Inspection on 06/12/07 for Ashleigh House

This inspection was carried out on 6th December 2007.

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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ashleigh House 07/08/06

Ashleigh House 14/12/05

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 Lynne Field Unannounced Inspection 6 December 2007 10:00 th Ashleigh House DS0000066388.V339688.R01.S.doc Version 5.2 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.V339688.R01.S.doc Version 5.2 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.V339688.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashleigh House Address 133 Bromley Road Catford London SE6 2NZ 020 8698 4166 020 8698 4166 ashleighhouse@googlemail.com 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.V339688.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th February 2007 Brief Description of the Service: Ashleigh House is a registered care home for eight adults with mental health needs. The current residents 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 longterm basis. The current group is all male and aged from early forties to late sixties. The residents 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 overlooking a large back garden have been extended and is still in the process of being further developed. 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. The provider owns two other homes in the area and is in the process of developing the home and the service since taking over the ownership of the home. At the time of this inspection visit the home had no vacancies. Fees range from £450-£520-93 per week and includes accommodation, food and staffing. Personal expenditure such as clothing, toiletries and outings are not included. Residents Guide and Statement of Purpose are available in residents’ rooms. Inspection reports are available on request from the home. Ashleigh House DS0000066388.V339688.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection took place on 6th December 2007. The inspection involved speaking with the people using the service, the staff on duty and the acting manager. The registered manager was on annual leave on the day of the inspection and a senor support worker facilitated the main part of the inspection. The inspection also involved the case tracking of three people’s care, the assessment of a range of the home’s records, procedures and forms as well as observation and a tour of the premises. The inspector spoke to the acting manager about how the home was developing and systems that are in place to ensure the residents are given the service they want and need. During a tour of the home the inspector met and spoke to all the residents and two staff. The inspection included a tour of the home, garden and the examination of records on care plans, medication records and the complaints book. The manager returned a standard form, the Annual Quality Assurance Assessment (AQAA), to CSCI. This was taken into consideration. What the service does well: What has improved since the last inspection? The home has strived to meet requirements made at the previous inspection. There have been improvements to the physical standards of the home since the last inspection visit. The home is in the process of being extended and refurbished and has more communal space for the residents to use including a smoking room. This has made it more homely and spacious. Ashleigh House DS0000066388.V339688.R01.S.doc Version 5.2 Page 6 Care plans and risk assessments are more detailed and being up dated on a more regular basis. The dispensing and administration has improved. The registered provider has developed a quality assurance and quality monitoring systems to seek the views of residents, their representatives and community professionals and the results of surveys have been given to the inspector. 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. The summary of this inspection report can be made available in other formats on request. Ashleigh House DS0000066388.V339688.R01.S.doc Version 5.2 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.V339688.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents’ needs and aspirations are assessed, so that a service tailored to their needs could be provided. EVIDENCE: The inspector was shown the statement of purpose and the resident’s guide, which includes the complaints procedure in the resident’s guide are in the process of being reviewed. The inspector saw that these had been checked and updated to reflect the changes in the home and the organisation that runs the service. There have been no admissions to the home since all the residents have lived at the home for more than eleven years. Should a vacancy arise, the manager said, the home would follow the homes admissions procedure that it is in the process of revising to meet current standards. This would include a complete assessment based on personal history, a care management assessment and a full needs assessment to ensure the home could meet the prospective residents needs. The prospective resident would be invited to visit the home with family members or friends to help them decide if the home could meet their needs. Ashleigh House DS0000066388.V339688.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents are involved in planning their care with their key worker, the manager, appropriate professionals and family members. Potential risks are identified and residents are supported to take risks within a risk management framework. EVIDENCE: The inspector looked at three residents files. The resident’s are involved in planning their care with their key worker, the manager, appropriate professionals and family members. The inspector was shown copies of the residents key worker meetings that are held every month. The records showed mental health issues, personal hygiene, finance, medication and any other issues that have arisen are all discussed at these meetings and were signed by the resident and their key worker. Each resident has an activities planner that is reviewed during key worker sessions. Each resident has a daily book that Ashleigh House DS0000066388.V339688.R01.S.doc Version 5.2 Page 10 records activities, outings or appointments the resident has taken part in. The residents told the inspector they were happy with their key worker and felt the benefit of having a key worker session. The senior care worker told the inspector that all residents had six monthly reviews or earlier if the need arises. Care plans reviews are kept on file. The annual review is conducted by the residents’ care manager and includes the residents’ family members, key worker and any relevant professional involved in the residents’ development. Medication is reviewed at the same time. It was recorded that one resident refused to attend his review even though it was being held in the home. There were detailed guidelines and risk assessments on file on how the residents behaviour could be managed and supported safely. Potential risks are identified and residents are supported to take risks within a risk management framework. The inspector was told residents are involved in their risk assessments and managing the risks in their life. The homes management said they try to encourage the residents to participate more actively in the decision making of the home, for instance, decoration of their room, choice of furniture and their own choice of paintings. They are always kept informed on activities and they participate actively in the choice of their outings and leisure activities. Through out the inspection the inspector noted residents came and went as they pleased, having made decisions about what they wanted to do for the day. One resident retuned from a hospital appointment he had attended independently and told the staff about what had happened and the outcome. The member of staff said they would follow this up with the hospital and GP. Ashleigh House DS0000066388.V339688.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents engage in appropriate, enjoyable and fulfilling activities and mix with the general community. Residents are actively encouraged to keep in touch with friends and family and develop appropriate friendships. Residents’ rights and responsibilities are respected. The meals are enjoyable and nutritious. EVIDENCE: The inspector noted the daily routines are flexible at the home. On the day of the inspection residents were seen to be freely coming and going from the house, moving around the home, and making drinks in the kitchen. The Ashleigh House DS0000066388.V339688.R01.S.doc Version 5.2 Page 12 inspector met all the residents who lived in the home during the course of the inspection and spoke to three residents in depth. At previous inspections it was found that motivation is a problem for residents at the home and most prefer to spend time doing solitary activities such as reading, watching television, or listening to music. At the inspection in February 2007, the inspectors noted there was little evidence of any rehabilitation work or the involvement in daily life skills, which would equip them to become more independent. Since then the registered manager has referred a number of residents to the occupation therapist. The inspector spoke to the occupation therapist at the last inspection and she said she had come to assess the residents’ needs and work with residents to help them to become more independent. This is slowly changing with staff encouraging and supporting residents to develop daily living skills they will need should they move on into a flat of their own. Each resident has an individual daily activities record. The inspector was shown copies of the resident’s activities and daily living skills. The staff said they continued to try to motivate the residents and it is an ongoing. One resident told the inspector he “hoped to get a place of his own”. The senior support worker spoke to him about his development program and he said he was cooking some meals for himself with support from staff. The three residents the inspector spoke to all had very different interests that they followed and took part in. They said they felt free to come and go as they pleased and were supported to continue with their activities. Seven of the residents go out independently. One resident said he “goes all over the place using his freedom pass” and another said he “goes shopping and does small chores for the home”. One resident is a keen photographer and does his own printing. He said he hoped to get a work placement doing photography. The home consults with residents about the type of individual and group activities they would like to take part in at key worker sessions and residents meetings. The inspector was shown copies of the minutes of residents meetings that are held on monthly basis. The inspector saw during a resident meeting meeting they were asked if they would be interested in spending a week in a holiday resort paid by the home or having several different outings. The response was overwhelmingly in favour of a week at the holiday resort of Mills Rythe. All the residents, except two went for an accompanied stay at Mills Rythe. The inspector joined residents for lunch, which was a sandwich. The main meal of the day is in the evening at the home. Weekly menus showed that the meals offered are balanced and nutritious and varied every week. The home has a flexible approach to menus and depending on resident’s wishes the meal offered is not always as stated on the menu. The manager try’s to ensure that whilst taking into account the preferences of residents, sufficient variation of meals is offered. At this inspection it was found that menus were varied and residents meeting minutes showed that residents were happy with the variation of the meals. Ashleigh House DS0000066388.V339688.R01.S.doc Version 5.2 Page 13 The inspector was told the home encourages the residents to see their family often. Families are invited for meals from time to time and are encouraged to join in the Christmas meals, birthday parties and barbecues. On the day of the inspection one resident was visiting their family for the weekend. They do this on a regular basis as well as their family visiting them in the home. Residents are encouraged to go out for walks and fresh air. The home respects the daily routines the residents have and mealtimes are very flexible. If a resident has to go out, they either serve his meal earlier or save it for him depending on his wish. One resident who had been for a hospital appointment had his lunch when he came back. Ashleigh House DS0000066388.V339688.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19.20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive personal support, in the way they prefer and their physical and emotional needs are met. Residents are protected by the homes policies and procedures for dealing with medicines. Risk assessments need to be done to check that residents are able to take their medication out with them and the box needs to be labelled. Medication administration was found to be properly documented and is handled safely. EVIDENCE: The inspector was told the staff help the residents maintain their self respect and dignity and they try to maximise their independence and control over their lives. The home works in partnership with residents to find the most effective Ashleigh House DS0000066388.V339688.R01.S.doc Version 5.2 Page 15 way to manage their health care. The residents who need support are helped to attend their appointments with the GPs or other health professionals. The care plans the inspector checked contain information about how residents like to be supported in all aspects of their daily lives. 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 residents. One resident needs support to bath and the inspector was told the home had employed a male carer to help him with this although he was happy to be support ed by a female carer. Residents spoken with confirmed that they get the support they need. As part of the care plan, each resident is encouraged to take part in the running of the home. These are discussed with residents in key worker meetings. The resident’s medication is stored securely in a locked medication cabinet in the dinning room of the home. The inspector inspected three of the resident’s medication with the senior support worker. Only care staff that have completed the medication training are allowed to dispense medication. Copies of training records where seen by the inspector that confirmed this. The home uses a blister pack system and all medication stocks checked where in order. Homely remedies are signed as being able to be given by the GP. The inspector was told the registered manager audits the medication weekly. On the day of the inspection the inspector observed medication being dispensed into a residents pillbox to take out with him to the day centre. The home needs to do a risk assessment to check that he is able to take his medication out with him and the box needs to be labelled. The inspector has since spoken to the pharmacy inspector for further guidance and this has been sent to the home. Staff induction includes medication training and medication administration records. All staff has been on the First Aid course to ensure there is always some one who is qualified to give First Aid on duty. The inspector was shown copies of the certificates that confirmed this. There was a copy of all staff signatures that dispense medication and information about the medications in use. Staff told the inspector medication was discussed at individual residents reviews. The manager and staff have annual medication refresher training. The training records that were shown to the inspector confirmed this. As the inspector arrived a member of staff was administering the medication for the morning medication round. This was being dispensed into pots as each resident came down to breakfast. Two staff checks medication before being dispensed. The medication records viewed were printed and in general complete. Where the medication is hand written there are two signatures to conform the accuracy of the transcription. All the records viewed contained photographs of the residents. All records stated whether or not a resident had any allergies. Ashleigh House DS0000066388.V339688.R01.S.doc Version 5.2 Page 16 One resident who was prescribed warfarin had the details recorded on a medication chart. At the previous inspection it was noted the administration details had been completed in two places. The inspector was concerned that there was potential for the staff to administer the medication twice. This has been changed and it is only recorded in one place. The home now ensures there is a safe recording system and there is an individual risk assessment for monitoring the changes to the warfarin. These are kept and recorded on the residents record card supplied by the hospital. Mar charts continue to be signed by the CPN when they administer an injection and this is witnessed and counter signed by the registered manager. The medication policy has been reviewed and all the staff had medication training at the Mulberry Centre. All staff has been on the First Aid course to ensure there is always someone who is qualified to give First Aid on duty. The inspector was shown copies of the certificates that confirmed this. The registered manager told the inspector the district nurse had come into the home to speak to the staff and the resident, who is diabetic, about his condition. She gave each member of staff an information pack and training about how diabetes can be controlled by diet and what signs and symptoms they need to be aware of that could endanger the residents’ health. There is a risk assessment is on file and how the risk could be minimised. The inspector met the district nurse on the day of the inspection, when she came to check on the residents’ progress and confirmed staff have been trained to check the blood glucose levels of the resident. The inspector noted that this was part of the residents’ care plan. Ashleigh House DS0000066388.V339688.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are safeguards in place to protect the resident from abuse, neglect and self-harm. EVIDENCE: There is a complaints policy and the inspector saw the complaints book. There were five complaints since the last inspection. These had been dealt with within the time scale of 28 days. The inspector saw copies of the responses and outcomes. Residents are encouraged to speak up in the meetings about issues that concern them and this is helped them be more confident about speaking up for themselves. One resident who spoke to the inspector said he would speak to the manager if he was unhappy with anything and felt he was able to do this. The inspector was shown a copy of the home’s Adult Protection and Whistle Blowing policy, which has been developed in line with the Local Authority requirements and the governments “No Secrets” legislation. The organisation refers staff to POVA as appropriate. None of the staff in the home have been referred for inclusion on the POVA list. The manager and staff told the inspector they had all received POVA training and the training records seen by the inspector confirmed this. Ashleigh House DS0000066388.V339688.R01.S.doc Version 5.2 Page 18 The home has a policy regarding the protection of the resident’s finances. As part of the inspection the residents’ money and petty cash accounts were inspected and they were in order. A receipt must be obtained for all purchases and the amount spent recorded in the residents’ accounts book. The member of staff supporting the resident when the money is spent signs this. The manager does weekly financial checks and audit by the service manager every three months. These are monitored during the providers monthly registered persons visit. Ashleigh House DS0000066388.V339688.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,28,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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 residents, one of which is shared. The work on refurbishing program of the home has started on the ground floor by extending this area of the home to make space for more communal areas. There is now a large lounge / dining room which over looks the garden at the rear of the home. On the day of the inspection the electrician was there putting up lights in the dinning area. The old dining room will be changed into the staff office and is large enough to be used as a meeting room. The inspector was Ashleigh House DS0000066388.V339688.R01.S.doc Version 5.2 Page 20 told they hoped to have the ground floor finished in time for Christmas. There are further plans to extend the home into the roof space and the home has applied to the local council for planning permission to do this. The ground floor communal toilet will be refurbished as soon as the extension is completed. The inspector saw liquid soap dispensers and paper towel dispensers have been put in place to promote hygiene and control of infection. 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. New and stylish radiator covers have been installed together with new seats for the lobby, which looks homely and welcoming. Garden furniture was purchased and the garden is well maintained. The whole of the concrete surface around the home has been pressure cleaned to make it more welcoming. Residents showed the inspector their bedrooms. One told the inspector he helped to keep it clean and tidy. He said he was happy with his bedroom and was comfortable with it. There is a small smoking room on the second floor that has a small fridge with a supply of snacks and a kettle. Residents said they can make themselves a hot drink and have a snack. Ashleigh House DS0000066388.V339688.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35,36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Training needs for all staff has been identified and is formally planned, including NVQ training for all staff, to ensure that 50 of the homes staff achieved NVQ level 2 or 3. Appropriately supervised staff meets the residents’ individual needs. EVIDENCE: The homes recruitment procedure is based on equal opportunities. No new staff had been employed since the previous inspection, so it was not possible to assess recent recruitment practices. The inspector was told they make sure that during the induction programme, that new staff understand the principle of care and relates that to the experiences and in particular to the needs of the residents. Copies of signed contacts were on file. Staff records are kept in a cabinet in the dining room. Any member of staff who holds the keys can access these. Staff files hold information that is confidential and must be locked up so confidentiality is not breached. See Standard 41. Ashleigh House DS0000066388.V339688.R01.S.doc Version 5.2 Page 22 The inspector looked at four staff files during the course of the inspection. All the staff files had detailed records of recruitment with all the required checks having been made. All staff has a training and development profile. The manager had developed a training plan in conjunction with an external consultant from the learning skills council. This offers a comprehensive plan of training for the next 12 months including an in house training programme for all staff based on the identified needs of residents and staff. This will take place once every month for the next 12 months. Staff has been provided with a range of training and copies of training records and supervision records were seen on file. Staff meetings are held monthly and the inspector was shown copies of the minutes of the meetings. The inspector was told the home is planning to carry out more training such as moving and handling, infection control, mental health. Four staff have already gained NVQ level 2 or above and two more staff are starting their training towards NVQ level 3. Ashleigh House DS0000066388.V339688.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,41,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents know the home is well managed and planned. Working practices and associated records ensure that the health and safety of residents is promoted. Confidentiality of staff records was lax. 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. Ashleigh House DS0000066388.V339688.R01.S.doc Version 5.2 Page 24 The home had a policy on health and safety and the inspector viewed health & safety records held in the home. Certification was in place regarding the Landlord’s Record of Gas Safety, Portable Electrical Appliance testing, and Certificate of Electrical Installation. Records showed that regular checks of the fire alarm call points were made and that fire drills were conducted. Staff confirmed that they attended mandatory health and safety training, which included fire safety and staff training records confirmed this. All confidential records must be kept locked up and accessible only to the management of the home. See “Staffing” above. As was required at a previous inspection the quality assurance system has been developed including anonymous surveys of residents in addition to seeking the views of relatives, other representatives and community professionals. All residents and residents’ relatives were asked to complete a quality monitoring form. The home had three replies from resident’s relatives, seven from the residents and three from professionals who support residents who live in the home. Comments from professional were “the home is very good”, “would recommend this home” and “staff are very professional and have good interpersonal skills”. All responses were viewed by the inspector and found to be positive. Ashleigh House DS0000066388.V339688.R01.S.doc Version 5.2 Page 25 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 Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 3 2 3 X Ashleigh House DS0000066388.V339688.R01.S.doc Version 5.2 Page 26 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 YA20 Regulation 13 Requirement The registered person must ensure that risk assessments are done to check that residents are able to take their medication out with them and the box needs to be labelled. The registered person must ensure all confidential records are kept in a locked cabinet that is only accessible to the management of the home. Timescale for action 31/01/08 2 YA41 17 Sch 3 &4 31/01/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Ashleigh House DS0000066388.V339688.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V339688.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!