Inspection on 02/08/05 for Ashlar House

This inspection was carried out on 2nd August 2005.

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

The inspector 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

Ashlar House 30/05/07

Ashlar House 24/01/06

Ashlar House 19/01/05

Ashlar House 19/08/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 Ashlar House 76 Potternewton Lane Leeds LS7 3LW Lead Inspector Ann Stoner Unannounced 10.30am: 2 August 2005 nd 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. Ashlar House J52 J03 S1416 Ashlar House V241139 020805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Ashlar House Address 76 Potternewton Lane Leeds LS7 3LW 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) 0113 2262700 0113 2262700 Leeds Christian Home for Adults with Autism Mrs Christine Ann Pullinger Care Home Only 8 Category(ies) of Learning Disability (8) registration, with number of places Ashlar House J52 J03 S1416 Ashlar House V241139 020805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 19th January 2005 Brief Description of the Service: Ashlar House is a large detached property, providing residential care without nursing, for eight people with Autism. The National Autistic Society accredits the organisation in control of the home, which is a local Christian charity. The aim of the home is to meet the wide range of needs of the service user group, as determined by their autism, much of it being linked to and complemented by a day centre, which is also run by the same charity. The home is situated in a residential area of the suburbs of Leeds, close to a range of local facilities, including shops, pubs, and bars. There are eight single bedrooms for service users, and overnight accomodation is provided for visitors. There are a range of communal rooms. Ashlar House J52 J03 S1416 Ashlar House V241139 020805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Over an inspection year from April until March, care homes have a minimum of two inspections a year; these may be announced or unannounced. The last inspection on 19th January 2005 was unannounced; there have been no further visits until this unannounced inspection. During the inspection, I looked at records, saw care staff carrying out their work and spoke with some service users, staff, and the residential co-ordinator, who was in charge of the home in the absence of the registered manager. Comment cards/questionnaires are left for residents, visitors and other professionals at each inspection, thereby giving the opportunity for anonymous feedback. None have been returned since the last inspection. What the service does well: What has improved since the last inspection? What they could do better: Written information for service users could be improved by making it available on audio or video tape. The medication policy needs changing slightly. Recommendations have been made to address these issues. Ashlar House J52 J03 S1416 Ashlar House V241139 020805 Stage 4.doc Version 1.40 Page 6 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. Ashlar House J52 J03 S1416 Ashlar House V241139 020805 Stage 4.doc Version 1.40 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 Ashlar House J52 J03 S1416 Ashlar House V241139 020805 Stage 4.doc Version 1.40 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) 2. The needs of service users are assessed and reviewed. EVIDENCE: There have been no recent admissions to the home, but policies are in place to make sure that the home can meet assessed need. There was evidence in care plans that service user’s needs are reviewed on a regular basis, and that limits or restrictions on choice are based on a risk assessment process, and after discussion with the service user and/or his or her relative or representative becomes part of the service user plan. Ashlar House J52 J03 S1416 Ashlar House V241139 020805 Stage 4.doc Version 1.40 Page 9 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 & 9. The needs and goals of service users are reflected in their care plan. Service users are encouraged to make decisions, and are supported to take risks associated with an independent lifestyle. EVIDENCE: Three care plans were sampled. These records contain the needs and goals of service users, and individual objectives are identified, monitored and reviewed on a regular basis. Care plans contain unique information relating to the ritualistic behaviours of service users, with specific information about morning and bedtime routines. A senior staff member explained how he supports service users to make decisions, and gave examples of service users choosing their own holiday destination and leisure activities. One service user explained about the decisions he makes, such as his visits to a local pub and restaurant. Service users are encouraged to take risks associated with independent living, but this is always within a risk assessment framework. One service user has been on caving holidays, one travels unaccompanied to a part-time job, and another person goes to a local swimming pool. Ashlar House J52 J03 S1416 Ashlar House V241139 020805 Stage 4.doc Version 1.40 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15 & 16. Service users take part in a range of leisure activities and have opportunities for personal development. Their rights are respected, and family relationships encouraged. EVIDENCE: Records showed that service users enjoy a range of activities that include potholing, caving, walking, visits to pubs, cafes, shops, the cinema and leisure centres. Staff also described the range of indoor activities that are available. Some service users attend evening classes, and one person has a part time job. One service user told of his interest in history and politics and confirmed that he uses his right to vote. A senior staff member explained how service users integrate into the local community and gave examples of service users who regularly attend church, and are welcomed by the congregation. Service users also attend community events such at the local annual Chapel Allerton festival. On the morning of this inspection, one service user had been escorted to Leeds to catch a bus to Victoria Station in London, where she was meeting her Ashlar House J52 J03 S1416 Ashlar House V241139 020805 Stage 4.doc Version 1.40 Page 11 mother, before both continuing their journey to the Isle of Wight. Another service user was away visiting her parents. The residential coordinator said that her parents collected her by car from the home, but at the request of the service user and to reduce her anxiety, staff escort her back to the home by train. This staff activity is funded through the normal staffing rota, and is good practice. A senior staff member explained how he supports a service user to keep links with his siblings. Staff said that overnight accommodation is provided by the home for visitors wanting to make use of this facility. A staff member explained about the rights of service users, such as the right to choose and wear clothing according to their own personal taste, and gave the example of one service user who chooses to eat her meals in the privacy of her room. The residential coordinator said that access to the home, for security purposes, is via a digital lock, the sequence of which is known and used by some service users. The responsibilities of the service users, particularly in relation to alcohol, drugs and smoking are outlined in the contract. Ashlar House J52 J03 S1416 Ashlar House V241139 020805 Stage 4.doc Version 1.40 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 & 20. Service user choice in respect of personal support is respected. The health care needs of service users are met and medication is given properly. EVIDENCE: Due to the nature of their autism, most service users have very definite routines, which are carefully recorded in care plans and are followed by staff. One new staff member said that she found this information invaluable. Another staff member described how she gives care according to one person’s care plan. Evidence within care plans confirmed that service users receive dental, optical and other health care services. There was evidence of all service users receiving an annual health check by their GP. Where necessary the services of other healthcare professionals such as psychologists are sought. A senior staff member explained how medication is given according the correct procedures. Medication Administration Records were checked and found to be in order. The home has a policy relating to medication but this is need of amendment to meet the guidelines from the Royal Pharmaceutical Society. A recommendation has been made. Ashlar House J52 J03 S1416 Ashlar House V241139 020805 Stage 4.doc Version 1.40 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 & 23. Complaints are taken seriously and service users are protected from abuse. EVIDENCE: The home keeps a record of all complaints; there have been none since the last inspection. A senior member of staff explained how he would deal with a complaint. The home has a policy relating to adult abuse, and has a copy of the multiagency adult protection procedures. A new member of staff, still completing an induction programme, had a good knowledge of the different types of abuse, including the more subtle kinds of institutional abuse. She was very clear about reporting any suspicions of abuse to the registered manager, and was also clear about her actions should she suspect the registered manager of abuse. Her knowledge and understanding was impressive. She confirmed that abuse had been covered during her induction. Ashlar House J52 J03 S1416 Ashlar House V241139 020805 Stage 4.doc Version 1.40 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These standards were not assessed at this visit. EVIDENCE: Ashlar House J52 J03 S1416 Ashlar House V241139 020805 Stage 4.doc Version 1.40 Page 15 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) 35. Training opportunities are offered and provided to staff. EVIDENCE: A new member of staff confirmed that she was completing a thorough induction programme that included watching videos, reading written information, answering questions and shadowing more experienced members of staff. More senior staff described the range of training opportunities offered to them, and confirmed that they had at least 5 paid training days a year. One person said that training was an agenda item in supervision sessions, where a two way process was adopted, with both the registered manager and the staff member identifying training needs and opportunities. Ashlar House J52 J03 S1416 Ashlar House V241139 020805 Stage 4.doc Version 1.40 Page 16 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) These standards were not assessed at this visit. EVIDENCE: Ashlar House J52 J03 S1416 Ashlar House V241139 020805 Stage 4.doc Version 1.40 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x x Standard No 11 12 13 14 15 16 17 x 3 3 3 4 3 x Standard No 31 32 33 34 35 36 Score x x x x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Ashlar House Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x x x x x x x J52 J03 S1416 Ashlar House V241139 020805 Stage 4.doc Version 1.40 Page 18 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 Regulation Requirement There are no requirements from this inspection. Timescale for action 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 YA 6 Good Practice Recommendations It is recommended that the service user guide, care plans and the adapted version of the complaints procedure be made available on both video and audio tape. This recommendation was made at the last inspection. The medication policy should be amended to make sure that printed labels are not attached to the Medication Administration Record (MAR). Where required, and necessary, handwritten entries should replace the use of labels. All handwritten entries should be checked and countersigned by a second person. The policy statement relating to the administration of wrong medication should state that the Commission for Social Care Inspection must be notified if and when an error occurs. The home should take follow up action with those relatives and carers who have failed to return their questionnaire relating to bereavement. J52 J03 S1416 Ashlar House V241139 020805 Stage 4.doc Version 1.40 Page 19 2. YA 20 3. YA 21 Ashlar House This recommendation was made at the last inspection.. Ashlar House J52 J03 S1416 Ashlar House V241139 020805 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection Aire House Town street Rodley Leeds LS13 1HP 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 Ashlar House J52 J03 S1416 Ashlar House V241139 020805 Stage 4.doc Version 1.40 Page 21 - 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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