Inspection on 12/12/05 for Ashgrange House

This inspection was carried out on 12th December 2005.

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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ashgrange House 20/02/07

Ashgrange House 12/07/05

Ashgrange House 18/01/05

Ashgrange House 07/06/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Ashgrange House 9 De Roos Road Eastbourne East Sussex BN21 2QA Lead Inspector Mr James Houston Unannounced Inspection 12th December 2005 08:30 Ashgrange House DS0000021430.V266688.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 Ashgrange House DS0000021430.V266688.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. Ashgrange House DS0000021430.V266688.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ashgrange House Address 9 De Roos Road Eastbourne East Sussex BN21 2QA 01323 732544 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) Alliance Home Care (Learning Disabilities) Limited Mrs Geraldine Connelly Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Ashgrange House DS0000021430.V266688.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. That the resident identified can continue to live at Ashgrange House although he is over sixty-five years of age. The maximum number of residents to be accommodated is eight (8) Residents may also exhibit some forms of challenging behaviour Date of last inspection 12th July 2005 Brief Description of the Service: Ashgrange House is a detached property situated in a quiet residential area of Eastbourne, approximately half a mile from the town centre. Local shops and bus routes are a short walk away. Accommodation is provided on three floors, the home does not have a lift and therefore people accommodated at Ashgrange must be independently mobile. The home is registered to accommodate eight adults with a learning disability who may also have challenging needs. The registered providers are Alliance Home Care (Learning Disabilities) Limited. Ashgrange House DS0000021430.V266688.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over 5.9 hours during the morning and early afternoon of the twelfth of December 2005. The registered manager assisted throughout the inspection. Before the inspection the inspector read records held on the home by the Commission for Social Care Inspection and prepared those sections of the standards to be inspected. During the inspection the inspector spoke with four residents and three members of staff. A tour was made of the whole premises. During the inspection a range of records, including three care plans, and policies and procedures were read. After the inspection the inspector spoke with a relative by telephone. Eight residents were being accommodated on the day of the inspection. What the service does well: 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. Ashgrange House DS0000021430.V266688.R01.S.doc Version 5.0 Page 6 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 Ashgrange House DS0000021430.V266688.R01.S.doc Version 5.0 Page 7 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): 1 and 5. The home gives full information to residents to enable them and their representatives to make the decision about whether or not to enter the home. EVIDENCE: The home has a suitable and satisfactory Statement of Purpose and Service Users Guide that outline the services provided at Ashgrange House. These documents are also available in pictorial format. The Service User’s Guide for each resident is usually placed in their room, but on the day of the inspection these were in the home’s office for revision. All residents are issued with a contract that lists the terms and conditions of their stay in the home. More detailed contracts are issued by placing authorities. These list the services that should be provided and the fees agreed. Ashgrange House DS0000021430.V266688.R01.S.doc Version 5.0 Page 8 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): 6,9 and 10. Care planning is comprehensive. Confidentiality is respected. EVIDENCE: Residents’ care plans are comprehensive and include personal histories, daily reports, monthly updates and formal reviews. A relative said they had been fully involved in this process. A key worker system is operated. Staff were knowledgeable about the needs of those residents for whom they were the key worker. A clear record is held of any infringement of residents’ rights in their own best interests and is to them. Full risk assessments are drawn up. Staff said that they see it as part of their role to give guidance and advice as needed to residents about their personal safety. The home has a suitable policy on the action to be taken by staff in the event of a resident having been found to have gone missing, and staff had signed to acknowledge that they had read it. The home has a confidentiality policy of which staff were aware. Discussion with staff showed that staff knew when information given to them in confidence must be shared with their manager or others. Ashgrange House DS0000021430.V266688.R01.S.doc Version 5.0 Page 9 Ashgrange House DS0000021430.V266688.R01.S.doc Version 5.0 Page 10 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): 11,12,15 and 17. Links with the community are good, supporting and enriching resident’s lives. Food is a source of enjoyment and variety. EVIDENCE: The home benefits from regular professional input from the local Community Learning Disability Team. The manager said that staff take one resident to church whenever she wishes to go. Discussions with residents and staff showed that residents have a very full programme of activities in–house and away from the home. During the inspection staff took the residents out bowling and reported that most had taken part, with some preferring to sit in the café. A wide range of activities is available and a resident mentioned enjoying bingo. The home has its own minibus and a people carrier, and several staff are able to drive them. Several residents said that they go to college and enjoy this. The manager said that in November 2005 all the residents had gone up to London for an activity day, when they could access a wide variety of activities and they had greatly enjoyed this. Ashgrange House DS0000021430.V266688.R01.S.doc Version 5.0 Page 11 A resident and a relative said that visitors are made welcome, and staff said that greeting visitors and offering them hospitality is seen by them as an important part of their role. Residents said that they like the food served in the home. A relative said that the food appeared to be of a high standard. Records inspected showed that a full record is kept of food served and alternatives to the main menu offered. The home keeps a record of the weight of residents and the advice of a dietician has been sought recently in respect of one resident. Particular medical or other diets are catered for as needed. Ashgrange House DS0000021430.V266688.R01.S.doc Version 5.0 Page 12 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): 19,20 and 21. Residents’ health care needs are well met. Medication systems are thorough but medicine administration records need some attention. The home has suitable systems for meeting the needs of dying residents. EVIDENCE: Records inspected showed that careful attention is paid to meeting the healthcare needs of residents and to recording outcomes. A relative confirmed this. Staff said that they take residents to the doctor when needed and one resident was taken to see the doctor during the inspection. Medications for residents are securely stored, and a visiting pharmacist reviews the home’s systems regularly. The medicine administration records inspected were found to be incomplete. Currently no controlled drugs are held for residents and no resident holds their own medications. Staff said that they had had suitable medication training and records inspected confirmed this. The home has suitable policies for the care of residents who are dying. It holds the necessary information in care plans to tell staff what action to take to ensure that,in the event of a resident’s death, any wishes they or their family have expressed about action to be taken are carried out. Ashgrange House DS0000021430.V266688.R01.S.doc Version 5.0 Page 13 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): 22 and 23. The home has a suitable complaints system and the adult protection procedures protect residents in the event of abuse or allegations of abuse. EVIDENCE: The home has a suitable complaints procedure that is available to residents. The home has a complaints log that was made available to the inspector. The matters there had been well recorded and resolved. The home has suitable adult and whistle-blowing policies, which staff had signed to say that they had read. Staff said that they had had suitable training in adult protection and challenging behaviour and records inspected confirmed this. Staff had signed to say that they were aware of the home’s policy of staff not receiving gifts or benefiting from bequests from residents. Ashgrange House DS0000021430.V266688.R01.S.doc Version 5.0 Page 14 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): 24,25,26 and 27. The overall standard of the premises is good, providing residents with a safe and homely place in which to live. EVIDENCE: The home is a large detached house on three floors, set in a quiet residential area of Eastbourne. The home has its own maintenance staff member shared with a nearby home in the same group. The standard of décor and furnishings is satisfactory in all areas of the home occupied by residents. Two fire doors were found not to close onto their stops. The home is not generally suitable for residents with mobility problems as there is only one bedroom on the ground floor and no lift. The home has eight bedrooms. The two rooms accommodating residents on the second floor do not meet minimum space requirements and Funding Authorities are made aware of this at the time of making referrals for admission to the home, i.e. the information is included in the home’s Statement of Purpose. Ashgrange House DS0000021430.V266688.R01.S.doc Version 5.0 Page 15 Resident’s rooms have been individually decorated and furnished, with them having a say in choosing the décor. Residents said that they liked their rooms. Furniture and fittings were to a good level. An inventory of residents’ own furniture is kept. Residents’ rooms’ are lockable and residents said that they choose whether or not to hold a key. The home has two bathrooms and a shower room for use by residents. There are four toilets in the house. The manager acted during the inspection to improve the privacy of one toilet door. All residents’ bedrooms have hand basins. There are no toilet or bathing facilities on the second floor. Ashgrange House DS0000021430.V266688.R01.S.doc Version 5.0 Page 16 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): 31,33 and 36. Residents are cared for by a competent, experienced and properly supervised staff group. EVIDENCE: Staff confirmed that they have been provided with suitable job descriptions. The home has codes of conduct and good practice for staff guidance. Staff said that they are aware of the General Social Care Council Code of Conduct and records inspected confirmed that they sign to acknowledge receipt of this. The manager said that the home does not have any volunteers at present. The home has a staffing rota that was made available for inspection. The home has a stable staff group, and there are currently no staff vacancies. A new deputy manager will start in the home in January 2006. The home has at least three staff on duty during the waking day, with two staff on duty at night, including one asleep. Sufficient staff were on duty during the inspection to meet the needs of residents. There is an on call system, both for senior staff from the home and for more senior staff. Staff said that these systems work well. The manager gave an assurance that the senior staff member on duty in the home is always at least twenty-one years of age. Staff said that there are regular staff meetings that are minuted and the minutes of these were made available to the inspector. Records inspected showed that staff receive regular supervision and annual appraisals. The manager said that senior staff have received suitable training on the giving of supervision. Ashgrange House DS0000021430.V266688.R01.S.doc Version 5.0 Page 17 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): 38,40,41 and 43. Residents benefit from an open management approach in a well run home. EVIDENCE: The home has regular satisfaction surveys for residents, relatives, staff and visiting professionals and these were made available to the inspector. The home has regular staff and residents meetings. Residents said that they can talk to staff, and staff and a relative said that the manager is approachable. Interactions observed between staff and residents were appropriate and caring. The home has comprehensive policies and procedures and those sampled were well drawn up. They were seen to be reviewed from time to time as needed. Staff said that they had access to them, and the home has a thorough system of staff signing that they have read them. The manager said that selected policies are reviewed at staff handover. Ashgrange House DS0000021430.V266688.R01.S.doc Version 5.0 Page 18 Those records sampled, except where mentioned elsewhere in this report, were found to be securely held, maintained up to date and well recorded. The manager said that residents are able to access their records if they so wish but that to date this has not been sought. The home has good administrative systems. The home, part of a larger group, has the support of the headquarters in aspects such as finance and human resources, and also has access to a legal helpline. The home’s line manager makes regular visits to the home and her reports on her visits were in the home and available for inspection. Staff said that they were clear about the lines of communication inside and beyond the home. A current certificate of insurance was on display. Ashgrange House DS0000021430.V266688.R01.S.doc Version 5.0 Page 19 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 3 X X X 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 X X X LIFESTYLES Standard No Score 11 3 12 3 13 X 14 X 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score 3 X 3 X X 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Ashgrange House Score X 3 2 3 Standard No 37 38 39 40 41 42 43 Score X 3 X 3 3 X 3 DS0000021430.V266688.R01.S.doc Version 5.0 Page 20 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2 Standard YA20 YA24 Regulation Requirement Timescale for action 12/12/05 14/12/05 17(1)(a)&Sch3 Record fully medicines (3)(i) administered to residents. 23(4)(a) Ensure all fire doors close fully onto their stops. 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 Ashgrange House DS0000021430.V266688.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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. Extracts may not be used or reproduced without the express permission of CSCI Ashgrange House DS0000021430.V266688.R01.S.doc Version 5.0 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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