Inspection on 03/05/05 for Ashington House

This inspection was carried out on 3rd May 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Ashington House 17/06/08

Ashington House 05/06/07

Ashington House 17/05/06

Ashington House 16/11/05

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 James OHara Announced Inspection 3 May 2005 09:30 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 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 Stationary 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 G53 S13378 AshingtonHse V178260 030505 stage 2.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Ashington House Address 402 Malden Road Worcester Park Surrey KT4 7NJ 020 8330 7476 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) AshingtonHouse@aol.com Ashington House Limited Gemma Tevlin Care Home 6 Category(ies) of Learning Disability (6) registration, with number of places Ashington House G53 S13378 AshingtonHse V178260 030505 stage 2.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: The handbasin in one bedroom may be removed, to be reviewed at least annually. Date of last inspection 22 September 2004 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. Many of the service users have communication difficulties, and may express their feelings in unconventional ways. The service aims to provide six permanent placements in time. At the time of the inspection there were five permanent service users residing at the house. Ashington House G53 S13378 AshingtonHse V178260 030505 stage 2.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This home was inspected under the National Minimum Standards Care Homes for Younger Adults. The inspection took place over one day. Methods of inspection included a tour of the premises observation of contact between staff and service users however three service users went for a trip to Wales and the two other service users went out for most of the day. Other methods of inspection included discussion with the home manager and the area manager, examination of service user plans, risk assessments, complaints, staffing records, training, menus and health and safety. Requirements and recommendations from previous inspections were also discussed with the home manager. A small number of comment cards were returned to the Commission for Social Care Inspection as feedback from service users and their relatives. What the service does well: What has improved since the last inspection? What they could do better: There were a large number of requirements set at the last inspection. The inspector the home manager and the area manager discussed these on the day of the inspection and agreed with the inspector that he will visit the home to Ashington House G53 S13378 AshingtonHse V178260 030505 stage 2.doc Version 1.30 Page 6 complete a number of “Themed Inspections” over the coming inspection year in order to support the home to implement a programme of continuous improvement. These “Themed Inspections” would concentrate on each section of the inspection report starting in July 2005 with Choice of Home. As a result of this inspection a number of requirements from the previous inspection have been reviewed and reworded in order to be consistent with the Commission for Social Care Inspections “Inspecting for Better Lives” document. A number of new requirements and recommendations have been set. None of the service users had their needs assessed by their care manager prior to moving into the home or had them assessed by their care manager since. These assessments are needed so that care plans can be drawn up for the service user, service users plans can be drawn from the care plan and staff training needs can be identified so that the home can support the service user. The home has not yet been assessed as able to meet the needs of any of the service users. The home could better evidence that service users are offered opportunities to participate in the day-to-day running of the home. The home could better evidence and record service user behaviours in order to evidence the reduction in the service users behaviours. The home could do more to aid service user privacy regarding inappropriate behaviours and reduce the risk of offending local residents. Staff records can be improved upon. The home must pay particular attention to previous requirements that the home ensures that a bath is replaced with an accessible shower as recommended by the occupational therapist and the home be reassessed by an occupational therapist in respect of all the service users living at the home to verify that the home is still able to provide an environment that meets the needs of service users. The inspector would like to thank the service users and their relatives for their feedback and staff and management of the home for their support on the day of the inspection. 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 G53 S13378 AshingtonHse V178260 030505 stage 2.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Ashington House G53 S13378 AshingtonHse V178260 030505 stage 2.doc Version 1.30 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 standard(s) 1, 2, 3 and 5. The home has recently carried out needs assessments for all of the service users using the Cared4 (a consultancy company) Format. However none of the service users had their needs assessed prior to moving into the home. This means that the home has not yet been assessed as able to meet the needs of any of the service users. EVIDENCE: The inspector was shown the homes recently developed Statement of Purpose although informative it does not include all the information as required in Schedule 1 of the National Minimum Standards. The Statement of Purpose should be completed referring to the 18 points indicated Schedule 1 of the National Minimum Standards as guidance and updated to include Points 5 the age range and sex of the service users, 7 whether nursing care is provided, 9 the arrangements made for service users to social activities, hobbies and leisure interests and 10 the arrangements made for consultation with service users about the operation of the care home. The registered manager must also develop a Service User Guide using Regulation 5 National Minimum Standards as guidance. The home manager and the inspector discussed various ways of communicating the Service User Guide to the service user such as, the written word, widget and audiotape. None of the service users had their needs assessed prior to moving into the home. This means that the home has not yet been assessed as able to meet Ashington House G53 S13378 AshingtonHse V178260 030505 stage 2.doc Version 1.30 Page 9 the needs of individual service users. The home manager showed the inspector evidence that she has written to care managers requesting these assessments. Service users should only be admitted on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user, using an appropriate communication method and with an independent advocate as appropriate. The home manager must ensure that all service users have their needs assessed by their care managers. These are needed so that care plans can be drawn up for the service user, service users plans can be drawn from the care plan and staff training needs can be identified so that the home can support the service user. The inspector was shown the service users files all service users have a contract as required at the last inspection. Ashington House G53 S13378 AshingtonHse V178260 030505 stage 2.doc Version 1.30 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 standard(s) 6, 7, 8, 9 and 10. The home is developing and implementing service users plans (Lifestyle Plan). This will hopefully improve the staff and service users’ knowledge about their changing needs Some of the service users are able make decisions about activities in and out of the home however there was no recorded evidence that service users are offered opportunities to participate in the day to day running of the home and to contribute to the development and review of policies, procedures and services. EVIDENCE: All service users have Lifestyle Plan (Cared4 Format) this is similar to the Person Centred Plan approach and includes important information about the service user such as personal details, relatives and friends, things I would like to do, what I do during the week, my communication, my health, daily living activities, personal care, managing my money, my support plan. The inspector was also shown monthly reviews carried out by the service users key-worker however these reviews should be recorded I the service users Lifestyle Plan. Ashington House G53 S13378 AshingtonHse V178260 030505 stage 2.doc Version 1.30 Page 11 A requirement was set at the last inspection that the Registered Provider ensure that the intervention strategy for an individual service user is dated, and consistent with current strategies in use at the home, and involves the service user. The home manager explained that since the requirement was set the home has had the support of the Challenging Needs Team Psychologist who has advised the team on how to work with this particular service user. The home manager stated that the incidents of Challenging Behaviours have decreased for this service user and the intervention strategy is due to be reviewed. The inspector was also shown evidence that a Psychiatrist is running a pilot scheme on risk assessment for an individual service user at the home this is due to be reviewed this month. The inspector also viewed risk assessments and risk management strategies in individual service user files. The Area Manager showed the inspector recently developed Service User Involvement Guidelines that will be employed in the home. The home manager must ensure that service users are offered opportunities to participate in the day-to-day running of the home and records/minutes is kept in the home. At the previous inspection the inspector noted that the kitchen area inappropriately contained personal information relating to service users. This has greatly improved however the kitchen still contains working documents. The home manager and the inspector discussed the issue of minimising evidence that this is a place of work and maximizing that it is the service users home. The inspector recommends that the home manager reduce the amount of working documentation located in communal areas of the home. Ashington House G53 S13378 AshingtonHse V178260 030505 stage 2.doc Version 1.30 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 standard(s) 12, 13, 14, 15 and 17. Service users opportunities to attend and partake in activities both in and out of the home have greatly improved. EVIDENCE: On the day of the inspection three service users went for a trip to Wales and the two other service users went out on planned activities. The inspector examined service user files. Each service user has a Weekly achievement and Activity plan. Activities include bowling, horse riding, cycling, arts and crafts, local shopping, meal’s out at local cafes and bakeries, cooking, community awareness, walks in local parks, cinema and board games. Some service users attend day centres, the Monday Club and the Thursday Club. The home manager also stated that an Activities Co-ordinator visits the home to facilitate in house activities for the service users. The inspector verified this in the homes visitors book. Ashington House G53 S13378 AshingtonHse V178260 030505 stage 2.doc Version 1.30 Page 13 The home provides five staff on the morning shift and four staff on the evening shift this allows for one-to-one support to the service users. The home manager stated that the level of activities has had a positive effect on the reduction of Challenging Behaviour incidents in the home. One service user expresses him-self by screaming. This has caused some local residents to raise their concerns with the Commission for Social Care Inspection and their local Member of Parliament. The home manager explained that the service user in questions screaming has lessened due to input and support for from the Challenging Needs Team Psychologist and a Psychiatrist. The inspector was shown step-by-step guidelines for staff to follow when support this service user. The home must monitor and record when, where and why the service user screams in order to evidence the reduction in the service users behaviours. The inspector and the home manager discussed a previous requirement that the registered provider ensure that staff are supported to provide specialist interventions and opportunities to service users for instance hydrotherapy, unless there is a compelling recognised reason not to do this. The home manager stated that the service user attended six sessions at hydrotherapy pool but his since declined to attend. This information should be recorded in the Lifestyle Plan. A small number of comment cards were returned to the Commission for Social Care Inspection as feedback from service users and their relatives. Service users indicated that they liked living here, that they are well treated, that they feel safe here. One service user answered, No, to the question “if you are not happy with your care do you know who to speak to?” As previously mentioned in the report the Service User Guide should be developed. Service users relatives comment cards returned to the Commission for Social Care Inspection indicated that staff welcome them to the home at any time, that they can visit their relative in private, in their opinion there are always sufficient numbers of staff and that they are satisfied with the overall care provided at the home. However one relative indicated that they are not aware of the homes complaints procedure. The inspector recommends that the home manager send a copy of the homes complaints procedure to all the service users relatives. A requirement was set at the last inspection that the Registered Provider must ensure that service users are offered opportunities to express their wishes and feelings regarding food provided, where necessary supporting communication, for example with the use of objects of reference. The inspector observed one service user making tea and coffee and Lifestyle Plans indicate that service users have opportunities to cook meals in the home. The inspector was shown the homes four weekly rolling menu’s these the home manager stated have been developed by the service users with input from a Dietician. Ashington House G53 S13378 AshingtonHse V178260 030505 stage 2.doc Version 1.30 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 standard(s) 19, 20 and 21. Service users at the home have the support of Kingston Community Learning Disability Team which contributes to the maintenance of their physical and emotional needs. EVIDENCE: A requirement was set at the last inspection that the registered provider ensure that service users are involved in purchasing their clothes, and that known preferences are acted up, service users supported to present themselves respecting their dignity. All service users were appropriately dressed the home manager stated that service users go out with their keyworkers on shopping trips to purchase their own clothes. The home manager explained that the home has had the support of the Challenging Needs Team Psychologist. The inspector was also shown evidence that a Psychiatrist is running a pilot scheme on risk assessment for an individual service user at the home this is due to be reviewed this month. A requirement was set at the last inspection that the registered provider ensure that family members are involved and clear about support regarding death and dying, whether service users will be able to remain in the home when they grow older and/or if they require nursing care, that wishes concerning terminal care and death are discussed and carried out, including observation of religious and cultural customs, as recorded in the Service Users Plan. Ashington House G53 S13378 AshingtonHse V178260 030505 stage 2.doc Version 1.30 Page 15 The inspector was shown evidence that the home manager has written to service users relatives to obtain this information and she is awaiting reply. This requirement will be assessed as part of the Themed Inspection to the home. Ashington House G53 S13378 AshingtonHse V178260 030505 stage 2.doc Version 1.30 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 standard(s) 22 and 23. Generally there has been concerns that the staff in the home have been unable to meet the needs of the residents thus leading to their needs being neglected and their frustration at this leading to self harm or aggression to others. EVIDENCE: Some local residents have raised concerns about the home with the Commission for Social Care Inspection and their local Member of Parliament. One service user expresses himself by screaming. This has caused local residents to raise their concerns with the Commission for Social Care Inspection and their local Member of Parliament. The home manager has contacted the local Member of Parliament about these concerns and is keen to improve good communication with local residents. The home manager explained that the service user in questions screaming has lessened due to input and support for from the Challenging Needs Team Psychologist and a Psychiatrist. The inspector was shown step-by-step guidelines for staff to follow when support this service user. The inspector was shown evidence that eleven members of staff has had training; Abuse of Adults with Learning Disabilities. The home manager must keep the Commission for Social Care Inspection informed of all complaints received at the home from local residents and actions taken by the home to address these complaints. Ashington House G53 S13378 AshingtonHse V178260 030505 stage 2.doc Version 1.30 Page 17 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 standard(s) 24, 25, 27, 29 and 30. The home is generally comfortable and safe, clean and hygienic but not necessarily homely. The bedrooms do not meet the needs and lifestyles of all the service users. EVIDENCE: At the last inspection a requirement was set that the registered provide ensure that the kitchen is redecorated and made good, the dining table made good or replaced, and risk assessment agreed with the purchasing authority regarding any restrictions on choice including locks to kitchen cupboards. All of these requirements have been met. The home manager showed the inspector around the home. The lounge floor has been covered with laminate flooring, the lounge seating is plastic covered, and there was only one item of soft furnishing which had no back cushions. The lounge has been redecorated however it looks bare. The home manager must ensure that appropriate furnishing such as settee’s, pictures and a rug is purchased for the lounge. The fan in the lounge has been removed as required at the last inspection. Previous requirements that the home ensures that a bath is replaced with an accessible shower as recommended by the occupational therapist and other Ashington House G53 S13378 AshingtonHse V178260 030505 stage 2.doc Version 1.30 Page 18 health professionals and that the home should also ensure that the home is reassessed by an occupational therapist in respect of all the service users living at the home to verify that the home is still able to provide an environment that meet the needs of service users have yet to addressed. The area manager spoke to the estates manager these requirements on the day of the inspection. The home manager explained to the inspector that due to the inappropriate behaviours of one of the service users the windows in her room have been partially covered with plastic screening in order to aid service user privacy and reduce the risk of offending local residents. Another service user also presents inappropriate behaviours. The home manager explained that net curtains had been placed however the service user removes these. The home manager must ensure that the service user who displays inappropriate behaviour has his bedroom windows partially covered with plastic screening so as to aid his privacy and reduce the risk of offending local residents. All service users bedrooms have a sink however all of these have been disabled. The home manager stated that this was because the sinks pose a risk to some of the service users drowning and drinking the water, however not all of the service users are at risk. Those service users who have sinks in their bedrooms and have not been risk assessed as being at risk having a sink in their bedroom, must have their sinks reconnected. The home was clean and free of offensive odours on the day of the inspection. Previous Requirement Outstanding. The Registered Provider must ensure that support is provided according to a risk assessment for service users to secure their rooms. Ashington House G53 S13378 AshingtonHse V178260 030505 stage 2.doc Version 1.30 Page 19 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 34 and 36 The home has begun to provided staff with appropriate levels of training over the last six months. The service users should begin to benefit from a more effective staff team and the staff from an increased level of support from their manager. EVIDENCE: The inspector sampled two staff files, the deputy manager had a Criminal Records Bureau Check from his previous employer completed in March this year. The home manager must apply to the Criminal Records Bureau for portability of the deputy managers Criminal Records Bureau Check. Another new member of staff has applied for and is awaiting her Criminal Records Bureau Check. The home manager stated that these members of staff are supported/shadowed on a one to one basis by an established member of staff at all times the home manager is required to continue this arrangement until their Criminal Records Bureau Check are received by the home. Staff files examined did not have a recent photograph however the home manager was able to obtain one for one file on the day of the inspection. The home manager should review all staff files to ensure that they include a recent photograph. The inspector was shown evidence that staff receive regular supervision. Ashington House G53 S13378 AshingtonHse V178260 030505 stage 2.doc Version 1.30 Page 20 The inspector was shown evidence that staff has had training on; 11 Staff: Abuse of Adults with Learning Disabilities 04/03/05 11 Staff: Risk assessment and Risk awareness 07/02/05 3 Staff: Moving and Handling 26/02/05 3 Staff: Equal Opportunities 25/01/05 9 Staff: Sexual Awareness 08/03/05 2 Staff: Health and Safety 4 Staff: Bereavement and Loss Awareness. The inspector was shown evidence that all members of staff have complete the Cared4 induction pack. Ashington House G53 S13378 AshingtonHse V178260 030505 stage 2.doc Version 1.30 Page 21 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38 and 39. The home manager has worked at the home since August 2004. Staff training and support has improved and service user activities have increased. The home has introduced Cared4 policy, procedures and formats in the home this has helped improved the homes administration system and structure and should ensure that service users best interests are safeguarded EVIDENCE: The home manager has worked at the home since August 2004 however she is not the registered manager for the home. The organisation must appoint a manager to run and the home the manager must be registered with Commission for Social Care Inspection. The home manager plans to attend college in September this year to complete a Management Qualification and NVQ level 4 in Care. The home has a relatively new management team. The home manager and the Area Manager have agreed with the inspector that he will visit the home to complete a number of “Themed Inspections” over the coming inspection year to support the home on a programme of continuous improvement. Ashington House G53 S13378 AshingtonHse V178260 030505 stage 2.doc Version 1.30 Page 22 Previous Requirements Outstanding. The Registered Provider must ensure that unannounced visits are made to the home every month, and a written report on the conduct of the Care Home provided to the Commission for Social Care Inspection (CSCI). The Registered Provider must ensure that an annual plan of development including action, planning and review, to include surveys of service users and other stakeholders or other proof that feedback has been sought, is completed. The Registered Provider must ensure that a business plan, demonstrating that the home is financially viable for the purpose of achieving the aims and objectives set out in the Statement of Purpose, is supplied to the Commission for Social Care Inspection. Ashington House G53 S13378 AshingtonHse V178260 030505 stage 2.doc Version 1.30 Page 23 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 2 1 x 3 Standard No 22 23 ENVIRONMENT Score 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 2 2 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 2 x 3 x 2 3 Standard No 11 12 13 14 15 16 17 x 3 3 2 3 x 3 Standard No 31 32 33 34 35 36 Score 3 x x 2 x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Ashington House Score x 3 3 2 Standard No 37 38 39 40 41 42 43 Score 2 3 2 x x x x G53 S13378 AshingtonHse V178260 030505 stage 2.doc Version 1.30 Page 24 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. Standard 2 Regulation 5 Requirement Timescale for action 31/07/05 2. 3 3. 8 4. 14 5. 21 The registered manager must also develop a Service User Guide using Regulation 5 National Minimum Standards as guidance. 14(1)a. The home manager must ensure that all service users have their needs assessed by their care managers. 12(2) The home manager must ensure that service users are offered opportunities to participate in the day-to-day running of the home and records/minutes is kept in the home. 15(1)&13( The home must monitor and 4)b. record when, where and why the service user screams in order to evidence the reduction in the service users behaviours. 15(1) The home must ensure that family members are involved and clear about support regarding death and dying, whether service users will be able to remain in the home when they grow older and/or if they require nursing care, that wishes concerning terminal care and death are discussed and carried out, including observation of religious G53 S13378 AshingtonHse V178260 030505 stage 2.doc 31/07/05 31/07/05 31/07/05 31/07/05 Ashington House Version 1.30 Page 25 6. 22 22 7. 24 23(2)a&g. 8. 25 13(4)b 9. 29 23(2)J and cultural customs, as recorded in the Service Users Plan. The home manager must keep the Commission for Social Care Inspection informed of all complaints received at the home from local residents and actions taken by the home to address these complaints. The home manager must ensure that appropriate furnishing such as settee’s, pictures and a rug is purchased for the lounge. The home manager must ensure that the service user who displays inappropriate behaviour has his bedroom windows partially covered with plastic screening so as to aid his privacy and reduce the risk of offending local residents. Those service users who have sinks in their bedrooms and have not been risk assessed as being at risk having a sink in their bedroom, must have their sinks reconnected. As stated. 31/07/05 31/07/05 31/07/05 10. 29 11. 29 12(3)&23( The home must ensure that the 31/07/05 3)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. 23(2)n The home manager must ensure 31/07/05 that the home is reassessed by an occupational therapist, regarding the needs of all the service users living at the home, and that the capacity of the homes environment to meet the needs of service users is made clear in the Statement of Purpose. G53 S13378 AshingtonHse V178260 030505 stage 2.doc Version 1.30 Page 26 Ashington House 12. 34 19(1) 13. 34 19(1) 14. 37 10(1) 15. 39 26 16. 39 25 17. 9 13(4)&15 (1) 18. 29 13(4)a. The home manager must apply to the Criminal Records Bureau for portability of the deputy managers Criminal Records Bureau Check. The home manager must ensure that the members of staff who do not yet have full clearence are supported/shadowed on a one to one basis by an established member of staff at all times the home manager is required to continue this arrangement until their Criminal Records Bureau Checks are received by the home. The organisation must appoint a manager to run and the home the manager must be registered with Commission for Social Care Inspection. The Registered Provider must ensure that unannounced visits are made to the home every month, and a written report on the conduct of the Care Home provided to the Commission for Social Care Inspection (CSCI). The Registered Provider must ensure that a business plan, demonstrating that the home is financially viable for the purpose of achieving the aims and objectives set out in the Statement of Purpose, is supplied to the Commission for Social Care Inspection (CSCI). The Registered Provider must ensure that service users, their friends and family as appropriate, and funding authority, are involved in the assessment of risk, evidenced in recording. The home manager must ensure that risk assessments are completed for service users to securing their rooms. 31/07/05 31/07/05 31/07/05 31/07/05 31/07/05 31/07/05 31/07/05 Ashington House G53 S13378 AshingtonHse V178260 030505 stage 2.doc Version 1.30 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 1 Good Practice Recommendations The Statement of Purpose should be completed referring to the 18 points indicated Schedule 1 of the National Minimum Standards as guidance and updated to include Points 5. the age range and sex of the service users, 7. whether nursing care is provided, 9. the arrangements made for service users to social activities, hobbies and leisure interests and 10. the arrangements made for consultation with service users about the operation of the care home. The inspector recommends that the home manager reduce the amount of working documentation located in communal areas of the home. The home manager stated that the service user attended six sessions at hydrotherapy pool but his since declined to attend. This information should be recorded in the Lifestyle Plan. The inspector recommends that the home manager send a copy of the homes complaints procedure to all the service users relatives. The home manager should review all staff files to ensure that they include a recent photograph. 2. 3. 10 14 4. 5. 22 34 Ashington House G53 S13378 AshingtonHse V178260 030505 stage 2.doc Version 1.30 Page 28 Commission for Social Care Inspection 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 G53 S13378 AshingtonHse V178260 030505 stage 2.doc Version 1.30 Page 29 - 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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