Inspection on 17/05/06 for Ashington House

This inspection was carried out on 17th May 2006.

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

Other inspections for this house

Ashington House 17/06/08

Ashington House 05/06/07

Ashington House 16/11/05

Ashington House 03/05/05

Ashington House 22/09/04

Ashington House 29/04/04

Ashington House 06/01/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Ashington House 402 Malden Road Worcester Park Surrey KT4 7NJ Lead Inspector David Halliwell Key Unannounced Inspection 17th May 2006 09:30 Ashington House DS0000013378.V294159.R01.S.doc Version 5.1 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 Ashington House DS0000013378.V294159.R01.S.doc Version 5.1 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. Ashington House DS0000013378.V294159.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Ashington House Address 402 Malden Road Worcester Park Surrey KT4 7NJ 020 8330 7476 020 8330 7476 AshingtonHouse@aol.com 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) Ashington House Limited Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Ashington House DS0000013378.V294159.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The handbasin in one bedroom may be removed, to be reviewed at least annually. 16th November 2005 Date of last inspection Brief Description of the Service: Ashington House is owned and managed by Allied Care, a private organisation. It is a large semi-detached property on the main road from New Malden to Worcester Park. It is situated close to local amenities and is a short distance from a large local park. The home offers accommodation to adults who have a learning disability, with challenging behaviour. The service aims to provide six permanent placements in time. At the time of the inspection there were two permanent service users residing at the house. Ashington House DS0000013378.V294159.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection. The Inspection covered all the key standards and involved a review of all the homes records and interviews with staff and a service user who has been resident at the home for 2 years. At the time of this inspection there were only 2 service users living at the home. Both were present over the course of the inspection, there are 4 vacancies with 2 new prospective service users considering their placement at the home. The current fee charges for a placement at the home range from £1300 per week to £2500 for 2:1 staffing levels. Since the last inspection a number of the requirements identified then have now been met. The process of continuous improvement mentioned in the last inspection report has gathered momentum and there was a positive feel to the unit which reflects a good deal of effort and input made by the Area Manager, the Home’s Manager and the staff on behalf of the residents. The Inspector found the residents and staff very helpful and they are to be thanked for the assistance that they gave him over the course of this inspection visit. What the service does well: The home is taking all of the necessary action to ensure that the service users are well cared for, have their health and social care needs assessed and provided with the support that they require. The service users are actively encouraged to make informed choices and they are supported in order to help them maximise their full potential. Service users are able to make choices in many aspects of their daily living including with their preferred activities. Service users are treated with the appropriate degree of dignity and respect and are clearly happy living in this their home. Ashington House DS0000013378.V294159.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ashington House DS0000013378.V294159.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ashington House DS0000013378.V294159.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 & 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides service users and their representatives with the information they need to make an informed choice about where to live. The needs assessment and care planning process should assure service users that their needs will be met. The admission procedure indicates that the care manager and the home carry out thorough assessments of prospective service users needs before they move in. There are two service users living in the home at present and two prospective service users and their representatives are considering a future move to the unit. It is clear that the home are taking the opportunity to ensure that these two new service users needs are suitably matched to the needs of the two current service users and the skills and abilities of the staff team. Service users are provided with an individual contract and statement of the terms and conditions within the home. Ashington House DS0000013378.V294159.R01.S.doc Version 5.1 Page 9 EVIDENCE: The home’s Statement of Purpose was recently updated in line with Schedule 1 of the National Minimum Standards. A Service User Guide has been developed using Regulation 5 National Minimum Standards as guidance. These have been completed in written word and widget form for the benefit of the service users. The home’s admissions procedure is included in the homes Statement of Purpose. The home’s manager had contacted both of the service users care managers to arrange for placement and needs assessment reviews. Both of the service users care managers contacted the home and arranged for assessments to be carried out. Evidence of these assessments were seen on the service users files inspected. For both residents the needs assessments and the care plans provided by the referring agencies and the home were seen to be comprehensive in their detail and appropriate to the needs of these residents. With respect to the two prospective new residents the home’s manager stated that no new service users will move into the home until they have had a full care manager needs assessment carried out and the appropriate risk assessments which will take into account the needs of the new and existing residents. The home’s manager assured the Inspector that the home will follow its own procedure for admitting service users as stated in the Statement of Purpose and that the home will remind prospective service users and their representatives that the home adheres rigidly to this procedure. Both service users living at the home had a copy of their contract with the home. Ashington House DS0000013378.V294159.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service user Lifestyle Plans (Person Centred Plans) are comprehensive and include detailed information on the service users needs. There is evidence that service users are fully involved in completing their own plans so that they can express their wishes and personal goals for the future. Where possible service users are supported in taking risks as part of an independent lifestyle. Service users can be assured that information about them is handled appropriately and confidentially. EVIDENCE: Service users have a Lifestyle Plan which follows the Person Centred Plan approach. The plan is completed indicating that the service user is fully involved. These plans are very comprehensive and include detailed information on the service user’s needs and personal goals. The plans are being reviewed every at least once every six months. Ashington House DS0000013378.V294159.R01.S.doc Version 5.1 Page 11 The home’s manager stated that service user’s risk assessments have been completed with the support of Kingston’s Psychologist of Learning Disability Roselands Clinic. The home manager stated that a section of the service users Lifestyle plans entitled “My Safety and My Security” is where service users discuss risks to themselves. Both service users files were inspected and all the appropriate documents required in Schedule 3 were held on these files. It was also evidenced that appropriate risk assessments have now been completed for service users covering all aspects of potential risks including a previous requirement that was to cover the risks associated with service users being able to lock their own bedrooms. The Inspector found evidence to suggest that residents are enabled wherever possible to make decisions about their own lives. Choices were seen by the Inspector to be offered to the residents to do with many aspects of their daily lives including choice of menu, activities, holidays, what to wear, when to get up and when to see their friends or families. This was also supported by evidence seen in the residents file review and by staff interviewed by the Inspector. Risk assessments have been completed and were seen by the Inspector to be held on file for both residents. These risk assessments are part of the service users plan; they have been agreed with the relevant professionals and the service users where possible. The risk assessments seen by the Inspector detail actions which must be taken in order to minimise potential risks and hazards for service users and yet support them to be as independent as possible. Following a recommendation made at the last inspection the amount of working documentation located in communal areas of the home has been reduced. A file specifically for the use of agency staff has been created which should enable bank and agency staff to be aware of the homes procedures. The Inspector saw the agency file which contains all the information referred to above. Over the course of this inspection the Inspector found that appropriate measures have been taken to ensure that information held about service users is handled appropriately and confidentially. Files were seen to be held securely in the office and the staff interviewed were aware of and work to the home’s confidentiality policy. Ashington House DS0000013378.V294159.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 15, 16 & 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Opportunities for the personal development of service users are provided through the care planning process in operation within the home. Programmes have been developed to encourage and develop resident’s skills wherever possible. Service users are able to take part in appropriate leisure and other activities some of which are part of the local community. Service users are also encouraged to maintain appropriate relationships with their families and friends. There is strong emphasis in the home on respecting resident’s rights in all aspects of daily living. The menu is varied, offers choice and provides a healthy enjoyable diet. Ashington House DS0000013378.V294159.R01.S.doc Version 5.1 Page 13 EVIDENCE: Significant relationship links were recorded in the care plans seen by the Inspector and there was evidence that staff appropriately encourage the maintenance of these relationships if residents wish to do so. One of the resident’s families visits their relative fairly regularly and are involved in the support of their service user. Visitors to the home are encouraged and use the visitor’s book to sign in. Interviews with residents and staff identified that one resident who is more able, is involved in some local activities such as going to Church, fairs and other local events. The Manager informed the Inspector that residents are registered to vote in elections and are supported by staff to do so if they wish. However staff interviewed by the Inspector also reflected the difficulty in encouraging and motivating some residents to take an active part in this and other activities. Opportunities for the personal development of these service users are limited by their disabilities. However the Inspector saw that within the range of what is possible, care plans include some objectives for development including help with household chores, food preparation and gardening. At the time of the inspection one resident was seen to be developing their skills by undertaking some work in several areas of the home. The home employs an activities coordinator to encourage a range of appropriate activities within the home in which residents can take an active part and feel stimulated by. Policies seen by the Inspector to be established within the unit ensure that service user’s rights to privacy, respect and dignity are respected. Residents who were interviewed also confirmed that they felt staff respected these rights. Resident’s mail is unopened, the resident’s preferred form of address is used by staff and staff do knock on their doors before entering. The Inspector observed staff to be interacting with residents in a friendly and respectful manner. With regards to meals and meal times there is a planned and varied menu which residents told the Inspector they enjoyed. The Inspector saw suitably planned menus for 3 weeks ahead. Specific needs are catered for and a visiting dietician is fully involved given the diabetic needs of one resident. Ashington House DS0000013378.V294159.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 & 21. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal care is carried out in a way that service users prefer so that dignity and choice are maintained. Following appropriate risk assessments service users are not able to retain responsibility for their own medication but are protected by the unit’s policies and procedures for medication. The physical, health and emotional needs of residents are being met but there would be improvements in this area with the further development of supervision and training of the staff group. The home has sought and recorded the wishes of the service users and their relatives regarding death and dying. EVIDENCE: The service users wishes on how they are supported with personal care is outlined in detail in the very comprehensive Lifestyle plans which the Inspector saw as a part of each residents file. Ashington House DS0000013378.V294159.R01.S.doc Version 5.1 Page 15 Service users families wishes for the service users upon death and dying are now recorded in the service user Lifestyle plan files. During the themed inspection in July this year it was noted that care plans indicate staff training needs; staff were attending training on Autism, Epilepsy and Physical Intervention. The home and the Challenging Needs Team had also drawn up guidelines for staff to follow in the event of service users presenting challenging behaviours. The Manager informed the Inspector that the healthcare needs of residents are assessed and reviewed regularly as a part of the care planning process. This was supported by evidence on resident’s files. All service users do have access to the full range of healthcare professionals thereby ensuring that their needs are being met. Resident’s health checks are usually undertaken by the GP within the home. When the Inspector reviewed the medication records no errors were evidenced. Appropriate medication records were seen and reviewed by the Inspector. 2 members of staff have daily responsibility for supervising medication administration for the residents who have been assessed as being unable to administer their own medication. The Manager informed the Inspector that staff have all been involved in discussions about the importance of following the policy on the administration of medication within the home and have received appropriate training from “Opus” on administering medication. Ashington House DS0000013378.V294159.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users views are both listened to and where ever possible acted upon at Ashington House. Service users are protected from abuse, neglect and self-harm by the policies and procedures of the home. EVIDENCE: The service user spoken to by the Inspector confirmed that she feels her views are listened to and acted upon. A copy of the complaints procedure is made available in the Statement of Purpose and in the Service User Guide so that residents, families and other representatives know the procedure to be followed and would be able to do so if required. Staff interviewed confirmed to the Inspector their awareness of the complaints process and the Manager confirmed that the whole staff group take any issues raised by residents seriously. The complaints record was reviewed by the Inspector no complaints had been made since the last inspection visit. The home has an adult protection policy and the Manager informed the Inspector that the whole staff group had received appropriate training recently. This was confirmed by the 2 members of staff interviewed and by the Area Manager. This means that service users should be protected from abuse, neglect and self-harm. Ashington House DS0000013378.V294159.R01.S.doc Version 5.1 Page 17 The Inspector saw the allegation of abuse record; no allegations had been made since the last inspection. The Manager confirmed this to the Inspector. The policies and procedures manual for the home includes a whistle blowing policy and a policy on dealing with violence and aggression. Understanding the policies and procedures is a part of the staff induction process and staff need to be asked to sign to say that they have read and understood the policies and procedures. A review of staffing records held on staff files by the Inspector confirmed that staff had not signed such an agreement. This therefore is required as it will ensure that staff are aware of and operating within the units policies and procedures. An inventory of residents belongings is taken when they come to live at the home however this is not being maintained and kept up to date by key workers for all residents’ belongings that kept in their bedrooms. The Inspector checked these records and it is recommended that this be carried out as soon as possible. Ashington House DS0000013378.V294159.R01.S.doc Version 5.1 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, 27 & 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service users can feel confident that they live in a safe, well maintained, hygienic and clean home. The bathrooms and toilets provide sufficient privacy to meet the resident’s individual needs. EVIDENCE: The Inspector visited all areas of the home on this visit in order to assess whether or not it provides a safe and well maintained environment for its residents. The standard of décor was seen to be reasonable, it is clean and bright and residents are able to choose the colours and decoration for each of their bedrooms. Residents were seen to have their personal possessions arranged as they wish in their bedrooms. The communal areas such as the dining room and the lounge, bathrooms and toilets are also in a reasonable state of decoration and the overall impression provided is one of a well maintained and clean home. There are 3 bathrooms / toilets for the unit, 1 of which is ensuite and is wheelchair accessible. A previous inspection found that the ensuite bathroom should be replaced with a Ashington House DS0000013378.V294159.R01.S.doc Version 5.1 Page 19 new bathroom shower. The Manager has agreed that this will be done before any new resident is admitted to that bedroom unit. This will be re assessed at a later stage when a new admission is being considered. A further requirement was made to ensure that service users must have the associated risks assessed and that those residents to whom a sink would not present a risk should have their sinks reconnected. The Inspector saw risk assessments for the 2 current residents, which do identify hazards for them, and therefore their sinks remain unconnected. The Manager assured the Inspector however that for all new residents a risk assessment will be undertaken and where no risks are identified sinks will be reconnected. As before this will be re assessed at a later stage when a new admission is being considered. The garden is accessible to the residents and is well kept and has a pleasant well maintained feel. The last report undertaken by the LFEPA in December 2005 identified 4 requirements that needed to be met. The Manager confirmed to the Inspector that 3 of these requirements have now been met and the Inspector toured the building with the Manager to check these areas and can confirm they have been satisfactorily met. One requirement remains to do with the installation of a screen that needs to be fitted to the back door. This must be met as soon as possible. It was also highlighted in the last Environmental Health check undertaken last year in August 2005; all the other requirements identified have since been met. There are a number of general maintenance repairs required in the unit which need to be addressed and would be assisted if there was an identified maintenance person who could carry out these jobs regularly. It is recommended that this issue is addressed before work required to be done becomes a hazard. The last check on the unit’s fire equipment found everything to be satisfactory, Fire and Security Ltd undertook this on 28th April 2006. Emergency alarm systems were all checked on 14th May 2006 including the fire alarm, automatic door releases and the nurse call cords and all were found to be satisfactory. A check on water temperatures found both hot and cold water to be within the recommended temperature levels. The unit’s large freezer however is faulty and is unable to maintain recommended temperature levels and should be replaced – this is a requirement. Ashington House DS0000013378.V294159.R01.S.doc Version 5.1 Page 20 A satisfactory test was carried out on the unit’s water storage facilities for legionnaires disease in October 2005. Ashington House DS0000013378.V294159.R01.S.doc Version 5.1 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, 34, 35 & 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. An appropriate recruitment policy and induction process helps protects residents and ensure that they are supported appropriately. Service users will be better supported by the staff team: • When staff have been issued with new Job descriptions, • When staff have reviewed all the units policies and procedures and signed to say that they have understood them and are willing to work within them, • When staff have completed the current training programme that they are undergoing, • With regular and more structured supervision. Emphasis must continue to be placed on recruiting staff with experience of working with service users who present with challenging behaviour so ensuring service users benefit from having a consistent approach to their needs. EVIDENCE: At this inspection all 7 staff files were examined. All the required documents were found to be held on these files except on 3 files where there were no Job Descriptions (JDs). The Manager informed the Inspector that the current JDs Ashington House DS0000013378.V294159.R01.S.doc Version 5.1 Page 22 are under review and new ones will be supplied to all staff. Up to date and appropriate JDs are important tools in the recruitment process which helps to ensure that staff are clear about their roles and responsibilities. It is therefore recommended that new JDs are in place before any new posts are recruited to. Staff confirmed in their interviews with the Inspector that they have completed relevant training courses such as in the protection of vulnerable adults, health and safety, medication, secure care and risk assessments. Evidence of training undertaken by staff was also seen on staff files. At present staff are all near to completing their NVQ level 2 training and when this is completed at the end of June 2006 it should mean that staff have all the appropriate skills to undertake their roles and service users should benefit from this. The Manager informed the Inspector that in August 2006 she will complete her training as a Registered Manager. When this training programme for staff is completed the requirements of the National Minimum Standards for 50 of the staff team to hold NVQ level 2 and the Manager to hold an NVQ level 4 will have been met. Evidence of the completion of the NVQ training will be required later in the year. It is recommended that a copy of the General Social Care Council’s Code of Conduct be issued to all staff. Staff were seen by the Inspector to be friendly, supportive and approachable to the service users. The review of staff files did show that staff have not signed to say they have read the units policies and procedures. The Manager informed the Inspector whilst this is the case, staff have actually read the policies and procedures and can access the appropriate files which are held in the office. Staff can discuss any issues both at supervision and at team meetings. The Inspector has made a requirement for the Manager to ensure that staff are given specific time to read and discuss the policies and procedures and then subsequently to sign to say they have read and understood them and are willing to work within the scope of them. There is in place a recruitment policy and staff files evidenced that suitable application forms are completed, that 2 references are obtained including one from the last employer. All staff files reviewed by the Inspector evidenced that proper CRB checks have been carried out for staff employed within this unit. Equally that all other documentary evidence required to be gathered for staff was seen to be held on the staff files reviewed. The Manager informed the Inspector that where possible residents play a part in the recruitment of new staff. A part of the recruitment process for new candidates is to meet residents and there is a chance for residents to provide feedback to the recruitment panel. Ashington House DS0000013378.V294159.R01.S.doc Version 5.1 Page 23 The Manager informed the Inspector that a structured induction programme is offered to new staff and documentary evidence of this was seen by the Inspector and supported in the interview of a new staff member. At present staff receive ongoing daily support from the Manager in the work they undertake but they do not receive 1:1 supervision more often than once every 3 months. The structure of supervision needs to be improved and should include the: • Translation of the homes philosophy and aims into working with individuals, • Structured monitoring of work with individual service users and the analysis of care plan outcomes, • Support and professional guidance, and the • Identification of training and development needs, • Annual appraisals. The Manager has informed the Inspector that this form of supervision is being planned now for implementation in the near future. This is welcomed, as this structured supervision will greatly assist the unit in meeting some of the needs identified in this inspection report. The Manager advises the Inspector that all staff will receive supervision at least once every 2 months. It is recommended that the Manager receive specific training as soon as possible on staff supervision to assist with the process outlined above. Ashington House DS0000013378.V294159.R01.S.doc Version 5.1 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management of the home continues to show commitment to improving the quality of care in the home however the main objective must be to build a qualified and experienced staff team. The organisation should appoint a Deputy Manager who can assist in the development and running of the home so that service users are offered a consistent approach to their needs and aspirations and staff are confident that they will continue to be well managed and supervised. EVIDENCE: A requirement was set at the last inspection that the organisation must appoint a manager to run the home and the manager must be registered with Commission for Social Care Inspection. The home manager had stated that she had applied for Criminal Records clearance; this has now been seen by the Ashington House DS0000013378.V294159.R01.S.doc Version 5.1 Page 25 Inspector and is confirmed as being satisfactory. The Manager told the Inspector that she has now submitted her registered manager’s application. The home’s manager is currently completing the Registered Managers Award due to be completed by August 2006. During this inspection the Inspector asked the Manager about the quality assurance process being used within the home which will help assure service users and their representatives that their views underpin all service improvements and developments made by the home. The Manager informed the Inspector that every year a questionnaire is used to ask service users, their families and their representatives for their views about the services offered by Ashington House. This information is used by management to build on and improve these services. Evidence of this feedback was seen by the Inspector in the records inspected. It would be useful if this information was included in the business and annual development plan for the home. A copy of the organisations business plan was seen on the inspection which indicates that the home is financially viable for the purpose of achieving the aims and objectives set out in the Statement of Purpose was sent to the Commission as required at the last inspection. Monthly Regulation 26 visit reports have been sent to the Commission for Social Care Inspection as required at the last inspection. Ashington House DS0000013378.V294159.R01.S.doc Version 5.1 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 Standard No Score 1 X 2 3 3 3 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 2 32 3 33 X 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 X 3 X X 3 X Ashington House DS0000013378.V294159.R01.S.doc Version 5.1 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 YA23YA23 Regulation 13(6) Requirement Timescale for action 09/08/06 2. YA27 3. 4. 5. YA37 YA24YA24 YA4 6. YA24YA24 Staff must be asked to sign to say that they have read and understood the homes policies and procedures. 12(3)&23(3) The home must ensure that the d & n. bath is replaced with an accessible shower, according to the recommendations of the occupational therapist and health professionals, according to the service users needs, involving service users in the redecoration of the room. 10(1) The Manager must be registered with Commission for Social Care Inspection. 16(2)j The installation of a screen which needs to be fitted to the back door. 4 (1) The home must ensure that it follows its own procedure for admitting service users as stated in the Statement of Purpose and that the home remind prospective service users and their representatives that the home adheres rigidly to this procedure. 16 The unit’s large freezer is faulty and is unable to maintain DS0000013378.V294159.R01.S.doc 31/07/06 30/09/06 01/07/06 30/06/06 30/06/06 Ashington House Version 5.1 Page 28 7. YA29 14 and 23. 8. YA32 18 (1) recommended temperature levels and should be replaced. The home manager must ensure that the home can meet the needs of any prospective service users; this should include care managers needs assessments and if appropriate an occupational therapist assessment. The home manager must ensure that the home recruits staff with experience of working with service users who present with challenging behaviour. 30/06/06 16/11/06 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. 3. 4. 5. Refer to Standard YA23YA23 YA24YA24 YA32YA32 YA31YA31 YA36YA36 Good Practice Recommendations The inventory of resident’s personal belongings must be kept up to date. A maintenance person should be appointed to carry out the maintenance of work for the home. A copy of the General Social Care Council’s Code of Conduct be issued to all staff. That new Job Descriptions are in place before any new posts are recruited to. The Manager receives specific training on staff supervision. Ashington House DS0000013378.V294159.R01.S.doc Version 5.1 Page 29 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Ashington House DS0000013378.V294159.R01.S.doc Version 5.1 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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