Inspection on 18/03/08 for Ashleigh House Care Home

This inspection was carried out on 18th March 2008.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Ashleigh House Care Home 04/08/09

Ashleigh House Care Home 16/08/08

Ashleigh House Care Home 05/09/07

Ashleigh House Care Home 11/04/07

Ashleigh House Care Home 07/12/06

Ashleigh House Care Home 04/04/06

Ashleigh House Care Home 08/12/05

Ashleigh House Care Home 11/05/05

Ashleigh House Care Home 03/11/04

Ashleigh House Care Home 19/05/04

Ashleigh House Care Home 17/12/03

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Ashleigh House Care Home 18-20 Devon Drive Sherwood Nottingham NG5 2EN Lead Inspector Lee West Unannounced Inspection 18th March 2008 10:30a X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ashleigh House Care Home DS0000002188.V361550.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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ashleigh House Care Home DS0000002188.V361550.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashleigh House Care Home Address 18-20 Devon Drive Sherwood Nottingham NG5 2EN 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) 0115 969 1165 Mr William Scott vacant Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Ashleigh House Care Home DS0000002188.V361550.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th September 2007 Brief Description of the Service: Ashleigh House is a care home providing personal care and accommodation for 19 older people. The home is owned by William Scott, which is run as a family business. The home is located in a residential area of Sherwood, close to shops, pubs, the post office and other amenities. Opened in 1987 it consists of 2 converted terraced houses with a purpose built extension. Fifteen of the homes bedrooms are single, and none of the bedrooms have en-suite facilities. Bedrooms are located on 3 floors and there is a passenger lift. The home has a small, enclosed garden and a small car park. The home has recently appointed a new acting manager. The fees for the service are listed in the Service User guide as £279 to £313 per week, depending on dependency needs. There are additional charges for hairdressing and chiropody. Further information about the home is available from the provider or acting manager. A copy of the latest inspection report is available in the office. Ashleigh House Care Home DS0000002188.V361550.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service users and their views on the service provided. This process considers the provider’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. This inspection was unannounced and involved one inspector and an “expert by experience.” The role of the ‘expert by experience’ is to talk with residents. The ‘expert’ is arranged through the charity Help the Aged. An ‘expert by experience’ means they have experience and skills to be able to speak with residents at an inspection. Their experience could be from previous work or they may have used care services themselves. The ‘expert by experience’ spoke with four residents at some length, and two others, some in the privacy of their own rooms. The lunchtime-meal was also shared with the residents. The main method of inspection used is “case tracking”, which involves selecting three residents and looking at the quality of the care they receive by speaking with them, observation, reading their records, and asking staff about their needs. Three members of staff and three residents were spoken with, in addition to those spoken to by the expert by experience. At the time of this inspection, the Annual Quality Assurance Assessment for 2007 had not been completed as required by Regulation 24, but other information kept by the Commission, documents, including care plans, risk assessments, and medication administration records were inspected to help form an opinion about the health, safety and welfare of residents at the home. The quality rating for this service is 0 star. This means people who use this service experience poor quality outcomes. Ashleigh House Care Home DS0000002188.V361550.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: All prospective residents must have a pre-admission assessment to provide information that the home can meet all the physical, mental, spiritual and cultural needs of the person, which takes into account the person’s personal wishes and preferences and any specialist needs, to make sure staff working at the home are competent to meet those needs. Care plans must identify, in a person centred way, all the needs of the resident, outlined in the pre-admission assessment, and, with input from the resident, must set out how the person’s needs are to be met, including Ashleigh House Care Home DS0000002188.V361550.R01.S.doc Version 5.2 Page 7 whether specialist equipment is required, for example, when being assisted with personal hygiene, personal preferences of bath or shower, or being assisted to move from one place to another. The care plans must be regularly reviewed, with input from the resident, so any changes in condition, preferences or wishes are identified and any changes put into the care plan to effectively support the resident. A programme of activities, including visits outside the home must be designed to support the individual preferences for physical, mental, cultural and leisure requirements of each resident, to provide opportunities for them to maintain their physical and mental capacity, and support their well-being. To make sure residents are cared for safely, equipment, including bathing and moving aids, for use by residents and staff, must be maintained in good working order, and records of servicing of this equipment kept up to date. Recruitment procedures must be followed, with records containing evidence of competence, previous employment history, health, identity and eligibility to work with vulnerable people completed and stored securely. Staff must not work within the home until thorough checks, including Criminal Records Bureau checks and two professional references have been received to provide evidence the recruit is suitable to work with vulnerable people. Annual Quality Assessment Reports must be completed and returned to the Commission, as requested, It is an offence under Regulation 24 of the Care Standards Act 2000(Establishments and Agencies)(Miscellaneous amendments) Regulations 2006 not to do so. You must develop and carry out an effective quality monitoring system of planning, action and review of all aspects of the service, including outcomes for residents, policies and procedures and health and safety processes to monitor the quality of service provided and the well being of residents. A long-term, ongoing, programme of maintenance, to make sure the home is fit for purpose, kept in a good state of repair and decoration, must be developed and put into action, as part of the quality assurance process, to provide the residents a safe, pleasant environment and improve their well-being Ashleigh House Care Home DS0000002188.V361550.R01.S.doc Version 5.2 Page 8 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 Care Home DS0000002188.V361550.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ashleigh House Care Home DS0000002188.V361550.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 5, 6, Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Prospective residents have a basic assessment of their needs before moving into the home. They are given opportunities to stay at the home before making any decisions about the suitability of the home to meet their needs. EVIDENCE: I spoke with the relatives of a new resident, who said they felt they were given enough information to make the right choice for their relative and the home met the needs of their relative. Assessments were seen in the residents’ records, although these did not contain a thorough history of the person, they contained information on when the person wants to go to bed, or get up in the morning, whether they wished to be checked during the night, but did not explore the likes, dislikes and other personal preferences on how they wished to be care for. There was also no Ashleigh House Care Home DS0000002188.V361550.R01.S.doc Version 5.2 Page 11 indication of any specialist needs within the assessments, to ensure appropriately competent staff would be available to meet those needs. Ethnic origin and faith were identified, but again not explored to help the person maintain their diversity. However, there was one exception, where a resident had a weekly visit from his religious leader organised, to help support faith. The expert by experience spoke to residents about their admission to the home and one said they had visited the home before becoming a resident, another was admitted from hospital, so didn’t have much information before being admitted, but those spoken with felt they had the information they needed about the home to make a decision about moving in. Ashleigh House Care Home DS0000002188.V361550.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Not all personal care needs are identified and met in a way the resident wishes, but care is generally carried out in such a way that supports their privacy and dignity. EVIDENCE: The care plans case tracked identified what individual assistance the resident needed and there was evidence that they were reviewed, the latest date being 10th March 2008. There was no evidence though of any input from the residents, to make sure the plan was person centred, took into consideration their personal preferences and wishes, or any special needs to make sure their needs were met. Records were seen of bathing or showering of residents, but though signed and dated, it did not indicate whether the person had had a shower or a bath, or if specialist equipment was required, or used. Ashleigh House Care Home DS0000002188.V361550.R01.S.doc Version 5.2 Page 13 One entry stated a resident did not like a shower or a bath, yet this was not identified in the person’s care plan, and there was no information from the resident of any special reasons for this, or whether it was personal choice. This could have a negative impact on the resident if it was not a personal choice. One resident, who spoke to the expert by experience, explained how help was needed when using the toilet facilities, and this was not available, which caused some distress. The care plan documentation for this resident did not identify any issues around support for using toilet facilities, which could lead to carers not assisting when needed. Whilst in the lounge area, both the inspector and the expert by experience observed a care worker giving a resident, who required moving with a hoist, assistance on her own, which caused the resident some anxiety, as it was difficult for the carer to use the hoist alone and at the same time support the resident. I spoke with some relatives, who said they were happy with the care their mother was given, and felt their mum had actually improved since being admitted to the home. However, when asked about their mother’s care plan they said they, “didn’t know anything about that.” Visits by healthcare professionals, chiropodists, doctors, district nurses and opticians were recorded in the care plans, and residents confirmed they only had to ask if they needed to see a doctor and staff would contact their doctor for them. Medication was stored securely in the trolley in the manager’s office, from where it was administered. Medication Administration Records were inspected and all were correctly completed, with no gaps, and clear indications that medication which was given only when necessary, had been supplied and the residents were observed being asked if this was required. Records contained photographs of residents and all medicines were in date, properly labelled and being stored correctly. The lunchtime administration of medication was observed and medicines were given in line with procedures, and documents signed only after the resident had taken the medication. None of the residents self-administer medication, but there was no evidence within the care plans to say why this was the case, which implies the resident’s choice to do this may not have been considered. All the residents spoken with said they felt they were treated with dignity and interactions between staff and residents was observed to be positive and friendly, supporting this. Ashleigh House Care Home DS0000002188.V361550.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Though there has been some improvement in the activities provided, there remains very little stimulation for residents, who are left to their own devices a lot of the time. Meals provided are wholesome, with choices available. EVIDENCE: Assessments and care plans seen did not contain any information on the activities residents liked, or were able to take part in, leaving some residents unable to participate due to their physical, or mental limitations, creating a negative impact on their lifestyle expectations and preferences. Although ethnic and religious origins were identified, there was evidence in only one care plan of addressing these, with the visits by a religious minister for a resident arranged. Since the last inspection, a group “Motivation” has provided a monthly activity focusing on physical movement. Residents spoken with said they enjoyed this activity. Ashleigh House Care Home DS0000002188.V361550.R01.S.doc Version 5.2 Page 15 Some residents had been involved with drawing and Easter craft work, which was displayed around the dining area. Activity charts were seen in some residents’ files, but these were filled in with activities such as “watched t.v.” “read” and “joined in bingo,” and failed to identify personal leisure and social preferences. During this visit there were no activities being carried out, but on a subsequent visit (3rd April 2008) a number of residents were observed playing a variety of board games with care staff, and they were observed to be enjoying this activity. Residents who spoke to the expert by experience spoke about chair exercises and bingo, which they enjoyed. Relatives spoken with said they would like to see more activities but especially perhaps trips out as they spend all day every day in the home. Some of the residents spoken with also expressed their wish to leave the home for “at least a few hours.” One said, “I feel like a greenhouse plant, never getting any real daylight, or wind on my face.” Staff spoken with said residents didn’t get out of the home very often, unless they were able to go unescorted. None of the care plans case tracked identified any residents able to go out unescorted. I spoke to three visitors in the home and they all confirmed they were made to feel welcome and staff were always polite to them and offered them drinks. They also said if they wished to see their resident in private they would go to their private room. All residents spoken with said they enjoyed the food, there were choices and they could eat when they wanted. The meal observed, and shared by the expert by experience, was wholesome and nutritious and served in a homely dining area, the tables having been set by one of the residents. There were facilities available for residents to make hot drinks whenever they wished and jugs of juice and water were also available around the home to enable residents to have drinks whenever they wished and residents were observed making their own hot drinks during the day. Ashleigh House Care Home DS0000002188.V361550.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18, Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The complaints procedure has been updated and is displayed around the home and staff training around safeguarding adults has been undertaken to protect residents from harm. EVIDENCE: The service has updated their complaints procedure and this was displayed, alongside the Certificate of Registration, in the foyer of the home. It contained information on how to make a complaint and also the new CSCI Commission contact details. There was a complaints book on the table in the foyer, but this did not contain any complaints, or comments. Any information in it would not be confidential, so there was a potential for people not to use it because of this lack of privacy. Residents spoken with said would speak to the manager if they had any complaints, but were not aware of any formal procedure. One said, “if I want to complain, I just speak to the staff, or tell Billy(Mr Scott),” and said he didn’t know about any book. Staff have received training in safeguarding adults, certificates were seen in the staff files inspected, and those spoken with were able to explain their role Ashleigh House Care Home DS0000002188.V361550.R01.S.doc Version 5.2 Page 17 in this area. They were unsure though if the home had a whistle blowing policy, but said they would inform the manager anyway, if there were any suspicions. Ashleigh House Care Home DS0000002188.V361550.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26, Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The quality of life for residents is made worse by the environment they are living in, with essential maintenance only done when a problem has already arisen and there are potential risks to residents not recognised or responded to by the management, which could make it unsafe for people living at the home. EVIDENCE: The management had responded to the requirements made during the last inspection. Work on the garden at the rear of the home was well underway, with a concrete slab patio, lawn and flowers planted near the back wall, making a pleasant area for residents to use. However, although the metal ramp from the side of the house had been cleared of debris, there still remained no direct access to this area for people Ashleigh House Care Home DS0000002188.V361550.R01.S.doc Version 5.2 Page 19 who had mobility problems, unless they used the ramp at the side, or exited the home at the front and walked around the side of the home. Some decoration of the home had also been undertaken, but there remained major repairs to be carried out, including inside residents’ own rooms. One resident had a wet patch on the ceiling of her room, which had been there, she said, “for a long time and it isn’t very nice.” Indicating the negative impact on the resident of this. Other residents spoken with were all happy with their rooms, and said they had their personal possessions with them. One visitor said, “my mum is comfortable in her room.” However, there were a number of items of broken furniture and fittings in other residents’ rooms, wardrobes with doors broken, chests of drawers with drawers broken, carpets with threadbare areas were examples of this. There were other problems in the maintenance and fabric of the building identified, which could have an impact on the safety of residents. Examples include, air vents in the shower room and one in the ground floor corridor, with missing covers, not only unsightly, but also leaving residents at risk from dust and droughts. A number of windows in residents’ own rooms had broken or no restrictors, making them vulnerable to intruders or risks of falls. The toilet used by staff on the first floor had no lock on the inside of the door and a gaping hole in the door where the locking device had been removed, which creates a lack of privacy for anyone using the facility. Carpetting in the corridors was puckered and in one area there were a number of metal strips to try to keep it in place. These strips though were observed to cause difficulty for residents who use zimmer frames to move around the home, as they were getting stuck between the strips, causing a trip hazard. On a visit to the home on the 3rd April 2008, these strips had been removed, reducing the risks for residents. Some corridors had been redecorated, making them appear brighter and some redecoration had begun in residents’ rooms. The downstairs shower room had some broken tiling around the base and the bathing equipment in the two bathrooms was in a poor state of repair. The batteries were kept in the manager’s office. Staff spoken with said they showered people and didn’t use the baths. However, there were no records in care plans to indicate this was preferred by Ashleigh House Care Home DS0000002188.V361550.R01.S.doc Version 5.2 Page 20 all residents, reflecting the lack of personal preferences within the plans, and having a negative impact on anyone who would prefer a bath. The cleaner was observed working within the residents’ rooms and cleaning the corridors and lounge areas, keeping the rooms clean, and residents spoken with said they were satisfied with the cleanliness of their rooms. There was a nurse call system in place. Within the lounge area, the call button was set on the wall with no pull-cord, which meant only people who could move independently could access this in an emergency. This could have a negative impact on residents, as there were long periods noted, due to low staff numbers, when no staff were with the residents in the lounge areas. In the extension, there was a room, next to the laundry room, which was full, from floor to ceiling, with unwanted and broken beds, and equipment, which could be a fire hazard and this was discussed with the manager. On the 3rd April 2008, this room had been cleared in preparation for a visit from the fire officer due in April. Ashleigh House Care Home DS0000002188.V361550.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30, Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The low staff numbers severely restrict the ability of the service to deliver person centred support, provide activities, or meet their personal cultural or religious needs. The service does not follow their recruitment procedures and leave residents vulnerable, when checks on the suitability of prospective carers have not been carried out. EVIDENCE: During this visit, only the manager and one carer were working to meet the needs of the sixteen residents, with one carer working in the kitchen to prepare the meals in the absence of the cook. The expert by experience, in the lounge area, noted one resident called for help for over five minutes to get to the toilet, and only received help when the resident’s distress was pointed out to the care assistant. Whilst in the lounge area, the expert by experience and I observed the carer trying to manoeuvre a resident who wished to go to the toilet into a hoist. As she was working alone, this was proving very difficult for her and the resident, as the carer tried to support her at the same time as working the hoist. Ashleigh House Care Home DS0000002188.V361550.R01.S.doc Version 5.2 Page 22 I spoke to the carer about this incident and she felt if there had been other staff available there wouldn’t have been a problem, but the majority of residents needed minimal assistance. I spoke to a male resident who had not had a shave and he informed me that he hadn’t had a shave because “the staff were too busy today.” This had a negative impact on him as he said he liked to have a shave every day. The rapport between the carer and residents was observed to be polite, cheerful and positive, even though she was the only person working with them. Residents spoken with, though, said they were satisfied with the care they get from the staff, but did say it was sometimes a long time before help came. Carers working during the day also go into the laundry room, which is in the basement, and do the laundry for the residents, which leaves residents at risk when there is only one working. The two staff spoken with both had National Vocational Qualifications at Level 2 and had received training in moving and handling on the 4th January 2008. A certificate of attendance at safeguarding training was seen in one file, and an induction pack was also in the file, with signatures on sections completed. Evidence was seen of training organised, but not yet undertaken, for dementia care, fire, first aid and basic food hygiene training, for carers. Recruitment procedures had not been followed as evidenced in the staff files seen. There were basic, outdated, application forms, which ask for information now considered discriminatory, for example “how many children? “ There was no evidence of interview, or responses to any interview questions to discover the experience, skills and suitability of the prospective carer, which could put residents at risk. None of the staff files had evidence of proof of identity, or photographs. There were no indications of previous employment, or health histories, to ensure the person was suitable and competent to work in the home. One staff file had no Criminal Records Bureau check completed and only one reference, which did not identify who it was from, whether professional or personal, but the duty rota clearly shows the carer working at the home. There was a POVA First (Protection of Vulnerable Adults) in place, but due to the shortage of staff, the rota shows this carer was involved with care of residents, not just shadowing, putting residents at potential risk. Ashleigh House Care Home DS0000002188.V361550.R01.S.doc Version 5.2 Page 23 Following discussions with the acting manager, this carer was sent home to await the Criminal Records Bureau check and also receipt of a professional reference to evidence suitability to work within the home. Agency staff were arranged to cover gaps in the duty rota and ensure there were more than two people working and during the visit made on the 3rd April, three carers were seen working, with two from an agency, supporting the care needs of residents and applications had been received from other prospective carers. Ashleigh House Care Home DS0000002188.V361550.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33, 37, 38, Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. Residents are being put at risk because of the lack of consistent management within the home, with low staffing levels, poor record keeping and poor quality reviewing of the service. EVIDENCE: This service has been run without a registered manager for a considerable time now, since April 2007, and the current acting manager has not yet applied for registration, although the Criminal Records Bureau check has been received. These frequent changes, and lack of management, direction and leadership, put residents at risk. Ashleigh House Care Home DS0000002188.V361550.R01.S.doc Version 5.2 Page 25 The lack of consistent management has had a detrimental effect on the quality of the service provided and this is evidenced with the number of areas where the home could do better. Staff do not have any contracts, terms and conditions, or job descriptions, which could lead to misunderstandings and staff not carrying out their roles effectively, putting residents at further risk. Staff spoken with said they were concerned they didn’t have a contract, but relied on their skills from previous jobs to carry out their role as carers. The provider said he visits the home almost every day to support the manager and carers, but there was no record of these visits in the signing in book. There were no records in the home of any visits by the registered provider, required by Regulation 26, to monitor, monthly, the quality of the service. However, these were subsequently viewed at the other home owned by Mr. Scott. None of the reports seen though, identified any issues of concern. The records kept by the Commission showed there had been no notifications of any untoward incidents, or deaths at the home, as required by Regulation 37, for a considerable time, a further indication of the lack of management of the service. Also required by the Commission was the Annual Quality Assurance Assessment Report, but this had not been returned by the registered provider, or acting manager. On questioning, both said they were not aware of this document, despite evidence, with the Commission, of letters requesting its return when overdue, and a warning letter sent directly to the provider, earlier in the year, and both the acting manager and the provider were informed this was an offence under Regulation 24 of the Care Standards Act 2000(Establishments and Agencies)(Miscellaneous amendments) Regulations 2006 not to do so. The acting manager had developed a simple quality assurance system to gain responses from residents about the standard of service they receive. This was carried out in January and identified issues around laundry, which were dealt with. There had also been a resident’s meeting, where, as minutes kept showed, residents discussed fire alarms, and what to do if there was a fire. There was no evidence though of a structured quality assurance system, for the provider and manager to monitor and audit all aspects of the service, as well as finding out the opinions of the residents to ensure the service continues to meet their needs, in the way they prefer, safely and in accordance with national standards. Ashleigh House Care Home DS0000002188.V361550.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 2 x 2 x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 3 1 2 2 1 2 2 1 2 STAFFING Standard No Score 27 1 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 1 1 x x x 1 1 Ashleigh House Care Home DS0000002188.V361550.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14(1)cd Requirement Timescale for action 06/06/08 2. OP7 15(2) 3. OP12 16(2)m You must make sure all prospective residents are consulted and a pre-admission assessment developed to provide information that the home is suitable and can meet all their physical, mental, spiritual and cultural needs, in accordance with their wishes and preferences. 06/06/08 You must make sure care plans are prepared in consultation with the service user and developed to meet all their physical, mental, spiritual, social and cultural needs, in a person centred way and are kept under review, notifying the service user of any revisions, so care workers can support them in the way they prefer. You must make arrangements, 06/06/08 after consulting with service users, to enable them to go outside the home on trips and take part in preferred, local, social and community activities, to help them improve their physical and mental well-being. DS0000002188.V361550.R01.S.doc Version 5.2 Ashleigh House Care Home Page 28 4. OP29 19(4) 5. OP33 24 6. OP33 24 You must make sure staff do not work within the home until thorough checks, including Criminal Records Bureau checks, two professional references, proof of identity, skills, health and experience have been received, and checked and recorded, to provide evidence the recruit is suitable to work with vulnerable people. You must develop and carry out an effective quality monitoring system of planning, action and review of all aspects of the service to make sure it is fit for purpose, including the structure and fabric of the building, and audits of policies, procedures and health and safety processes to monitor the quality of service provided and the well being of residents. Annual Quality Assessment Reports must be completed and returned to the Commission, as requested, It is an offence under Regulation 24 of the Care Standards Act 2000(Establishments and Agencies)(Miscellaneous amendments) Regulations 2006 not to do so. Referred for enforcement as failed to supply 2007 Annual Quality Assessment Report . 06/06/08 06/06/08 18/03/08 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 Care Home DS0000002188.V361550.R01.S.doc Version 5.2 Page 29 Ashleigh House Care Home DS0000002188.V361550.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Care Home DS0000002188.V361550.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. 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