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Inspection on 19/04/06 for Ashlea Park Residential Home

Also see our care home review for Ashlea Park Residential Home for more information

This inspection was carried out on 19th April 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 but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

What has improved since the last inspection?

The registered manager, and the recently recruited line manager have introduced improvements in the way the home is managed. A programme of refurbishment in the home has started, and includes the replacement of worn out furnishings. The manager has actively sought the views of service users on proposed changes to menus, and the Commission for Social Care Inspection (CSCI) continues to work with Winnie Care and the local Social Services Department to improve the way service users` savings are managed. An activities worker has been recruited to the home, although she is awaiting various recruitment checks to be completed before she can start duty. The manager has expressed the need for this worker to initially get to know the service users living in the home and to then develop an activities programme based on their choices and aspirations. The way staff are recruited to the home ensures that appropriate pre employment checks, such as two references and criminal records checks, are undertaken prior to an offer of employment being confirmed. The recruitment of staff is governed, in part, by the home`s equal opportunities policy. Quality assurance checks are being introduced, and the way medication is recorded after being administered has improved. The way staff training is monitored and planned has improved, and forthcoming training is to include topics such as equality and diversity, adult protection, and care related topics.

What the care home could do better:

Some areas that have been identified in previous inspections are yet to be fully addressed. Importantly, quality assurance checks need to more accurately reflect the areas audited, such as the quality of furnishings, and the manager should provide training or additional guidance to those staff undertaking quality checks. The provision of new lounge chairs (with spare covers) and the provision of new bedroom furnishings (to replace those that are heavily stained and worn) remains to be fully undertaken. All of the en-suites that havewindows require blinds fitted to preserve the privacy of those using these rooms. The neighbouring care home shares a garden with Ashlea Park and an enclosed area has been created here. There was no consultation with either the service users or management of Ashlea Park regarding the placement of this enclosed area, indeed service users appeared unsure of the purpose of the enclosed garden area. This has also blocked a walk way between the two homes, has been located in an area with raised edging on the paths and limited seating. This may present a trip hazard to service users. If it is planned and developed effectively the garden area can have the potential to benefit both care homes, by providing a safe and secure area outside of the home. The development of the garden should be subject of consultation and review.

CARE HOMES FOR OLDER PEOPLE Ashlea Park Residential Home Archer Road Farringdon Sunderland SR3 3DJ Lead Inspector Mr Lee Bennett Unannounced Inspection 08:45 19 and 20th April 2006 th X10015.doc Version 1.40 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 Ashlea Park Residential Home DS0000034305.V291178.R02.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 Older People. 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. Ashlea Park Residential Home DS0000034305.V291178.R02.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Ashlea Park Residential Home Address Archer Road Farringdon Sunderland SR3 3DJ 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) 0191 522 5977 0191 528 2044 Winnie Care Limited Mrs Jean Robson Care Home 40 Category(ies) of Dementia - over 65 years of age (22), Old age, registration, with number not falling within any other category (28), of places Physical disability over 65 years of age (8), Sensory Impairment over 65 years of age (5) Ashlea Park Residential Home DS0000034305.V291178.R02.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The SI(E) service user category relates to current service users only. Date of last inspection 20th December 2005 Brief Description of the Service: Ashlea Park is care home, providing personal care for up to 40 older people, some of whom may have dementia related needs. Nursing care is not provided, but District Nursing services can be arranged where necessary. It is a purpose built care home with accommodation provided over two floors, with level access throughout. A lift provides access between the two floors of the home. There is a garden area in front of the home, which includes a paved seating area. The home is situated on the outskirts of Sunderland near to local public transport links. It is also situated near to a range of local facilities, including a doctors surgery, shops, pubs and places of worship. The fees for the home range from £346.00 to £365.00. Additional charges are made for hairdressing, chiropody, newspapers and toiletries. What is included within the fee is outlined within the ‘statement of terms and conditions’ available from the home. Ashlea Park Residential Home DS0000034305.V291178.R02.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over two days in April 2006 and was a scheduled unannounced inspection. The inspection included a separate look at the pre-inspection questionnaire (completed by the manager), and comment cards received from service users and their relatives before, during and after the inspection. A tour of the building took place, and a sample of staffing and service users’ records was inspected. Service users, staff, the registered manager and visitors were spoken with, and the inspector took a meal with service users on both the ground and first floors. The judgements made are based on the evidence available to the inspector during the inspection, the pre-inspection questionnaire supplied by the registered manager and the comment cards completed by service users and their relatives. Judgements relating to the management of service users savings are based on evidence provided centrally by Winnie Care, and meetings held with the registered person and information supplied by them. What the service does well: Service users benefit from level access on both floors, and equipment and adaptations are available to help physically disabled and frail service users to get around the home. This can help make the service accessible for service users with diverse needs. Each bed room had its own en-suite WC’s and hand washbasin. Staff in the home work hard to meet service users’ needs, and have a good rapport with them. Staff demonstrate a good understanding of service users needs. Attractively presented and nutritious meals are provided, which service users commented on in a complimentary manner. Service users’ comments included: • • • “The manager is excellent and staff are very good shes a goodum her.” “Theres no nastiness here, everyones nice.” “The food is good.” DS0000034305.V291178.R02.S.doc Version 5.1 Page 6 Ashlea Park Residential Home • • • “The food is excellent, the staff have always been very very caring, but theres not enough carers” “The managers excellent, she always says if theres anything you need you need to tell me so I can do something about it.” “Yes, they (the staff) come quickly when I call”. What has improved since the last inspection? What they could do better: Some areas that have been identified in previous inspections are yet to be fully addressed. Importantly, quality assurance checks need to more accurately reflect the areas audited, such as the quality of furnishings, and the manager should provide training or additional guidance to those staff undertaking quality checks. The provision of new lounge chairs (with spare covers) and the provision of new bedroom furnishings (to replace those that are heavily stained and worn) remains to be fully undertaken. All of the en-suites that have Ashlea Park Residential Home DS0000034305.V291178.R02.S.doc Version 5.1 Page 7 windows require blinds fitted to preserve the privacy of those using these rooms. The neighbouring care home shares a garden with Ashlea Park and an enclosed area has been created here. There was no consultation with either the service users or management of Ashlea Park regarding the placement of this enclosed area, indeed service users appeared unsure of the purpose of the enclosed garden area. This has also blocked a walk way between the two homes, has been located in an area with raised edging on the paths and limited seating. This may present a trip hazard to service users. If it is planned and developed effectively the garden area can have the potential to benefit both care homes, by providing a safe and secure area outside of the home. The development of the garden should be subject of consultation and review. 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. Ashlea Park Residential Home DS0000034305.V291178.R02.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ashlea Park Residential Home DS0000034305.V291178.R02.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 2, 3 and 6. Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. Each service user has an adequate written contract / statement of terms and conditions with the home, which provides information on the rights and obligations of both parties. This helps to ensure that service users and their representatives are clear about what they can expect from the home. The admissions process ensures that service users’ needs are adequately assessed prior to care being offered. This helps to ensure that service users are offered the right type of care at the home. Intermediate care is not provided at Ashlea Park. EVIDENCE: Each service user is provided with a contract, outlining various terms and conditions regarding their occupancy within the home. Where a service user Ashlea Park Residential Home DS0000034305.V291178.R02.S.doc Version 5.1 Page 10 has been placed with the assistance of a local authority their residency is also determined by the detail of the contract between the local authority and the home. Should a person move to the home under a ‘private’ arrangement then they would be supplied with a standard form of contract between the home and service user only. Service users deemed as ‘self-funding’ by the local authority can still, if assessed by that authority, be placed under the local authority contract. Prior to the last inspection of the home, the Commission for Social Care Inspection received a letter of enquiry relating to the contract, and it’s implementation. Although the Commission has a limited regulatory role in respect of agreements between care homes and service users, and in effect they are a matter between the signatories, a recommendation was made encouraging the care provider to review, and consequently amended in the light of this review the contract document. In particular the contract states that fees may be increased upon one weeks written notice. This would not provide sufficient time to allow alternative care to be sought should a service user be unhappy with the fees increase, does not detail in what circumstances fees might be increased, or identify any appeals mechanism. Further advice for service users, those acting on their behalf, and the care provider, may be available from the Office of Fair Trading, who have published a detailed report on the fairness of contracts between care homes and service users. For those service users most recently admitted to the home (whose placement and needs were case tracked – a method by which inspectors are required to look at the service provided at the home, by focusing specifically on individual service users experiences of care), a Care managers’ assessments was received before care was offered to them. Following this a plan of care was developed, and a review planned to take place after six weeks. This involves the service user, their social worker and other representatives. Care plans are, thereafter reviewed by senior member care staff on a regular basis. Should a reassessment of need be required, this is arranged with the relevant Social Services Department, as was found to be the case for another service user whose needs were specifically looked at. Ashlea Park Residential Home DS0000034305.V291178.R02.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. Service users’ care plans are in place, and generally reflect their observed needs. However, some clear gaps are evident. Effective care planning can offer guidance to care staff regarding care practice and ensure consistency where necessary. Service users’ health care needs are identified through assessment and observation, and areas such as pressure care and falls prevention are subject to adequate supervision and care practice. The medication policy is poor and remains in need of significant review, as it is disjointed and does not systematically outline local practices regarding the prescription, ordering, receipt, storage, administration, recording and disposal arrangements adopted in the home. Nevertheless, medication is administered following recognised good practice, and recording and auditing arrangements continue to improve. The effective management of service users’ medication can help contribute to their general health and wellbeing. Staff undertake appropriate care practices that help to preserve service users’ privacy and dignity. Ashlea Park Residential Home DS0000034305.V291178.R02.S.doc Version 5.1 Page 12 EVIDENCE: Each service user (whose needs and experience of care was ‘case tracked’) has a plan of care in place, and the manager and senior carers have, and continue to undertaken significant revisions of these documents. Each service user’s care file follows a standardised format, and a template file has been developed to act as a guide. A system whereby assessments are used to guide the development of care plans, which are then monitored, evaluated and reviewed has been developed for service users. Specific advice continues to be offered (through the inspection process) to the manager regarding individual care plans, such as those relating to activities and diet / nutrition. Such care plans must more accurately reflect assessed needs, and thereby provide the guidance necessary to ensure consistent care practice, and offer a mechanism to monitor service users’ needs and progress. Monitoring of specific needs occurs by using monitoring charts (for pressure relief, continence, diabetes and falls) and through daily progress notes. Highlighted risk areas, such as smoking, are also care planned/risk assessed, although some omissions were found in respect of a service user at high risk of falling. The management and administration of service users’ medication is governed by a set of policies and procedures, available to staff responsible for this task. These documents have been developed in a gradual way to respond to identified omissions, and past inspection requirements and recommendations. These documents are not currently indexed, and areas such as the ordering, disposal and audit arrangements are not included. A systematic review and overhaul of the homes policy and procedures, reflective of the Royal Pharmaceutical Society of Great Britain guidelines entitled The Control and Administration of Medicines in Care Homes and Childrens Services, is an outstanding requirement. Medication is, in the vast majority of cases, handled and administered by senior care staff. Medication rounds take place during the morning, at lunchtime, at teatime and in the evening. A monitored dosage system (Nomad) is used, whereby the dispensing pharmacist supplies each service users’ medication within a tray. This contains a series of small boxes that correspond to the four medication rounds of the day, and the seven days of the week. Printed ‘medication administration records’ are also supplied by the pharmacist. The morning medication round is the longest, and continues to take the senior carer a considerable proportion of the morning shift to complete. The registered manager is requesting that some service users have their medication reviewed by their GP, in particular to see if alternatives to calcium supplements currently prescribed can be obtained. The registered manager has also introduced a recording system for staff to document the Ashlea Park Residential Home DS0000034305.V291178.R02.S.doc Version 5.1 Page 13 amount of variable dose medication administered. This can help ensure that accurate auditing can be undertaken. Ashlea Park Residential Home DS0000034305.V291178.R02.S.doc Version 5.1 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15. Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. Arrangements to provide activities and occupation have improved but remain underdeveloped within the home. The development of a planned, structured and well delivered activities programme can contribute to a more interesting and stimulating lifestyle for service users. Service users are able to maintain family and other contacts to a good degree should they wish. This can help ensure they do not become socially isolated. Service users are actively encouraged by staff to a good degree in exercising choice and control over their lives. This can help promote their independence. Service users receive a good, varied and well presented, choice based, menu. This can help promote their general health and wellbeing. EVIDENCE: The home has recently recruited a worker specifically to plan and coordinate activities for service users, but they are yet to commence duty. Activities, Ashlea Park Residential Home DS0000034305.V291178.R02.S.doc Version 5.1 Page 15 although underdeveloped, are nevertheless still carried out, and on the day of the inspection several staff had volunteered to come in during their own time to assist with an outing to the coast. Further development of activities arrangements remains an outstanding requirement. Visitors regularly call to the home, and all of the questionnaires received from service user’s relatives and representatives indicated that they are welcomed in the home, and that they are able to visit their relative or friend in private. During the inspection several visitors called to the home. The home has a variety of communal lounges available, should service users wish to meet people in private outside of their own room. Relatives are also encouraged to contribute to the care of the service user to whom they are related, and able to share meals in the home if they so wish. Meals are provided within two large lounge areas, one on each floor. Some service users take meals within their own bedrooms. Service users are offered a range of choices for meal times and consultation has taken place with service users about a revised summer menu. Staff, are attentive to service users’ requests, and provide support and prompts where necessary. The lunchtime meal was attractively presented and service users were very complimentary about the food provided. Staffing support at mealtimes has been increased which allows support to be offered to service users and for difficult behaviours to be addressed and managed. Where service users have specific dietary needs care plans need to accurately reflect their needs, preferences and how staff are to promote their independence, as this was not the case for one service user whose dietary needs were looked at as part of the ‘case tracking’ process. Ashlea Park Residential Home DS0000034305.V291178.R02.S.doc Version 5.1 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. A clear complaints procedure is available and is now being more fully implemented. This can allow service users’, and their relatives, confidence in the process, and provide opportunity for the management team to improve the service provided. Local adult protection procedures have been implemented and instigated to good effect to help contribute to the protection of service users from abuse. EVIDENCE: Since the last inspection there have been no complaints referred directly to CSCI to investigate. Service users and relatives indicated that they were aware of the home’s complaints process. All of the service users questioned stated that they were aware of who to speak to if they were unhappy with their care, as were relatives. The homes own records indicate that 2 complaints have been received since the last inspection of the home. These both related to the quality and condition of the home’s furnishings, and the home has been required by the Commission for Social Care Inspection to replace furnishings (see comments in ‘Environment’ section of this report and the relevant requirements made). Ashlea Park Residential Home DS0000034305.V291178.R02.S.doc Version 5.1 Page 17 The host local authority (Sunderland) publishes clear adult protection procedures, of which the registered manager and staff are aware. Staff receive training and guidance on adult protection from the local authority, internally, and through their work to attain an NVQ award in care. Ashlea Park Residential Home DS0000034305.V291178.R02.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20, 21, 24 and 26. Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. The home is generally clean, and well maintained. This can help promote a positive image for service users, and ensure they remain safe. The majority of lounge chairs are in a poor condition and are worn. Although some have been replaced, a considerable number still need to be repaired or replaced, as they do not promote good hygiene, or a positive image of the home and those living there. Service users’ bedrooms, communal areas and bathing/WC facilities are accessible to a good level to help meet service users’ mobility needs. EVIDENCE: Ashlea Park Residential Home DS0000034305.V291178.R02.S.doc Version 5.1 Page 19 The service users rooms were clean and many contained furniture and possessions personal to the individual. New carpets have been fitted in some areas of the home. Service users own rooms have en-suite facilities. Some en-suites benefit from natural lighting, and although windows have been frosted, they lack blinds to ensure the privacy of service users. These must be provided, and this is an outstanding requirement of the previous inspection report, and needs to be addressed as a matter of urgency. Much of the bedroom furniture, such as wardrobes, chests of drawers and bedside tables, were purchased when the home first opened. Several are worn and stained inside. These require replacement. The majority of dining room chairs have now been replaced with those fitted with glide rails, which can help staff in meeting the needs of service users who require help to sit in at the dining tables. They can also promote independence by making it easier for service users to move these chairs. Some lounge chairs have been obtained, and more are now on order. Spare covers should be obtained to ensure cushions remain covered whilst laundering is being progressed. Corridors and WC / bathing facilities have been provided with grab rails, and other adaptations to enable access for service users who are disabled or who are physically frail. This can help ensure the service is accessible to service users with diverse needs, and promote the equality of people with a range of disabilities and needs. Plans to redecorate the home are being developed, and the registered manager was advised to seek guidance and advice to ensure that décor schemes help to meet the needs of those service users with dementia or a visual impairment. This would further promote accessibility for people with diverse and varied needs. Ashlea Park Residential Home DS0000034305.V291178.R02.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30. Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. Staffing levels are adequate and have been increased to allow service users’ needs to be effectively met. The staff team benefits from an excellent level with care qualifications, which can help ensure that a competent staff team is available to meet service users’ needs. Service users are protected by the home’s recruitment procedures, which are implemented to a good standard. This can help ensure that unsuitable candidates do not gain employment in the home. The way training is planned has improved to a good standard, which has highlighted where staff require broader and more frequent training opportunities. A range of appropriate training can contribute to staffs’ understanding of service users’ needs and ensure sufficient competence to undertake their job. EVIDENCE: There are six care staff deployed within the home during the daytime (08:00 to 22:00) one of whom acts in a senior capacity. One member of care staff Ashlea Park Residential Home DS0000034305.V291178.R02.S.doc Version 5.1 Page 21 commences duty at 07:00 to provide additional assistance to the night shift workers, who finish duty at 08:00. A worker employed specifically to plan and help undertake activities has been recruited to the home. Staff records indicate that the manager receives an ‘enhanced’ Criminal Records Bureau disclosure prior to staff commencing duties. POVA first checks are also being received. Two references are always obtained prior to employment being offered. Staff recruitment practices are governed by a policy that aims to ensure equal opportunities practices are adhered to. Care staff have received training in fire safety and adult protection, food hygiene, manual handling, infection control, aging and disability, dementia care, first aid and medication during 2005. Several have undertaken a course of study to attain an NVQ award in care. Several care specific courses are planned for 2006, which includes training specific to diverse or minority care needs, and training on equality and diversity is planned for later this year. The manager has indicated that 85 of the care staff team have attained an NVQ qualification in care, at level 2 or higher. Ashlea Park Residential Home DS0000034305.V291178.R02.S.doc Version 5.1 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 and 38. Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. External management support and oversight arrangements have been improved with the recruitment of an Area Manager. This operates at a good level, and can help ensure that the service is run in the best interests of service users. Internal quality assurance systems have been developed to an adequate level, but with scope for further improvement. This can allow the views of service users, relatives and others to be sought and the internal quality management of the service to be progressed. Centralised arrangements for the handling of service users’ personal savings have been reviewed to help ensure service users’ interests are better served. Risks to the health and safety of service users, visitors and staff are minimised in a generally adequate manner. Ashlea Park Residential Home DS0000034305.V291178.R02.S.doc Version 5.1 Page 23 EVIDENCE: The registered manager has compiled a quality assurance file, which incorporates the views of service users and their relatives. Since the last inspection an Area Manager has been recruited who is providing regular, professionally based support, oversight and supervision of the home. Monthly inspections of the home by this person are also being progressed, which includes a focus on the quality, practices and procedures operated within the home. This can contribute to an effective quality assurance and management system focusing on service processes and outcomes. The home is kept generally clear of hazards to the health and safety of service users, visitors and staff, although one lounge chair recently collapsed, possibly due to a woodworm infestation. Other chairs have been checked, and no woodworm found. Risks to service users are subject to periodic assessments, and staff receive training on health and safety related topics. Ashlea Park Residential Home DS0000034305.V291178.R02.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 2 3 X X 2 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 X X 2 Ashlea Park Residential Home DS0000034305.V291178.R02.S.doc Version 5.1 Page 25 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 OP12 Regulation 16 Requirement The registered manager must ensure that a programme of group and one to one activities, based on service users needs and preferences, is developed and implemented within the home. It is acknowledged that an Activities Worker has been recruited, but they have yet to commence duty. This requirement was first identified at the inspection of 9/7/04 and the previous action plan dates were 1/7/05, 17/9/05 and 14/4/06. The registered manager must ensure that policies and procedures, covering all aspects of medicines management (including correct ordering procedures, covert administration and dealing with drug errors) are reviewed in line with current Royal Pharmaceutical Society of Great Britain guidelines entitled The Control and Administration of Medicines in Care Homes and DS0000034305.V291178.R02.S.doc Timescale for action 30/06/06 2. OP9 13(2) 30/06/06 Ashlea Park Residential Home Version 5.1 Page 26 Childrens Services. The previous action plan dates for this requirement were 30/6/05, 17/9/05 and 14/04/06. 3. OP22 23(2)(c) The registered manager must arrange for the repair or replacement of lounge chairs that have worn covers. The previous action plan dates for this requirement were 8/7/05 and 14/4/06. 30/06/06 4. OP35 13(6), 20(1)(a & b) The registered person must 30/06/06 equitably allocate to service users (or should they have died their estate) the interest earned on their savings, but not paid out to them. Work to finalise the closure of the pooled service user account is being progressed by Winnie Care. A final auditors report is awaited by CSCI. The previous action plan date for this requirement was 17/10/05 and 14/4/06. The registered person must replace bedroom furnishings that are worn and / or heavily stained. The previous action plan date for this requirement was 14/6/06. The registered person must arrange for blinds to be fitted to service users’ en-suite windows to help ensure their privacy. The previous action plan date for this requirement was 14/6/06. 31/07/06 5. OP24 23(2)(c) 6. OP24 12(4)(a), 16(2)(c) 30/06/06 Ashlea Park Residential Home DS0000034305.V291178.R02.S.doc Version 5.1 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 OP2 Good Practice Recommendations The registered person should undertake a review of the statement of terms and conditions in respect of notice periods for increases in fee levels. The registered person should employ a worker responsible for the co-ordination and implementation of an activities programme, including group and one to one activities for service users. The registered person should actively seek the views of stakeholders about the services provided at the care home and should have an annual development plan. The registered manager should develop criteria for the administration of when required and variable dose medication for all service users prescribed such items. The registered manager should introduce a falls prevention strategy within the home. The registered person should consult interested parties, including service users, on the development of a safe, secure and accessible garden area for the home. 2. OP12 3. OP33 4. OP9 5. 6. OP38 OP19 Ashlea Park Residential Home DS0000034305.V291178.R02.S.doc Version 5.1 Page 28 Commission for Social Care Inspection South of Tyne Area Office Baltic House Port of Tyne Tyne Dock South Shields NE34 9PT 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 Ashlea Park Residential Home DS0000034305.V291178.R02.S.doc Version 5.1 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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