CARE HOME ADULTS 18-65
Ashgale House 39-41 Hindes Road Harrow Middlesex HA1 1SQ Lead Inspector
Julie Schofield Key Unannounced Inspection 19 December 2006, 15 ,28th February 2007 11:00
th th Ashgale House DS0000017514.V319500.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.V319500.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.V319500.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) Allied Care Ltd 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.V319500.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. 20th April 2006 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. 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. Information regarding the fees charged is available, on request, from the manager of the home. Ashgale House DS0000017514.V319500.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection consisted of visiting the home on 3 separate days. The first inspection day was on the 19th December. It started at 11 am and finished at 1pm. A postal survey of relatives of residents and members of staff was undertaken. The second inspection day took place on the 15th February 2007. A visit was made in the morning between 8.25 am and 11.30 am. A visit in the afternoon took place between 1.50 pm and 5 pm. The third inspection day took place on the 28th February. It started at 10.40 am and finished at 3.50 pm. During the inspection discussions took place with the manager, deputy manager, area manager, members of staff, residents and a relative. Records were examined, a site visit took place and care practices were observed. The Inspector would like to thank everyone for his or her comments and assistance during the inspection. Previously, a random unannounced inspection took place on the 26th July 2006 to check compliance with the statutory requirements identified during the key inspection in April 2006. Sixty six statutory requirements were identified during the key inspection in April and this number had reduced to 13 statutory requirements during the random inspection in July. What the service does well: What has improved since the last inspection?
Ashgale House DS0000017514.V319500.R01.S.doc Version 5.2 Page 6 During the random inspection in July 2006 progress towards compliance with the statutory requirements identified during the key inspection in April 2006 was checked. The home was commended for the progress made. It was noted that care plans were being reviewed on a regular basis. A system had been introduced to check that items purchased for/by residents are brought into the home. There was evidence that where there is a risk of self-harm a risk assessment is included on the case file. There were also risk assessments in respect of pressure sores for residents with limited mobility. Case files examined contained evidence that risk assessments had been recently reviewed. Daily logs included a record of whether a resident wished to take part in an activity. Parking spaces outside the home were clearly marked with their use and included a space reserved for visitors to the home. Menus shown demonstrated that there is a choice of dishes available to residents. Monthly records are kept of residents’ weights and the home now has a facility for weighing non-weight bearing residents, subject to their cooperation. Records of meals consumed by residents indicate that alternative meals are served, to accommodate the likes and dislikes of residents and the records were up to date. Moving and handling assessments examined were in sufficient detail to inform staff of the assistance required from them. Case files contained guidance for staff when supporting residents who have a risk of developing pressure sores. The home has followed up a request for information about a possible accident or incident sustained by a resident when they were attending a day centre. During a tour of the premises it was evident that the home had made every effort to meet outstanding statutory requirements in respect of the building. The home met 33 of the 35 statutory requirements regarding the physical environment, made during the key inspection in April 2006. Four staff files were examined during the random inspection and it was noted that all necessary documents were on file. Five staff have completed their NVQ in Care and four care staff have handed in their portfolio to be internally verified. It was noted that the home has undertaken service users surveys and the annual service review was viewed and assessed during this visit. This inspection checked compliance with the statutory requirements identified or that remained outstanding during the random inspection of July 2006. Of the 13 statutory requirements identified 10 are now met. A record of the preadmission visits made to the home is now kept and the content is comprehensive. Each resident, whether permanent or receiving respite care, has a comprehensive care plan, which addresses personal, health and social care needs. ‘Body maps’ are completed when required and are linked to any follow up action. Each resident has an activities programme for the days of the week that they are accommodated in the home and activities are offered according to the individual activities programme. The broken bath chair in the ground floor bathroom has been replaced. The light bulbs in the first floor hallway have been replaced. The doorbell is now working. The
Ashgale House DS0000017514.V319500.R01.S.doc Version 5.2 Page 7 washing machines have been repaired. Accidents are recorded in the accident book. The timescale for 1 requirement in respect of induction training has been extended, as the home has not had the opportunity to demonstrate compliance. 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.V319500.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.V319500.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, 4 A comprehensive 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. A programme of preadmission visits to the home enables the prospective resident to sample life in the home and to decide whether the service provided is acceptable. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two files of residents newly admitted to the home were examined and it was noted that they included information provided by the funding authority. The local authorities had provided a copy of the assessment and care plan. There was also evidence that the manager had completed an assessment of the resident and identified their personal, health and social care needs. The needs assessment was then used as a basis to develop a care plan for the new resident. Files of the 2 residents most recently admitted to the home were examined. It was noted that the home has introduced a transition log where visits made to
Ashgale House DS0000017514.V319500.R01.S.doc Version 5.2 Page 10 the home by the prospective resident are recorded. Visits took place during the day and overnight, giving the prospective resident the opportunity to see the accommodation, have a meal with the other residents, meet the staff and take part in activities. The log recorded the date and time of the visit, who was on duty, what the resident did while they were in the home, how they appeared, any interaction with other residents, any incidents or accidents and the date and details of any further planned visits. The log sheet was signed and was accompanied by a daily report on the resident. The home is to be commended on the quality of the recording of preadmission visits to the home. Ashgale House DS0000017514.V319500.R01.S.doc Version 5.2 Page 11 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 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. It is not apparent whether the assistance given to residents with financial matters promotes and protects their best interests. Responsible risk taking contributes towards the resident leading an independent lifestyle. Overall quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Six case files were examined and it was noted that each contained a comprehensive care plan, which addressed personal, health and social care needs. The comprehensive plans included a section where what the resident
Ashgale House DS0000017514.V319500.R01.S.doc Version 5.2 Page 12 could do, what support the resident needed and how the service would meet the needs in this aspect of the resident’s life were recorded. Case files also contained guidelines for supporting residents and records of their preferred routines at different times of the day. There was evidence that the care plans were subject to regular reviews, either convened by the home or by the local authority, although the internal review of a care plan of a respite care resident was overdue. The home was still waiting for the minutes of the review meeting convened by a local authority for one of the residents. Staff gave examples of how they helped residents to make choices and how they interpreted the non-verbal communication of residents who were making their wishes known. Advocacy services have been requested for some of the residents and the deputy manager has begun training to be an advocate (but will not work in this role for residents in Ashgale House). Seven residents are supported with their financial affairs by the home and accounts are in the process of being set up for each individual resident. However 2 statutory requirements identified previously remain outstanding. The information sent to the home regarding the amount of money being held at head office on behalf of a resident still needs to be simplified. Residents have still not received interest on money held at head office. Six case files were examined and each contained risk assessments tailored to the needs of the individual resident. Each risk assessment identified the risk and whom it affected, how to minimise the risk, an action plan and who was responsible and when and by whom it was to be reviewed. Risk assessments included ones in respect of behaviour, personal care, taking part in activities in the community, road safety, absconding and food preparation. There was evidence that these are subject to regular review. Ashgale House DS0000017514.V319500.R01.S.doc Version 5.2 Page 13 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 Residents attend day care services, which provide an opportunity to develop their social skills, and/or have access to a weekly activities programme. Taking part in activities and using community resources gives residents the opportunity to enjoy an interesting and stimulating lifestyle. With staff support, residents are encouraged to maintain contact with their families and to enjoy fulfilling relationships. Residents are encouraged to make decisions and their wishes are respected. Residents need to be encouraged to follow a varied and wholesome diet. Overall quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Four of the 11 permanent residents have a day care programme that includes day centre attendance. However, if they choose not to go to the centre this is respected. The manager said that discussions are taking place regarding
Ashgale House DS0000017514.V319500.R01.S.doc Version 5.2 Page 14 another resident that wishes to attend a day centre. All residents have a programme of activities for the day(s) that they are based at home and this includes activities both inside and outside Ashgale House. It was noted that residents made full use of community resources and, with an escort, they either walked to facilities or used the company transport. The home has the use of a car or 2 minibuses. A resident confirmed that he used leisure facilities, parks, local shops and shopping centres, cinemas, churches etc. The deputy manager said that other facilities used included pubs, restaurants, cafes, theatres and the Temple. Throughout the inspection it was noted that residents went out of the home, with an escort. Several times it was as a result of a resident identifying something that they wanted to do e.g. purchase a lampshade for their room or change their library books. 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 enjoyed an annual holiday, if they wished. A member of staff was part of a small team that accompanied 2 residents to Bognor Regis. Another member of staff said that residents had liked using the beach and had taken a sightseeing bus trip. If a small group of residents go on holiday together they are residents that get on well with each other. One of the residents had chosen to go to Florida for their holiday. On a Wednesday afternoon the residents using the first floor lounge were enjoying a video afternoon and a member of staff said that residents took turns in choosing the video. Staff said that there are music sessions, massage sessions and pottery sessions during the week. Outings had taken place to Watford and Hemel Hempstead. Two residents were enjoying a day out to Covent Garden to have lunch and then to go to the theatre to see The Lion King. Some residents have regular visitors and visits can take place in the lounge or in the privacy of the resident’ s room. A relative confirmed that the staff on duty made visitors welcome when they arrived. Some residents enjoy overnight or weekend visits to their family. The home will encourage residents to keep in touch with their relatives and will dial a telephone number for a resident wishing to speak to their relative. If the relative is unable to visit due to frailty the home will provide the resident with transport and an escort to visit the relative so that the relationship is maintained. A resident said that his privacy was respected and that staff knocked on the door and waited to be invited in, before entering. His choice of whether he socialises with other residents or whether he takes part in activities is respected. A member of staff said that residents are given options and staff respect the choices made. Sometimes a resident may refuse options offered. A member of staff said that some residents communicate by using Makaton or a billboard. The member of staff said that there would be “refresher” Makaton training next month. Where possible residents are encouraged to take part in Ashgale House DS0000017514.V319500.R01.S.doc Version 5.2 Page 15 daily routines e.g. bringing their laundry down or taking a plate to the sink when they have finished eating. The deputy manager said that the resident’s likes and dislikes in respect of food are included in the care plan. Cultural and religious needs are also met and an Asian resident has their food prepared by Asian members of staff. Menus were available. A record is kept of what residents eat each day. It was noted that in an 11-day period a resident had selected a meal of fish and chips on 4 occasions. It was noted that although assistance is given with feeding a resident was encouraged to feed herself, with the use of special cutlery. On the third inspection day an evening meal was being prepared. It consisted of chicken, salad and baps or a jacket potato with a choice of filling. Ashgale House DS0000017514.V319500.R01.S.doc Version 5.2 Page 16 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 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 although all staff need training in epilepsy. The general well being of residents is promoted by assistance or support from staff in taking medication, as prescribed. However the recording of the administration of medication must be complete. Overall quality in this outcome area is adequate. 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. It was noted that assistance was discreetly offered to residents. Female residents receive assistance from female carers. A member of staff said that residents were encouraged to be as independent as possible and to do what they were able to do for themselves. It was observed that residents were clean and tidy and smartly dressed and wore jewellery of their choice. The home has a system of key working and the
Ashgale House DS0000017514.V319500.R01.S.doc Version 5.2 Page 17 key worker checks that the resident has supplies of appropriate hair care and skin care products to meet their cultural needs. Case files contained information for carers in respect of the individual preferences of residents and how they wished to be supported. Five members of staff are able to speak Gujarati and they help support a Gujarati speaking resident. A Gujarati word list is on display in the resident’s room and a copy is included in the daily report folder. Body maps are used appropriately. Records were examined to check that residents had access to health care services in the community. It was noted that residents were supported to attend appointments with the GP or at out patient departments (e.g. the ophthalmic department, the epilepsy clinic etc). There were regular appointments with the chiropodist and the optician and a relative said that their resident had been to the dentist the day before. Residents were able to have a flu jab, if they wished. Referrals had been made for specialist services e.g. a request for an assessment by the speech and language therapist, an appointment with the dietician etc. Medication reviews and appointments with the psychiatrist had taken place. The deputy manager said that 4 of the 11 permanent residents have epilepsy and that 14 members of the staff team have received epilepsy training. Guidelines for staff are present on the files of the residents that have epilepsy. Medication records were inspected. It was noted that not all staff had entered their specimen initials in the record of members of staff authorised to administer medication. The manager said that there was a rolling programme of “refresher” medication training for all staff authorised to administer medication. A member of staff on duty confirmed that he had received medication training. There was information regarding the medication prescribed for each resident, which included the name of the medication, indications, route form, special points and side effects. There were guidelines for the use of PRN medication. Although most recording was up to date and complete there was a gap on one of the residents’ record sheets. The medication had been administered. Medication had been administered prior to the inspection appropriately and in accordance with the day of the week and time of day that the medication was examined. Storage was safe and secure. Ashgale House DS0000017514.V319500.R01.S.doc Version 5.2 Page 18 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 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. Recruitment practices need to be thorough so that these also contribute towards protecting the welfare and safety of residents. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A complaints procedure is in place in the home. It includes the stages of the process and timescales for completion. Complainants are advised of their right to contact the CSCI. No complaints have been recorded since the last inspection. A relative that was present on one of the inspection days confirmed that if they had any concerns regarding the care of the resident they would be able to talk to one of the managers. Two residents said that if they had a concern or complaint they would talk to one of the managers. Since the last inspection 5 anonymous complaints have been received by the CSCI. These complaints have been investigated by the home. The first four complaints were not substantiated. The last complaint was partly substantiated in that some information required during recruitment had not been obtained. Ashgale House DS0000017514.V319500.R01.S.doc Version 5.2 Page 19 A protection of vulnerable adults procedure is in place in the home. Staff on duty confirmed that they had received training in adult protection procedures and were able to describe their responsibilities in the event of a disclosure being made. Since the last inspection 2 allegations of abuse have been received. One was not substantiated and the other allegation is still under investigation. The home notified the adult protection team and the CSCI of the allegation that they were notified of as part of their protection of vulnerable adults procedures. When checking recruitment processes in the home a representative from the Human Resources department at head office drew up a list of documents that were absent from staff files. Ashgale House DS0000017514.V319500.R01.S.doc Version 5.2 Page 20 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 Residents live in a home where the general standard of maintenance is satisfactory although some refurbishment is needed. Residents live in a home where standards of cleanliness are good. Overall quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the tour of the premises, although the general upkeep and state of repair was satisfactory it was noted that on the ground floor Room 3 needed decorating, the skirting boards in Room 8 need repainting, the flooring in Rooms 1 and 6 needs attention and that the seam on the flooring in the kitchen/dining room is lifting. On the first floor the kitchen/dining area needs redecorating and the seam on the flooring is lifting, the separate toilet needs redecorating, Room 10 needs the mattress replacing and the room redecorated and the carpet in the room at the front of the house needs cleaning or
Ashgale House DS0000017514.V319500.R01.S.doc Version 5.2 Page 21 replacing. On the second floor the carpet in the lounge needs cleaning or replacing. It was noted that the home was furnished and decorated in a “homely manner”. Levels of heating and lighting were appropriate for the season. Residents using a wheelchair are able to access all areas of the ground floor and the garden. A relative said that their resident had changed their room recently and that a chair and computer table had been provided so that the resident did not have to put away the jigsaw puzzle that they were working on. During the tour of the premises it was noted that the home was clean and tidy and free from offensive odours. There are laundry rooms on both floors. A relative said that the home was kept clean and tidy. Staff have received training in infection control procedures. Ashgale House DS0000017514.V319500.R01.S.doc Version 5.2 Page 22 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 Members of staff that are undertaking or have completed their NVQ training support residents. The home needs to continue to support the programme of NVQ training for support workers. The rota demonstrated that there were sufficient staff on duty to support the residents and to meet their needs. Recruitment practices must protect the welfare and safety of residents and the home needs to obtain all the documents to demonstrate this. The training needs of members of staff are identified and reviewed. Overall quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A review took place with the deputy manager in respect of the progress made by the home in meeting a target of 50 of carers achieving an NVQ level 2 or 3 qualification. The review included both staff working during the day and those working at night. Ten of the 29 senior support workers/support workers named on the rota have completed their training (7 at level 3 and 3 at level 2). Seventeen of the remaining 19 carers are currently studying for their qualification.
Ashgale House DS0000017514.V319500.R01.S.doc Version 5.2 Page 23 A copy of the rota was available for inspection. At the time of the inspection there were 11 residents living in the home and 5 people that were using the respite care service in the home, which consists of 2 respite care beds. It was noted that there were 7 members of staff on duty on both the early shift and on the late shift. At night there were 3 staff on duty when there were no respite care residents and 4 staff on duty when there were respite care residents being accommodated. Staffing levels were maintained at the weekend. The number of staff on duty was sufficient for the layout of the building and for the provision of an escort when a resident was taking part in an activity in the community. Members of staff were able to discuss means of communicating with residents that were unable to communicate verbally. A representative from the Human Resources department at head office has recently carried out a review of recruitment practices in the home. Staffing files were audited for the presence of the required checks, documentation and references. A significant number of documents etc were absent from the files. The managers have been made aware of what documents need to be supplied by individual members of staff and are checking that these are being supplied. The CSCI has been provided with information regarding the audit and the subsequent action plan. A statutory requirement had been identified during a previous inspection that a record is maintained of the induction training undertaken by new staff in the home and that their individual records are available for inspection. At the time of the inspection no members of staff were undertaking induction training. Therefore the timescale for compliance has been extended. There is a programme of training for the home and they are notified by head office of future courses. There are individual training profiles so that managers can monitor when “refresher training” is needed. At present 18 members of staff have commenced an intensive health and safety training course. A member of staff undertaking this training said that the course covered infection control, COSHH, first aid and manual handling. Some of the training courses that members of staff took part in during 2006 included manual handling, infection control, fire safety, first aid, challenging behaviour, autism, epilepsy, medication and protection of vulnerable adults procedures. Ashgale House DS0000017514.V319500.R01.S.doc Version 5.2 Page 24 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 The manager demonstrates his competence by continuing to develop his understanding, skills and knowledge through further training. Systems are in place to gather feedback on the quality of the service provided to enable the service to develop in ways that meet the changing needs of the residents. Training in safe working practice topics enables members of staff to safeguard the health, safety and welfare of the residents and regular servicing and checking of equipment used in the home ensures that items are in working order and safe to use. Storage of items used in the home must be safe. Overall quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Ashgale House DS0000017514.V319500.R01.S.doc Version 5.2 Page 25 The manager has successfully completed his NVQ level 4 in management qualification. He has also undertaken periodic training to update his knowledge and understanding. An annual survey is undertaken and this includes questionnaires being distributed to residents, relatives, funding authorities and member of staff. A member of staff confirmed that she had completed the staff questionnaire. The information is recorded on a form, which has a marking system. The form is analysed by the QA team and any problems or concerns are fed back to the home with a request for the home to complete an action plan. A copy of the annual service review was available during the random inspection in July 2006. In addition to the annual service review there also means of obtaining feedback on an informal basis. There is a section for visitors to the home to record any comments they may have in the visitors’ book. Residents or their relatives can also give feedback at review meetings, during 1 to 1 sessions with the key worker or by a meeting with or telephone call to one of the managers. The managers regularly walk through the home talking with staff and residents. Copies of the Regulation 26 reports are sent to the CSCI. There were valid certificates for the testing/servicing of the portable electrical appliances, the assisted bath, the hoists, the hot water system, fire precautionary systems and equipment and the gas supply. Records demonstrated that the fire alarms and smoke detectors are tested on a weekly basis and that fire drills are carried out on a monthly basis. Staff confirmed that they have received training in safe working practice topics. The accident book was available for inspection and the recording was satisfactory. It was noted during the site inspection that boxes of incontinence pads were being stored underneath the stairwell on the ground floor. Ashgale House DS0000017514.V319500.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 4 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 1 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 3 X 3 X X 2 X Ashgale House DS0000017514.V319500.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 YA7 Regulation 17.2S4.9 Requirement Timescale for action 01/06/07 2 YA7 3 4 5 YA17 YA19 YA20 6 7 YA20 YA24 Clear information to be 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 i.e. the balance of any savings held. (Previous timescale of 1st July and 1st October 2006 not met). 17.2S4.9 That the home demonstrates how each individual resident will receive any interest applicable to their individual savings. (Previous timescale of 1st July and the 1st October 2006 not met). 16.2 That residents are encouraged to follow a varied and balanced diet. 18.1 That all members of staff have received epilepsy training. 13.2 That all members of staff authorised to administer medication record their sample initials in the medication record book. 13.2 That all medication record sheets are up to date and complete. 16.2&23.2 That Room 3 is redecorated, the
DS0000017514.V319500.R01.S.doc 01/06/07 16/04/07 01/06/07 12/04/07 12/04/07 01/07/07
Page 28 Ashgale House Version 5.2 8 YA32 18.1 skirting boards in Room 8 are repainted, the flooring in Rooms 1 and 6 are repaired, the seam on the flooring in the kitchen/dining room (ground floor and first floor) is levelled, the kitchen/dining area (first floor) is redecorated, the separate toilet (first floor) is redecorated, the mattress in Room 10 is replaced and the room redecorated, the carpet in the room at the front of the house (first floor) and in the lounge (second floor) needs cleaning or replacing. That 50 of carers achieve an NVQ level 2 or 3 qualification. 01/10/07 9 YA34 19.1 10 YA34 19.1 11 YA35 18.1 That each staff file contains 2 12/04/07 satisfactory references and enhanced CRB disclosure, proof of identity and evidence of right to work (if required). That the home contacts the CSCI 12/04/07 to confirm that each staff file now contains all the required documentation and information. That a record is maintained of 01/07/07 the induction training undertaken by new staff in the home and that their individual records are available for inspection. That items are not stored underneath stairwells. 12/07/07 12 YA42 13.4 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.V319500.R01.S.doc Version 5.2 Page 29 1 2 YA6 YA6 That the overdue internal review of the care plan and placement of a respite care resident takes place. That the home contacts the placing authority for a copy of the minutes of the review meeting. Ashgale House DS0000017514.V319500.R01.S.doc Version 5.2 Page 30 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
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