Inspection on 26/02/07 for Ashglen House

This inspection was carried out on 26th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Similar services:

1 Marten Road

Daubeney House

Three Gables

Aldwick House

49 Glendale

The Springs Community

Crossways Community

Belle Vue Country House

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

CARE HOME ADULTS 18-65 Ashglen House Market Street Hailsham East Sussex BN27 2AG Lead Inspector Helen Martin Key Unannounced Inspection 26th February 2007 1:30 Ashglen House DS0000068134.V324991.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 Ashglen House DS0000068134.V324991.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. Ashglen House DS0000068134.V324991.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashglen House Address Market Street Hailsham East Sussex BN27 2AG 01323 845813 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) ashglenhouse@tiscali.co.uk Ashglen House Limited Maria de-Lourdes Hutchins Care Home 10 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (10) of places Ashglen House DS0000068134.V324991.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is ten (10). That service users are aged between eighteen (18) and sixty-five (65) years on admission. Only service users with a mental disorder, excluding learning disability, or dementia are to be admitted. N/A Date of last inspection Brief Description of the Service: Ashglen House provides a service for up to ten adults with or recovering from a mental illness. Residents are provided with opportunities for personal, emotional and social development and are supported towards improving their living skills. The home, owned by Allied Care Limited, is located in a quiet residential street, two minutes walk from the town centre of Hailsham, within easy reach of the usual town amenities and public transport. All residents are accommodated in single rooms, three of which contain ensuite facilities. The accommodation is arranged over two floors. There is no passenger lift. Communal space provided includes a lounge, dining area, quiet room and a garden. There is limited off road parking to the front of the property. The home has an organisational structure, which includes a manager, deputy manager and support workers, operating a roster, which gives 24-hour cover. Staff also undertake catering and domestic duties; there is a designated handyman/driver. Current fees for the home are £411.00 per week. Full information about the fees payable, the service provided, the home’s Statement of Purpose and the latest inspection report by the CSCI are available from the manager. Ashglen House DS0000068134.V324991.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit took place on 26th February 2007. The visit included talking with the manager, two members of staff and five people who live in the home. Some judgements about the quality of life within the home were taken from observation and conversation. Some records were looked at. A tour of the house and garden was undertaken. The home has given the CSCI a completed pre-inspection questionnaire and this information has been used within this report where appropriate. Postal surveys from six residents and one relative have been received by the CSCI and have been used within this inspection process. Currently there are ten residents accommodated with no vacancies. All rooms are for single occupancy. Comments made by residents spoken with at the time of this visit included: ‘I’m very happy at the home’ ‘The home has been like a family to me after my relative died’ ‘I like my room’ ‘I’ve been out for a blood test and to get some medication’ ‘I like the staff and manager, they’re helpful’ ‘I like the food and can choose what I want’ What the service does well: Residents enjoy living in an open and friendly atmosphere. The home is run effectively and in their best interests. They benefit from living in a clean, comfortable and homely environment, which suits their needs and lifestyle. Before residents move in, they are assessed, so they know if the home will suit them. Residents benefit from appropriately supervised, enthusiastic and caring staff, who have a good understanding of their needs. Their views and concerns are listened to and receive appropriate consideration. Residents benefit from personal support which meets their individual needs. Their privacy and dignity is respected. Residents are able to make their own choices and decisions about their lives. They enjoy individual lifestyles and are supported to develop their life skills. Residents have the opportunity to experience a variety of social, educational and recreational activities. They are able to choose what they eat. Residents can see their family and friends whenever they want to. Information about them is kept confidential. Residents are protected from potential abuse. Ashglen House DS0000068134.V324991.R01.S.doc Version 5.2 Page 6 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. Ashglen House DS0000068134.V324991.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 Ashglen House DS0000068134.V324991.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, 3, 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents benefit from assessment before they move into the home, to ensure their needs can be met. Residents are given written information about the home, although they would benefit from more accurate detail. EVIDENCE: A statement of purpose and service users guide is provided, which contains information about the home. The manager said that they were in the process of reviewing the documents. Whilst most of the required information was included in the statement of purpose, the organisational structure and room sizes were not. It was noted that there was one reference to another named home. A report of March 2005 was quoted, although the home was not registered until September 2006. The service users guide contained numerous references to another named home and some information included was clearly not related to Ashglen House. Residents have benefited from assessment before they moved into the home, to ensure that their needs could be met. Individuals living in the home have Ashglen House DS0000068134.V324991.R01.S.doc Version 5.2 Page 9 been there for some time and no new residents have moved in since the manager has been in post. There are currently no vacancies. The manager explained that should a vacancy arise, information from the local authority would be obtained where necessary and the home would undertake an assessment. It was said that the organisation provides a detailed recording format. Residents spoken with said that they were happy living in the home. The manager demonstrated an understanding of the range of needs that the home could and could not meet. Each resident has a tenancy agreement with the home. The blank format seen was an example of a tenancy agreement and as such, although the document states the need to include the amount of fees, who pays them and any additional services to be paid for, details are not included. The format does not allow for more personalised aspects of the agreement, including a copy of the care plan and arrangements for reviewing this or elements of a Care Management care plan where applicable. Ashglen House DS0000068134.V324991.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, 8, 9, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to make their own choices and decisions about their lives. Information about them is kept confidential. Residents’ changing needs could be better reflected in care plans. EVIDENCE: Care plans reflect residents’ changing needs and give staff guidance about action to be taken to promote their health and welfare. Documentation contains a range of holistic issues. Reviews are ongoing, with one taking place recently. The manager has introduced a new format for care plans and is in the process of transferring information. The new format is clear, whereas the older care plans are difficult to follow. Residents are supported to take risks as part of maximising their independence. Risk assessments and staff guidelines are recorded for a range Ashglen House DS0000068134.V324991.R01.S.doc Version 5.2 Page 11 of issues. The manager has introduced new, recorded risk assessments since they have been in post; these will continue to be updated and developed together with care plans. Discussion around this issue indicated that people living in the home are given the freedom to make decisions about their lives considering risk management and group living. They are provided with assistance to support their individual choices. Regular residents’ meetings are held. One resident described how they were planning for independent living. Residents’ confidentiality is maintained and their privacy respected, in that personal records are maintained and stored in such a way as to be available solely to appropriate and authorised people. Ashglen House DS0000068134.V324991.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): 11, 12, 13, 14, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents enjoy individual lifestyles and are supported to develop their life skills. They have the opportunity to experience a variety of social, educational and recreational activities. Residents are able to choose what they eat. EVIDENCE: Residents benefit from opportunities for personal, emotional and social development and are supported towards improving their living skills, tailored to their abilities. They are treated as individuals and have different interests, aspirations and abilities. Personal development is enabled through work, day centres, leisure activities and relationships with friends and family. Residents are part of the local community. Transport is provided by the home. Staff at the home support their attendance at work and day centres and also Ashglen House DS0000068134.V324991.R01.S.doc Version 5.2 Page 13 provide activities from the home. A range of opportunities are available to residents including art and craft, a music class, woodwork, computers, visits to garden centres, tea rooms, the coast and places of interest. One resident undertakes voluntary work in a charity shop, one works in a nursery and others take part in therapeutic work at a day centre. Day centres offer opportunities to improve numeracy and literacy skills. Information about religious observance is recorded in residents’ care plans. Residents are able to see their family and friends as often as they wish. Individuals can visit the home at any reasonable time. They spend time in the home relaxing or undertaking activities that interest them. At the time of this visit some were listening to music. One resident keeps canaries and the home has a pet cat. Residents are supported with laundry and household tasks. They enjoy privacy in their rooms and staff respect this. Staff talk to residents in a friendly and polite way. Residents enjoy a variety of meals and their choices are recorded. Staff ask individual residents what they would like to eat and this was observed at the time of this visit. Menus have been reviewed and these continue to be developed in discussion with residents. Meals are in accordance with agreed menus, individual choices and nutritional needs or preferences. Special diets are catered for, such as diabetic. It was said that fresh fruit and yoghurt are always available. Since the manager has been in post they have introduced the constant availability of tea and coffee in the lounge. Residents enjoyed a meal together in the ding room at the time of this visit. Ashglen House DS0000068134.V324991.R01.S.doc Version 5.2 Page 14 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 good. This judgement has been made using available evidence including a visit to this service. Residents benefit from personal support which meets their individual needs. Their privacy and dignity is respected. Residents would be better protected by improvements to the procedures for the administration of medication. EVIDENCE: Residents are given the personal support they need to maximise their independence, while respecting their dignity and privacy. They are able to exercise choice regarding this. Staff demonstrated a good understanding of the preferred routines and varying requirements of each individual. Residents have access to health and social care professionals, including mental health and diabetes specialists. They are supported with any appointments and/or interventions and these are recorded. One resident described the process for monitoring their blood levels and diet, as they were diabetic, whilst another said that they go for regular blood tests because of their medication. The manager stated that incidents regarding one resident had not been Ashglen House DS0000068134.V324991.R01.S.doc Version 5.2 Page 15 ongoing, although they continued to be monitored. Diet and weight are monitored and recorded in residents’ care plans together with food consumed if necessary. It was said that care managers visit the home often. The manager and staff demonstrated a good understanding of the needs of residents. A procedure is in place for the administration of medication by the home. Although stored in a locked metal cabinet, this is not a designated medication storage facility. The manager explained that this was due to be fitted shortly. Residents’ current medication is recorded in their care plans. The manager stated that the home usually uses a monitored dosage system and receives printed medication administration records from the pharmacy; previous documentation confirmed this. Due to an error in re-ordering medication, this is currently being secondarily dispensed into dossette boxes by staff; medication administration records for this month are all handwritten. The manager assured the inspector that this would not re-occur in future. All medication is prescribed on an individual basis and the home does not use ‘homely remedies’. The manager said that only trained staff administer medication; this was confirmed by staff spoken with who explained that their competency was tested as part of the course. Course updates will be undertaken in March of this year. A signature list of staff trained to administer medication is not kept. Ashglen House DS0000068134.V324991.R01.S.doc Version 5.2 Page 16 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 good. This judgement has been made using available evidence including a visit to this service. Residents’ views and concerns are listened to and receive appropriate consideration. Residents are protected from potential abuse. EVIDENCE: Residents are at ease with staff who listen to their views and concerns. A regular meeting is held to discuss these. Residents receive continuity of care by having individual key workers. The home provides a written complaints procedure. The manager confirmed that no complaints had been received since they had been in post, but that appropriate records would be kept, should this be the case. Procedures are in place, which aim to protect residents from potential abuse. Staff have access to adult protection and whistleblowing policies and procedures. The home has a system in place, which protects the financial interests of residents. This includes holding small amounts of cash on behalf of a few. This is kept securely. All money is stored individually and transaction records are maintained; these have been reviewed since the manager has been in post. Cash checked tallied with accounts seen; one account contained an error, which was corrected by the manager at the time of this visit. Receipts are kept Ashglen House DS0000068134.V324991.R01.S.doc Version 5.2 Page 17 for purchases made on residents’ behalf. All cash given to residents is signed for. Ashglen House DS0000068134.V324991.R01.S.doc Version 5.2 Page 18 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, 25, 26, 27, 28, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from living in a clean, comfortable and homely environment, which suits their needs and lifestyle. EVIDENCE: The building fits in with the local community and has a style and atmosphere that meets individuals’ needs. Residents benefit from living in clean and comfortable accommodation. They have access to an attractive garden. The manager has developed a maintenance and refurbishment plan for the home. It was said that a new kitchen was planned for April of this year. Adequate recreational, dining, toilet, bathing and individual accommodation are available to residents. The home provides a lounge, dining area and quiet room. Ashglen House DS0000068134.V324991.R01.S.doc Version 5.2 Page 19 All residents have their own rooms, which are highly personalised with their possessions. Three contain ensuite facilities. Bedrooms are comfortable, furnished and decorated according to individual taste and reflect the interests of the occupant. The premises are clean and hygienic. There is a laundry room with domestic facilities used by residents with support from staff; appropriate procedures are in place for infection control. Ashglen House DS0000068134.V324991.R01.S.doc Version 5.2 Page 20 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): 31, 32, 33, 34, 35, 36, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from appropriately supervised, enthusiastic and caring staff, who have a good understanding of their needs. They would be better protected by improvements to the systems for staff recruitment, training and records. EVIDENCE: People living in the home benefit from enthusiastic and caring staff, who demonstrate a good understanding of their needs, including their role as keyworker. Residents receive good support and interaction. Residents spoken with confirmed this. At the time of the site visit, there were sufficient numbers of staff on duty to support people within the home. The manager has increased staffing numbers since they have been in post; in addition to themselves, there are now usually two in the morning, three in the afternoon, two in the evening and one sleeping-in. There is an on-call system. Staff spoken with explained that there is a core of people who have worked within the home for some time and recent Ashglen House DS0000068134.V324991.R01.S.doc Version 5.2 Page 21 recruitment to increase numbers had brought in newer people. It was said that all individuals got on well together and that there is a good staff team. Support staff undertake cooking and cleaning and a handyman/driver has recently been employed. The staff roster does not include the full names of all individuals on duty or their allocations. The home aims to meet the needs of residents by providing appropriate staff training. A member of staff said that they had undertaken training in fire, medication, health and safety, first aid, food hygiene, health and nutrition, the protection of vulnerable adults, infection control and manual handling. The manager said that they were in the process of reviewing training for staff; some updates had been undertaken recently such as manual handling and food hygiene, other courses were booked, such as fire prevention and more was planned, such as the protection of vulnerable adults and challenging behaviour. It was said that all staff had received training in mental health and that over 50 of the staff team had obtained an NVQ qualification. Course certificates are kept in staff files, although the training matrix is not current; the manager said that this would be updated. Induction training is recorded, although not in detail. One newer member of staff is undertaking an external training course, which leads into NVQ level 2. A recruitment procedure is in place that aims to appoint staff suitable to meet residents needs. Staff files seen contained evidence of pre-employment checks, such as proof of identity, employment history, a health statement and references and included checks with the criminal records bureau (CRB) and against the protection of vulnerable adults list (POVA). Although most checks had been undertaken appropriately, it was noted that two files contained references from family members and one did not contain a comprehensive employment history or a reference from the most recent employer. The manager assured the inspector that this would not re-occur. The current application form does not contain the facility for the self-disclosure of any police cautions in addition to convictions. The manager confirmed that they had received a CRB for all staff with the exception of one, who was employed after the receipt of a POVA First check. It was stated that this individual was supervised appropriately and this was noted on the staffing roster and observed at the time of this visit. . Staff supervision is undertaken on an ongoing and regular basis to ensure that work is monitored and any training and development needs are identified. Staff spoken with confirmed this. It was stated that regular staff meetings are held and this, together with supervision is recorded. Ashglen House DS0000068134.V324991.R01.S.doc Version 5.2 Page 22 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, 38, 39, 40, 41, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents enjoy living in an open and friendly atmosphere. The home is run effectively and in their best interests, although they would benefit from some improvements in the systems for health and safety and record keeping. EVIDENCE: The manager has relevant experience of service provision for people with mental health difficulties. They have previous management experience. The manager’s qualifications include the Registered Managers’ Award, Assessors Award, Community Mental Health, Advanced Care Management and Delivering Training. Ashglen House DS0000068134.V324991.R01.S.doc Version 5.2 Page 23 There is an open and inclusive atmosphere in the home. Regular meetings for residents and staff are held. There is a lot of formal and informal chat and feedback on a day-to-day basis. Residents indicated that any comments they had about the service would be listened to. The home has a quality assurance system. The manager explained that questionnaires were sent to residents, their relatives and relevant health and social care professionals at the time of residents’ reviews and on an annual basis. Regular visits to the home by the provider are undertaken and recorded. The home has recorded policies and procedures that are available for staff. It was said that these were reviewed recently. The manager explained that all policies and procedures are signed for as read by staff. In order to evidence consistency of care for residents, a number of records have been looked at as part of the inspection process. These have been mentioned within this report where necessary. Accidents and incidents are recorded appropriately and the relevant people and agencies are now notified. Records seen indicated the regular testing and maintenance of systems and equipment within the home. Risk assessments for the environment, fire, cleaning chemicals and safe working practices have been undertaken. Cleaning chemicals are stored securely. Hot water temperatures are monitored by regular testing and pre-set valves. An environmental health report stated that the home had excellent food hygiene procedures in place and a high standard of cleanliness throughout. All fire doors left open are fitted with an automatic closing device should the alarm sound. The manager stated that following an electrical hard wiring test, recommendations giving rise to risk had been addressed; it was said that others would be looked at as part of the ongoing programme of refurbishment. Some radiators are guarded and some are not; the manager explained that they were in the process of providing guards for all, prioritising those that could cause the most potential risk. The manager stated that they would record risk assessments shortly for window restrictors, as currently none are provided. Ashglen House DS0000068134.V324991.R01.S.doc Version 5.2 Page 24 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 2 2 3 3 3 4 X 5 2 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 3 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 2 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 3 3 3 2 2 X Ashglen House DS0000068134.V324991.R01.S.doc Version 5.2 Page 25 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 YA1 Regulation 4(1) Requirement The registered person shall compile in relation to the care home a written statement…which shall consist of…a statement as to the facilities and services which are to be provided…and a statement as to the matters listed in Schedule 1. In that, the organisational structure of the home and room sizes must be included within the statement of purpose. Information and named homes not relevant to Ashglen House must be removed. The document must contain information about Ashglen House only. 2 YA1 YA5 5 The registered person shall produce a written guide to the home which shall include…a description of the standard services offered…the terms and conditions of…accommodation; details of the total fee payable…paying for any services additional to those mentioned… In that, information and named Ashglen House DS0000068134.V324991.R01.S.doc Version 5.2 Page 26 Timescale for action 30/03/07 30/03/07 homes not relevant to Ashglen House must be removed from the service users’ guide. The document must contain information about Ashglen House only. Residents’ tenancy agreements must include the amount of fees, who pays them and detail regarding any additional services to be paid for. 3 YA33 YA41 17(2) The registered person shall maintain in the care home the records specified in Schedule 4: A copy of the duty roster of persons working at the care home, and a record of whether the roster was actually worked. In that: The written roster must ensure that all staff employed are recorded with their full names and allocated duties on shift, including the identification of senior staff. 30/03/07 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 Refer to Standard YA5 Good Practice Recommendations It is recommended that residents’ tenancy agreements should be reviewed to allow for more personalised aspects of the agreement, including a copy of the care plan and arrangements for reviewing this or elements of a Care Management care plan where applicable. It is strongly recommended that the manager should complete their stated intention to review, develop and DS0000068134.V324991.R01.S.doc Version 5.2 Page 27 2 YA6 Ashglen House YA41 3 YA9 update all recorded care plans and risk assessments. It is strongly recommended that, with regard to medication: 1. The manager should complete their stated intention to provide a designated medication storage facility. 2. The manager should complete their stated intention to carry out a review to ensure that medication orders are undertaken appropriately and do not secondarily dispense medication. 3. Pre-printed medication administration records should be obtained from the supplying pharmacy wherever possible. 4. A signature of staff trained to administer medication should be kept. 4 YA35 YA41 It is strongly recommended that, with regard to staff training: 1. The manager should complete their stated intention of reviewing training for all staff. 2. The training matrix should be updated. 3. Induction training should be recorded in greater detail. 5 YA34 YA41 It is strongly recommended that, with regard to staff recruitment: 1. The manager should complete their stated intention to gain a comprehensive employment history and a reference from the most recent employer; references from family members should not be used as one of the two references required. 2. The current staff application form should be amended to contain the facility for the self-disclosure of any police cautions in addition to convictions. 6 YA42 It is strongly recommended that, with regard to the health and safety of residents: 1. The manager should complete their stated intention Ashglen House DS0000068134.V324991.R01.S.doc Version 5.2 Page 28 to provide guards for all radiators assessed as causing a potential risk to residents. 2. The manager should complete their stated intention to record risk assessments for window restrictors and review whether these are needed. 3. The manager should complete their stated intention, following the electrical hard wiring test, to address non-urgent recommendations as part of the ongoing programme of refurbishment. Ashglen House DS0000068134.V324991.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Ashglen House DS0000068134.V324991.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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