Inspection on 07/08/06 for Ashleigh House

This inspection was carried out on 7th August 2006.

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 13 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 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 Wendy Owen Unannounced Inspection 7 August 2006 11:45 th Ashleigh House DS0000066388.V297825.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.V297825.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.V297825.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 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.V297825.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th December 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. Fees range from £450-£500 per week and include accommodation, food and staffing. Personal expenditure such as clothing, toiletries and outings are not included. Service Users Guide and Statement of Purpose are available in residents’ rooms. Inspection reports are available on request from the home. Ashleigh House DS0000066388.V297825.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken by two inspectors and took place over three and a half hours. The inspection included a tour of the home; viewing of records, policies and procedures; written feedback from relatives and discussions with residents, Provider, staff and the manager. There are no vacancies in the home at present. What the service does well: What has improved since the last inspection? Ashleigh House DS0000066388.V297825.R01.S.doc Version 5.2 Page 6 Since the last inspection there has been some improvement in the recording of the activities offered including discussions held. There is also evidence of activities undertaken. The Provider has also been more robust in undertaking the monthly visits and reporting on the quality of care as required by Regulation 26. He also visits the home for at least two hours every day. This was confirmed by his arrival on the day and subsequent discussions. There has been a significant amount of work completed particular in the decoration and purchasing of new furniture. Residents and staff are pleased with these changes All residents are free to access all areas of the home except residents’ private space. All have keys to the front door and to their rooms. Consultation with residents, relatives and other stakeholders has also taken place since the last inspection. It is now necessary to ensure this information is collated, analysed and a report produced on the outcome, with details of any actions required to address the shortfalls. What they could do better: The Service Users Guide and Statement of Purpose must be updated to ensure the information contained is accurate and up to date. Risk assessments must be more comprehensive and detail not only the identified risk but the action the home is taking to minimise the risk to the residents or others. All residents must have a contract or placement agreement detailing the terms and condition of residency and the fees to be paid and by whom. It must also include the cost of a holiday each year. It is also good practice for Local Authority funded residents to be provided with the home’s terms and conditions in addition to the placement agreement. Medication procedures require a little improvement to ensure that the administration of medication is safe. Relatives and stakeholders must be made aware of the home’s procedures and how to raise any concerns or complaints. Adult protection procedures must Ashleigh House DS0000066388.V297825.R01.S.doc Version 5.2 Page 7 also be improved to ensure staff have the guidance and knowledge to protect residents from abuse. Whilst staffing in the home is satisfactory improvements are required in the provision of specific and induction training to ensure staff have the knowledge and understanding of the individuals’ needs. Recruitment practices are not robust enough to provide protection to the vulnerable people living in the home. The required checks must be undertaken for all new staff recruited. Residents’ safety is compromised by the high hot water temperatures and lack of window restrictors in place on windows above the ground floor. Risk assessments must also be produced detailing the use of portable heaters, and fire drills and fire training must be kept separate. All staff must have current and valid first aid certificates if left in charge 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.V297825.R01.S.doc Version 5.2 Page 8 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.V297825.R01.S.doc Version 5.2 Page 9 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): 1,2 & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and interested parties have the information they require to make a decision on whether the home meets their needs. Some of this information requires updating to reflect the change in Provider. EVIDENCE: Of those residents case tracked, all had been in the home for a number of years; admission assessments were not therefore inspected, except to say that an admission form was in place for all. The Service User’s Guide and the Statement of Purpose were available in residents’ bedrooms. Both these documents require updating to ensure they reflect the current situation including the changes to the Provider. (See requirement 1) The Service Users Guide states that “all applications must be accompanied by a comprehensive assessment of need. …….Assessments are usually multidisciplinary and submitted by a local authority social services care manager, specialist community learning disability team, mental health social work team or nominated key worker of a multi-disciplinary team.” The Guide goes on to explain the admission process which includes a number of gradually extended visits enabling the residents to get to know staff and other residents and identify a basis for a continuing plan of care. All admissions include a trial visit. Ashleigh House DS0000066388.V297825.R01.S.doc Version 5.2 Page 10 The three residents’ files viewed contained terms and conditions of residency. This detailed what the fees include but not what the actual fees are and who is responsible for their payment. The terms and conditions also include the notice period for terminating the arrangement and that an annual holiday or days out will be arranged. Once again there was no clarity over who funds this activity. None of the files viewed contained the Local Authority placement agreement. This would include fee amounts and who and how fees are to be paid. (See requirement 2) Ashleigh House DS0000066388.V297825.R01.S.doc Version 5.2 Page 11 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): 6,7 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff have detailed information on the support required by individuals. Risk assessments, however, are not detailed enough to ensure risks to the individual are identified and potential for harm minimised. EVIDENCE: Care plans were laid out in an easily accessible typed format, with different sections for information. The care plans covered physical, mental and social activities including long and short-term goals. The interventions were workable and appropriate in their content. The care plans had the date of generation and review dates on all items. There was evidence of the resident’s and staff signature. All residents are on the Enhanced CPA level, and evidence of these reviews were in place. Residents’ care plans are reviewed every six months or sooner, if required. In addition there was a form indicating health care input such as the GP, chiropodist, dentist etc. This did not give details of treatment provided, simply the date of attendance. (See recommendation 1) There was evidence of key worker session in care plans. Ashleigh House DS0000066388.V297825.R01.S.doc Version 5.2 Page 12 A general risk assessments form was in place. This was limited in its content and the information provided would not sufficiently address the issue either by reducing it or eliminating it. (See requirement 3) In the daily record books some of the entries were limited in their content and some had staff initials used . Daily events should where possible reflect the actual support given and reflect the care plan issues. (See recommendation 1) Ashleigh House DS0000066388.V297825.R01.S.doc Version 5.2 Page 13 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): 12,13,15,16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home offers a flexible approach to caring for residents with residents determining how they wish to live their lives. EVIDENCE: Three residents met with the inspector. In general they were happy in the home and satisfied with the level of support that they received. They all confirmed that they were able to do as they wished within reason; however, all said that they did not wish to engage in day centre activities. From the three residents spoken to there seemed to be little in the way of restrictions. Previous inspections found that motivation is a problem for most of the residents. It is usual for most to spend their days doing solitary activities such as reading, watching television, or listening to music. Since the last inspection there is evidence that the home has tried to motivate residents into going out for the day but this is often met with resistance. The fact that the home had tried to introduce structure and activities was confirmed by one of the consultants. She said that due to the long standing mental health problems of the residents the home had done well to introduce the activities and Ashleigh House DS0000066388.V297825.R01.S.doc Version 5.2 Page 14 stimulation. Those residents spoken to said they did not wish to do much and felt no reason to go out. There was evidence of visits to the Imperial War Museum, Margate and a BBQ held in the home. One resident spoke of his enjoyment of travelling on the buses. He would like to go on holiday although “not with mentally ill people”. He also would like to move into a flat. Regular meetings are held with residents and there was evidence that activities had been discussed during these times. The last inspection required the home to include in the contract the cost of a seven-day holiday or days out. Whilst there is evidence that this is in the terms and conditions, it is not clear who pays for the cost of this. (See requirement 4) Daily routines are flexible at the home with residents seen to be freely coming and going from the house, moving around the home, and making drinks in the kitchen. All residents have a key to their room and a key to the front door. The only stipulation is that residents advise staff of when they leave the home and when they return. The kitchen is no longer out of bounds at night. One resident said he visits his family frequently whilst another said his family visits him in the home. Visiting is open until 8 pm and visitors are not encouraged to stay overnight. Individual activities including items such as laundry and caring for their own bedrooms was itemised in the care plan. Smoking is not permitted in individual bedrooms, and therefore the majority of residents spend time in the newly designated smoking area. This has improved life in the home, especially for the non-smokers. None of the current residents shop or cook for themselves. Staff prepare all meals according to the four-weekly menu and all residents get together for the evening meal. Residents said the food was varied and any preferences would be catered for. They enjoyed the home cooking staff did. There was evidence of freshly baked cakes and fresh fruit around the home. Meals and times of meals are discussed at residents’ meetings and a record of the meal served is made in the diary. This is also where the food temperatures are recorded. Ashleigh House DS0000066388.V297825.R01.S.doc Version 5.2 Page 15 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): 18,19 & 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents are supported in maintaining their health and well-being. Improvement in the medication practices and the training of staff in this area would further ensure their health needs are met. 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 inspector viewed records in relation to the healthcare needs and also feedback from health professionals who visit the home. This showed they were satisfied with the level of care and knowledge and understanding of the staff team, in particular, the Manager. The inspectors also obtained verbal feedback from a consultant who has regular input into the home. This was also positive without any issues raised. The medications were inspected. In the medication file there was list of homely remedies signed by the GP in February 2006. This included the items to be used, amount to be administered and duration. It was to be used for all Ashleigh House DS0000066388.V297825.R01.S.doc Version 5.2 Page 16 residents in the home. The file held the medication procedures, including disposal of medication, and a list of staff signatures with their initials. The medication charts were inspected. These had clear photographs of the residents in place. In some cases the allergies were not recorded, and on two charts the allergies, which were recorded, were inappropriate. One stated the allergy as “ depression” and the other “epilepsy”. This needs to be amended. Medications were signed in and charts were generally well completed. On the reverse of the MAR chart all omissions to medications were noted and explanations given. It was noted that there were some hand transcriptions of medications which had no signatures in place to confirm the accuracy of the information recorded. Two staff should sign to confirm the information recorded for all hand transcriptions. (See recommendation 2) Only one medication, diazepam, was noted to be used “ as required”. The instructions for its use were in the file, although generated in 2004. This needs to be reviewed. There are no controlled drugs in this home and never have been. The Controlled Drug cabinet was used for the storage of items of medicines. Storage space was limited for medications, although adequate. The inspector met with two staff and medications were discussed. Medications used with mental health residents can have a number of serious side effects and staff need to be aware of these so appropriate action can be taken. One staff member confirmed that she had received training in respect of medication administration. She was unable to tell the inspector what any of the five medications selected were used for or their side effects. The second staff member had not received training in medication procedures and she too was unable to respond to questions in respect of medications. Both staff stated that they did administer medications on a regular basis. Staff must have a knowledge of all medications that they administer and have a reference manual for assistance on queries. (See requirement 5) Ashleigh House DS0000066388.V297825.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents and relatives feel that their concerns and complaints are listened to and acted upon. The information on complaints must be made more available to interested parties and the procedures on how staff are to protect vulnerable individuals must be improved. EVIDENCE: A complaints procedure is in place and a copy of this is available in the Service Users Guide and on display in the hallway. However, the three written feedback cards received from relatives all stated that they were not aware of the complaints procedures. This must be addressed to ensure all relatives and other interested parties are provided with information on how to make a complaint or raise concerns. (See requirement 6) Complaints received, written and verbal are recorded in the complaints book. All recent complaints have been verbal with none regarding the quality of care provided but “minor” issues affecting the residents’ day-to-day lives. These had been recorded with statement of what action had been taken and if the issue had been resolved. All appeared to be dealt with quickly and effectively. Residents spoken to all stated that they would have no hesitation in bringing any concerns to the Manager. Adult protection procedures include basic information on types of abuse and information on management and safe keeping of residents’ monies. However, there was no information on what to do if there is any suspicion of abuse or allegation and what the member of staff would do in the event of such an incident. There was no information on other agencies involvement in the protection of vulnerable adults. The home did have policies and procedures in Ashleigh House DS0000066388.V297825.R01.S.doc Version 5.2 Page 18 relation to Whistle-blowing, restraint, challenging behaviour and managing residents’ monies. Two staff were spoken to on their knowledge and understanding of abuse and how they would deal with suspected abuse. One was clear in what action she would take with verbal aggression and abuse, although was less clear on the reporting of abuse. The other demonstrated a clear knowledge on abuse and the reporting of it through the home’s management structure. (See requirement 7) Ashleigh House DS0000066388.V297825.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,27,28 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Ashleigh House provides a comfortable and homely environment for individuals living in the home. 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. The inspectors were advised that significant work had been undertaken since the new owners had taken over, some six months previously. Work was still underway with the former office converted to a smoking area for residents. The office is due to be relocated into the roof space. New carpets had been laid and some redecoration was evident. The lounge was very comfortable with new sofas, TV and other furnishings. Ashleigh House DS0000066388.V297825.R01.S.doc Version 5.2 Page 20 The home was clean and to a good standard. However, the kitchen handwashing facilities included bar soap which should not be used even though it is anti-bacterial. The last Environmental Health Officer report required regular cleaning in the kitchen. There is now a cleaning schedule and evidence that the tasks are being completed. Fly screens are in place in the kitchen. The three bedrooms, which the inspector was able to access, were all of a satisfactory standard. They were clean and odour free with evidence of individualisation by the residents. In the double room there was a divider curtain to afford some privacy. It was noted that those windows above ground floor level could be opened wide. Restrictors are due to be fitted; in the interim risk assessments need to be in place to reduce the hazard. Radiator guards were also not in place in bedrooms. There was a portable fan in the lounge. This needs to be risk assessed, as with all portable items which may pose a risk to residents. (See requirement 8) All residents in this facility are mobile therefore there is no lift or adaptations; access throughout the floors is by the stairs. Bathroom and toilets were hygienic with soap and towels provided. Please see previous comments regarding the use of bar soap. Some towels were noted to be rather worn. The hot water was running very hot; this needs to be checked and the temperature recorded. Safety measures need to be put in place, especially as residents do bath on their own. (See requirement 9) The smoking area on the first floor was to a reasonable standard with a door leading to the fire escape. A TV was provided in this area and tea/coffee making facilities. Ashleigh House DS0000066388.V297825.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,34 & 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is well staffed with individuals who have a general understanding of the residents’ needs. More specific training would further ensure the individual needs of the residents are being met. Recruitment practices must be improved to ensure residents are protected from potential abuse. EVIDENCE: The manager stated that 5 staff had completed NVQ level 2 and one staff is doing level 3. The bank staff used from one other home in the group are either undertaking or have completed the NVQ 2 or above. Three staff have been recruited since the previous inspection. The three members of staff have been recruited to work as bank staff and currently work in one of the other homes in the group. The records were well organised. Application forms were completed but did not allow for a full employment history with dates. This means it would be difficult to ascertain previous employment. Interview schedules were in place as were terms and conditions etc. Codes of conduct are available. There was evidence of proof of identity for all new employees. However one file contained only one reference, whilst in another, the reference had been written by a senior carer and not the Manager or Provider. Criminal Records Bureau (CRB) checks were all those for the original home dated 2003. This home is, in theory, a different employer and Ashleigh House DS0000066388.V297825.R01.S.doc Version 5.2 Page 22 therefore the required CRB must be completed. The manager should also be aware of the need to update CRBs every few years. (See requirement 10) 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 last inspection commented that the manager recorded how much of the plan has been achieved. This was difficult to determine. The files of the three bank workers viewed showed that they had undertaken the home’s induction and signed the records. The home is still developing an induction programme for staff to ensure it meets the skills sector council standards. (See requirement 11) The inspector met with two care staff. Both were pleasant and friendly in their manner. One staff member had been in post four years and enjoyed her work. She confirmed training in the last year as including medication, completion of her NVQ 2, mental health and protection of adults from abuse. Health and safety had also been covered. English was not her first language and it was difficult to assess her level of understanding in respect of some of the questions asked. The second care staff was able to answer all questions and she demonstrated a clear knowledge on abuse and the reporting of it through the home’s own management structure. She had received little in the way of training, including medication, even though she was administering medications. She had not received training in respect of mental health, aggression, first aid or manual handling. She had received training on abuse included as part of another training session. The Service Users Guide states that the home cares for people with mild to moderate mental health needs whose disabilities include epilepsy, manic depression and schizophrenia. It is therefore expected that staff receive some training in these areas. (See requirement 11) Both confirmed that they felt there were enough staff on duty at all times and that one “sleeping staff” was sufficient. They were positive about the workings and management of the home. In relation to supervision both stated this was on a day-to-day basis, although could not confirm formal supervision sessions. They felt the Manager was supportive and knowledgeable about residents needs. Ashleigh House DS0000066388.V297825.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is generally well run with a manager who is organised and ensures the health and safety of the residents and staff to an adequate level. However, there are areas for potential harm to residents. The systems in place ensure the care provided is monitored and improved upon. 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 completed recently. These include relatives, residents and stakeholders. These show positive feedback about the quality of care. However the results of the surveys must be collated, analysed and evaluated to produce a report on the outcome and what action the home should take to address the shortfalls. (See requirement 12) Ashleigh House DS0000066388.V297825.R01.S.doc Version 5.2 Page 24 The last inspection also required that the registered provider must visit the care home on an unannounced monthly basis to inspect the premises, records and interview service users about the quality of service provided. This has now commenced and there is evidence of such reports being completed and sent to the Commission. In fact the registered provider visits the home daily for approximately two hours and is therefore kept up to date with issues and monitoring of the service. The manager monitors the health and safety of the home to a satisfactory level. A number of service contracts and agreements were cross-referenced against the pre-inspection questionnaire. These were accurate and in date. However, the Manager must ensure that fire drills are kept separate from fire instruction. Please also note the comments made in the environmental standards regarding window restrictors and the high hot water temperature. (See recommendation 3) There is also a need to ensure staff are provided with moving and handling training regularly unless a risk assessment determines a less regular frequency. A number of staff also require updating of their First Aid certificates, including the Manager. (See requirement 13) Ashleigh House DS0000066388.V297825.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 2 2 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 X 30 2 STAFFING Standard No Score 31 3 32 3 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 x 3 X 2 X X 2 X Ashleigh House DS0000066388.V297825.R01.S.doc Version 5.2 Page 26 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 YA1 Regulation 4&5 Requirement The Registered Person must ensure that the Statement of Purpose and Service Users Guide are updated with information which reflects the current situation. The Registered Person must ensure that Local Authority placement agreements are obtained for those residents who are funded by the Local Authority. Contracts must include fees payable, how they are o be paid and by whom. The Registered Person must ensure that risk assessments detail the identified need and what action the home is to take to minimise the risk to the resident or others. The Registered Provider must include a holiday as part of the basic contract price for service users living in the home. This is a repeated DS0000066388.V297825.R01.S.doc Timescale for action 01/11/06 2 YA5 5 01/11/06 3 YA9 13 01/10/06 4 YA14 12 (1) (a) 01/11/06 Ashleigh House Version 5.2 Page 27 requirement. The previous timescale of 31/05/06 is not met. 5 YA20 13 The Registered Person must ensure that • The administration guidelines for the use of diazepam, are up to date. • Staff who administer medication are provided with comprehensive training including the nature of the medication administered and possible side effects. The Registered Person must ensure that all interested parties are aware of the home’s complaints procedures. The Registered Person must ensure that adult protection procedures are reviewed and contain the detailed guidance on abuse and what action staff should take in reporting abuse. Staff must be trained in these procedures. The Registered Person must ensure that risk assessments are produced for the use of portable fans. Window openings without any restrictors must also be risk assessed for residents’ safety. The Registered Person must ensure that the temperature of the hot water is kept within the DS0000066388.V297825.R01.S.doc 01/09/06 6 YA22 22 01/11/06 7 YA23 13 01/11/06 8 YA42 23 01/09/06 9 YA42 23 01/09/06 Ashleigh House Version 5.2 Page 28 required safe levels. 10 YA34 18 The Registered Person must ensure that recruitment checks as required by the Regulations are undertaken for all new staff members before employment commences. The Registered Person must ensure that staff are provided with • training specific to the needs of the residents diagnosis. • Induction training 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 partly met) The Registered Person must ensure that staff are provided with updated First Aid training. 01/09/06 11 YA35 18 01/11/06 12 YA39 24 01/11/06 13 YA42 13 01/10/06 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 YA41 Good Practice Recommendations Daily records should include more detailed information on DS0000066388.V297825.R01.S.doc Version 5.2 Page 29 Ashleigh House 2 YA20 3 YA42 the interventions and treatment provided. Medication records should include specific allergies. Where there are none known this should be made clear on the record. Where the records are hand transcribed two signatures should be in place to check the accuracy of the transcription. The home should ensure that fire drills and fire instruction are carried out separately. All staff should undergo fire instruction at least once every twelve months. Ashleigh House DS0000066388.V297825.R01.S.doc Version 5.2 Page 30 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.V297825.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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