Inspection on 24/01/06 for Ashlar House

This inspection was carried out on 24th January 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 no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ashlar House 30/05/07

Ashlar House 02/08/05

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 West Yorkshire LS7 3LW Lead Inspector Ann Stoner Unannounced Inspection 24th January 2006 11:00 Ashlar House DS0000001416.V270158.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ashlar House DS0000001416.V270158.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ashlar House DS0000001416.V270158.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ashlar House Address 76 Potternewton Lane Leeds West Yorkshire LS7 3LW 0113 2262700 (0113) 2262700 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) Leeds Autism Services Mrs Christine Ann Pullinger Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Ashlar House DS0000001416.V270158.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd August 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 accommodation is provided for visitors. There are several communal rooms. Ashlar House DS0000001416.V270158.R01.S.doc Version 5.0 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 was unannounced and took place on the 2nd August 2005. There have been no further visits until this unannounced inspection. The purpose of this inspection was to monitor the home’s progress in meeting the recommendations made at the last inspection and to look at the standard of care for people living in the home. This inspection was carried out by one inspector between 11.00am – 2.30pm. During the inspection, I looked at records, I saw staff carrying out their work and spoke with some service users, staff, and a senior care worker who was in charge of the shift in the absence of the manager. Feedback at the end of the inspection was given to the senior care worker. Comment cards/questionnaires are left for residents, visitors and other professionals at each inspection. These provide an opportunity for people to share their views of the home with the Commission for Social Care Inspection. Comments received in this way are shared with the provider without revealing the identity of those completing them. Since the last inspection seven have been returned and no negative comments have been made. What the service does well: What has improved since the last inspection? The home is never at a standstill as the team are constantly trying to improve practices. At this visit a greater use of ‘compic’, words reinforced by pictures was evident. Ashlar House DS0000001416.V270158.R01.S.doc Version 5.0 Page 6 The manager and directors are aware of the constraints of the building, but are looking at ways of increasing the opportunities for service users to maintain and develop independent living skills. 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. Ashlar House DS0000001416.V270158.R01.S.doc Version 5.0 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 Ashlar House DS0000001416.V270158.R01.S.doc Version 5.0 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): These standards were not assessed at this visit. EVIDENCE: Ashlar House DS0000001416.V270158.R01.S.doc Version 5.0 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 the following standard(s): 6 The needs and goals of service users are identified in their care plan. EVIDENCE: In the care plans sampled, there was good information about the needs and goals of service users and individual objectives were identified, monitored and reviewed on a regular basis. The plans contained unique information about the ritualistic behaviours of service users, with specific information about morning and bedtime routines. The care plans were well sequenced, with sections for risk assessments, records of medical visits, annual reviews, activities and communication with significant others. There were guidelines for staff on completing daily records, with prompts to include dietary information, activities, communication, mood and progress. Terms such as ‘grumpy’ were used to describe the mood of one person. This ‘labelling’ term is open to misinterpretation and staff should describe the service user’s actual behaviour. The format of the care plans is not one that can be easily understood by all of the service users. Ashlar House DS0000001416.V270158.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 17 A varied and healthy diet is provided. EVIDENCE: Monday to Friday most service users are engaged in activities either at college, work or a day centre, so the lunchtime meal is not taken in the home, although some people do take a packed lunch prepared by the home. The home has a 4-week rotating menu, and service users are consulted on the choices available at their regular meetings. The dining area is attractive with pine tables and chairs, and a ‘what’s for tea’ board is displayed, with words and photographs of the meal, showing the weeks menu. One service user, who becomes anxious with increasing noise levels, said that she eats in the privacy of her room. When asked about the teatime meal, which was broccoli and cauliflower cheese with jacket potato, she immediately consulted the menu board. The home works well with the individual dietary needs of service users. One person has successfully lost a significant amount of weight and is now maintaining his target weight; another person has had dietetic advice and Ashlar House DS0000001416.V270158.R01.S.doc Version 5.0 Page 11 avoids sugars and yeast products, while another person has a strict diet due to intolerance to lactose. Ashlar House DS0000001416.V270158.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed at this visit. EVIDENCE: Ashlar House DS0000001416.V270158.R01.S.doc Version 5.0 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed at this visit. EVIDENCE: Ashlar House DS0000001416.V270158.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26 & 30. The home is clean, comfortable and spacious. Bedrooms reflect the choices and interests of individual service users, and promote independence. Not all staff have received training in infection control, which creates the risk of the spread of infection. EVIDENCE: The lounge and dining room are spacious, light and airy, providing ample seating areas for service users. Bedrooms are personalised according to individual interests and taste and reflect the personality of the service users. Some service users are enabled and encouraged to be as independent as possible, with the help of pictures and symbols on drawers, for example there was a picture of a shirt on a drawer containing shirts. To assist one person there was a chart of his morning routine, along with a list of his normal weekly activities. Again, pictures supplemented this. There were names and identifiable pictures on the bedroom doors of some, but not all, service users. Staff explained that this depended on individual need and service user choice. Not all radiators are guarded, there are no facilities for people with limited mobility, and there is no emergency call system. The manager is aware of these and other issues associated with ageing and independent living and proposed long-term business plans are being developed. Ashlar House DS0000001416.V270158.R01.S.doc Version 5.0 Page 15 The home uses water-soluble bags for laundering soiled linen, but there is no disposal system in the laundry for used gloves and aprons. Staff said that these are carried to a clinical waste bin in another part of the home, and although they said that they would wrap the apron and gloves in a plastic bag, there were none in the laundry. There was no lockable cupboard for storing plastic bags in the laundry, which given the ‘pica’ behaviour of one service user, poses a risk. Ariel tablets and Vanish Liquid Plus were on an open shelf. Not all staff have received training in infection control, and staff were unclear about safe procedures for cleaning up bodily fluids such as vomit. Ashlar House DS0000001416.V270158.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 & 34 Recruitment is robust and the staff team are effective in providing a caring environment for service users. EVIDENCE: There has been a significant amount of staff sickness, resulting in the use of relief staff on a regular basis. Staff who work on a relief basis, are experienced in the field of autism, know the service users and understand the home’s way of working. Two relief members of staff on duty at the time of this inspection demonstrated a good understanding of the needs of individual service users and one spoke of a thorough induction before he started work with service users. This person said that he felt included in all aspects of the home, and had received some mandatory training such as moving and handling and first aid. Staff spoke of regular team meetings, where the needs of service users are discussed and any issues arising are actioned. Completed application forms, 2 written references, interview records and CRB/POVA (Criminal Record Bureau/Protection of Vulnerable Adults) checks are all in place before new staff are appointed. As well as the formal recruitment interview, candidates are also invited for an informal visit of the home, following which staff members on duty and service users give feedback, which forms part of the final selection process. Ashlar House DS0000001416.V270158.R01.S.doc Version 5.0 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42. The home is well managed with systems in place to monitor and review performance. Health & safety practices must be reviewed to make sure that risks to service users are minimised. EVIDENCE: The manager has many years of experience in caring for people with autism, and now holds qualifications in both NVQ (National Vocational Qualifications) in Management and Care at level 4. Staff said that they felt supported by the management team and had the opportunity to voice their opinions at regular staff meetings. There are a number of effective quality assurance systems in place. During this inspection a director of the service was carrying out his own unannounced visit, in line with Regulation 26 of The Care Home’s Regulations. As part of the home’s accreditation with the National Autistic Society (NAS), they are subject to annual inspections. The home notifies all service users and their relatives and/or representatives of any announced inspection, and relatives attended the recent announced inspection of the NAS, which was carried out two weeks before this unannounced visit. The home regularly surveys service users and Ashlar House DS0000001416.V270158.R01.S.doc Version 5.0 Page 18 relatives. Feedback from these surveys is discussed at the Quality Action Group, whose membership includes relatives, management and directors of the service. Training records for mandatory training were clear and identified when training was carried out and was next due. These records indicated that training for a number of staff on moving and handling, food hygiene and health & safety was overdue. A member of the domestic staff had not received any training on COSHH (Control of Substances Hazardous to Health) and infection control. A management consultant has completed some COSHH risk assessments, but there were no risk assessment in place for cleaning products such as Cif and Ariel Tablets. Kitchen cleaning materials, such as dishwasher tablets, Dettol, Fairy Liquid and Brillo pads were in an unlocked cupboard in the kitchen, and toiletries were on a shelf in one bathroom. This poses a considerable risk as one service user has ‘Pica’ behaviour. The risk assessment for this person should be reviewed and consideration given to providing alarms on kitchen doors (with self closures), and other doors as deemed necessary, and alarms/restrictor catches on doors and cupboards where food and other items are stored. Ashlar House DS0000001416.V270158.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 X X X 2 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 X X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Ashlar House Score X X X X Standard No 37 38 39 40 41 42 43 Score 3 X 3 X X 2 X DS0000001416.V270158.R01.S.doc Version 5.0 Page 20 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA30YA42 Regulation 13 Requirement Timescale for action 31/01/06 2 3 4 YA30 YA30 YA42 13 13 18 18 All toiletries, and cleaning materials must be kept in a locked cupboard when not in use. There must be a system in the 28/02/06 laundry for the disposal of used gloves and aprons. All staff, including cleaning staff, 31/03/06 must undertake training on infection control. All staff must undertake 31/03/06 mandatory training with regular updates on moving and handling, food hygiene and health & safety and COSHH (control of substances hazardous to health) 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 YA6 Good Practice Recommendations The home should consider ways of including pictures and symbols into the care plan, so that all service users can DS0000001416.V270158.R01.S.doc Version 5.0 Page 21 Ashlar House access and understand their own plan of care. Ways to develop the service user guide, care plans and the adapted version of the complaints procedure on both video and audio tape should be considered. Terms such as ‘grumpy’ should be replaced with descriptions of actual behaviour. Any future long-term development plans should include provision of a lift to all floors and an accessible emergency call system. The home should consider fitting radiator guards, or replacing the radiators with a type that have a guaranteed low surface temperature There should be a lockable storage cupboard in the laundry room. In order to protect service users with ‘Pica’ behaviour consideration should be given to the provision of alarms/restrictor catches on doors and cupboards. 2 3 YA6 YA24 4 5 YA30 YA42 Ashlar House DS0000001416.V270158.R01.S.doc Version 5.0 Page 22 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 DS0000001416.V270158.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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