Inspection on 15/11/05 for Ashingham House

This inspection was carried out on 15th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ashingham House 06/11/07

Ashingham House 19/07/06

Ashingham House 10/05/05

Ashingham House 16/11/04

Ashingham House 15/06/04

Ashingham House 17/02/04

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 Ashingham House London Road Temple Ewell Dover Kent CT16 3DJ Lead Inspector Mary Cochrane Unannounced Inspection 15th November 2005 09:30 Ashingham House DS0000023339.V256919.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 Ashingham House DS0000023339.V256919.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. Ashingham House DS0000023339.V256919.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ashingham House Address London Road Temple Ewell Dover Kent CT16 3DJ 01304 826842 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) Ashingham House Limited Mrs Dawn Joyce Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Ashingham House DS0000023339.V256919.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 10 People with learning disabilities between 18 & 65 years of age. Date of last inspection 10th May 2005 Brief Description of the Service: Ashingham House is a large detached property standing in its own grounds between the rural villages of Temple Ewell and Lydden, close to the port town of Dover. The home is registered to provide 24-hour care and support for up to 10 people with learning disabilities between the ages of 18 and 65. At the present time Ashingham House has 9 service users in residence. Individual bedrooms are provided for all the service users. The accommodation is arranged over 2 floors. Most of the communal facilities are on the ground floor but there is a small activities room on the 1st floor. There are 2 bathrooms and 2 separate toilets within the building. The kitchen has recently been up-graded. There is a large garden surrounding the property, which service users enjoy and use in the better weather The home is owned by the Allied Care Company who have several other homes in the areas. Ashingham House DS0000023339.V256919.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 unannounced inspection at Ashingham house this year. The visit commenced at 9.30am and finished at 6.30p.m.on the 15/11/05. The inspector returned to the home on the 21/11/05 for one and half hours to complete the inspection. Not all of the key standards were looked at during the previous inspection so they were looked at this time. These were mainly the standards concerned with complaints, adult protection and the finances and funding of the service users. The inspector also focused on the requirements and recommendation made during the last visit. The following methods of inspection and information gathering were used: one-to-one discussion with staff, communicating with service users, observing interactions, care interventions and activities, reading and discussing individual support plans, risk assessments, selected policies, medication charts, training matrix and training programmes and looking at the financial arrangements for the service users. At the previous visit 13 requirements and 6 recommendations were made. There have been some improvements and the home is slowly heading in the right direction. This will be reflected throughout the report. The home still has a lot of work to do before all standards are met. All of the service users within the home have limited verbal communication skills; some do use a limited amount Makaton. The care staff at the home know the service users well enough to anticipate and interpret a lot of their needs and are able to communicate through body language, behaviours and verbal sounds. On arrival at the home 2 of the service users were just leaving to attend G.P. appointments, some were still receiving personal care and the remaining service users were in the lounge, where activities were being organised by staff. Service users were encouraged to participate. All the service users were well dressed and looked physically well cared for. This is an improvement on the previous inspection. At the present time the home employs 1 manager, 1senior team leader, 1 team leader and 22 care staff. There is also a full time cook and regular input from the maintenance team. The registered manager was unavailable for the initial part of the inspection. The homes’ team leader assisted, she was helpful and co-operative and was able to demonstrate a good knowledge of the service users. The adult protection alert, which was opened on the home last year, has now closed. The adult protection co-ordinator is no longer involved. The local learning disability team, care managers, other specialists and the CSCI will still be actively involved with the service users and the home. Ashingham House DS0000023339.V256919.R01.S.doc Version 5.0 Page 6 What the service does well: What has improved since the last inspection? There have been significant improvements made with regards the skills, abilities and competences of the staff team. The staff are now aware of their responsibilities and roles. The needs of the service users were seen to be put first. The care staff reported that the team now work better together; the atmosphere in the home reflected this. Activities within and out-side the home have increased and residents are participating in more time structuring and meaningful pursuits. All service users are now going out into the community to participate in a range of different activities and environments. At the time of the inspection the manager had just completed developing individual activity programmes. These now have to be implemented. Staff training has improved significantly and although some training is still outstanding training programmes are in place and are on-going. This will ensure all staff receive the necessary training and will receive up-dates at the necessary intervals. Relationships with the service users G.P’s has improved and there has been an improvement in the service provided. Each service users now has an individual written contract in place, which stipulates their terms and conditions with the home. Ashingham House DS0000023339.V256919.R01.S.doc Version 5.0 Page 7 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. Ashingham House DS0000023339.V256919.R01.S.doc Version 5.0 Page 8 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 Ashingham House DS0000023339.V256919.R01.S.doc Version 5.0 Page 9 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&5 The homes Statement of Purpose and Service Users Guide do not provide sufficient information for service users and their family/advocates to make informed decisions about the homes ability to meet their needs. Service users places at the home are now protected, as there are terms and conditions of residency and signed contracts in place. The company need to inform the service users about what is covered and what is not by the fees. So they know what they are paying for. EVIDENCE: The registered manager has up-dated the homes Statement of Purpose but it still does not contain all the information required by schedule 1.The Service Users Guide is well written and informative. It includes a summary of the Statement of Purpose and details of the complaints procedure. Due to the complex needs and limited communication skills of the service user’s living at Ashingham House the guide needs to be produced in the language and format that can be understood by the Service Users. The registered manager is going to develop a pictorial guide. Since the last inspection the manager has obtained the information from head office, which has enable her to develop individual contracts for the service users. All of the service users in the house have now been given a written contract of terms and conditions of residency. The company also needs to Ashingham House DS0000023339.V256919.R01.S.doc Version 5.0 Page 10 make available the information on what the fees cover when they must be paid and by whom and also the cost of any extras. e.g. what does the company charge individual service users for the use of the homes transport? Ashingham House DS0000023339.V256919.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 & 9 There are short- falls in the planning and implementing of the assessed and changing needs of the service users. Not all risks to the service users are identified, recorded and minimised. Service users are therefore potentially at risk. Service users need to be able to make decisions about their own lives. EVIDENCE: 3 of the homes care plans were looked at during this visit. The care plans home do continue to improve however as stated in the previous report some are of a better standard than others. One of the care plans had not been completed and was sparse in information on how the service users needs would be met. The staff need to have all the information available to enable them to deliver the individuals care in the most effective and safest way. It was evidenced that newly identified needs are not incorporated into the care plan, especially with regards to the service users physical needs. One service users had recently visited the G.P and the treatment prescribed had not been Ashingham House DS0000023339.V256919.R01.S.doc Version 5.0 Page 12 added to his care plan. Care plans need to be up-dated when necessary and used as a daily working document by all the staff. Care staff did report that they are using the information more frequently. One of the team leaders is in the process of developing the daily records sheet so that all the information about the service users day is gathered together for staff handovers. The registered manager is also looking at other areas in the house, which will be more conducive for staff handovers as the staff office is too small and often disruptions and distractions occur. The service users at the home all have communication difficulties. Wherever possible service users are encouraged to choose and make decisions. Through observation and talking to service users and staff there was evidence to support that some service users are involved in making decisions on how they live their lives. The home needs to be able to evidence that the service users are offered choices and how individual decisions are reached. Evidence also needs to be available when decisions are made by others and why. Some infringements and restrictions are documented in the plans. Risk assessments are in place and further work needs to be done to ensure that all individual risks have been identified and that procedures and are in place to minimise them. Staff did report that there is now a more consistent approach when dealing with challenging behaviours and they feel more supported by the staff team. Although there are still many reports of incidents of behaviours for the majority of the time staff are now following the guidelines that are in place. The registered manager remains pro-active in organising multi agency review to look at whether or not the home can carry on meeting the service users needs. It needs to be ensured that if a new risk is identified it is then documented into the individuals care plan as soon as possible. Care plans and risk assessments need to be up-dated as often as necessary so as to reflect the changing needs of the service users. All staff need to access and be aware of the information. At the time of the inspection this had not been done for some service users Ashingham House DS0000023339.V256919.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, & 16 The home has improved the opportunities and facilities to enable the service users to develop and maintain appropriate and fulfilling lifestyles in and outside the home. EVIDENCE: All the service users living at Ashingham house have complex learning needs. The level of activities that can be undertaken is varied and needs to be individually tailored. At the time of the visit it was evidenced and observed that activities, community presence, and leisure pursuits have improved since the last inspection. The registered manager has just developed individual activities programme for each of the service users and these are now going to be implemented. The plan is for the large shed in the garden, which presently used as a snoozelam will be converted into an activities room (the snoozelam is going to be moved up-stairs). This will allow a dedicated space for several different activities to be available to the service users to meet their different need and different attention spans. Most of the residents now go out on a daily bases for a walk or drive. Some service users attend individual session at the local specialist unit and others Ashingham House DS0000023339.V256919.R01.S.doc Version 5.0 Page 14 attend a day centre in a nearby town. The home also has access to social and disco evenings. The new programmes will include swimming sessions and other pursuits. The programmes have more individual focus and are linked to the likes and dislikes of the service users. The staff need to encourage and support the service users to participate in the activities. The home also needs to evidence that the service users have a choice about what they do and if someone decides not to do an activity the staff need to be able to evidence how that decision was reached and what alternatives were offered. Interactions and communications between the staff and the service users has improved. This was evidenced through observations and also through the minutes of meetings with the staff and the management. At the time of the visit staff spent time with the service users trying to engage them in activities even if it was only for a short time, they were inclusive in conversations and were to be respectful of the service users privacy. Service users are able to choose when to be alone or in company and have unrestricted access was to the house, and gardens. Ashingham House DS0000023339.V256919.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 & 20 The home now provides appropriate personal support for the service users. The home needs to ensure that systems for the administration of medication are kept up-to date to ensure that the service users receive the treatment they need. EVIDENCE: The home operates a key worker system to provide individual support to service users. This is in place so as to promote the homes philosophy in personal care, developing life skills and maintaining dignity. Service users are encouraged to do as much as possible for themselves. It was seen that some service users are assisted to choose their own clothes and are supported to shop. The inspector was now able to evidence a significant improvement with regards the personal support of the service users. The care staff now give the guidance and support to the service users that they may require. At the time of the visit the service users looked well cared for and were dressed appropriately and in keeping with age and personalities. Systems have been introduced to ensure that each member of staff is aware of their role and responsibilities for the shift. It was evidenced at the inspection that protocols for newly prescribed PRN medication were not in place. This was mainly with regards to topical Ashingham House DS0000023339.V256919.R01.S.doc Version 5.0 Page 16 preparations. The home needs to ensure that new information is incorporated in to the protocols. Ashingham House DS0000023339.V256919.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): Concerns and complaints are acted on. Arrangements for protecting service users from most types of abuse are in place, however arrangements for protecting from financial abuse are not satisfactory and leave service users at risk. EVIDENCE: There have been 2 complaints made to the home since the last inspections. The registered manager has handled these complaints appropriately and according to the homes policies and procedures. The home does have a satisfactory complaints procedure in place clearly outlining the different stages for making a complaint, and how to contact the Commission. The registered manager and staff have a good understanding of the adult protection procedure and whistle blowing policy in the home. Some staff have experienced involvement with adult protection investigations and although they have found it daunting, they have felt supported and their concerns are taken seriously. The registered manager has been involved with adult protection issues since starting at the home and feels that the process has been beneficial and necessary to maintain the safety of the service users. Ashingham is no-longer open to the adult protection team. The homes policies and practices do not adequately safeguard service users money and financial affairs. Each individual has a bankbook but this is kept at the company’s office. Service users do not receive bank statements. There is a lack of clear accountability and no audit trails in place. The home has recently Ashingham House DS0000023339.V256919.R01.S.doc Version 5.0 Page 18 started to receive some information on service users in-comings and outgoings but it is not clear or understandable. These systems need to be reviewed demonstrating clearly how service users finances are to be safeguarded and managed. The responsible individual needs to provided the Commission with some information on the management and transfer of service users finances, this was lacking in clarity and consistency. On a day-to-day bases the petty cash of the service users is managed appropriately and satisfactorily. This was evidenced at the inspection by crossreferencing in-comings and outgoings of the service users monies. Monies are stored safely within the home. Ashingham House DS0000023339.V256919.R01.S.doc Version 5.0 Page 19 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): 24,26 & 30 The home needs to continue with its on-going maintenance and refurbishment plans so as to create an environment that is homely, comfortable and safe for those living there. The service users are provided with a home that is clean and hygienic. Procedures are now in place to prevent the risk of cross infection. EVIDENCE: The kitchen at the home has now been completed, however at the time of the inspection the staff were having problems with the oven door not closing. The registered manager was addressing this problem. The decoration in the homes 2nd bathroom still needs completing and the maintenance man is going to do this within the next few weeks. The home is presently trialling a specially designed chair that is more robust than normal in the hope that it might last longer than the homes present chairs, which are replaced regularly. If it is successful the registered manager hopes to purchase enough chairs to furnish the lounge with seating that meets the needs of the service users. Ashingham House DS0000023339.V256919.R01.S.doc Version 5.0 Page 20 2 of the service users bedrooms have been decorated since the last inspection and are comfortable and personalised. The broken wardrobe door has been repaired. 2 of the bedrooms still have the linoleum flooring, which is old, worn and cracked in places. The registered manager has recently required estimates for replacement flooring and is awaiting authorisation from head office before she is able to give the go ahead for replacing the flooring. Procedures and practises regarding soiled laundry now meet the requirements, laundry is transported safely and kept separate from other clothing. Alginate red bags are used for gathering and washing the soiled laundry. Disposable gloves and aprons are now available and worn and liquid soap and disposable towels are sited in the necessary areas. Ashingham House DS0000023339.V256919.R01.S.doc Version 5.0 Page 21 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 There have been improvements in the abilities and attitudes of the care staff to deliver care effectively and meet the complex, challenging needs of the service users. The staff still require further training, support and guidance to ensure that the improvements continue to make sure that service users are assisted to live fulfilling life’s and reach their full potential. The service users are protected by the homes recruitment policies. EVIDENCE: Progress and improvement has been made in addressing the requirements that were made around Standards 31-36 in the last inspection report. The registered manager is aware that there is still more work to do and is working towards meeting the national minimum standards. The staffing issues at the home have been difficult to deal with and the registered manager should be commended on the work she has undertaken to improve effectiveness, competencies and skills of the staff team. During this inspection it was seen and reported that staff are now working to support the main aims and values of the home. Staff who were unable to do this no-longer work at the home. The registered manager ensures that the homes aims and objectives are promoted by having the support and back up of the team leaders. Staff are more closely monitored and observed. Any Ashingham House DS0000023339.V256919.R01.S.doc Version 5.0 Page 22 concerns are followed up and dealt with. There are regular team meetings and formalised supervision sessions have started. It needs to be ensured that supervision is on-going and kept up to date. The duty rota is now developed depending on the needs of the service users. This ensures that there is the appropriate skill mix and numbers of staff on duty at any one time to meet all the service users needs. Extra funding to provide more staff time for service users has been obtained. Therefore the home are able to provide more staff support for those who need it. The home ensures that there is a minimum of 7 staff on duty for the day shifts and the home are now putting a case forward to the company for 2 wake night staff as this has been identified necessary to meet the changing needs of the service users. The inspector spoke to several members of staff who were aware of the expectations and limitations of their role and the lines of accountability. The staff still need to obtain further skills and knowledge in order to prioritise the needs of the service users and minimise risks at all times. This is being addressed through the training programme. More staff need to receive specialist training to give them a better understanding of the service users within the home. Mandatory training is still on-going extra sessions have been introduced into the programme and it is hoped that by the end of the year all staff working at the home will be up-to –date. It then needs to be ensured that training is on going. Staff reported that they are aware of the policies and procedures of the home and how to access them. There are 24 care staff employed by the home plus a cook and a domestic. Only 2 member of the care staff has NVQ level 2 or above. 3 are awaiting assessment for NVQ3. 3 staff members have been booked onto NVQ 3 and 6 onto NVQ2. The home still needs to reach the 50 of staff with NVQ level 2 or above qualifications. The home has thorough recruitment practises in place and staff files contain all the necessary information to ensure that the service users are protected. At this visit it was observed that the needs of the service users are put first New practises have been put in place to ensure this happens at all times. The issues of responsibility and accountability have been addressed with the staff group. Staff have improved and developed good relationships with the service users. The registered manager must be able to evidence that all the staff have the competencies, qualities, skills and abilities to meet the needs of the service users. The CSCI is still getting a high number of incident reports from the home involving service users to service users and service users to staff incidences, which does raise the issue as to whether staff are able to anticipate and diffuse behaviours before they happen. The registered manager is Ashingham House DS0000023339.V256919.R01.S.doc Version 5.0 Page 23 monitoring this very closely and is looking for emerging patterns and ways of dealing with the problems. The staff reported that they now feel more supported by their colleagues when incidences do occur. They also stated that the atmosphere in the home has improved and that everyone ‘gets-on’ better. The Registered Manager is making progress in developing an effective staff team with the skills to ensure that the needs of the service users are met at all times and the inspector does recognise that more time is needed to achieve this. The staff still require training, guidance, direction and support to develop a value base, knowledge and skills to assist them in prioritising and acting effectively so as to meet the individual and collective needs of the all the service users. Specialist services are accessed on a regular basis and the local learning disability team is regularly involved with the service users. Ashingham House DS0000023339.V256919.R01.S.doc Version 5.0 Page 24 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): 39, 42 &43 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. Gaps in staff training and in testing of fire equipment potentially leave service users and staff at risk. There is no evidence available to demonstrate that the service users are benefiting from an effective, financially viable and accountable service EVIDENCE: 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 Ashingham House DS0000023339.V256919.R01.S.doc Version 5.0 Page 25 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. Ashingham 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 has commenced an in-house audit. At the present this consists of mainly environmental issues. This needs to be extended to include the views of the service users, staff, relatives and other visitors about the home and the service it provides. Effective quality assurance and monitoring systems will measure the success of the home in achieving its main aims and objectives. All staff need to complete mandatory training. This needs to be on going and up-dated as required. The staff were able to produce evidence of accidents and injuries sustained on the premises, which were all in order and environmental risk assessments were available. All maintenance checks on the homes systems, equipment and vehicles were up-to date except for fire checks. There was no evidence to show that the fire warning system had been checked since the 16/10/05, this needs to be checked weekly. Heat and smoke detectors need to be regularly tested and a record kept. Fire fighting equipment also needs to be checked. Staff thought that the designated person had done this but there was no record available. The registered manager was going to ensure it was undertaken as soon as possible. The Inspector was unable to evidence an annual development plan. There was no evidence available at the home at the time of the inspection to show the overall management, effectiveness and accountability of the service. The home is required to produce as evidence an annual business and financial plan for the home and the service, which the CSCI can inspect at times of visits. Systems need to be in place to ensure financial planning and control and budget monitoring. Lines of accountability within the home and with the external management need to be clearly understood by service users and staff. Ashingham House DS0000023339.V256919.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 2 X X X 3 Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 1 X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X 2 X X X 3 LIFESTYLES Standard No Score 11 X 12 2 13 2 14 2 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score 2 1 3 3 1 2 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Ashingham House Score 3 X 2 X Standard No 37 38 39 40 41 42 43 Score X X 1 X X 1 1 DS0000023339.V256919.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 YA6 Regulation 15 Requirement The registered manager develops and agrees with each service user an individual plan, describing the services and facilities to be provided by the home, and how these services will meet current, changing need,aspirations and achieve goals.(Out-standing requirement from the 2 previous inspection Timescale of the 31/08/05 not met). Staff respect service users’ right to make decisions, and that right is limited only through the assessment process, involving the service user, as recorded in the individual Service User Plan. (Out-standing requirement from the previous inspection Timescale of the 31/07/05 not met). The staff should only allow Service Users to take identified risks based on decisions formulated in the Individual care plans and risk assessments. These need to be clearly documented, up-dated DS0000023339.V256919.R01.S.doc Timescale for action 28/02/06 2 YA7 12(2) 28/02/06 3 YA9 13(4) 28/02/06 Ashingham House Version 5.0 Page 28 4 YA23 16(2)(l), 20 5 YA32 18(1)(a) 6 YA35 18(1)(c) 7 YA39 24,26 8 YA42 23 and reviewed as necessary. Individual risk assessments need to be identified and completed for each Service Users(Out-standing requirement from the previous 2 inspection.s Timescale of the 31/08/05 not met). The registered provider ensures that service users are safeguarded from any financial abuse in accordance with written policy.(Outstanding requirement from the previous 2 inspections.Timescale of the 31/08/05 not met). To ensure that the staff have the competencies, qualities,skills and abilities required to meet the service users needs and achieve Sector Skills Council workforce targets The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users’.(Outstanding requirement from the previous inspection.Timescale of the 31/08/05 not met). The Registered Manager to ensure that there is an annual development plan in place specifically for the home and that quality assurance systems are developed. .(Outstanding requirement from the previous inspection.Timescale of the 31/08/05 not met). The registered person ensures so far as is reasonably practicable the health, safety and welfare of service users and staff by ensuring that all DS0000023339.V256919.R01.S.doc 31/12/06 31/01/06 31/01/06 31/01/06 22/11/05 Ashingham House Version 5.0 Page 29 9 YA42 10 YA43 fire checks are carried out at the required intervals. 23(4)(a,b,c,) To ensure that all staff have received the required mandatory training for all the care staff. 25 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.(Outstanding requirement from the previous inspection.Timescale of the 31/08/05 not met). 31/01/06 31/01/06 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 2 Refer to Standard YA1 YA5 YA12 YA13YA14 Good Practice Recommendations The Registered Manager to develop the Statement of Purpose and produce a more suitable format of the Service Users Guide. Information needs to beprovided on what the fees covered and if there are any additional extras. The home needs to ensure that the activities programmes are implemented and arrangements to participate in local, social and community activities are encouraged and supported by the staff team. DS0000023339.V256919.R01.S.doc Version 5.0 Page 30 Ashingham House 3 4 5 YA20 YA26 YA31 6 YA36 To ensure that protocols are in place when new PRN medications. To replace the old linoleum flooring in 2 of the bedrooms as soon as possible. To continue to reinforce and ensure and that staff team understand their own role and responsibilities and others’ roles and responsibilities. To ensure that the staff continue to be aware and understand the values of the home. Supervision of staff needs to be kept up-to date. Ashingham House DS0000023339.V256919.R01.S.doc Version 5.0 Page 31 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. Extracts may not be used or reproduced without the express permission of CSCI Ashingham House DS0000023339.V256919.R01.S.doc Version 5.0 Page 32 - 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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