons they apply to. None of the information is written in a way people who cannot read could understand. There little or no evidence to show that people are having a say in running their own lives. People who may benefit from communication aids have not had assessments. Where care plans say they are needed, they have not been developed. Ashdene House DS0000023721.V341526.R01.S.doc Version 5.2 Page 7 Risk assessments are poor, and do not explore how people can improve or develop their skills. This home sees risk as something to avoid, and that means people don’t get a chance to try out new things. Staff need help to develop better ways of supporting people, and move away from doing things for them. They need to understand what is an acceptable risk and how to teach people to be safe. They need to read, understand and act upon the Mental Capacity Act 2005 as soon as possible. Opportunities for activities that engage people are missed, like art that residents can really get involved in. Potential for therapeutic activities is limited as only one staff member does ‘activities’, while other staff ‘gate-keep’ the other residents. The home has become institutional in the way it does things. There has not been review of practice and many things, such as the lack of personal development have been simply accepted. The internal quality assurance process has not picked up these big issues. There needs to be effective, critical self-monitoring in place. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ashdene House DS0000023721.V341526.R01.S.doc Version 5.2 Page 8 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 Ashdene House DS0000023721.V341526.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The assessment process needs to make sure both needs and aspirations are assessed. The statement of purpose and contract need to reflect the aims of the home and the service users rights and responsibilities. EVIDENCE: Current service users have had pre-admissions assessments, but these were not within the care plan file. The manager could not locate the documents for assessing needs and aspirations during this visit, but said she had a lot of experience assessing and would make sure the individual and their advocates were fully consulted. The last inspection found that contracts did not state what services were provided for the fee paid. The manager said that contracts had not been reviewed yet but hoped to do so in the coming months. The new manager will need to review the statement of purpose. The statement of purpose and the individual contract must be clear about the rules on smoking. A service user from a ‘semi-independent’ home within the registration is using the smoking room in the big house. No service users in the big house smoke, only the staff. This seems disrespectful to the people who live in the home. This needs to be reviewed in light of changing legislation. Ashdene House DS0000023721.V341526.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users changing needs and potential for decision-making is not supported well within the home. There is a risk aversive culture that misses a persons need for development. EVIDENCE: Every service user has a care and support plan. Much of the information is out of date, and is being reviewed by the current manager and staff team. There is no evidence that people are truly involved in making decisions about their support and care. No ‘person-centred’ approaches have been adopted yet, although the new manager is keen to look into this and involve service users more. Many of the opportunities for decision making around the home have been limited by the environmental restrictions – no access to the kitchen, infrequent access to the laundry room and ‘training’ kitchen. Where communication or memory difficulties have been identified, no communication Ashdene House DS0000023721.V341526.R01.S.doc Version 5.2 Page 11 passports or support aids have been introduced. There is a risk aversive culture, which prevents people from having freedom to develop ordinary life skills. Care plans say that a person can’t do an activity, such as making a hot drink, but do not explore how this can be made possible. Some staff have supported people do ordinary life things, but this has not led to increased opportunities for development. Their work contradicts the information in the care plan. Freedom to come and go within the home is restricted too. This was discussed at length with the manager, who must make sure that limitations on freedom are the least restrictive and can be justified by an assessment involving all service users. Looking to the Mental Capacity Act 2005 for support in this area would help improvement. Risk assessments are poor, they do not explore risk reduction to increase opportunity and reviewing has not taken knowledge about the ‘risk’ into account. The new manager is clear that these areas need development, and has begun improvement. Ashdene House DS0000023721.V341526.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People have good lifestyles outside of the home, but opportunities to develop ordinary life and independence skills within the home are poor. EVIDENCE: There is a wide range of activities available away from the home. People enjoy going to town, pubs, outings and college. Some people have work experience placements and are quite independent out and about. Discos and other social events (at day centres) help people get to know and make friends. Some people have partners, but overnight visits do not currently take place. The manager said that there would be no reason why people could not come to stay, it just had not happened. Art activities observed did not engage the service users. They were passively watching staff do fine, skilled work, which has little developmental or Ashdene House DS0000023721.V341526.R01.S.doc Version 5.2 Page 13 therapeutic value. Daily routines within the home need to improve. Currently, there are locks on almost every door, and only a minority of service users have keys or free access to their bedrooms. The locks are ordinary key type, which limits people who have dexterity problems from using them. Many service users cannot choose to be alone by going to their room, they have no choice but to rely on staff to interpret their actions and then open the doors. Some service users have pass-keys, giving them access to others private rooms. Service users cannot lock their doors open, when, for example, leaving to use the loo in the night. The range and quality of food is very good. People looked like they enjoyed the meals during the visit. Those living in the cottage have some involvement preparing the meal, but those in the big house are not permitted to go into the kitchen. There is a ‘training kitchen’ in the garden, but this is also an art and craft room. People do not have free access to it, and cannot make their own drinks and snacks. People have no choice but to rely totally on staff to have their needs met, they are being held back from developing self care skills. This is the social model of disability that needs rapid reviewing. People must be supported to have an active life, not be passive recipients of care. Ashdene House DS0000023721.V341526.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal and healthcare support plans are clear, but do not aim to increase service user skill or independence. EVIDENCE: Since coming to post, the manager has made sure that each service users health support plan has been reviewed. All people rely on the support staff to prompt their attendance at health appointments. There are clear records in place of personal support and healthcare support, but again, this is staff led. How people wish to be supported is written in the first person, but it is not clear if this is what the individual wishes. None of the personal support plans have teaching plans or goals for increasing individuals self care ability. Health action plans could help people feel more in charge of their personal support. Medication is managed centrally, and is done so safely. Procedures are in place that recognise and respect peoples’ right to refuse medication, and strategies exist to support people who may do so frequently. Discussion took place around assessing peoples’ ability to take on some of the control around Ashdene House DS0000023721.V341526.R01.S.doc Version 5.2 Page 15 their medication. There is a risk aversive fear that people must be able to do the entire task, or the possibility of them being involved cannot be entertained. Some people living in the ‘semi-independent’ house still either come to or have medication taken to them from the main house. This needs carefully assessing and improving. Returning spoilt medication was discussed, and the procedure for making this safer was reviewed during the visit. Ashdene House DS0000023721.V341526.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are safe, but the home does not have a system for people to express their views about the home and how they feel. EVIDENCE: Four service users said, or indicated, that they felt safe living at the home. There is a type written complaints procedure in the staff office, but nothing easily accessible for service users to use. People may wish to say they are unhappy, but communication systems for non-verbal service users are poor or non-existent. Work with the community learning disability team is planned. The majority of staff have had adult protection training. It is the managers aim to have this reviewed on a semi-regular basis. Improved understanding within the home and organisation of the potential for unwitting abuse through restricting access to everyday things needs reviewing. Clear records are in place to support money management. The manager now receives a monthly statement for each individual from the centrally held individual bank accounts. Ashdene House DS0000023721.V341526.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 28, 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The main house is not homely. It restricts service users freedom of movement and does not protect privacy. EVIDENCE: The premises are divided into two separate homes, a main house (with 15 bedrooms) and a cottage (3 bedrooms). There is no known plan to make sure a maximum of 10 people are sharing common facilities and a staff team. At the moment, there are only 9 people living in the main building. The communal parts of the home seen were in good condition and were quite comfortable, but shared space in the main house, if the home were full, is limited. There is a lounge / diner / conservatory all in one room, and insufficient sofa space for all residents and staff to sit down at once. Getting away to your own room requires staff support. Only a few people have keys to their bedrooms, which are always locked, as the device for keeping the lock open has been removed from the mechanism. Locked hallway doors also restrict access to and from the 1st floor. Ashdene House DS0000023721.V341526.R01.S.doc Version 5.2 Page 18 The main kitchen is out of bounds to service users. There is a training kitchen, but this is in an outbuilding, and requires staff to support to get in. This gives a really institutional, controlling feel to the home. The environment does not encourage independence or spontaneity. People cannot leave their room to go to the toilet at night without staff having to let them back in. The manager said that there are sufficient staff to make sure everyone’s needs are met, but this is supporting a social model of disability, whereby potential independence is stifled through poor environmental management and design. Staff numbers are sufficient to meet people’s support needs. Use of locks must be assessed and the least restrictive alternative used. Locks should be the type service users can use, and the choice to use them or not should be theirs. In the cottage, people do have keys, but they are master keys, so service users can access each others rooms. Access around the home for people using wheelchairs is not level. Entry into the main house from the art room observed a person having to be bumped over a doorframe. Some bathrooms and toilets (main house and cottage) need improvement, as flooring is coming away, paint is flaking and urinal bottles are being soaked in this area. There is no suitable storage for urinal bottles in bathrooms, and the sluice room is not being used for its intended purpose. Some bathrooms require a staff pass key to enter, but once a person is in, they cannot lock the door for privacy. Other toilets do not have locks at all. The laundry room is kept locked, and is situated off the main house. Ashdene House DS0000023721.V341526.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A staff team who are kind and have had all the necessary safety checks supports service users. EVIDENCE: Staff are encouraged to use Makaton signs with service users, which is an assessed need. Only 6 of the 18 care staff have had basic training in this communication technique. Service users would benefit from staff signing to each other and non-signers, so signing people could be included in conversations and it become part of the culture. The forthcoming training schedule is said to offer more service user focused training; the manager said the new area manager is committed to securing the right training for the service user group needs. Although individual planning is set to improve, training around person centred planning would help staff support people to have a bigger say in their lives. The staff team were kind and enthusiastic, but were unable to promote much independence as there are so many environmental restrictions and rules based on poorly assessed ‘risks’. There is Ashdene House DS0000023721.V341526.R01.S.doc Version 5.2 Page 20 an ethos and culture of containing service users, not enabling them to achieve. Staff need support to engage people in ordinary life activities and do things in the home that they are able to participate in. Staff numbers are provided to meet service users planned activities away from the home. The manager said that 13 staff have now completed NVQ level 2 and 4 NVQ level 3. Service users who were able to say or indicate, said they are happy with the level of staffing, they can get out and about. Recruitment processes are now solid and gather all the data necessary to make sure service users are protected. Work permits were verbally confirmed as checked and meet the requirements of the Home Office. The manager said the ‘Skills for Care’ induction pack was now in place, but had not yet been used. Ashdene House DS0000023721.V341526.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Management of the home has not been in the service users best interests. It has not engaged them as full stakeholders in developments, so has stifled improvement. EVIDENCE: The manager had only been in post 8 weeks at the time of this visit, having transferred from within the organisation. She has many years management experience, and has the Registered Managers Award, but not NVQ level 4 in care or management (or a similar qualification). She discussed looking for training to help with the progression and development of this home. The aims and objectives of the home are not clear, which means that service users are being ‘contained’ rather than ‘developed’. We discussed that the ethos of the home needs to change, and that the home must run in the service users best Ashdene House DS0000023721.V341526.R01.S.doc Version 5.2 Page 22 interests. Currently, service users have very little say in how the home is run and how they want to be supported. Some people are spending lots of time with staff effectively ‘guarding’ them while they watch TV, rather than doing some enjoyable developmental activity. The home has suffered from a lack of continuous critical evaluation, and as such, is not promoting people’s rights and choices. The health and safety aspects of the home, such as training and servicing of appliances, have been managed well, with problems being sorted out quickly. Controlled temperature hot water keeps service users safe, but scalding water in the basin of the staff toilet makes hand washing under a running stream impossible. The fire risk assessment is being reviewed at the moment, and the environmental risk assessment was discussed. It was unclear if the locked doors had been included in the evacuation plan. Evidence that environmental risk is poorly understood has been highlighted throughout this report. It is not clear how use of locks and big environmental restrictions in this home benefits service users. This must be reassessed and the least restrictive solution be found. The manager said that she is determined to change and develop the home for the better, which is really encouraging. Ashdene House DS0000023721.V341526.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 2 2 2 3 2 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 1 25 X 26 1 27 1 28 2 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 1 X 1 X LIFESTYLES Standard No Score 11 X 12 1 13 3 14 X 15 2 16 1 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 X 2 X 1 X X 2 X Ashdene House DS0000023721.V341526.R01.S.doc Version 5.2 Page 24 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 Requirement Previous requirement dated 30/06/06 Standards 1 & 5 To enable service users to know what the aims, objectives & rules of the service are the statement of purpose and contracts must be reviewed. Previous requirement dated 30/01/07, So individual baselines and development plans can be created and monitored, admission assessments must be available. Standards 6, 7, 9, 18 & 20. To make sure all service users know that their assessed needs and decisions about their lives will be supported, the individual plan must reflect the consultation that takes place with service users. Risk taking in this respect must promote an independent lifestyle and these documents must be reviewed with aiming to improve developmental opportunities. Assessment in these key areas must promote the lifestyle the DS0000023721.V341526.R01.S.doc Timescale for action 01/08/07 2 YA2 14,15 01/07/07 3 YA6 15 01/08/07 Ashdene House Version 5.2 Page 25 individual wishes. 4 YA12 4, 15, 17 Previous requirement dated 28/02/06. Standards 12, 16, 17. To improve the quality of service users lifestyle, opportunities for everyday, ordinary life activities within the home must be improved. People must have the freedom to move about their home, and restrictions on liberty must be the least restrictive and be deemed, through multi-agency assessment, to be in the individual’s best interest. Standards 22 & 23. To make sure individuals can speak up and say if they are unhappy, develop communication tools to help this happen. Have a service user friendly complaints procedure in an accessible place and make arrangements for service users to learn about it. Standards 16, 24, 25, 27, 28. To protect service user dignity and liberty, review the use of and type of locks used in the home. Apply locks that service users can manage to toilets and increase access to all parts of the home, using positive approaches to risk assessment. To enable people who have mobility difficulties to get around comfortably, review all doorways and bumps that interfere with smooth access. To improve dignity and reduce the potential of infection from hazardous waste, improve toilet and bathroom areas, including storage facilities for urinals. Review the policy and procedures around the use of the DS0000023721.V341526.R01.S.doc 01/08/07 5 YA22 22 01/08/07 6 YA24 4, 14, 15, 16, 17 25/06/07 7 YA24 23 25/06/07 8 YA30 13, 23 25/06/07 Ashdene House Version 5.2 Page 26 sluice room. 9 YA32 18 Standards 32 & 35. To make sure individuals assessed needs are met, implement a training schedule that considers what these needs are and meets them. Standards 39 & 42. To improve service user lifestyle and to maintain improvement in the service, develop a quality assurance system that seeks the views of service users and other stakeholders. It should enable systematic planning, action and critical review. Submit a copy of the improvement plan setting out the methods and timescales by which you intend to improve services within this home. To protect all people in the home from harm, review the fire risk assessment with the input of a competent person, seeking advice from the local fire authority as required. 01/08/07 10 YA39 24 01/08/07 11 YA39 24A 21/07/07 12 YA42 23 01/07/07 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 YA24 Good Practice Recommendations Take action to address the National Minimum Standard 24.3 in respect of no more than clusters of ten service users sharing a staff team and common facilities. Make the situation clear in the statement of purpose. Ashdene House DS0000023721.V341526.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ashdene House DS0000023721.V341526.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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