Inspection on 18/12/07 for Ashgate Cottage

This inspection was carried out on 18th December 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

1 Lanark Close

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

CARE HOME ADULTS 18-65 Ashgate Cottage Beresford Park Sunderland Tyne & Wear SR2 7JU Lead Inspector Hilary Stewart Key Unannounced Inspection 18 and 28 December 2007 10:30 th th Ashgate Cottage DS0000069771.V354115.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 Ashgate Cottage DS0000069771.V354115.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. Ashgate Cottage DS0000069771.V354115.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashgate Cottage Address Beresford Park Sunderland Tyne & Wear SR2 7JU 0191 5657907 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) michaelross18@msn.com Tyne and Wear Autistic Society Michael John Ross Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Ashgate Cottage DS0000069771.V354115.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: 2. Learning Disability - Code LD, maximum number of places: 3 The maximum number of service users who can be accommodated is: 3 New Service Date of last inspection Brief Description of the Service: Ashgate is small bungalow near to the town centre of Sunderland. It has been converted in to a care home for three people who have autism specific needs. The home is on a residential street where the society already has another residential home. The society is a member of the local Resident’s Association. The accommodation includes: • Entrance porch and hall • Lounge • Dining kitchen • Laundry • Three bedrooms • Bathroom • Shower room • Staff/sleep in room There is a laundry which is accessed through the kitchen. The home is close to public transport and local; services. The home charges from £690.96p to £787.13p per week. Ashgate Cottage DS0000069771.V354115.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Before the visit: We looked at: • Information we have received since the home was registered. • How the service dealt with any complaints & concerns. • Any changes to how the home is run. • The provider’s view of how well they care for people. • The views of people who use the service and of the staff . The Visit: An unannounced visit was made on 18th and 28th December 2007. During the visit we: • • • • • Talked with people who use the service, staff and the manager. Looked at information about the people who use the service & how well their needs are met, Looked at other records which must be kept, Checked that staff had the knowledge, skills & training to meet the needs of the people they care for, Looked around the building to make sure it was clean, safe & comfortable, We told the manager what we found. What the service does well: Staffs on duty at the time of the visit were approachable and helpful. The staff support people at the home to have contact with their friends and family. The relationships between staff and the people were good and personal support was provided in a way that promotes their privacy and dignity. The meals served are varied and nutritious which promote the health of the people at the home. They all have support plans so the staff know how to meet their needs. This means that people get the care and support they need. The staff team at the home value the differing needs of the people who live there and make sure that they are aware of each person’s preferences. They treat the people as individuals and support them to live the life they choose as Ashgate Cottage DS0000069771.V354115.R01.S.doc Version 5.2 Page 6 much as possible so they will have new experiences and know that their opinions are valued. People who live at the home experience a variety of activities. This gives them choice as well as building their self-esteem and confidence. The staff team make sure that the home is clean, warm and pleasantly furnished so the people who live at the home have a comfortable place to live. The staff are supervised and trained so they know how to provide the people who live at the home with good care. The home has procedures for staff when they administer medication. This makes sure the people who live at the home receive their medication when they need it and at the correct times. The home has procedures for dealing with complaints and protecting the people who live there from abuse. This means that the people who live at the home feel safe and are protected from harm. What has improved since the last inspection? 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. Ashgate Cottage DS0000069771.V354115.R01.S.doc Version 5.2 Page 7 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 Ashgate Cottage DS0000069771.V354115.R01.S.doc Version 5.2 Page 8 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 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The needs and wishes of each person who live at the home have been assessed. This means that staff at the home know that they can provide the people with the care and support they require. EVIDENCE: People have their needs assessed before they use the service. The manager and staff said that a person would only be offered the service if they are certain that their needs can be met there. Records showed that each person needs had been assessed. Before people use the service they are gradually introduced by having visits to another service and meeting the staff, they could not visit the home as some peoples funding was not agreed until the date the home opened. Ashgate Cottage DS0000069771.V354115.R01.S.doc Version 5.2 Page 9 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 and 9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. All of the people who use the service have individual care plans. Some did not have enough detail so did not show fully how the needs of the people would be met. People who use the service get personal support and at the same time staff make sure that their privacy, dignity and independence are respected. They are supported to become more independent but risk needs to be adequately assessed so staff can try to reduce the risks and keep the people who use the service as safe as possible. EVIDENCE: The manager confirmed and records showed that all of the people at the home have individual care plans. They did not contain enough detail to show how their assessed needs were being met at the home. The manager said that the care plans would be completed by the 4th January 2008. Ashgate Cottage DS0000069771.V354115.R01.S.doc Version 5.2 Page 10 The manager and staff said that the people who use the service are supported to be as independent as they can be safely. Some plans did not show if the risks had been assessed or what safeguards had been put in place to reduce risk as much as possible for people when they for example take part in activities. One risk assessment had been completed and a plan put in place to keep one person safe when they are beside roads. The manager said that risk assessments have been carried out and were in place. They would be in the care plans by the 4th January 2008 as well. The people who live at the home are encouraged to make choices and decisions about what they want to do. House meetings are informal and people discuss things such as activities. Records showed that they had discussed the Christmas party going to a disco and horse riding. One person had been asked if they were happy at the home and they had replied, “ yes Ashgate is my home”. Some people do not use the spoken word so staff have to observe gesture and body language to communicate with them. Records showed that pictorial symbols are used in the house meeting so staff can make sure that everyone is included. One person had used a catalogue to choose things for their room. Ashgate Cottage DS0000069771.V354115.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The people who use the service experience healthy stimulating activities, supported by staff that value them, while maintaining links with their families and friends. This means they can have new experiences and interests and not become isolated. The meals provide by the home are varied and nutritious so the health of the people who live there is promoted. EVIDENCE: The manager said that they regularly look at the options open to the people in relation to leisure and social activities. At the same time they have to be realistic about the choices. On the day of the visit the people who live at the home were involved in various activities. They were all attending college and two were going to the theatre. Ashgate Cottage DS0000069771.V354115.R01.S.doc Version 5.2 Page 12 The friends and family of the people who live at the home are encouraged to keep in contact with them. Staff support people to visit their friends as well. Staff said that the privacy of the people who live at the home is always respected and they always ask before they enter people’s bedrooms. They said that the people could always have privacy if they want. One person said, when asked if the staff ask before they come in their room they said “yes”. The home’s menus are based on the known likes and dislikes of the people who use the service. Staff said that people are involved in planning the menus as much as possible. The staff said that at least three meals are served to the people, which are varied and nutritious. Fresh fruit and vegetables were in the kitchen. Some of the people who use the service do not use the spoken word so staff said they observe their facial expression and gesture to learn about their preferences. Records of food served are kept so they can check that people are getting a varied nutritional diet. The people who use the service go to the shops and some are supported to prepare their own meals. If people attend college the staff at the home support them to attend. Ashgate Cottage DS0000069771.V354115.R01.S.doc Version 5.2 Page 13 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 and 20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The people who live at the home have personal support when they need it so they can be as independent as possible. Staff monitor and promote the health of the people to maintain their well-being. EVIDENCE: The health needs of the people at the home are written down so the staff have accurate information and know how to care for them. Staff said that the health and welfare of the people is constantly being monitored and it is discussed in staff meetings. The manager said as some people do not communicate with the spoken word they may find it difficult to say if they feel ill so staff receive training in how to identify when a person is ill and what appropriate action they should take. If there are concerns about a person’s health action is taken. The staff could describe and records showed how people are provided with personal support when they need it, such as bathing and hygiene. The staff said that the medication procedures in the home make sure that the people who live their get their medication when they need it. All of the Ashgate Cottage DS0000069771.V354115.R01.S.doc Version 5.2 Page 14 medication is checked weekly. Medication records were up to date. Any discrepancies are taken very seriously and the staff have a procedure to follow to make sure medication is given correctly. The manager said that before staff can administer medication at the home they attend a training programme in the safe handling of medicines. If it is thought to be safe following a risk assessment the people who live at the home can control their medication. Details of health checks, visits to their GP and hospital appointments are recorded in each individuals file. One person said that they go to the dentists. Ashgate Cottage DS0000069771.V354115.R01.S.doc Version 5.2 Page 15 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 and 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure. This means that complaints can be dealt with effectively and to the satisfaction of the person who made the complaint so good relationships can be maintained. Staff know about adult protection procedures, so the people who live at the home are kept safe from harm. EVIDENCE: Staff said and records showed that they have had training in how to protect vulnerable people from abuse. Staff could describe the procedure to be followed if an allegation of abuse was made. The people who live at the home looked comfortable and relaxed during the visit. They approached staff and interacted with them easily. The manager said that the local Authority has agreed the home’s adult protection procedures and the organisation whop run the home has a person in charge of safeguarding who has received training by the City of Sunderland. The home has a complaints procedure. Staff said that they would support the people who live at the home if they wanted to make a complaint. The manager said that all of the people and their families are provided with a copy of the homes complaints procedure when they moved into the home. The manager said that there have not been any complaints since the home opened. Ashgate Cottage DS0000069771.V354115.R01.S.doc Version 5.2 Page 16 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 and 30 Quality in this outcome area is Good This judgement has been made using available evidence including a visit to this service. The home is comfortable, warm and clean so the people have a pleasant place to live. EVIDENCE: There are enough bathrooms and showers for the people who live at the home. The bedrooms looked comfortable and the people who live at the home had personalised them. They had been made very individual. The building is clean and generally well maintained; it is clean and hygienic so the people have a pleasant comfortable place to stay in. The home looked in a good state of repair and was odour free. Ashgate Cottage DS0000069771.V354115.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staff have opportunities for training so they know how to give the people who live at the home good care and meet their needs. Sufficient numbers of staff are in post to meet the diverse needs of residents. The homes has a recruitment procedure to make sure that only suitable people work there. . EVIDENCE: Staff said that they receive training, which helps them with their work. The manager said that all staff have an indivual development plan, which makes sure they get the training and support they need. All have mandatory training such as first aid; food hygiene and safeguarding adults training. The manager said that 60 of staff has vocational qualifications. Sufficient staff were on duty at the time of the visit. Staff said and records showed that sufficient staff had been on duty in the home the previous week. Ashgate Cottage DS0000069771.V354115.R01.S.doc Version 5.2 Page 18 The manager said that all staff have been CRB (Criminal Records Bureau) checked at an enhanced level to make sure they are suitable people to work at the home. They go through a recruitment process and they cannot not start to work at the home until this is completed. Part of this process is to meet some of the people who use the service who are then consulted afterwards. They are interviewed and are only successful when they have two satisfactory references. The staff records are kept at the organisations main office so were not available at the home. . Ashgate Cottage DS0000069771.V354115.R01.S.doc Version 5.2 Page 19 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 and 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The opinions of the people who live at the home are sought about how the home is run so they know their views are valued and are used to improve the service. Monitoring visits of the home take place to check that the people who live there get the care they need and their health, safety and welfare is always promoted. EVIDENCE: The manager said that the people who live at the home and their families are asked their views about the running of the home as much as possible. They home has quality assurance audits carried out monthly. Ashgate Cottage DS0000069771.V354115.R01.S.doc Version 5.2 Page 20 Safety checks have been carried out on the equipment in the home; such as testing electrical equipment and the servicing the central heating boiler. The home has just recently been registered so the building and services will have been checked by the Commission as part of this process. Fire safety risk assessments had been completed. The fire logbook showed that regular fire drills and fire instruction take place. Staff said that they have fire drills and instruction. Records showed that regular training is provided for staff in fire safety and first aid. Records showed that some monitoring visits take place at the home. Reports from the visits show that they happen every month. Ashgate Cottage DS0000069771.V354115.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Ashgate Cottage DS0000069771.V354115.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? N/A 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 Requirement The registered manager must make sure that all residents have an accurate and completed care plan. The registered manager must have risk assessments in line with peoples assessed needs. Timescale for action 01/02/08 2 YA9 13 01/02/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Ashgate Cottage DS0000069771.V354115.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Ashgate Cottage DS0000069771.V354115.R01.S.doc Version 5.2 Page 24 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!