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Inspection on 03/11/08 for Ashgale House
Also see our care home review for Ashgale House for more information
This inspection was carried out on 3rd November 2008.
CSCI found this care home to be providing an Good service.
The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.
What follows are excerpts from this inspection report. For more information read the full report on the next tab.
Extracts from inspection reports are licensed from CQC, this page was updated on 18/06/2009.
Inspecting for better lives Key inspection report
Care homes for adults (18-65 years)
Name: Address: Ashgale House 39-41 Hindes Road Harrow Middlesex HA1 1SQ two star good service The quality rating for this care home is: A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Julie Schofield Date: 0 3 1 1 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area
Outcome area (for example: Choice of home) These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: ï· Put the people who use social care first ï· Improve services and stamp out bad practice ï· Be an expert voice on social care ï· Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Internet address www.csci.org.uk Information about the care home
Name of care home: Address: Ashgale House 39-41 Hindes Road Harrow Middlesex HA1 1SQ 02088638356 02088638491 ashgalehouse@aol.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Mr Aslam Dahya care home 14 Number of places (if applicable): Under 65 Over 65 14 0 learning disability Additional conditions: The registered person may provide the following category of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Learning disability - Code LD The maximum number of service users who can be accommodated is: 14 Date of last inspection 1 5 1 1 2 0 0 7 A bit about the care home Ashgale House is near to central Harrow. There are shops and buses close by. Fourteen people who have learning disabilities can live in the home and during the inspection there was 1 vacancy. Each resident has their own room. There are 2 units in the home and each unit has its own lounge and kitchen with dining room. Residents who have difficulty walking or who use a wheelchair live on the ground floor. There is a garden for residents to use and visitors to the home are able to park at the front of the house. The Registered Provider is Allied Care Ltd and the Responsible Individual is Mr Aslam Dahya. Please contact the home to find out how much the fees are. Summary
This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home How we did our inspection: This is what the inspector did when they were at the care home We visited Ashgale House in the morning and in the afternoon. We talked with members of staff and some residents. We looked at records and walked around the house. We sent survey forms to people that visit the home. Thank you to everyone for your help. What the care home does well People from the local authority told us that the home knows what your needs are and checks that they are met. They say that you are happy with the support and that you are well cared for. They tell us that they are satisfied that the staff treat you well. Members of staff tell us that they look after you so that you are healthy. They say that they make sure that you are able to choose. They tell us that that they give good support to all residents even though you may different cultural needs. You tell us that you are able to do what you want. If you want to go out and need someone to go with you there is someone to help. You enjoy the holidays that take place and the things to do in the home. You like your own rooms and you like the people that work in the home. Visitors to the home tell us that Ashgale House provides a nice lovely atmosphere. Another said that residents look happy and contented. One visitor praised the managers. What has got better from the last inspection What the care home could do better If you want to read the full report of our inspection please ask the person in charge of the care home If you want to speak to the inspector please contact Julie Schofield
RCT 4th Floor CSCI 223 Pentonville Road London N1 9NG 0207 239 0330 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line - 0870 240 7535 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Choice of home
These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service
. An assessment of the needs of a new resident enables the home to determine whether a service tailored to their individual needs can be provided. Evidence: We were told that since the last key inspection 2 new residents have been admitted to the home. Both residents were admitted on an emergency basis and both admissions were recent. One resident was transferring from a care home because it could no longer meet the residents needs and the other resident was transferring from a care home that was closing. One case file contained referral details and information from the funding authority, including a copy of the FACE overview assessment. A service users assessment and a risk assessment had been completed by a representative of the company, prior to the residents admission to the home. The other file contained referral details and an initial assessment completed by the manager of the care home. There was also information from the care home that was closing. Individual needs and choices
These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service
. 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. Evidence: We looked at 5 case files to case track the care pathways of residents. We saw that files contained an assessment of need that formed the basis for the development of a care plan. Files contained a care plan, which identified personal, health and social care needs. One care plan included information about high risk foods causing a choking hazard and information about warning signs of swallowing difficulties. Case files also contained a lifestyle plan. The lifestyle plan contained photographs and its format was recording needs and wishes from the perspective of the resident. There was evidence that care plans had all been reviewed in 2008. Four files also contained evidence of a review of the care plan and placement by the funding authority in 2008. A list of persons attending review meetings confirmed the involvement of the resident and their representative, if the resident wished. There was a note on the fifth case file that the funding authority only reviewed placements on a 2 yearly basis and the last review had been carried out in September 2007. The care home had not received the minutes of a review meeting that had taken place in August 2008. There is a system of key working that is in place in the care home. When asked whether they were given up to date information about the needs of the people they supported 5 of the 6 members of staff that completed a survey form ticked always and 1 member of staff ticked usually. Evidence: During the inspection we saw residents making decisions. Residents were choosing what activities to take part in and one resident went to the cinema and another resident went out to do some shopping. One resident had a sore throat and decided that she would like to go back to bed and watch her television. We discussed residents finances and the deputy manager said that the company helped 8 residents to manage their financial affairs. There were up to date records of money kept in the home, belonging to residents. A record was kept of when money was spent, what the money was spent on and what balance remained. All of the residents have individual bank accounts but the residents savings held at head office have not been transferred into the individual bank accounts yet, nor have the direct debits been set up for client contributions towards the care home fees etc. Case files included risk assessments, which were tailored to the individual needs of the resident. These included food preparation, personal care, swimming and eating. Risk assessments included risk management strategies. We saw that files contained a risk review form and that the forms had been completed within a period of 6 months prior to this inspection. Lifestyle
These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service
. 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 residents 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. Evidence: Each file examined contained a programme of activities. The content of these depended on the interests of the resident. Activities include day centre attendance for four of the residents and a member of staff from the home supports one of these residents when they attend the centre. Activities when residents are home based may take place inside Ashgale House and include relaxing in the sensory room or taking part in the pottery class. Activities taking place outside the home may include going out shopping, going to change library books, playing football in the park or going swimming. During the inspection we saw some of these activities taking place. The deputy manager said that they try to ensure that residents go out of the care home either every day or every other day, depending on their needs. Venues for shopping and eating take into account residents cultural needs. 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 Evidence: inspection. We saw that when review meetings took place the support given to residents to meet the residents religious and cultural needs was assessed. One set of minutes recorded that access to hair and body products and to food was available but noted that the resident does not wish to attend a church. Another set of minutes recorded that the residents cultural needs are met and that the resident is C of E and practicing. A third set of minutes recorded that the resident attends church on a Sunday and that the resident celebrates all traditional festivals. 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 one of the residents said that she had loved the holiday and the accommodation. One resident also went for a holiday in Cornwall and another resident had also been to Disneyland Paris. The minibus is used to take residents out for the day and examples of a trip to the London Aquarium and Whipsnade were given. Some residents continue to receive regular visits from their families and some families, when they visit, take the resident out. 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. 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. Members of staff have previously told us that some residents communicate by using Makaton, a billboard or a communications book. Where possible residents are encouraged to take part in daily routines and we were given examples of the resident bringing their laundry down or taking a plate to the sink when they have finished eating. The daily records note the choice of meals offered to the resident and the meal that they have selected. Generally lunch consists of a sandwich or a hot snack and the evening meal is a cooked meal. One of the residents has some problems which necessitate little and often meals and there are guidelines on file from the dietician regarding a pureed diet. The dietician had also provided guidelines for assisting a resident that is diabetic. There was information in the file of another resident regarding their specific cultural and dietary needs. The home has previously told us that there are 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 or spices used, they have the main role in meeting this clients cultural and dietary needs. Members of staff took part in a training course on food and nutrition in October 2007. The content of the course included how to encourage residents to eat healthily and how to encourage residents to take part in menu planning. Residents told us about party foods being served in the home to celebrate Diwali and how much they had enjoyed this. We saw that a record was kept, on a monthly basis, of the residents weights. Personal and healthcare support
These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service
. 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. Evidence: Residents require different levels of support with personal care tasks ranging from prompting to direct assistance. We saw that residents were clean and tidy and smartly dressed. When going out residents were appropriately dressed for the season and for the weather conditions and outside temperature. The deputy manager confirmed that female residents receive assistance from female carers. We saw that case files contained information for carers in respect of the individual preferences of residents and how they wished to be supported. A Gujarati speaking residents key worker is Gujarati speaking and there is a list of key words in Gujarati so that other members of staff are able to communicate in the residents first language. There is evidence on the case files that, where necessary, specialist support is requested and this has included advice from the dietician and from the speech and language therapist. 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 include opportunities for exercise and we saw that an older resident, that had a fall previously, has made good progress and has regained their level of mobility. There was information on the residents case files about any particular illness(es) that a resident Evidence: might have. A newly admitted resident had pressure ulcers on arrival at the care home. A record had been kept regarding the visits made by the district nurse and of the leg care given by carers in the home to help with eczema. The resident told us that since her admission to the home the condition of her legs had improved. We saw that the storage of medication was satisfactory. We looked at the monthly blister packs and saw that the blisters had been appropriately popped prior to the inspection, according to the week and to the day and to the time of day that this examination took place. The records were examined and it was noted that they were up to date and complete. We saw that the records also included a copy of guidelines for administering PRN medication. The deputy manager confirmed that the members of staff responsible for administering medication to residents have received appropriate training. When we spoke with 2 members of staff on duty they confirmed that they had received medication training. Medication records included a list of the names of members of staff authorised to administer medication and sample initials. Concerns, complaints and protection
These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service
. 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. Evidence: There is a policy and procedure in place, which includes details of the stages involved and the timescales allocated to each stage. This is on display in the home, close to the entrance. We discussed how residents might complain or make their feelings known. Some residents are able to express themselves verbally, while members of staff observe body language or facial expressions to gauge whether other residents are satisfied or content. The deputy manager said that since the last key inspection no complaints have been recorded. The CSCI has not received any complaints about Ashgale House. The deputy manager told us that since the last inspection no allegations or incidents of abuse have been recorded. A procedure is in place in the home and this includes the action to be taken in response to an allegation or suspicion of abuse. There is a copy of the interagency guidelines in the event of abuse that staff can refer to and use, if necessary. Members of staff on duty confirmed that they had received training in the protection of vulnerable adults procedures and were clear about their role and duties in the event of a disclosure being made. They were able to link the procedure in the home with whistle blowing and said that they had to report any concerns. Environment
These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service
. Residents enjoy a comfortable and homely environment with pleasant communal and private facilities in which to relax, although the replacement of carpets and some minor redecoration and repairs are needed. Residents live in a home where standards of cleanliness are good, although odour control systems need to be monitored. Evidence: A site visit took place during the inspection. There are bedrooms on the ground floor and bathing facilities on the ground floor. All facilities are accessible by wheelchair and there is level access at the front of the building and at the back of the building, into the garden. Levels of lighting, heating and ventilation were appropriate for the season. The home is within walking distance of shops, including a super market, and bus routes are close by. The outside of the building is in keeping with neighbouring properties. We saw that generally the up keep of the building was good and that it was decorated and furnished to promote a homely environment for residents. We saw that the bathroom on the ground floor has been redecorated and modern shelving and fitments have been installed making this facility appear more attractive than purely functional. However, carpets were worn and stained on the landings and in bedrooms and are in need of replacement. The open plan kitchen and dining room on the first floor needed repainting. The laundry room on the ground floor needs a new extractor fan. The sealant between the sections of flooring in the open plan kitchen and dining room on the ground floor needs replacing. During the site visit it was noted that all areas seen were clean and tidy and most areas were free from offensive odour. However, there was an odour of urine outside the bedroom door of one room, where the resident has continence problems. 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 inspection confirmed that they have received infection control training. Staffing
These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service
. 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 exceeded 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. Regular supervision sessions would assure residents that members of staff are supported and that their work practice is kept under review. Evidence: We discussed NVQ training with the deputy manager. She confirmed that 2 members of staff are currently undertaking training while all the other members of the staff team have completed an NVQ level 2 or 3 qualification. Access to level 3 training is open to all carers and not just senior carers. The home has exceeded the target of half of all carers achieving an NVQ level 2 or 3 qualification. We observed staffing levels on the day of the inspection and considered whether they were sufficient to meet the needs of residents and for residents to take part in activities, both inside and outside the home. The hours of the deputy manager and one of the senior carers were supernumerary to allow for supervisory, administrative and managerial tasks to be attended to. On the rota there were 2 senior carers, 4 carers and a driver/carer. One of the carers left the home to accompany a resident that was attending a day centre. During the inspection one resident went to the shops in the morning, accompanied by a member of staff, and another resident went to the cinema in the afternoon, accompanied by a member of staff. The manager confirmed that one of the members of staff on duty was Gujarati speaking. She told us that there 7 carers for the early shift and 7 carers for the late shift. At night there are 3 members of staff on waking night duties. When asked whether there are enough staff to meet the individual needs of all the residents using the service 3 members of staff that Evidence: completed a survey form ticked always, 2 members of staff ticked usually and 1 member of staff ticked sometimes. Staff are invited to attend staff meetings, that are usually held on a monthly basis. We examined 4 staff files. These included the file of a member of staff that had joined the care home since the last inspection. We saw that each file contained evidence of an enhanced CRB disclosure being obtained and we noted that for the newly appointed member of staff this was dated prior to their first day of employment. There had also been a pova first check for each member of staff. Each file contained an application form and the applicant had completed a declaration of fitness in respect of their health. There were 2 references on each file, although for one member of staff the references were to whom it may concern. Files contained proof of identity and the right to work and to reside in the UK had been established. 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 the Common Induction Standards formulated by Skills for Care. The company has recently reviewed its induction training and this now takes place during the new carers first 6 months of employment. When asked whether their induction covered everything they needed to know to do the job when they started 5 of the 6 members of staff completing a survey form ticked very well and 1 member of staff ticked mostly. A copy of the current annual training plan was available in the office. Mandatory training includes equalities and diversity training. The care home has a training grid that includes all members of the team and which records the courses attended and when any certificates expire. This enables the managers to identify what training is required and when refreshers are needed. We saw that copies of training attendance certificates are kept on file. When asked whether they were given training that was relevant to their role, helps them to understand and meet the individual needs of the resident and keeps them up to date with new ways of working all of the 6 members of staff that completed a survey form ticked yes. We discussed the supervision of the staff team with the deputy manager. We noted from staff files and the supervision records that some members of staff were not receiving individual supervision sessions on a regular basis. This included the newer member of staff. Staff appraisals have been delayed although the manager said that the home was preparing to carry these out before the end of the year. When asked whether the managers met with them to give them support and to discuss how they were working 3 of the 6 members that completed a survey form ticked regularly, 1 member of staff ticked often and 2 members of staff ticked sometimes. Conduct and management of the home
These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service
. Systems are in place to gain feedback on the quality of the service from all interested parties. Regular servicing and checking of equipment used in the home ensures that items are in working order and safe to use. However, testing of the fire alarm system on a weekly basis assures residents that in the event of a fire everyone present in the home receives adequate warning of the need to evacuate the premises. Standard 37 was not assessed as the post of registered manager was vacant. Evidence: The post of registered manager was vacant at the time of the inspection. The deputy manager told us that the company is in the process of recruiting a new manager. We discussed the systems in place for obtaining feedback on the quality of service provided. Quality assurance forms are used annually to obtain feedback from relatives, members of staff and from the local authorities that have a contract with the care home. Service users are also surveyed, where they are able to respond. Results from this survey for June 2008 showed that residents were happy or very happy. We asked whether comments or suggestions have been used to inform developments in the service and we were told that the relatives of one of the residents had asked for more outings to take place and the number of these had now increased. The company has a quality assurance team in place and a quality assurance manager visits the home, on an unannounced basis, to identify any areas of non compliance. After a recent visit the deputy manager said that the quality assurance manager had stayed in the home until a programme of implementation had been completed. In addition to the formal systems in place we noted during the inspection that the open door policy encouraged residents to come to the office and to talk with managers and to give Evidence: feedback on a daily basis. There are also opportunities for feedback to be given at review meetings and when relatives are visiting the care home. We discussed training in safe working practice topics with members of staff. They confirmed that they had received training in first aid, manual handling, food hygiene, fire safety awareness and infection control procedures. They also confirmed that this training is refreshed on a regular basis. The LFEPA had recently visited the home and their letter confirmed that the home was deemed to comply with the legislation. There were valid certificates for the inspection or servicing of the hoists, the portable electrical appliances, the electrical installation, the fire extinguishers and the fire alarms,smoke detectors and emergency lighting. The Landlords Gas Safety Record had recently expired and an appointment had been made for this to be carried out in November 2008. There was a record of regular fire drills being held in the care home although the weekly fire alarm testing had not taken place while the maintenance person was on annual leave or since their return to work. Are there any outstanding requirements from the last inspection? Yes ï£ No ï Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards.
No Standard Regulation Requirement Timescale for action Requirements and recommendations from this inspection
Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours.
No Standard Regulation Description Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set
No Standard Regulation Description Timescale for action 1 6 14 A copy of the minutes of a review meeting must be requested from the funding authority if they have not been received in the home within 6 weeks of the meeting being convened. 01/01/2009 This will make sure that there is a record in the home of any changes agreed during the meeting that require action. 2 7 17 Savings held at head office 28/02/2009 are to be transferred to the residents individual bank account at the same time that arrangements are made for the collection of the residents contribution to their care home fees. This will make sure that the financial records are up to date and complete. 3 24 16 The replacement of worn and 28/02/2009 stained carpet must take place. This will ensure that residents enjoy a well maintained environment. 4 24 23 Some minor repairs and 28/02/2009 redecoration need to be included in the care homes maintenance programme and carried out. This will enable residents to enjoy an environment that is pleasing to look at and is in a good state of repair. 5 30 16 A review of odour control measures needs to be undertaken and an action plan put into place. 01/01/2009 This will enable residents to enjoy an environment that is odour free. 6 34 19 If a reference is provided by 01/01/2009 an applicant and addressed to whom it may concern a request for a reference must be sent to the referee at their business address. This will ensure the authenticity and validity of references. 7 36 18 Regular individual supervision sessions, that are recorded, must take place. 01/01/2009 This will ensure that members of staff are supported and that the quality of their work is kept under review. 8 42 23 A weekly testing of the fire alarm system, with records being kept, must be carried out in the care home. 01/12/2008 This will ensure that in the event of a fire the fire alarm system will give adequate warning to everyone present in the home. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service.
No Refer to Standard Good Practice Recommendations 1 2 24 42 That other bathrooms within the home are redecorated and modern shelving and fitments installed. That the home books the need to arrange the 2009 Landlords Gas Safety Record visit in the diary, in advance of the expiry date. That arrangements are in place for another member of staff to assume responsibility for testing the fire alarm system on a weekly basis, in the absence of the maintenance person. 3 42 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website.
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