Inspection on 14/12/05 for Ashleigh House

This inspection was carried out on 14th December 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ashleigh House 06/12/07

Ashleigh House 07/08/06

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOME ADULTS 18-65 Ashleigh House 133 Bromley Road Catford London SE6 2NZ Lead Inspector Kate Matson Unannounced Inspection 14th December 2005 10:45 Ashleigh House DS0000066388.V273290.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 Ashleigh House DS0000066388.V273290.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. Ashleigh House DS0000066388.V273290.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ashleigh House Address 133 Bromley Road Catford London SE6 2NZ 020 8698 4166 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) Ashley Healthcare Limited T/A Ashleigh House Ms Zobeeda Hosany Care Home 8 Category(ies) of Learning disability (2), Mental disorder, registration, with number excluding learning disability or dementia (7), of places Mental Disorder, excluding learning disability or dementia - over 65 years of age (2) Ashleigh House DS0000066388.V273290.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th August 2005 Brief Description of the Service: Ashleigh House is a registered care home for eight adults with mental health needs. The current service users have all lived at the home for over nine years and some since it opened in 1992. Most are likely to remain at the home on a long-term basis. The current group is all male and aged from early forties to late sixties. The service user guide states that the home’s aim is to ‘provide a high standard of accommodation and care in a large family setting’. The accommodation consists of six single and one double bedroom, situated on the ground and first floors. A lounge and dining room are on the ground floor and the home has a front and back garden. The house is semi-detached and is situated on a busy road in a residential area. It is a short walk away from shops, railway services and other public transport links. A new provider that owns two other homes in the area had recently taken over the ownership of the home. At the time of this inspection visit the home had no vacancies. Ashleigh House DS0000066388.V273290.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced statutory inspection was carried out over 3.5 hours. It included discussion with three service users, the registered manager, the new registered provider, a tour of the premises and examination of care plans and other records. What the service does well: What has improved since the last inspection? What they could do better: The home needs to take a more proactive approach in ensuring the stimulation needs of service users are met, by working with service users as individuals and as a group to ensure they take part in a wider range of meaningful activities. It was found that daily records still did not include all of the activity relating to service users and must be addressed to ensure that the daily record gives an accurate overview of service users progress. In addition service users must be offered a holiday and more options for day trips or shorter breaks should also be offered. Some restrictions are in place that are not supported by documentary evidence for the decisions being made in consultation with the psychiatric team and this must be addressed to ensure that the rights of service users are protected. Ashleigh House DS0000066388.V273290.R01.S.doc Version 5.0 Page 6 Quality assurance and quality monitoring must be further developed based on seeking the views of service users, their representatives and community professionals to ensure that their views underpin development of the home. 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. Ashleigh House DS0000066388.V273290.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 Ashleigh House DS0000066388.V273290.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): None of these standards were examined at this inspection At the previous inspection, the following judgement was made :Prospective service users have the information they need to make an informed choice about where they live. The needs of service users are fully assessed before they are offered a place at the home. Each service user has a written contract with the home. EVIDENCE: Ashleigh House DS0000066388.V273290.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 Service users are involved in planning their care though as at the previous inspection, daily records do not fully evidence all activity regarding the service user. EVIDENCE: All four of the care plans examined had been recently reviewed and signed to show that service users had been involved in the care planning/reviewing process. Care plans now included all of the required areas, including mental health as required at the last inspection. Care plans are brief but the new provider has a more detailed care planning system in his other homes, which he will implement at Ashleigh House. At the last inspection it was also noted that although there is a daily record for each service user, this does fully evidence all activity regarding the service user, for example; action taken in response to concerns, contact with other professionals and visits to service users when in hospital. It was required that the daily record gives an accurate overview of all activity regarding each service user. At this inspection it was found that key information was not noted in the daily record such as contact with a CPN or family members. At the last inspection it was also noted that although reports are written for Care Programme Approach (CPA) meetings and following the meeting a summary written, the minutes from the Care Ashleigh House DS0000066388.V273290.R01.S.doc Version 5.0 Page 10 Coordinator were not available for any of the latest CPA meetings held. It was recommended that the manager write to the Community Mental Health Team to highlight this poor practice. It was found that this recommendation had been implemented and minutes of CPA meetings were available on service users files. Ashleigh House DS0000066388.V273290.R01.S.doc Version 5.0 Page 11 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): 12, 14, 16 and 17 Some service users take part in activities outside the home such as attending day centres and voluntary work though it is recommended that individual and group activities offered by the home are developed in order to meet their needs for stimulation. An annual holiday must also be offered. Service users rights are respected though restrictions must be made with the psychiatric team and recorded. Service users are offered a varied and nutritious diet. EVIDENCE: At previous inspections it was found that motivation is a problem for service users at the home and most prefer to spend time doing solitary activities such as reading, watching television, or listening to music. At the last inspection it was recommended that in consultation with service users individual and group activities offered by the home are developed in order to meet their needs for stimulation. At this inspection the manager stated that six of the service users had been out for a Christmas lunch the previous week but there was little change in the level of activity taking place at the home despite staff’s efforts. However discussions around activities had not been recorded in service users files or in the service user meeting minutes to evidence the efforts that were made. The recommendation is restated in this report. Ashleigh House DS0000066388.V273290.R01.S.doc Version 5.0 Page 12 A recommendation was made at previous inspections that the registered provider should include a holiday as part of the basic contract price for service users living in the home and that discussions about holidays should be evidenced in care plans. It was also recommended that alternatives to a seven-day holiday also be offered such as a few shorter breaks or more day trips. At this inspection the manager stated that service users did not wish to go on holiday, however discussions around holidays had not been recorded in service users files or in the service user meeting minutes to evidence that they had been offered a holiday. As it is usual for most people to take a holiday this is now a requirement. Daily routines are flexible at the home. On the day of the inspection service users were seen to be freely coming and going from the house, moving around the home, and making drinks in the kitchen. It was found at the last inspection that the kitchen is locked at night because one service user kept disturbing the others. Similarly the same service user did not have a key to the front door or his room but there was no documentation to show that this restriction had been reviewed recently. It was required that restriction’s be reviewed regularly with service users and the outcome documented in their files. At this inspection it was found that one service user had had his key taken from him by the manager as a result of a request by the relative. There was no records of the decision making process. This is an unacceptable infringement on someone’s rights and the manager agreed to give the key back on the day of the inspection. Where restrictions are made they must be made in discussion with the psychiatric team and fully documented. At the last inspection it was found that service users were generally satisfied with the meals offered at the home. Comments included; “Can’t grumble about the food”, “The food is well presented and there is plenty of it”, and “I’m happy with the meals”. However two service users had commented that there was little variation of the meals from one week to the next. Weekly menus showed that the meals offered are balanced and nutritious and varied every week. However the home has a flexible approach to menu’s and depending on service users wishes the meal offered is not always as the menu. The manager was required to ensure that whilst taking into account the preferences of service users, sufficient variation of meals is offered. At this inspection it was found that menus were varied and service user meeting minutes showed that service users were happy with the variation of the meals. Ashleigh House DS0000066388.V273290.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 and 20 Medication systems are largely robust though records must be kept securely and “homely remedies” must be more easily available and approved by the GP for each service user. EVIDENCE: Care plans detail how much support people need in various aspects of daily living. The home has a key worker system to ensure consistency for service users. Service users spoken with confirmed that they get the support they need. The records of receipt, administration and return of medication were all in order. All staff who administer medication have undergone a six-day training course to do so. The medication is kept in a locked cupboard in the dining room. However it was noted at the last inspection that some of the records do not fit in the cupboard and are kept close to the medication cupboard where service users could access them. It was required that these records be kept locked away in order to protect the privacy of service users. It was recommended that a larger medication cupboard be obtained for this purpose. It was also noted that there were no “homely remedies” available for service users. It was required that these are more easily accessible with an approval signed by the GP for each item stating which service users can use the remedy and at what dosage each service user can use it. At this inspection it was found that the new provider had ordered a cupboard so that records could be Ashleigh House DS0000066388.V273290.R01.S.doc Version 5.0 Page 14 stored securely, however this had not arrived at the time of the inspection. A list of homely remedies had been approved by the GP, though this did not include the names of service users as required. Also the homely remedies were not available. The requirement is partially met. Ashleigh House DS0000066388.V273290.R01.S.doc Version 5.0 Page 15 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): Both of these standards were considered met at the last inspection. At the last inspection, the following judgement was made :None of the service users had made a complaint but confirmed that they would if necessary. The home’s policies and procedures protect service users from abuse. EVIDENCE: Ashleigh House DS0000066388.V273290.R01.S.doc Version 5.0 Page 16 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 The home offers a homely, comfortable and safe environment, though it was noted that some window frames were dirty. EVIDENCE: The home is a large semi-detached house located on a main bus route and about ten minutes walk from Catford and Catford Bridge railway stations, shops and facilities. The home is in keeping with the local community and not identifiable as a care home. There are seven bedrooms for service users, one of which is shared. There is a lounge, kitchen, dining room and at the rear of the property a garden. There is a garden and space for parking at the front of the property. The home is furnished in a comfortable and homely way. The home is clean, and well maintained, and as required by the previous inspection the dining room, stairs and downstairs bedroom carpets had been replaced, and bedrooms redecorated. It was noted however that the window frames on the landing and in the bathroom were very dirty and detracted from the overall pleasant environment. Ashleigh House DS0000066388.V273290.R01.S.doc Version 5.0 Page 17 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 and 35 Staff are completing appropriate NVQ training. A comprehensive training plan has been developed to ensure staff get the training they need to meet service users needs. EVIDENCE: The manager stated that all staff were completing NVQ level 2 and one staff is doing level 3. This should ensure that all staff are trained to National minimum standards. No staff had been recruited since the previous inspection but staff records were now kept securely at the home as required at the last inspection. The manager had developed a training plan in conjunction with an external consultant from the learning skills council. This offered a comprehensive plan of training for the next 12 months based on the needs of staff and service users. If the plan is followed it should ensure staff have the training they need to meet the needs of service users. The manager needs to ensure that a record is kept of how much of the plan has been achieved. There had been no new staff starting at the home but the manager needs to ensure that evidence is available at future inspections that induction and foundation training are to sector skills specifications. Ashleigh House DS0000066388.V273290.R01.S.doc Version 5.0 Page 18 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 and 39 Quality assurance and quality monitoring must be further developed to ensure that service users views underpin development of the home. EVIDENCE: The registered manager is an experienced registered mental nurse who has been a ward sister and unit manager in psychiatric hospitals. She has managed the home since 1996. She is currently completing the NVQ level 4 in Management. Quality assurance questionnaires had been used in the past, however none had been completed recently. The manager stated that service users are asked on a daily basis about the service. However it was required at a previous inspection that a quality assurance system must be developed including anonymous surveys of service users in addition to seeking the views of relatives, other representatives and community professionals. It was also required that where the registered provider is not in day-to-day control of the care home, they must visit the care home on an unannounced, monthly basis to inspect the premises, records and interview service users about the quality Ashleigh House DS0000066388.V273290.R01.S.doc Version 5.0 Page 19 of service provided. The new provider stated that he was going to commence these visits the next day. Ashleigh House DS0000066388.V273290.R01.S.doc Version 5.0 Page 20 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 2 X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X X X LIFESTYLES Standard No Score 11 X 12 3 13 X 14 2 15 X 16 2 17 Standard No 31 32 33 34 35 36 Score X 3 X X 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Ashleigh House Score 3 X 2 X Standard No 37 38 39 40 41 42 43 Score 3 X 1 X X X X DS0000066388.V273290.R01.S.doc Version 5.0 Page 21 Yes 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 YA6 Regulation 17 (1) (a) Requirement Timescale for action 31/03/06 2 YA14 3 YA16 The registered manager must ensure that the daily record gives an accurate overview of all activity relating to the service user, including action taken in response to concerns and contact with other professionals.(Previous timescale of 31/10/05 not met) 12 (1) (a) The registered provider 31/05/06 must include a holiday as part of the basic contract price for service users living in the home. 17(1)(a)Sch3(3)(q) The registered manager 31/03/06 must ensure that where restrictions are in place, (such as the kitchen door being locked at night or service users not being given the keys to their room or the front door) the need for the restriction is reviewed with the psychiatric team and documented in the personal files of all those affected by the restriction. (Previous DS0000066388.V273290.R01.S.doc Version 5.0 Page 22 Ashleigh House 4 YA20 17 (1) (b) 5 YA20 13 (2) 6 YA24 23 (2) (d) 7 YA39 24 8 YA39 26 timescale of 31/10/05 not met) The registered manager must ensure that all records relating to service users are kept securely.(Previous timescale of 30/09/05 not met) The registered provider must ensure that homely remedies are freely available for service users, supported by written approval from the GP, detailing which service users and at what dose such remedies may be given. (Previous timescale of 31/10/05 not met, though partially met) The registered provider must ensure that all areas of the home are kept clean including window frames. The registered provider must develop effective quality assurance and quality monitoring systems based on seeking the views of service users, their representatives and community professionals and the results of surveys are published and made available to all those taking part.(Previous timescale of 31/03/06 not yet expired) The registered provider must conduct monthly, unannounced visits to the home in accordance with Regulation 26 and produce a report for the registered manager and CSCI.(Previous timescale of 30/11/05 not met) DS0000066388.V273290.R01.S.doc 31/01/06 31/03/06 31/03/06 31/03/06 31/03/06 Ashleigh House Version 5.0 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard 12 14 Good Practice Recommendations It is recommended that in consultation with service users individual and group activities offered by the home are developed in order to meet their needs for stimulation. It is recommended that alternatives to a seven-day holiday are also offered such as a few shorter breaks or more day trips. Ashleigh House DS0000066388.V273290.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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 Ashleigh House DS0000066388.V273290.R01.S.doc Version 5.0 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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