Inspection on 26/09/05 for Ashleigh [Minchinhampton]

This inspection was carried out on 26th September 2005.

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

Other inspections for this house

Ashleigh [Minchinhampton] 12/01/09

Ashleigh [Minchinhampton] 13/01/07

Ashleigh [Minchinhampton] 09/02/06

Ashleigh [Minchinhampton] 12/10/04

Ashleigh [Minchinhampton] 20/07/04

Ashleigh [Minchinhampton] 17/02/04

Ashleigh [Minchinhampton] 03/12/03

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Ashleigh 3 Box Crescent Minchinhampton Glos GL51 9DJ Lead Inspector Mr Paul Chapman Announced Inspection 26th September 2005 09:00 Ashleigh DS0000016369.V249765.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ashleigh DS0000016369.V249765.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ashleigh DS0000016369.V249765.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ashleigh Address 3 Box Crescent Minchinhampton Glos GL51 9DJ 01453 886636 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) Gloucestershire Group Homes Joanne Wheeler Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Ashleigh DS0000016369.V249765.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection: 12/10/04 Brief Description of the Service: Ashleigh is a semi-detached house with accommodation for three adults with Aspergers Syndrome/Autism. This home differs from other homes within the organisation as the service users display more autistic needs. The organisation offers a very specialised, individual service for its service users, and staff receive training to support them appropriately. The home is situated in Minchinhampton, near Nailsworth and enables service users to access local community facilities such as shops, take aways, chemists and a Post Office. Service users also have access to transport that is provided by the home and this enables them to access facilities in several other local towns. Family and friends are welcome to visit the home at any time and service users can meet them in private if they wish to. The service users attend various activities, which include Day services provided by Gloucester Group Homes and college courses. The inspector has visited the day service that is provided by the organisation. It has been developed specifically for people who have Aspergers syndrome/Autism and offers service users very individual programmes to meet their needs. Ashleigh DS0000016369.V249765.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was completed over a period of 4 hours on a day in September 2005. When the inspector arrived all three of the service users were at home before leaving to attend their day services. The inspector spoke with one of them and was able to observe the interactions between the staff and service users. As part of the inspection a tour of the premises was completed with a member of staff. The inspector examined one of the service user’s care packages in depth looking at their needs assessments and subsequent care plans. In addition to this the inspector examined other documents and records that the regulations require to be completed. What the service does well: Staff have produced a guide to working at the home that enables new and relief staff to work effectively and consistently with the service users. In addition to this guidelines have been written for one of the service users to identify the behaviour he might display and the staff’s strategy for supporting/managing them. Assessments of service users needs are comprehensive and IPP’s (individual Programme plans) are developed to meet those needs. Both of these documents are regularly reviewed. Service users have the opportunity for personal development and to take part in the leisure activities they wish to. The organisation provides the service users with a pleasant, homely environment that is safe and meets the current service users’ needs. Staff are caring and well informed about the needs of the service user group. Ashleigh DS0000016369.V249765.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? 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. Ashleigh DS0000016369.V249765.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ashleigh DS0000016369.V249765.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 The Statement of Purpose/Service User’s Guide provides prospective service users and their representatives with comprehensive information about the organisation and the service they can provide. EVIDENCE: No service users have been admitted to the home since the previous inspection. Since the previous inspection the organisation have developed a Statement of Purpose/Service User’s Guide that meets the criteria of the standards/regulations. Ashleigh DS0000016369.V249765.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 8, 9, 10 The completed assessments enable staff to identify service users needs and develop plans to meet those needs. Comprehensive risk assessments minimise the potential risks to the service users going about their daily lives. EVIDENCE: The inspector examined one service user’s file in depth looking at their assessments, care plans and other related and required documents. Service users are able to keep their files in their rooms if they wish. All the documents seen were stored and recorded appropriately. All of the service users have a key worker. Staff had completed a skill assessment for the service user that identified their ability to complete day-today tasks such as personal care, dressing, cooking, cleaning, washing, etc. This had been reviewed in April ’05. From this assessment staff had developed an Individual Programme Plan (IPP), which provided guidelines for meeting a goal identified by the skill assessment. When the service user completes this IPP staff record the service user’s actions and what support was required for them to complete the activity. Staff then review these records periodically. Ashleigh DS0000016369.V249765.R01.S.doc Version 5.0 Page 10 Evidence was seen of goals being changed after a period of time if they are deemed unachievable. Minutes of the service user’s annual review by their funding authority were present in their file. This had focused on reviewing their care plans and assessing their needs. Part of the review document had been completed by the service user with other information being supplied by the home and day service. The service user had signed the document. A staff member has written guidelines that identify behaviour that may be displayed by a service user and a strategy for staff to follow to manage it correctly. It highlights the phrases, speech and actions that may be effective. This is good practice and enables staff to provide a consistent approach. The service user’s records of recent income and expenditure were examined and seen to be correct at the time of this inspection. A financial management risk assessment had been completed by the staff. Staff have also completed an inventory of the service user’s personal possessions which was kept in his personal file, this was in need of updating and was brought to the attention of the staff. Each service user has a risk analysis that provides a summary of important information about them and their needs. All of the service users have risk assessments that identify different risks that may affect their safety and measures are identified to minimise those risks. The staff reviewed all of these assessments periodically, and these documents are then reviewed by the service co-ordinator. The service manager is going to supply the inspector with the names and addresses of the professionals involved the service users’ care so they can be sent comment cards asking about the service provided at the home. Ashleigh DS0000016369.V249765.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 17 Service users’ lead active lifestyles that include activities promoting their personal development and appropriate leisure activities. EVIDENCE: Every week each service user has a training day where they are supported by staff to complete tasks such as washing, cleaning and one to one leisure activities. Service users are also encouraged to complete day-to-day jobs around the home and a rota of these tasks was on the notice board in the kitchen. The activities completed by the service users include music, art and drama at the local college, swimming, horse riding, photography and attending the organisation’s day service and social centre. The service user who spoke to the inspector stated that he enjoyed the drama sessions he attended at the college and the staff member explained that they were involved in making the scenes for plays. Service users are able to choose when they get up and the activity timetable clearly identifies when service users have a “lie in”. All of the service users have had a holiday this year going to the Lake District, Cornwall, Ireland, Ashleigh DS0000016369.V249765.R01.S.doc Version 5.0 Page 12 North Devon and France. In addition to this service users are able to go on regular trips with the day service, recent and planned trips include: - The Great Western Railway, Cinema, Zoo, Symonds Yat, Stow on the Wold, Forest of Dean, Avebury, Chew Valley lake, Gerdd’ir Dyffryn Gardens, Fort Nelson, train journey (Watercress line), Cogges Farm Museum, Cosmeston Medieval Museum, Ham House, Coalport china Museum and tar tunnel and Kensington Palace. Staff stated that all of the service users use the local community facilities as well as those in the surrounding areas of Stroud, Nailsworth, Thornbury and Cheltenham as well. The current and previous menus were seen in the home’s kitchen and provided evidence that each of the service users chooses a meal per day and that everyone goes out for lunch at the weekend. The menus showed that a good range of healthy meals are available. The service users are encouraged to help prepare meals and staff make cakes regularly each week. The service manager is going to supply the inspector with the names and addresses of service users’ relatives so they can be sent comment cards asking about the service provided at the home. Ashleigh DS0000016369.V249765.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Personal care needs are highlighted through assessment and where required staff support service users to meet those needs. Physical and Emotional needs are addressed through the regular review of the service users needs. The manager must speak to the pharmacist about the practice of de-canting a service users medication into another container for their lunchtime medication. EVIDENCE: As highlighted previously in this report the skill assessment completed by the staff identifies whether a service user has any needs with their personal care. The service user’s file examined as part of this inspection provided an example of a personal care need being addressed with an IPP. Staff monitor the service user’s stocks of personal care goods (toothpaste, deodorant and shampoo) to ensure that they are always available. Each month staff complete a health check for each service user that records their weight and any appointments with other professionals. In addition to this more detailed notes of appointments with other professionals are recorded in personal files. Ashleigh DS0000016369.V249765.R01.S.doc Version 5.0 Page 14 Examination of the medication and the administration records raised a concern for the inspector because one service user must have medication administered at lunchtime. Staff decant the tablet into a pill bottle that he takes with him. The inspector recommends that the staff speak to a pharmacist about this practice as medication should not be decanted and the pharmacist may be able to suggest a method to address this problem. Records showed that two of the service users sign for their medication. Ashleigh DS0000016369.V249765.R01.S.doc Version 5.0 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 The complaints procedure enables service users to make their views heard if they are unhappy. Training in the protection and prevention from abuse will raise staff awareness of the issues that can present themselves when working with vulnerable adults. EVIDENCE: The home has a complaints procedure. No complaints have been made since the previous inspection. A requirement of a previous inspection report for one of the organisation’s other homes related to staff receiving training in Protection and prevention from abuse. The inspector has spoken to a member of the management team about this and they stated they will be organising training for all staff. Ashleigh DS0000016369.V249765.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27, 28, 29, 30 The home is attractively decorated to a good standard and provides the service users with a safe, homely environment in which to live. EVIDENCE: A tour of the premises showed them to be clean with no offensive odours. Since the previous inspection the home has employed a cleaner. Since the previous inspection the lounge has been decorated, a new kitchen has been installed and a conservatory has been built at the rear of the home. All of these areas were decorated to a high standard, and the new conservatory provides the service users with additional communal space. The staff member stated that it has made a real difference as it is used for eating meals in and also service users sit in there relaxing. Service users’ bedrooms were not seen on this occasion but at previous inspections they were seen to be decorated to a good standard and personalised with their possessions. Inspection of the bathroom showed that the requirement from the previous report had been met in that the bathroom ceiling had been refurbished. The Ashleigh DS0000016369.V249765.R01.S.doc Version 5.0 Page 17 rest of the bathroom looks a bit tired and requires decoration. The separate toilet next to the bathroom is also in need of decoration. To the rear of the property there is a good-sized garden with a greenhouse. The staff member explained that during the summer the service users had been growing tomatoes and lettuce. Ashleigh DS0000016369.V249765.R01.S.doc Version 5.0 Page 18 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): EVIDENCE: None of these standards were inspected on this occasion. The inspector has highlighted training needs for many of the staff across the organisation and has spoken with the service manager detailing the requirements. These were made a requirement of the inspection report for Wortley Villa. During a visit to the organisation’s office recent recruitment documents were examined and found to meet the criteria of the standards and regulations. Ashleigh DS0000016369.V249765.R01.S.doc Version 5.0 Page 19 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): 39, 42 Regular health and safety checks completed by the staff and other professionals ensure that risks to the service users are minimised. The staff are committed to providing a caring high quality service. EVIDENCE: The home is well run and comments from the staff member on duty showed them to have a genuine commitment to providing a high quality caring service in the home. Since the previous inspection the number of regulation 26 visits completed has increased and evidence was available of them being completed over recent months. August’s was missing and brought to the attention of the service manager. Since the previous inspection the home now has a locked COSHH cupboard. Cleaning materials used to be kept out but after and incident and a review of Ashleigh DS0000016369.V249765.R01.S.doc Version 5.0 Page 20 the risk assessment it was decided that they should be locked away. The home has an extensive health and safety file that has been developed by one of the staff and contains the relevant data sheets for the chemicals stored in the home. The organisation has a member of staff that is a qualified P.A.T (Portable Appliance Testing) engineer who is responsible for testing the electrical equipment across the organisation’s homes. P.A.T. was completed in May ’05. An engineer had serviced fire equipment in May ‘05 The fridge and freezer temperatures are monitored daily and the water temperatures are monitored weekly. Ashleigh DS0000016369.V249765.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 X X X X Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X 3 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X 2 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X X X X X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Ashleigh Score 3 3 2 X Standard No 37 38 39 40 41 42 43 Score X X 3 X X 3 X DS0000016369.V249765.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? no 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(2) Requirement The manager must contact the pharmacist to identify a safe method for administering a service user’s lunchtime medication. The manager must ensure that all staff receive training in the protection/prevention from abuse. The manager must ensure that the bathroom and toilet are redecorated. Timescale for action 28/10/05 2. YA23 13(6) 30/12/05 3. YA27 23(2)d 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Ashleigh DS0000016369.V249765.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 DS0000016369.V249765.R01.S.doc Version 5.0 Page 24 - 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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