Inspection on 21/06/07 for Ashgale House

This inspection was carried out on 21st June 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 16 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 15/10/07

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 21 and 22nd of June 2007 09:00 st Ashgale House DS0000017514.V337916.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.V337916.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.V337916.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.V337916.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. 19th December 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. At the time of the inspection 10 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. Information regarding the fees charged is available, on request, from the manager of the home. Ashgale House DS0000017514.V337916.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 over 2 days in June. The first visit started at 9.00 am and finished at 3.30 pm. The second visit started at 9.05 am on the following day and finished at 3.10 pm. During the visits a site inspection took place, records were examined, a number of residents were case tracked, discussions took place with the manager, members of staff and residents and care practices were observed. The Inspector would like to thank the senior carer on duty during the first visit and the manager who was on duty during the second visit for their assistance and to thank everyone for their comments. What the service does well: What has improved since the last inspection? During the previous inspection in December 2006 12 statutory requirements were identified. Eight of these have now been met and 1 has been partially met. Ashgale House DS0000017514.V337916.R01.S.doc Version 5.2 Page 6 All members of staff have received epilepsy training. Members of staff authorised to administer medication, record their sample initials in the medication record book. The items identified during the site visit that were in need of repair/redecoration/replacement have mainly been attended to although where rooms are vacant the choice of colour schemes etc will be left to the new occupant. No items were being stored beneath stairwells. The target of 50 of carers achieving an NVQ level 2 or 3 qualification has been reached and exceeded. Each staff file contained 2 satisfactory references and enhanced CRB disclosure, proof of identity and evidence of right to work (if required). The home has kept in contact with the CSCI to confirm the progress being made in respect of staff files containing all the required documentation and information. A record is kept of the induction training undertaken by new staff in the home and that their individual records were available for inspection. What they could do better: Sixteen statutory requirements were identified during the inspection, four of which were outstanding from a previous inspection(s). Files did not contain evidence of review meetings being held at regular intervals and the minutes of review meetings that had taken place were not always on file. When programmed activities do not take place a reason for this must be recorded on the daily record sheet, particularly when the activity is attending a place of religious devotion. Food records contained insufficient detail to demonstrate that meals respected cultural and dietary needs. Daily records of meals eaten lacked the variety contained in the weekly menu and staff need to encourage residents to include different foods in their diet. An immediate requirement form was issued during the inspection due to concerns with the lack of recording of the administration of medication. This was an outstanding requirement and standards had deteriorated further since the last inspection. Members of staff are failing to follow the home’s own policies and procedures when carrying out this task. Ashgale House DS0000017514.V337916.R01.S.doc Version 5.2 Page 7 The complaints procedure on display did not contain all the information necessary to make a complaint and the information in respect of the CSCI was out of date. There are 2 outstanding requirements in relation to handling residents’ finances. Information regarding what money is held at head office on behalf of each resident is still not forthcoming and there is no evidence that interest is being paid on this money despite sums that are known being thousands of pounds. Some minor repairs are needed in the home although generally the home is in a good state of repair. A copy of the electrical installation certificate was not available during the inspection and must be forwarded to the CSCI. The testing of the fire alarms/smoke detectors had stopped in May 2007 and must start up again and be carried out and recorded on a weekly basis. A first aid certificate on one of the staff files inspected had expired 4 months ago and the home must ensure that training is undertaken to renew qualifications when they expire. When residents meetings are held (this should be on a monthly basis) minutes need to be kept. A copy of the annual review needs to be kept in the home for residents, relatives or stakeholders to refer to. 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.V337916.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.V337916.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 Overall quality in this outcome area is good. 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. This judgement has been made using available evidence including a visit to this service. EVIDENCE: No new residents have been admitted to the home since the last inspection. However, in December 2006 two files of residents admitted to the home, prior to the inspection, were examined. 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. Ashgale House DS0000017514.V337916.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 Overall quality in this outcome area is adequate. Care plans are not always evaluated on a regular basis and therefore residents cannot be assured that changes in needs are identified and can be addressed. Regular reviews of the placement are needed to 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: The files of 3 permanent residents were selected by the Inspector for case tracking. Each file included a care plan and a lifestyle plan. The lifestyle plan had been developed from the assessment of daily living and needs document and had been completed by the resident, with assistance from their key worker. The plan included photographs of the resident and recorded things Ashgale House DS0000017514.V337916.R01.S.doc Version 5.2 Page 11 that the resident liked to do and what support the resident needed to reach their goals. When checking that plans had been subject to review it was noted that one file did not contain any minutes for either a recent review meeting convened by the home or one convened by the placing authority. An internal review meeting had been convened in December 2006 for the second resident but the minutes of the meeting did not record who had attended and although a review meeting had been convened by the placing authority in September 2006 the minutes of the meeting were absent. The third file contained minutes of both a recent meeting convened by the home and a meeting convened by the placing authority. Monthly reports were examined. For one of the residents these had not been completed during 2007. Files also contained individual guidelines e.g. assisting with toileting, pressure care, epilepsy or guidelines for when the resident exhibited challenging behaviour. The guidelines for assisting a resident when they exhibited challenging behaviour included de-escalation techniques. In discussions with staff examples were given of how residents were encouraged to make decisions in their lives. Daily records and observations also confirmed this. The manager said that the home had applied for the services of an advocate for residents without a relative in regular contact. 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 self-harming. They had been completed recently or had been subject to review. Risk assessments included risk management strategies. Ashgale House DS0000017514.V337916.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 Quality in this outcome area is adequate. Residents attending day care services are provided with an opportunity to develop their social skills. Taking part in activities and using community resources gives residents the opportunity to enjoy an interesting and stimulating lifestyle and so reasons for cancelling programmed activities need to be recorded. 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. Records do not demonstrate that residents enjoy variety in what they eat or that the residents’ cultural and religious needs are being met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Ashgale House DS0000017514.V337916.R01.S.doc Version 5.2 Page 13 Each file examined contained a programme of activities. The content of these depended on the interests of the resident. Six of the 10 residents attend a day centre. A member of staff from the home supports one of the residents when they attend the centre. The remaining 4 residents choose not to attend and have said this to the Inspector. 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. Daily records note the activities undertaken by residents. One of the residents has a visit to the Temple on their activities programme. This had not taken place on the 17th June and there was no reason recorded in the records. 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. 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. go out shopping 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 enjoy an annual holiday, if they wish. One of the residents said that they had been to Florida last year for their holiday and that they planned to go to Blackpool later this year. Another resident said that they had enjoyed their holiday to the coast last year. A resident had enjoyed a theatre trip 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. 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. Key workers also keep in contact with the relatives of the resident to update them with the resident’s condition and progress. It was noted that staff knocked on the door and waited to be invited in, before entering a resident’s room. 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 or a billboard. 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. Ashgale House DS0000017514.V337916.R01.S.doc Version 5.2 Page 14 Menus were inspected and these were varied and wholesome. There was a separate menu for an Asian resident that is vegetarian and a Jain. There are guidelines for staff about how to cook meals for the Asian resident. A member of staff on duty during the inspection confirmed that he knew how to make different parts of the meal e.g. chapattis. The daily records for this resident were examined to check what was actually eaten. Entries included “vegetable curry”. In order to maintain a balanced diet for this resident dhal, yoghurt or buttermilk, rice and/or chapattis, pickles, fresh salad and curried vegetables should be served. The lentils used in preparing the dhal and the vegetables used should be varied. Although the manager said that vegetable curry would only be part of the meal the home was unable to demonstrate that the cultural and dietary needs of the resident were being met. A statutory requirement was identified during a previous inspection that residents are encouraged to follow a varied and balanced diet. It was noted that there were some gaps in the daily records (which consist of a separate form for the early shift and a separate form for the late shift) of the 3 residents that were case tracked. However from the records that were available 1 resident had a chicken meal on the 20/6, 19/6, 17/6, 15/6 and the 10/6. Another resident had a chicken meal on the 19/6, 17/6, 16/6, 15/6 and the 10/6. Careful thought needs to be given when staff offer an alternative meal to the one on the menu so that variety is encouraged. This requirement remains outstanding. Ashgale House DS0000017514.V337916.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 Quality in this outcome area is adequate. Residents receive assistance 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. Failing to record the administration of medication and failing to follow the home’s policies and procedures compromises the safety and wellbeing of residents. 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. Case files contained information for carers in respect of the individual preferences of residents and how they wished to be Ashgale House DS0000017514.V337916.R01.S.doc Version 5.2 Page 16 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 Gujarati speaking staff within the staff team. 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, although a plan would assist the booking of future appointments to maintain regularity. Staff supported residents when residents had appointments with the psychiatrist or outpatient appointments at the hospital. Residents had the opportunity to have a flu jab 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. A statutory requirement was identified during the previous inspection that all members of staff have received epilepsy training. The senior on duty confirmed that this training has taken place and staff on duty during the inspection confirmed that they had attended. The requirement is now met. Medication is kept in each of the 2 units. In both units the storage of medication was satisfactory. The blister packs were examined and had been opened appropriately prior to the inspection; in relation to the time of day and day of the week that the inspection took place. A statutory requirement was identified during the previous inspection that all members of staff authorised to administer medication record their sample initials in the medication record book. This requirement has been met. Another statutory requirement identified during the previous inspection was that all medication record sheets are up to date and complete. During the last inspection there was one gap in the recording. It is of concern that this problem has increased and that the requirement remains outstanding. An immediate requirement form was issued during the inspection as no signatures had been recorded in the records kept in the ground floor lounge for 20:00 hours on the 20th June for any resident in this unit. There were also gaps in the ground floor records for one of the residents, for 16:00 hrs and 20:00 hrs on the 18th and 19th June and for 8:00 hrs and 16:00 hrs on the 20th June. The medication policy was checked and it advised staff that “this (medication) will be signed for, immediately after it has been given”, but the policy had not been followed. The manager confirmed that staff that administered medication had received medication training. Ashgale House DS0000017514.V337916.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 Quality in this outcome area is poor. A more robust complaints procedure is needed to protect the rights of residents. An adult protection procedure and training in protection of vulnerable adults procedures help to promote and protect the welfare and safety of residents. Records of the management of individual’s personal money are not available in the home and therefore the residents cannot be assured that their best interests are being upheld. This judgement has been made using available evidence including a visit to this service. EVIDENCE: It was noted that the complaints procedure on display in the entrance hall, adjacent to the visitors book was brief and lacked sufficient detail for anyone wishing to make a complaint. In respect of the Commission for Social Care Inspection (CSCI) it referred people to an Inspector that no longer is with the CSCI. The complaints records were examined. Three complaints had been received since the last inspection and each had been resolved. A protection of vulnerable adults (pova) procedure is in place and staff files contained evidence that staff had attended pova training. Staff were able to describe what to do in the event of a disclosure being made or an incident occurring. Since the last inspection an allegation has been made and a safeguarding adults referral followed. The complainant is now satisfied that their concerns have been addressed. Ashgale House DS0000017514.V337916.R01.S.doc Version 5.2 Page 18 A statutory requirement has been identified during 3 previous inspections that clear information is 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. A further statutory requirement has been identified during 3 previous inspections that the home demonstrates how each individual resident will receive any interest applicable to their individual savings. Financial records were examined. Receipts for items of expenditure accompany individual records. It was noted that the recording of an item of expenditure for 2 residents was 20 days after money had been debited from their petty cash. It was also noted that when money is taken from their petty cash for clothes shopping the amount needed is often overestimated and has to be returned. Only 2 of the 10 records indicated a sum of money that was being held at head office on behalf of the resident. The manager said that one of these figures was incorrect, as major items of expenditure had been made recently. The figures that were recorded had been given some time ago and were not based on any monthly information. There was no information available in respect of any resident receiving interest on their savings. Both of the requirements remain outstanding. Ashgale House DS0000017514.V337916.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 Overall quality in this outcome area is good. Residents live in a home where the general standard of maintenance is good, although some minor matters need attention. 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: During the site visit it was noted that on the outside of the building, on the ground floor, a section of the board supporting the guttering was rotten and broken. A statutory requirement was identified during the previous inspection that Room 3 is redecorated, the 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 Ashgale House DS0000017514.V337916.R01.S.doc Version 5.2 Page 20 the room at the front of the house (first floor) and in the lounge (second floor) needs cleaning or replacing. Most of these items have been attended to although in respect of Rooms 3, 6 and 10, that are currently vacant, redecoration etc will be done according to the preferences of the next occupants for these rooms. The seam on the flooring in the kitchen/dining room on the ground floor is still lifting in places although the timescale for attending to this has not yet expired. All other areas of the home that were inspected were satisfactory. During the site visit it was noted that all areas were clean and tidy and free from offensive odour. There are laundry facilities on both floors. Access to these did not involve carrying soiled clothing through any areas where food is stored, prepared or consumed. Staff on duty during the inspection confirmed that they have received infection control training. Ashgale House DS0000017514.V337916.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 Quality in this outcome area is good. 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 through the provision of NVQ training and 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: A statutory requirement was identified during the previous inspection that 50 of carers achieve an NVQ level 2 or 3 qualification by October 2007. Although this timescale has not yet expired a discussion took place with the manager about progress being made to meet the target. Of the 31 members of staff on the rota the manager said that 26 of the staff members have achieved an NVQ level 2 qualification and that eight of the 26 members of staff have a NVQ level 3 qualification. Therefore this requirement has been met. Ashgale House DS0000017514.V337916.R01.S.doc Version 5.2 Page 22 The rota was available for inspection. During the early and late shifts there are 6 members of staff on duty including either 2 or 3 senior support workers. At night there are 3 or 4 waking night staff, depending on whether there are respite care residents being accommodated. 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. Seven staff files were examined. Each file contained a satisfactory enhanced CRB disclosure and for recently appointed members of staff there was a pova first entry. Each file also contained 2 satisfactory references, proof of identity and right to work for the hours allocated during the week (if required). A statutory requirement was identified during the previous inspection that each staff file contains 2 satisfactory references and enhanced CRB disclosure, proof of identity and evidence of right to work (if required). This is now met. Another statutory requirement was identified during the previous inspection that the home contacts the CSCI to confirm that each staff file now contains all the required documentation and information. The company has updated the CSCI with progress as this task has been undertaken and the requirement is now met. A statutory requirement was identified during the 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. Two of the 7 staff files inspected belonged to newly appointed staff. Both files contained an induction training record book. One had been completed and “signed off” by manager and member of staff. The other member of staff was still undertaking induction training. There was a training profile and training needs analysis for the staff team as a whole that was made available during the inspection. This is used to select relevant training courses from the training programme that is circulated by the company. The manager said that where a large number of staff need training e.g. epilepsy training for the staff team, a trainer visits the home to conduct a course. Copies of training attendance certificates were on file. Ashgale House DS0000017514.V337916.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 Quality in this outcome area is adequate. The manager demonstrates his competence and commitment 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 but a lack of recording and analysis of information prevents the home from demonstrating that the planning and development of the service is based on the views of residents or stakeholders. Regular servicing and checking of equipment used in the home would ensure that items are in working order and safe to use but certificates and records were not available for all of these. Although staff have training in safe working practice topics these need to be retaken at required intervals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Ashgale House DS0000017514.V337916.R01.S.doc Version 5.2 Page 24 The manager said that he has now completed his NVQ level training and is waiting to receive his certificate. He started his RMA in June 2007. Since the last inspection he has undertaken fire marshal training and securicare training. The book where the minutes of residents’ meetings are recorded was examined. The last three entries had been made on the 6/2/07, 22/12/06 and the 2/12/06. The manager said that although meetings have taken place since February 2007 they have not been recorded. The manager said that some of the residents also are able to comment on the service on a day-to-day basis, during discussions with their key worker or at review meetings. 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. 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. Servicing/inspection certificates were examined. A valid certificate was available for the fire precautionary systems in the home (fire alarms, smoke detectors and emergency lighting), portable electrical appliances, the Landlord’s Gas Safety Record, the hoists and the fire extinguishers. No certificate was available for the electrical installation. The last fire drill was recorded in April 2007. The last recorded weekly check of the fire alarm system was on the 4th May 2007. Staff files included certificates of attendance for safe working practice topics i.e. food safety, fire safety, manual handling, infection control and first aid. It was noted that a first aid certificate that was valid for 3 years had expired in February 2007. A statutory requirement was identified during the previous inspection that items are not stored underneath stairwells. During the site visit it was observed that this requirement is now met. Ashgale House DS0000017514.V337916.R01.S.doc Version 5.2 Page 25 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 2 23 1 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 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 1 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 3 X 2 X X 1 X Ashgale House DS0000017514.V337916.R01.S.doc Version 5.2 Page 26 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 YA6 Regulation 15.2 Requirement 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. 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. Food records must be in sufficient detail to demonstrate that cultural and dietary needs are met. Residents must be encouraged to have variety in their choice of meals to promote a healthy lifestyle. (The previous timescale of the 16th April 2007 not met). When medication is administered to residents it must be clearly recorded, to ensure that residents receive the correct levels of medication. (The previous timescale of the 12th April 2007 not met). Members of staff must adhere to the home’s medication policies DS0000017514.V337916.R01.S.doc Timescale for action 01/10/07 2 YA13 12.4 & 16.2 16/07/07 3 YA17 12.4 & 16.2 16.2 16/07/09 4 YA17 16/07/07 5 YA20 13.2 22/06/07 6 YA20 13.2 16/07/07 Ashgale House Version 5.2 Page 27 7 YA22 22.1 8 YA23 17.2S4.9 9 YA23 17.2S4.9 10 YA24 23.2 and procedures so that when they assist residents they use safe working practices. 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. Clear information must 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, so that decisions on levels of expenditure are in accordance with the resident’s budget. (Previous timescale of 1st July 2006, 1st October 2006 and the 1st June 2007 not met). That the home demonstrates how each individual resident will receive interest on their savings so that financial interests are protected. (Previous timescale of 1st July 2006, 1st October 2006 and 1st June 2007 not met). A section of the board supporting the guttering on the outside of a wall on the ground fall was rotten and broken and needs to be replaced before the guttering becomes detached from the wall. That the seam on the flooring in the kitchen/dining room (ground floor) is levelled to prevent moisture, dirt of food debris becoming trapped. 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. DS0000017514.V337916.R01.S.doc 16/07/07 16/07/07 16/07/07 01/08/07 11 YA24 23.2 01/07/07 12 YA39 24.1 01/08/07 Ashgale House Version 5.2 Page 28 13 YA39 24.2 14 YA42 23.2 15 YA42 23.4 16 YA42 13.4 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. 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. That a weekly check of the fire alarm/smoke detectors is carried out and recorded to confirm that in the event of a fire the alarm system will protect residents, staff and visitors. Checks must be carried out on the validity of first aid certificates and where these have expired refresher training undertaken so that residents receive appropriate treatment in the event of an accident. 01/08/07 01/08/07 16/07/07 01/10/07 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 2 3 4 Refer to Standard YA6 YA6 YA6 YA14 & YA17 Good Practice Recommendations That the home contacts the placing authority to request a copy of the minutes of the review meeting if they have not received these within 4 weeks of the meeting taking place. That the minutes of review meetings convened by the home include a list of the names of persons attending the meeting. That monthly reports are completed on a regular basis. That daily record sheets are completed for each shift. Reasons for not offering the programmed activity need to be recorded and the record of food eaten should be in sufficient detail to demonstrate that a balanced meal has been offered. To assist in the booking of future health care appointments DS0000017514.V337916.R01.S.doc Version 5.2 Page 29 5 YA19 Ashgale House 6 7 YA23 YA39 a plan should be drawn up for each resident so that the regularity of appointments can be maintained. This would record the date of the last appointment and the date when the next appointment is due. That financial records are completed at the time and not several weeks later. That residents’ meetings are held on a monthly basis and that minutes are kept. Ashgale House DS0000017514.V337916.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Harrow Area Office 4th Floor, Aspect Gate 166 College Road Harrow London 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.V337916.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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