Inspection on 06/02/06 for Ashgold House

This inspection was carried out on 6th February 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ashgold House 22/08/06

Ashgold House 04/01/05

Ashgold House 05/10/04

Ashgold House 24/05/04

Ashgold House 02/02/04

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Insight - Eastchurch

Southfields

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Dovedale Court

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

CARE HOME ADULTS 18-65 Ashgold House Church Whitfield Road Whitfield Dover Kent CT16 3HZ Lead Inspector Mary Cochrane Unannounced Inspection 6th February 2006 10:00 Ashgold House DS0000031343.V258838.R01.S.doc Version 5.0 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 Ashgold House DS0000031343.V258838.R01.S.doc Version 5.0 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. Ashgold House DS0000031343.V258838.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ashgold House Address Church Whitfield Road Whitfield Dover Kent CT16 3HZ 01304 823966 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) Ashgold House Limited Mrs Christine Shaw Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Ashgold House DS0000031343.V258838.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th June 2005 Brief Description of the Service: Ashgold House is a residential home that provides care, support and accommodation are for Service Users with learning disabilities.some of whom also have health conditions and sensory impairment. The building is a detached chalet style bungalow, which is situated on a small country road, in the quiet Hamlet of Church Whitfield opposite the local church. It is about 1 mile away from Whitfield village, which offers a limited amount of amenities and 3 miles from the nearest town of Dover. Service Users are transported from the home in a ‘people carrier’ so they are able to under take activities, visits and other pursuits. Ashgold is registered to accommodate up to 5 Service Users. All Service Users have their own bedroom and the sleeping accommodation is arranged over the houses’ two floors. The communal living space consists of a dining room, lounge and conservatory. There is also a quiet room on the first floor, There is a garden to the rear and side of the building and this is well kempt and easily accessible and safe for those who wish to use it. Ashgold House DS0000031343.V258838.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the 2nd inspection at Ashgold House this year. This visit was unannounced and lasted from 10.00a.m until 3.30p.m. The majority of the key standards were looked at during the previous inspection in June ‘05, so the inspector focused on the requirements and recommendation identified in the previous report and the outstanding key standards. The new manager has been in post since July’05. She knows the home well as she was acting manager for a time in 2004. On the day of the visit she was on a training course so was unavailable. The inspector was assisted by the senior team leader, who was available and helpful throughout the day. The manager and staff are taking positive steps to meet the standards and regulations that are required of the home. At the time of the inspection it was found that the home still has work to do but the staff are working hard and moving in the right direction. At the time of the visit there were 5 service users in residence and 4 care staff. All the service users have complex learning disability needs and some also have physical disabilities. The service users require a high level of staffing input to ensure all their needs are met. They all require skilful management and care. During the inspection the atmosphere in the home was calm and the service users seemed settled and content. Staff were seen to be interacting and engaging service users in a positive and caring manner. The staff on duty at the time of the visit were helpful and co-operative. The following methods of inspection and information gathering were used: one-to-one discussion with staff and service users, observing interactions, care interventions and activities, reading and discussing individual support plans, risk assessments, selected policies, medication protocols, staff files and training programmes. 8 requirements and 4 recommendations were made at this inspection. Ashgold House DS0000031343.V258838.R01.S.doc Version 5.0 Page 6 What the service does well: What has improved since the last inspection? The home now has a staff group, which is stable and consistent. Service users now receive care from staff that they know and who they have built positive relationships with. The service users are able to interact with staff in a positive and meaningful way and staff are sensitive, caring and respectful The staff reported that since the appointment of the new manager there is a more open and inclusive atmosphere at Ashgold House. They said that they Ashgold House DS0000031343.V258838.R01.S.doc Version 5.0 Page 7 feel they are able to ask questions and get the support and the guidance that they need. The moral in the home has improved and they are positive and optimistic about the future. Risks to service users have now been identified and assessments have been developed and implemented to ensure that any risks to service users are kept to a minimum. The use of washing machine and dryer in the laundry room, which is next to the bedroom of a service user is now restricted to certain times. Noise and disturbance to the service users is now kept to a minimum. The service users reported that the he is no-longer disturbed by the washing machines as they are not on when he is in his room. The staff at the home have now received mandatory training, the manager needs to ensure that this is on going and kept up to date. There has been some repair work undertaken in the small lounge since the last inspection. The velux window and surrounding plaster have been made good. What they could do better: The manager of the home needs to ensure that each of the service users has an individual activities plan in place, which has been developed to meet their individual needs and interests. The manager needs to develop and implement individual activities plans for all the service users. The staff need direction and guidance to make sure that the service users are offered the opportunities and facilities to develop their lifestyles and abilities so as to maximise their capabilities and potential. There needs be enough staff on duty to enable the service users to undertake more activities and out-side interests. The homes environment needs to be more stimulating with interesting things to look at and touch especially for those who are visually impaired. The home needs to be able to evidence how service users make decisions and how individual choices are made. The care staff do require more specialist training to assist them in meeting the specific needs of the service users. Contracts/Terms and conditions of residency, which includes the amount and method of payment of fees what they cover, when they must paid and by whom and any extra charges are required for all the service users. Some areas of the house still require attention and these were identified in the 2 previous reports. The velux window in the bedroom of a service user and the one in the staff toilet do not stay open and are still in need of repair. The home Ashgold House DS0000031343.V258838.R01.S.doc Version 5.0 Page 8 needs to have a maintenance plan in place, which indicates timescales for work to be carried out. The manager of the home now needs to apply for her registration and obtain the relevant qualifications. 50 of the staff need have the NVQ level 2 or above to date only 2 members of the staff team have achieved this. The home needs to further develop ways for monitoring and assessing its performance. This will show whether or not the home is meeting its aims and objectives. 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. Ashgold House DS0000031343.V258838.R01.S.doc Version 5.0 Page 9 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 Ashgold House DS0000031343.V258838.R01.S.doc Version 5.0 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 5 The home does not provide the service users with costed contracts/terms and conditions of residency Therefore the service users do not know how much they are paying to the home for the services they receive. EVIDENCE: All the service users have contracts and terms and conditions of residency on file. It was noted that these do not include the information about the fees charged what they cover when they must be paid and by whom. The contracts also do not state the cost of facilities or services not covered by the fees. e.g. what does the company charge individual service users for the use of the homes transport? The contracts do not indicate how much service users pay to use the homes vehicle. The registered manager needs to access this information and incorporate it into the contracts. All contracts also need to be signed by the service users/representative and the registered manager. Ashgold House DS0000031343.V258838.R01.S.doc Version 5.0 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 & 10 There are some short- falls in the planning and implementing of the assessed and changing needs of the service users. Service users are able to make decisions about their lives but their participation is limited in the way the home is run. Their views are not considered. EVIDENCE: The majority of the care plans are now of a good standard and contain the information needed to ensure that all the needs of the service users are met. The plans are easy to follow and the staff said that they did use them on a daily basis. The inspector looked at 4 of the care plans. 3 of these were up-to date and identified the needs of the service users and what action the staff need to take to meet them. However, it was evidenced that the behaviour, treatment and care of one service user had changed over the past months this had not been reflected in the service users’ care plan. The manager needs to ensure that all the care plans are kept up-to date to reflect the changing needs of the service users. Ashgold House DS0000031343.V258838.R01.S.doc Version 5.0 Page 12 The plans are being reviewed at 6monthly intervals with care managers and families. Through observation and talking to staff and service users there was evidence to support that service users are involved in making decisions on how they live their life’s and any limitations and restrictions are recorded in the individuals care plan. At the previous inspection residents meeting were being held every month and also some individual sessions were taking place. This is no-longer happening. The manager needs to ensure that the service users are consulted and participate in all aspects of life at the home. They need to be involved in the daily running of the home and their choices and preferences need to be acted on. The manager and care staff encourage and support the service users to live an independent lifestyle as their abilities allow. There are now risk assessments in place, which are individualised and provide information on how to minimise identified risks, these are of a good standard and are up-dated as required. It was evidenced at the visit that all information pertaining to the service users is kept securely at the home. The staff office is locked if it is unoccupied. Staff were seen to respect the confidentiality of the service users. Ashgold House DS0000031343.V258838.R01.S.doc Version 5.0 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13 & 14 At the time of the inspection the home was not providing the service users with opportunities and facilities that enable them to maintain an appropriate and fulfilling lifestyle in and outside the home. EVIDENCE: There has been little progress made since the last inspection in meeting the above standards. From looking at documentation there was evidence to show that the home are not meeting the needs of the service users by providing them with a fulfilling and meaningful lifestyle. None of the service users have individual activities programmes in place. A record is kept of what the service users do on a daily basis. There was evidence to show that one service user attended the local learning disability centre on a weekly basis and on occasions the service users went swimming but activities and leisure pursuits are very limited and undertaken on an ad-hoc basis. No-one is going out in the evening or at weekends. At the time of the visit service users were asking to go out but staff were unable to take them because there was not enough staff on duty. Staff and service users reported that this is often the case. There needs to be enough Ashgold House DS0000031343.V258838.R01.S.doc Version 5.0 Page 14 staff on duty to ensure that all the needs of the service users are met. (Staffing numbers will be discussed in Standards 31-36). The home has recently employed a member of staff who is able to drive the homes transport so hopefully there will now be easier access to community facilities. The service users do need to have more of a community presence The manager is planning to designate the role of developing in-house activities to a member of the care staff team. This staff member will require direction, support and guidance to undertake this role successfully. There home needs to be some distinction made about what defines fulfilling activities and leisure pursuits. Activities need to be person centred and developed according to the needs and interests of the individual service users. The manager needs to ensure that more direction and guidance is given to all the staff to undertake this role. Ashgold House DS0000031343.V258838.R01.S.doc Version 5.0 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 The home provides good personal and healthcare facilities for the service users to ensure the health and welfare of the service users is maximise. EVIDENCE: The home operates a key worker system to provide sensitive and individual support to service users. Personal care, life skills and dignity are promoted. Service users are assisted to choose their own clothes and are supported to shop. There is a flexible approach to daily living activities e.g. getting up, bed, bath and mealtimes. Staff were seen to approach service users in a caring and nurturing manner. It was observed that the service users privacy and dignity was maximised allowing them independence and control of their own lives. The staff reported that the service users have a choice of staff who work with them. Some service users get on better with some members of staff and this choice is respected and encouraged. All service users have regular appointments with their G. P. The staff ensure that the service users have access to healthcare facilities and routine checks are carried out frequently. Health care needs are monitored and they are referred to professionals when necessary. A member of staff accompanies Ashgold House DS0000031343.V258838.R01.S.doc Version 5.0 Page 16 service users when they are attending appointments and visits from healthcare professionals are conducted in private. A medical report sheet is maintained by the home to evidence dental, chiropody, G.P. and other health care appointments. One of the service users is involved with the local learning disability team and another is awaiting and assessment Other service users have been involved in with the team in the past. The home needs to continue to engage specialist services especially for those with sensory impairment. The home has robust procedures in place for the administration of service users medication and has recently reviewed its policy on the administration of medication. One senior member of staff now administers and signs for the medication and this is then countersigned by another member of staff. There is also a drugs count at the end of each shift. Senior staff have received the necessary training. A list of staff competent to administer medication is kept. Sample signatures are also available. The medication is stored in a locked cupboard and the keys to this are kept on the person who is in charge of the shift. MDS were cross-referenced with MAR sheets and at the time of the visit these tallied. There are now PRN protocols in place to ensure that staff have accurate procedures to follow when administering PRN medication this also needs to be extended to the use of topical creams and ointments. PRN guidelines need to be discussed and signed up to by the service users G.P. Ashgold House DS0000031343.V258838.R01.S.doc Version 5.0 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were inspected and met at the previous inspection. There have been no complaints made to the home since the last visit and no adult protection issues have been raised. EVIDENCE: Ashgold House DS0000031343.V258838.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 28 & 30 The majority of home is well maintained and decorated to a satisfactory standard providing service users with an attractive and homely place to live. The home could provide a more interesting and stimulating areas for service users to enjoy. The home is clean and hygienic with systems in place to reduce the spread of infection. EVIDENCE: Ashgold House is suitable for its stated purpose and provides a homely, domestic environment for the service users. Since the last visit plaster work in the upstairs lounge has been renewed. This area of the home could be put to better use, at the moment it is not utilised. The velux window in a service users’ bedroom and also the one in the staff toilet are still in need of replacing/repairing. Staff report that they have requested for this work to be undertaken by the maintenance team but to date this has not happened. This was identified as a recommendation in the past 2 reports. The home does need Ashgold House DS0000031343.V258838.R01.S.doc Version 5.0 Page 19 a maintenance and renewal programme in place to ensure that the up –keep of the house is on-going and timescales are adhered to. The lounge and dining area of the home have little in them to stimulate the service users. The home needs to provide a more stimulating and interesting environment for the service users. Some of the service users have visual impairments and would benefit from different textures, colours and objects. The rooms are bright, airy and clean and at the time of the visit the home was free from any offensive odours. The home has systems and a rota in place to maintain a clean and hygienic environment and prevent the spread of infection. The home now has procedures in place for the occasions when staff have to transport soiled linen to the laundry room. The use of washing machine and dryer in the laundry room, which is next to the bedroom of a service user is now restricted to certain times. Noise and disturbance to the service users is now kept to a minimum. The service user reported that he is no-longer disturbed by the sound of the machines. This is still not an ideal situation but the manager has addressed the issues within the environmental constrictions. Alternatives still need to be explored. Ashgold House DS0000031343.V258838.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35 & 36 The staff have a good understanding of the service users and positive relationships have been formed. The staff group within the home is now stable. The arrangements for the induction and mandatory training of staff has improved. More specialist and NVQ training is required to evidence that they have the competencies and skills to meet all the needs of the service users. The home does not have the necessary numbers of staff on duty at all times to ensure that the service users live fulfilling and active lives. The procedures for recruitment protect the service users EVIDENCE: The staffing situation at the home has improved since the last inspection. Ashgold House now has a more static and consistent staff team who have developed good relationships with the service users and they are able to anticipate and meet the individual needs of the client group. Service users said “that the staff are good and give them the help and support that they need”. They also said that there was not enough staff at times. At the present time the home employs 9 care staff and the manager. One service user is funded for 15 hours of 1 to 1 time and needs 2 staff when he goes out plus a driver if the homes transport is used. Another is funded for 8 hours 1 to 1 and requires Ashgold House DS0000031343.V258838.R01.S.doc Version 5.0 Page 21 2 staff when out. At the moment the home usually has 5 staff on in the morning and 4 in the afternoon. At times during the day there are not enough staff on duty to ensure that the service users are able to go out and participate in activities and leisure pursuits in the community. If service users do go out then there is not enough staff left behind to undertake activities in the home. The manager of the home needs to address this issue and look at ways in which this the problem can be resolved. More staff are required for certain times during the day and evening if service users wish to go out. The number of staff on duty should depend on the needs of the service users. At the present time staff meetings are not taking place these need to be reintroduced recorded and actioned. The care staff employed by the home are all issued with a job description on starting employment. There was evidence to show that the staff were able to promote the main objectives of the home and are aware of their role and responsibilities and that of the other staff. The staff reported a good working relationship with the manager. There are no volunteers going into the home at the present time. It was observed that the staff are accessible and approachable to the service users and are able to exhibit good listening and communication skills. It was evidenced that the staff on duty put the needs of the service users first. At this visit it was evidenced that only 2 members of staff have obtained NVQ level 2. It was reported that 2 more staff have commenced training. More staff need to start and complete NVQ level2. The target of 50 is not met. A sample of staff files were looked at. The company has an equal opportunities policy. Two references and CRB/POVA are required prior to commencement of employment, these were evidenced in the files. All gaps in employment history need to be explored and reasons for gaps documented on the staff file at the time of interview. Terms and condition of employment are in place. All staff appointments are subject to a minimum probationary period of 3 months. Since the last inspection the home has made progress in obtaining mandatory training for all the staff. There is an induction programme at the home and all staff employed receive the appropriate training to induct them safely into the environment within the stated time limits. The staff have received all the required mandatory training. Training needs to on going and up-dated within the required timescales the registered manager needs to ensure that this is continued. There needs to be more specialist training for staff so they can develop the knowledge and skills to meet the specific needs of the individual service users in their care. Ashgold House DS0000031343.V258838.R01.S.doc Version 5.0 Page 22 All staff are now receiving regular formal supervision and annual appraisals have commenced. Ashgold House DS0000031343.V258838.R01.S.doc Version 5.0 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38,39, 42&43 The management of Ashgold House is improving. This needs to be evidenced by the manager becoming registered and obtaining the necessary qualifications to ensure that the aims and objectives of the home continue to be met. The home has leadership guidance and direction, which ensures the service users receive a consistent quality of care. Quality assurance and monitoring needs to be further developed to ensure the aims and objectives of the home are being met and the views of the service users/representative are acted on. The health, safety and welfare of the service users is promoted and protected There is no evidence available to demonstrate that the service users are benefiting from an effective, financially viable and accountable service. Ashgold House DS0000031343.V258838.R01.S.doc Version 5.0 Page 24 EVIDENCE: Since July ’05 the home has a new manager. She knows the home and the service users well as she covered a period of sick leave in 2004. She is also aware of the work that needs to be undertaken to ensure that the home meets the required standards. The manager now needs to obtain the necessary qualification and apply to the CSCI to become the registered manager of the home. On a day –to-day basis the manager of the home has created an open, positive and inclusive atmosphere, which the service users and staff understand and respond positively to. The staff reported that the manager is very approachable and they feel able to ask her questions and know that they will receive an appropriate response. The process of managing is now more open and transparent. The CSCI has received monthly regulation 26 reports from the area manager. The company has appointed a dedicated person to undertake effective quality assurance and quality monitoring systems. The aim is to look at managerial effectiveness, improve paper work and highlight any deficits so they can be addressed. The out-come is to ensure all homes within the company are working to the same remit and working to met the minimum standards. Ashgold House was visited in September ’04 and some issues were identified at this time. There have been no further visits or input into the home, which leaves them without any feed back or guidance on how to improve the service they are offering and keep in line with other homes within the company. The registered manager needs to commence an in-house audit. The views of the service users, staff, relatives and other professionals/visitors need to be sought and acted on so the home can monitor and improve the service it provides. Effective quality assurance and monitoring systems will measure the success of the home in achieving its main aims and objectives. Mandatory training is up to date and dates and the manager needs to ensure that training is on-going and up-dated. The staff were able to produce evidence of accidents and injuries sustained on the premises, which are all in order. Environmental risk assessments were available at the time of the inspection. Gas and electric maintenance was up to date. PATS tests have been done. Water temperature tests were done and satisfactory and all fire tests had been completed. The home does need to produce a business and financial plan for the home to ensure the effectiveness, financial viability and accountability of the home. This needs to be forwarded to the CSCI offices on completion. Ashgold House DS0000031343.V258838.R01.S.doc Version 5.0 Page 25 Ashgold House DS0000031343.V258838.R01.S.doc Version 5.0 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X 1 Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 2 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X 2 X 3 LIFESTYLES Standard No Score 11 X 12 1 13 1 14 1 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score 3 2 1 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Ashgold House Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score 1 3 1 X X 3 1 DS0000031343.V258838.R01.S.doc Version 5.0 Page 27 Are there any outstanding requirements from the last inspection? YES 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 YA5 Regulation 5(b)(c) Requirement Contract/Terms and conditions needs to include the fees charged what they cover and charges made by the company for any extras. Information needs to be incorporated about when fees are payed and by whom.(Out-standing requirement from the previous 2 inspections Timescale of the 31/08/05 not met) Each service user requires and individual activities programme arranged by or on behalf of the care the care home.(Outstanding requirement from the previous inspection Timescale of the 31/08/05 not met) To make arrangements for the service users to enable them to engage in local, social and community activities.(Outstanding requirement from the previous inspection Timescale of the 31/08/05 not met) Staff ensure that service users have access to, and choose from DS0000031343.V258838.R01.S.doc Timescale for action 30/04/06 2 YA12 16(2)(n) 30/04/06 3 YA13 16(2)(m) 30/04/06 4 YA14 16(2)(n) 30/04/06 Page 28 Ashgold House Version 5.0 5 YA32 18(1)(a) 6 YA33 18(1)(a) 7 YA37 9 8 YA43 25 a range of, appropriate leisure activities.(Out-standing requirement from the previous inspection Timescale of the 31/08/05 not met) Staff have the competencies and qualities required to meet service users’ needs and achieve Sector Skills Council workforce strategy targets within the required time-scales 50 of the care require to be NVQ trained.(Out-standing requirement from the previous inspection Timescale of the 31/07/05 not met) The home needs an effective staff team with sufficient numbers and complementary skills to support service users’ assessed needs at all times. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. .(Outstanding requirement from the previous inspection Timescale of the 31/07/05 not met) The manager needs to obtain her NVQ4/RMA .The manager also needs to become registered with the CSCI by under going a fit person interview Service Users are to benefit from competent and accountable management of the service and the inspector requires to see evidence of this when visiting the home 30/06/06 30/04/06 30/05/06 30/04/06 Ashgold House DS0000031343.V258838.R01.S.doc Version 5.0 Page 29 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA6 YA8 Good Practice Recommendations The staff need to ensure that all plans are kept up to date to reflect the changing needs of the service users. The manager ensures that service users are offered opportunities to participate in the day to day running of the home and service users receive feedback on the outcome of their involvement. The home needs a planned renewal and maintenance programme. To ensure velux windows are repaired/replaced. To provide a more stimulating and interesting environment in the communal areas of the home. 3 4 YA24 YA28 Ashgold House DS0000031343.V258838.R01.S.doc Version 5.0 Page 30 Commission for Social Care Inspection Kent and Medway Area Office 11th Floor International House Dover Place Ashford Kent TN23 1HU National Enquiry Line: 0845 015 0120 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. 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