Inspection on 15/10/07 for Ashgale House

This inspection was carried out on 15th October 2007.

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

Other inspections for this house

Ashgale House 03/11/08

Ashgale House 21/06/07

Ashgale House 19/12/06

Ashgale House 20/04/06

Ashgale House 22/02/06

Ashgale House 23/11/05

Ashgale House 02/11/04

Ashgale House 04/05/04

Ashgale House 26/02/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Ashgale House 39-41 Hindes Road Harrow Middlesex HA1 1SQ Lead Inspector Julie Schofield Key Unannounced Inspection 15th November 2007 9:45 Ashgale House DS0000017514.V347793.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 Ashgale House DS0000017514.V347793.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. Ashgale House DS0000017514.V347793.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashgale House Address 39-41 Hindes Road Harrow Middlesex HA1 1SQ 020 8863 8356 020 8863 8491 ashgalehouse@aol.com 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 Aslam Dahya Mr Siyoum Beyene Care Home 14 Category(ies) of Learning disability (13), Learning disability over registration, with number 65 years of age (1) of places Ashgale House DS0000017514.V347793.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Within this Fourteen , 4 People may be residents with additional Physical disability. People with Physical Disability will reside on the ground floor of the building. Temporary variation agreed for one named individual (MB) aged 66 years for the duration of her stay. 21st June 2007 Date of last inspection Brief Description of the Service: Ashgale House is a registered care home providing personal care and accommodation for a maximum of 14 adults aged 18-65 who have learning disabilities. The building is divided into 2 units, with the home registered to provide 8 places on the ground floor (four of these places may be occupied by service users who additionally have physical disabilities) and 6 places on the first floor. Within the 6 registered places in the first floor unit, 2 places are made available to residents (on a local authority contract basis) for respite care. At the time of the inspection 11 of the 12 places available for accommodating residents on a permanent basis were filled. The Registered Provider is Allied Care Ltd, the Responsible Individual being Mr Aslam Dahya. The Registered Manager is Mr Siyoum Beyene. The home is located in a busy residential road on the outskirts of central Harrow, close to shops, leisure and other community amenities. The home was registered in May 2001 and is a two-storey building. All the home’s bedrooms are single, and none have en-suite facilities. The home has a large garden to the rear that is accessed through the ground floor unit. There is off street parking at the front of the house, including a dedicated visitor’s parking space. Information regarding the fees charged is available, on request, from the manager of the home. Ashgale House DS0000017514.V347793.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on a Thursday in November. It started at 9.45am and finished at 1.15pm. During the inspection compliance with the statutory requirements identified during the previous key inspection in June 2007 was checked. All other key standards were monitored and assessed. Records were examined and discussions took place with the manager and a senior support worker. Three residents also spoke with the Inspector. A partial site visit took place and the preparation of the midday meal was observed. The Inspector would like to thank everyone for their assistance and comments. What the service does well: Three residents gave their opinions on living in the home. One resident said that they preferred living in Ashgale House to the previous care home where they had lived. The resident said that Ashgale House had larger rooms and they had a larger bedroom than before. The resident found it easier to move around this home in their wheelchair. Two residents said that they liked the staff and that they liked being able to go out. The third resident had their own routines and lifestyle and this was respected. It was noted that all 3 residents enjoyed a good rapport with the members of staff on duty, including the manager. Residents came to chat with the manager when he was working in the office. The members of staff on duty worked together as a team and consulted with each other so that each knew their own duties for the shift and those of their colleagues. There are members of staff within the staff team with linguistic skills to enable each resident to communicate in their first language. When preparing the menu the home is able to meet the dietary, religious and cultural needs of residents. Residents have access to activities both inside and outside the home as part of their individual weekly programme of activities. Staffing levels facilitate 1:1 support in the community. Support is given to residents so that residents’ cultural and religious needs are met. The pottery classes are very popular and there are examples of the residents’ handicrafts throughout the home and in their rooms. Residents were pleased with the recent holiday to Blackpool and said that they had enjoyed themselves. Ashgale House DS0000017514.V347793.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? During the last inspection 16 statutory requirements were identified and of these 16 requirements, 15 are now met. The care plan and the placement have been reviewed on a regular basis so that the changing needs of a resident can be identified and addressed. Daily records now state if planned activities do not take place, and why, so that the home can demonstrate that the resident’s religious and cultural needs are respected. Food records are now in sufficient detail to demonstrate that cultural and dietary needs are met. Residents are encouraged to have variety in their choice of meals to promote a healthy lifestyle. When medication is administered to residents it is clearly recorded and records are up to date and complete. Members of staff are adhering to the home’s medication policies and procedures when dealing with medication. The complaints procedure on display in the home has been reviewed and amended so that it now contains up to date and helpful information to anyone wishing to make a complaint. Clear information is sent to the home, on a monthly basis, about the money held at Head Office for each individual resident, after any contributions towards fees have been paid, so that decisions on levels of expenditure are in accordance with the resident’s budget. The home has now instituted individual accounts for residents so that they receive interest on their savings. A section of the board supporting the guttering on the outside wall of the building on the ground floor has been replaced so that the guttering is now firmly attached. The seam on the flooring in the kitchen/dining room on the ground floor has been levelled to prevent any food debris being trapped. Minutes of resident’s meetings are now kept and these demonstrate that meetings are held on a regular basis and that residents are consulted about proposed development or changes in the home. The home has forwarded a copy of the electrical installation certificate to the CSCI confirming that this was inspected in November 2006 and more recently November 2007. Records of weekly tests of fire alarms were up to date. A review of the first aid certificates held by staff was carried out to check whether they were still valid. Training has taken place for staff needing to renew their certificate and for new members of staff to ensure that the home has a qualified first aider on each shift. Ashgale House DS0000017514.V347793.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Ashgale House DS0000017514.V347793.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 Ashgale House DS0000017514.V347793.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): 2 People who use this service experience good outcomes in this area. An assessment of the needs of the resident, prior to admission to the home, enables the home to determine whether a service tailored to the individual needs of the resident can be provided. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection one resident that had been accommodated on a 5 days per week respite care basis has now been admitted to the home for a 7 days per week placement. The manager said that it has not yet been decided whether the placement will be on a short term or long term basis. The resident’s case file was examined and it was noted that it contained a copy of the CPA care plan, the local authority Adult Community Review form and a copy of the FACS. The manager had also visited the resident, at the hospital, to carry out an assessment and had consulted with health care professionals. There was evidence that the assessments carried out by the home and the other information received had been used to revise and to amend the existing care plan. Ashgale House DS0000017514.V347793.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 People who use this service experience good outcomes in this area. Evaluating care plans on a regular basis ensures that changes in the needs of residents are identified and can be addressed and regular reviews of the placement confirm that the care home continues to be able to meet the individual needs of the resident. Residents have the opportunity to exercise choice in their daily lives. Responsible risk taking contributes towards the resident leading an independent lifestyle. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A statutory requirement had been identified during the previous inspection in June 2007 that the care plan and the placement must be reviewed on a regular basis so that the changing needs of a resident are identified and can be addressed. Three residents were selected for case tracking and their files were examined. Each file included a care plan and there was evidence that these Ashgale House DS0000017514.V347793.R01.S.doc Version 5.2 Page 11 included updates or revisions, which were dated. The plan included photographs of the resident and recorded things that the resident liked to do and what support the resident needed to reach their goals. Case files also contained guidelines for staff including behavioural guidelines and guidelines for supporting a resident with epilepsy. There was evidence that the plans and placements had been reviewed in 2007 by the funding authority. There had also been an internal review that had been convened by the home. Therefore this requirement was now met. Minutes of review meetings demonstrated that the resident was invited to attend and did so, if they wished. Family members that attended, if the resident wished, also supported them. During the inspection a discussion took place with a senior support worker regarding communicating with residents that are unable to respond verbally and how to offer these residents choice and respect their decisions. The member of staff discussed the introduction of a communications book, developed by the hospital, for a second resident in the home and the ways in which it could be used to offer choice. Daily records and observations also confirmed that residents had opportunities for exercising choice. On the day of the inspection a resident had decided that they would like to go out shopping and this was facilitated. Another resident said that they had not wanted to go on a holiday that had been arranged by the home for residents and their wishes had been respected. The manager said that the home had applied for the services of an advocate for residents without a relative in regular contact. They are still on the waiting list for an assessment. Two residents have an advocate but do not have regular contact with them. Case files included risk assessments, which were tailored to the individual needs of the resident. These included food preparation, personal care, the risk of pressure sores developing and for damage to property. They had been completed recently or had been subject to review. Risk assessments included risk management strategies. Ashgale House DS0000017514.V347793.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, 14, 15, 16, 17 People who use this service experience good outcomes in this area. Taking part in activities, developing new skills and using community resources gives residents the opportunity to enjoy an interesting and stimulating lifestyle. By maintaining contact with their family and friends the resident’s need for company and fellowship is met. Residents are encouraged to become more independent by making decisions and by having their wishes respected. Menus respect the religious, cultural and dietary needs of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each file examined contained a programme of activities. The content of these depended on the interests of the resident. Six of the 11 residents attend a day centre. A member of staff from the home supports one of the residents when they attend the centre. Four residents choose not to attend and they have previously confirmed this with the Inspector. The manager said that they were Ashgale House DS0000017514.V347793.R01.S.doc Version 5.2 Page 13 trying to arrange a day centre for the remaining resident. Activities when residents are home based may take place inside Ashgale House e.g. relaxing in the sensory room or taking part in the pottery class or may include going out shopping, going to change library books, playing football in the park or going swimming. Venues for shopping and eating take into account residents’ cultural needs. A statutory requirement was identified during the previous inspection in June 2007 that daily records must state why planned activities do not take place so that the home can demonstrate that the resident’s religious and cultural needs are respected. This requirement was in respect of a resident attending the temple. The resident’s daily records were examined and it was noted that there was regular attendance at the temple, facilitated by the home. Therefore this requirement is now met. Daily records, observations and residents’ comments confirm use of facilities and resources within the community including leisure centres, pubs, cinemas, theatres and restaurants. The home has its own transport and the driver was on duty during the inspection. During the inspection it was noted that if a resident wanted to go out of the home, an escort was provided. Each resident has an activities planner although they are given a choice if they do not want to take part in the activity listed. Residents enjoy an annual holiday, if they wish. Two of the residents said that they had been to Blackpool this year and both agreed that they had enjoyed the holiday and the accommodation. One resident said that they had enjoyed the disco. The minibus is used to take residents out for the day and an example of a trip to Hampstead Heath was given. Some residents continue to receive regular visits from their families and where it is difficult for a family member to come to Ashgale House an escort from the home takes the resident to see the relative. The manager said that one resident is taken on a monthly basis to visit the resident’s sibling and another resident is taken to visit and to stay with their family for the weekend. Residents are also encouraged to keep in touch with their family by telephone and if the resident is unable to speak the key worker will keep in contact with the family and update them with the wellbeing of the resident. Residents can choose whether they wish to socialise with other residents or whether to take part in activities. Residents are given options from which they can make a choice. A member of staff said that some residents communicate by using Makaton, a billboard or a communications book. Where possible residents are encouraged to take part in daily routines e.g. bringing their laundry down or taking a plate to the sink when they have finished eating. Two statutory requirements were identified during the previous inspection in June 2007 in relation to dietary needs. The first requirement was that food records must be in sufficient detail to demonstrate that cultural and dietary Ashgale House DS0000017514.V347793.R01.S.doc Version 5.2 Page 14 needs are met. The second requirement was that residents must be encouraged to have variety in their choice of meals to promote a healthy lifestyle. The daily records note the choice of meals offered to the resident and the meal that they have selected. There was additional information in the file of a resident with specific cultural and dietary needs. This information had been prepared by the dietician and contained advice staff about what foods to prepare for the resident. The manager said that there are 3 members of staff in the home that share the cultural background of the resident and as they are more familiar with the meals to be prepared, the ingredients and seasonings/spices used etc they have the main role in meeting this clients’ cultural and dietary needs. Records demonstrated that the dietician’s advice was being followed therefore this requirement is now met. Generally food records showed that residents were enjoying more variety in the meals consumed and so the second requirement is now met. The manager said that a training course on food and nutrition had taken place for members of staff in October 2007. The content of the course had included how to encourage residents to eat healthily and how to encourage residents to take part in menu planning. Ashgale House DS0000017514.V347793.R01.S.doc Version 5.2 Page 15 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 People who use this service experience good outcomes in this area. Residents receive assistance with or prompting with personal care in a manner, which respects their privacy. Residents’ health care needs are met through access to health care services in the community. The general well being of residents is promoted by assistance or support from staff in taking medication, as prescribed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents require different levels of support with personal care tasks ranging from prompting to direct assistance. The manager confirmed that female residents receive assistance from female carers. It was observed that residents were clean and tidy and smartly dressed and wore jewellery of their choice. Case files contained information for carers in respect of the individual preferences of residents and how they wished to be supported. A Gujarati word list is on display in a resident’s room and a copy is included in the daily report folder to assist staff although there are now 3 Gujarati speaking staff Ashgale House DS0000017514.V347793.R01.S.doc Version 5.2 Page 16 within the staff team. The Gujarati speaking resident’s key worker and co-key worker are also Gujarati speaking. Residents’ case files included evidence that residents had access to health care services in the community. There were records of appointments with the chiropodist, dentist and optician. Staff supported residents when residents had appointments with the psychiatrist or outpatient appointments at the hospital. Residents have the opportunity to have a flu jab each year, in the autumn. Activity plans included opportunities for exercise e.g. swimming, playing football, riding a bicycle in the garden, going for a walk etc. During the previous inspection it was confirmed that the storage of medication was satisfactory. However 2 statutory requirements were identified in respect of medication practices. The first requirement was that when medication is administered to residents it must be clearly recorded. The second requirement was that members of staff must adhere to the home’s medication policies and procedures. The records were examined and it was noted that they were up to date and complete. Therefore both of the requirements were now met. The manager confirmed that the members of staff responsible for administering medication to residents have received appropriate training. Ashgale House DS0000017514.V347793.R01.S.doc Version 5.2 Page 17 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 People who use this service experience good outcomes in this area. A complaints procedure is in place to protect the rights of the residents. An adult protection procedure and training in protection of vulnerable adults procedures help to promote and protect the welfare and safety of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A statutory requirement was identified during the previous inspection in June 2007 that the complaints procedure on display in the home must be reviewed and amended so that it contains up to date and helpful information to anyone wishing to make a complaint. A copy of the procedure was on display in the entrance hall, adjacent to the visitors’ book. The amendments had been made so that the procedure was more informative and the information in respect of the Commission for Social Care Inspection (CSCI) was now up to date. The manager said that no complaints have been recorded since the last inspection. A protection of vulnerable adults (pova) procedure is in place and staff have attended pova training. The CSCI has not been notified of any allegations or incidents of abuse occurring in the home since the last inspection. Two statutory requirements were identified during the previous inspection in relation to residents’ finances. The first was that clear information must be Ashgale House DS0000017514.V347793.R01.S.doc Version 5.2 Page 18 sent to the home, on a monthly basis, about the money held at Head Office for each individual resident, after any contributions towards fees have been paid. The second requirement was that the home must demonstrate how each individual resident will receive interest on their savings. The records of 7 residents receiving assistance with their finances were examined. It was noted that individual records were kept for each resident and that individual bank/savings accounts were in place. The records included details of the resident’s weekly/monthly income and the balance of money in their account. The two statutory requirements are now met. Ashgale House DS0000017514.V347793.R01.S.doc Version 5.2 Page 19 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, 30 People who use this service experience good outcomes in this area. Residents enjoy a comfortable and “homely” environment with pleasant communal and private facilities in which to relax. Residents live in a home where standards of cleanliness are good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two statutory requirements were identified during the previous inspection in June 2007. The requirement was that a section of the board supporting the guttering on the outside wall of the building on the ground floor needed replacing, as it was rotten. The second requirement was that the seam on the flooring in the kitchen/dining room on the ground floor needs to be levelled. During a partial site inspection it was noted that repairs had been carried out in both areas and that these requirements were now met. One of the residents Ashgale House DS0000017514.V347793.R01.S.doc Version 5.2 Page 20 said that she liked her room, mainly because it was a big room and she had lots of ornaments and soft toys on display. During the site visit it was noted that all areas seen were clean and tidy and free from offensive odour. There are laundry facilities on both floors. Access to these does not involve carrying soiled clothing through any areas where food is stored, prepared or consumed. Staff on duty during the previous inspection confirmed that they have received infection control training. Ashgale House DS0000017514.V347793.R01.S.doc Version 5.2 Page 21 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, 33, 34, 35 People who use this service experience good outcomes in this area. The rota demonstrated that there were sufficient staff on duty to support the residents and to meet their needs. The home continues to support staff and to meet their developmental needs through the provision of NVQ training and it has met the target for staff completing this training. Recruitment practices protect the welfare and safety of residents. The training needs of members of staff are identified and met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the previous inspection the manager said that of the 31 members of staff on the rota, 26 members of staff have achieved an NVQ level 2 qualification (including 8 members of staff that have achieved an NVQ level 3 qualification). He said that since June 2007 a further 3 members of staff have completed their portfolios and are waiting for these to be assessed. The home has met the target of 50 of carers achieving an NVQ level 2 or 3 qualification. Ashgale House DS0000017514.V347793.R01.S.doc Version 5.2 Page 22 On the morning of the inspection the manager was on duty. There were also 7 carers (senior support workers or support workers) on duty. One of the support workers had accompanies a resident to the day centre and another support worker was acting as an escort on the company’s mini bus that was taking residents to day centres or on outings. The driver was on duty and the maintenance person was working in the home. It was observed that staffing levels were sufficient to allow residents to take part in activities outside the home, on a 1 to 1 basis with a member of staff. One member of staff has been employed since the last inspection in June 2007 and their staffing file was examined. The file contained evidence of proof of identity, 2 references and an enhanced CRB disclosure. The manager confirmed that he had verified the member of staff’s right to reside and to work in the UK. The staffing file also contained a record of the induction training undertaken and it was noted that the format of the induction training plan was compliant with TOPSS standards. Individual modules had been signed and dated by the manager and signed by the member of staff on completion. A training profile and training needs analysis for the staff team as a whole had been made available during the inspection in June 2007. It is used to select relevant training courses from the training programme that is circulated by the company. The manager confirmed that where a large number of staff need specific training an external trainer would conduct the training on site. Since the last inspection food and nutrition, health and safety, first aid and conflict management training has taken place. Copies of training attendance certificates are kept on file. Ashgale House DS0000017514.V347793.R01.S.doc Version 5.2 Page 23 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 People who use this service experience good outcomes in this area. The manager demonstrates his competence and commitment by continuing to develop his understanding, skills and knowledge through further training. Systems are in place to gain feedback on the quality of the service from all interested parties. However, future developments in the service must use this information in the planning stage to assure residents that their needs will continue to be met. Regular servicing and checking of equipment used in the home ensures that items are in working order and safe to use. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Ashgale House DS0000017514.V347793.R01.S.doc Version 5.2 Page 24 The manager has completed his NVQ level 4 training and started his RMA in June 2007. Since the last inspection he has undertaken food and nutrition and first aid training. Two statutory requirements were identified during the previous inspection in relation to quality assurance systems in the home. The first requirement was that minutes of resident’s meetings are made and kept to confirm that the views of residents are used in the planning and development of the service. The record book was examined and the minutes confirmed that meetings are held on a regular basis i.e. monthly. Recent agenda items included redecoration in the home, menus, holiday venues and activities and the views of residents were recorded. This requirement is now met. The second requirement was that a copy of the report of the annual review of the service, including the analysis of the satisfaction surveys, is kept in the home for anyone to read. A discussion took place with the manager regarding opportunities for feedback on the quality of the service to be obtained and to be used in the planning and development of the service. The manager said that some of the residents are able to comment on the service on a day-to-day basis, during discussions with their key worker or at review meetings. There is a section in the review meeting form to record the comments of resident or their relatives. Quality assurance satisfaction surveys are sent to staff, relatives of residents, health care professionals and placing authorities on an annual basis. Although these were distributed in September 2006 there was no analysis of results or subsequent development plan made available during the previous inspection and surveys have now been sent out as part of the 2007 process therefore the second requirement remains outstanding. The manager said that relatives gave feedback on the quality of the service if they attended review meetings or when they visited the home, if they wished. There is a comments book in the hallway, for this purpose. Three statutory requirements were identified during the previous inspection in respect of health and safety. The first requirement was that the home forwards a copy of the electrical installation certificate to the CSCI to confirm that the home provides a safe environment for residents, staff and visitors. A copy of a certificate dated the 24th November 2007 was forwarded to the CSCI, after the inspection. However, the certificate noted the date of the last inspection and this had taken place in November 2006. Therefore the home has checked that the electrical installation is safe and its documentation is up to date so this requirement is now met. Valid certificates were available for the testing of the portable electrical appliances, the Landlords Gas Safety Record, fire extinguishers and the servicing/testing of the fire alarms, emergency lighting and smoke detectors. The second statutory requirement was that a weekly check of the fire alarm/smoke detectors is carried out and recorded. Records were examined and they demonstrated that fire drills are held on a monthly basis and are up Ashgale House DS0000017514.V347793.R01.S.doc Version 5.2 Page 25 to date and that fire alarms were tested on a weekly basis and are also up to date. Therefore this requirement is now met. The third requirement was that the validity of first aid certificates must be checked and where these have expired the member of staff needs to undertake refresher training. Of the 7 carers on duty the manager confirmed that 2 of the carers were qualified first aiders and that there was at least 1 qualified first aider on duty on each shift. He said that 7 members of staff had undertaken first aid training in October 2007 and that these included both new members of staff and staff that needed to renew their certification. Therefore this requirement is now met. Ashgale House DS0000017514.V347793.R01.S.doc Version 5.2 Page 26 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 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X Ashgale House DS0000017514.V347793.R01.S.doc Version 5.2 Page 27 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA39 Regulation 24.2 Requirement The registered person must ensure that a copy of the report of the annual review of the service, including the analysis of the satisfaction surveys, is kept in the home for anyone to read. The report must demonstrate that the feedback received from surveys is used to inform the planning of future service developments and assure residents that their needs will continue to be met. (Previous timescale of the 1st August 2007 not met). Timescale for action 01/03/08 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 Ashgale House DS0000017514.V347793.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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 Ashgale House DS0000017514.V347793.R01.S.doc Version 5.2 Page 29 - 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. 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