Inspection on 02/10/07 for Ashley Cooper House

This inspection was carried out on 2nd October 2007.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 21 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ashley Cooper House 25/03/09

Ashley Cooper House 31/03/08

Ashley Cooper House 27/11/06

Similar services:

Ashlong House

Spring Lane Care Home

Avenues (The) (Neave Crescent)

Barrington Lodge Nursing Home

Beacon House Nursing Home

St Mary`s Convent & Nursing Home

1-3 Frederick Gardens

The Royal Star and Garter Home

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

CARE HOME ADULTS 18-65 Ashley Cooper House 25 Hillyard Street Brixton London SW9 0NJ Lead Inspector Sonia McKay Unannounced Inspection 29th October 2007 09:30 Ashley Cooper House DS0000067468.V347242.R02.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 Ashley Cooper House DS0000067468.V347242.R02.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. Ashley Cooper House DS0000067468.V347242.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashley Cooper House Address 25 Hillyard Street Brixton London SW9 0NJ 020 7582 0194 020 7735 2210 chhill@ashleyhomes.org.uk www.sanctuary-care.co.uk Sanctuary Care Ltd 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) Mr A McFarlane Care Home 16 Category(ies) of Physical disability (16) registration, with number of places Ashley Cooper House DS0000067468.V347242.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th November 2006 Brief Description of the Service: Ashley Cooper House is a purpose built residential care home for 16 people with a physical disability. The service is managed by Sanctuary Care. The aim of the service is to enable people with a disability to live as independently as their disability will allow. Accommodation is at ground floor level with a suite of rooms and offices on the first floor that are only accessible to staff. The home has attractive gardens that some residents can access from their bedrooms; others gain access via the communal lounge/dining area. The home is close to local amenities and public transport connections. A copy of the most recent Commission inspection report is available on request. Fees range from £850.00 to £995.00 per week and depend on the individual care needs of each person. Ashley Cooper House DS0000067468.V347242.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was conducted over the course of one day, during which staff and residents of the service and their visitors provided information about the service during discussion. Documents relating to care, staffing and the physical environment were also examined. Before the inspection a senior member of staff completed an Annual Quality Assurance Audit (sometimes called an AQQA) of the service with assistance from an area manager. This provides the Commission with written information about the service, staff and training. The registered manager was not available during the inspection, as he has been on a period of extended leave due to ill health. The company has since advised that he has tendered his resignation. Interim management arrangements were in place at the time of the inspection, this involves a senior member of the care team acting as a manager with extra support from the area management team. What the service does well: What has improved since the last inspection? Steps have been taken to ensure that the home is free from unpleasant odours. The building floor plan has been updated to include which resident is occupying which bedroom. This would be useful information during a fire evacuation. Ashley Cooper House DS0000067468.V347242.R02.S.doc Version 5.2 Page 6 People who are considering working in the home are advised of the type of criminal conviction that would mean they would not be able to. What they could do better: Prospective residents have not been given sufficient information about the services provided in the home. Care needs are not adequately assessed and residents have not been consulted on plans for how staff will provide care and support and any risks that there may be when doing so. This means that staff do not have clear information about the care and support that they should be providing. In some cases this means that care needs are not being met. There is a need for better consultation with residents in all areas, both individually and as a group. The service has yet to act on recommendations made by an Occupational Therapist about how the home premises can be altered to make it more accessible, safer and suitably adapted for people with mobility needs. Residents who need support to establish and attend suitable occupation and leisure activities must be given better support to do so. More must be done to ensure that the dining area meets the needs of residents who use a variety of mobility aids, to ensure that they have maximum accessibility and as much independence as possible. A resident commented, “ I am a bit bored here, there is not much to do in the daytime!” Professional advice must be taken when planning any special diets, to ensure health and wellbeing. More must be done to ensure that residents get appropriate support with their personal care. Staff must take better care to administer medications as prescribed and to record when they have done so. Senior staff must take better care to monitor how medication is being handled in the home. The complaints procedure meets with regulatory requirements but care must be taken to ensure that the actions taken when residents make a complaint are properly recorded. Procedures are in place to protect vulnerable adults and staff are trained to recognise abuse. Ashley Cooper House DS0000067468.V347242.R02.S.doc Version 5.2 Page 7 Considerable alteration must be completed to ensure that this home is suitably adapted to fully meet the needs of residents with a mobility need and building security must be assessed. Senior roles and responsibilities are unclear and more care staff must undertake a vocational qualification in providing Care. There is also a need for better planning around team training and development. There is insufficient evidence of thorough staff recruitment checks and the frequency of staff supervision meetings has reduced. There has been a lack of effective leadership in the home and the registered provider has failed to monitor the service during a period when additional support should have been provided to staff and residents. Health and safety monitoring has slipped and steps must be taken to ensure the safety of residents. 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. Ashley Cooper House DS0000067468.V347242.R02.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 Ashley Cooper House DS0000067468.V347242.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 & 4. Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. Prospective residents have not been given sufficient information about the services provided in the home, but they have been given an opportunity to visit the service before they move in. Care needs are not adequately assessed and residents have not been consulted on plans for how staff will provide care and support and any risks that there may be when doing so. Written care plans and risk assessments are not in place at all in some cases. This is not safe. The service has yet to act on recommendations made by an Occupational Therapist about how the home premises can be altered to make it more accessible, safer and suitably adapted for people with mobility needs. EVIDENCE: This service is now run by Sanctuary Care, who are in the process of revising the information supplied to prospective residents. The revised Statement of Purpose and ‘Service Users Guide’ must be supplied to the Commission. Staff could not locate either document. (See requirement 1) The registered persons should produce a Service Users Guide in a format that is suitable for people who find text only information inaccessible. Ashley Cooper House DS0000067468.V347242.R02.S.doc Version 5.2 Page 10 (See recommendation 1) Two residents who moved into the home since the last inspection, confirmed that they visited the service to meet staff and other residents before making a decision to move in, but neither could recollect being given a written guide telling them about the home and the services provided. The information gathered during the resettlement of these individuals includes assessments completed by placing authority social workers. These assessments provide information about the needs of the people who have moved into the home. However, there is no record of an assessment undertaken by the home manager and initial care plans and risk assessments are not in place. (See requirement 2) For one resident this has led to lack of clarity about the support that should be provided. The resident is unsure of what staff can/should help with and said that it is embarrassing to ask for help with things like taking a shower, laundry and room care. Initial care plans and risk assessments must be drawn up in consultation with all new residents. These care plans and risk assessments must be reviewed soon after the placement begins to ensure that the service is appropriate and to allow adjustments to be made if necessary. Reviews of care plans and risk assessments must then take place at least twice a year or when a persons needs change in any way. Failure to produce written plans describing the care and support that staff must provide and failure to assess the associated risks, including that of selfmedication and moving and handling, places residents and staff at risk of injury and of resident’s individual care needs not being addressed or met. These are areas identified in the previous inspection, when a requirement was made for care plans to be put in place for all residents covering the full range of their need. This requirement is therefore not met. Urgent action must be taken to ensure the safety of residents. Additionally, as the home is registered for people with a physical disability, who often use wheelchairs and other mobility aids, the Commission required an Occupational Therapists assessment of the premises and facilities, to ensure that all areas of the home are accessible and safe for people with mobility needs. An Occupational Therapist assessed the premises in May 2005. The detailed report of the findings of this assessment was supplied to the CSCI. Recommendations are prioritised in the report: Ashley Cooper House DS0000067468.V347242.R02.S.doc Version 5.2 Page 11 Urgent priority. One recommendation. • To provide suitable wet room seating for drying, the use of a basin in all bathrooms, adjustable perching stools suitable for wet room use and shower chairs High priority. Eighty recommendations, including: • Detailed assessment of needs (equipment and therapeutic) to be completed prior to admission • Activities profiles for each resident o be completed prior to admission and an increase in the range of activities available in the home • Labelling all mobility equipment used by individual residents • Providing a designated pedestrian path to serve the entrance of the home • Providing adequate lighting on the entrance path and parking area • Providing a disabled parking bay • Providing suitable outdoor support railings and covered seating area • Providing kitchen facilities that are accessible to service users who use wheelchairs and other mobility aids • Extensive refurbishment of bathroom and toilet facilities There are also a number of medium and low priority recommendations. One area highlighted in the report has been addressed. Door opening at the main entrance is automated. This means that residents who are able to use an electronic key have independent access to the premises. The Occupational Therapists report is detailed and makes many urgent recommendations. An action plan of work to be completed on the premises, based on the assessment, has not been completed. This was also a requirement in previous inspection reports. This requirement is not met. (See requirement 3) Ashley Cooper House DS0000067468.V347242.R02.S.doc Version 5.2 Page 12 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9. Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. Failure to consult and plan with residents and failure to assess any risks that the person may be exposed to places residents and staff in danger of injury. Assessed and changing needs are not reflected in written care plans. This means that staff do not have clear information about the care and support that they should be providing. In some cases this means that care needs are not being met. There is a need for better consultation with residents in all areas, both individually and as a group. EVIDENCE: Discussion with senior management during the inspection indicates that Sanctuary housing, who run the home, are introducing a new format for writing care plans and risk assessments. There are plans in place for staff to be trained to use the new system. Ashley Cooper House DS0000067468.V347242.R02.S.doc Version 5.2 Page 13 Care plans and risk assessments examined during this inspection, were either not in place at all (in the case of a new resident), or had not been reviewed with the required frequency. (See requirements 2 & 4) The registered persons should develop care plans around areas identified in National Minimum Standard 2 ‘Needs Assessment’. (See recommendation 2) Residents house meetings are held occasionally, but there have been few meetings this year. The records of issues discussed and decisions made at these meetings are recorded and stored in a staff office. They would be more accessible to residents if they were stored in a communal area. (See recommendations 3, 4 & 5) Senior Sanctuary managers, who visited the home during the inspection to conduct staff recruitment interviews, discussed the arrangements that Sanctuary have for consultation with residents and resident groups. These include regular steering group meetings, although residents of Ashley Cooper House are not yet involved. Given that the majority of residents will require support to make an initial contact to an advocacy service, care must be taken to ensure that staff provide support to make this initial contact as necessary. (See recommendation 6) Ashley Cooper House DS0000067468.V347242.R02.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents, who are more able, can pursue the lifestyles of their choice whilst living in the home. Residents who need more support to establish and attend suitable occupation and leisure activities must be given better support to do so. Residents are generally happy with the meals prepared, and some are able to prepare meals for themselves. More must be done to ensure that the dining area meets the needs of residents who use a variety of mobility aids, to ensure that they have maximum accessibility and as much independence as possible. Professional advice must be taken when planning any special diets, to ensure health and wellbeing. EVIDENCE: Most residents require support to access community activities and resources. The majority of residents attend a daytime activity, like a day centre or college course. Some residents attend faith meetings with the support of their families. Ashley Cooper House DS0000067468.V347242.R02.S.doc Version 5.2 Page 15 Some residents go out without staff support and many have keys to the building and come and go as they please. There is a house vehicle, but it is not currently in use, this, along with a shortage of drivers, has reduced the amount of community-based activities available to residents. Alternative transport arrangements are in place in some cases, either from the local authority or ‘dial-a ride’ taxi services. These are not always reliable and on the day of the inspection, one resident was disappointed that transport did not arrive to take him to his planned activity. Transport has to be arranged in advance and this is less flexible than the home having the use of a vehicle. (See recommendation 7) The AQAA (Annual Quality Assurance Audit) states that the current residents are supported to go shopping, visit the library, the pub and the cinema. One resident, who moved to the home earlier this year, commented that “There is not much to do in the daytime, I often fall asleep, which makes it harder for me to sleep well at night”. There is no plan in place for how this resident will be introduced to local day services and leisure opportunities. (See requirement 2) Another resident, who has lived in the service for many years with minimal staff support, is quite happy with the lifestyle that she leads whilst living in the home. She spoke of having friends over for dinner and cooking for them and of enjoying the college courses that she is currently attending. The AQAA (Annual Quality Assurance Audit) states that a planned area of improvement is to identify and designate areas of the home that can be used for residents to entertain guests in as an alternative to entertaining them in their bedrooms. A small music centre and television is available in the communal lounge/diner. The majority of residents watch television and listen to music in their own bedrooms. There are two payphones available for residents to use. There is no computer or Internet access. Residents have been requesting Internet access for some time. (See recommendation 8) There is a catering style kitchen and main meals are prepared by a catering service. Meals are served in the communal lounge/dining room at reasonably set times. Snacks are available at other times. The main kitchen is Ashley Cooper House DS0000067468.V347242.R02.S.doc Version 5.2 Page 16 inaccessible to residents with mobility needs, but there are more accessible cooking facilities in the communal hallway, that some residents make use of. (See requirement 3) A record is kept of the meal choices of each resident. A four-week rolling menu programme is advertised in the communal lounge. A chef prepares culturally appropriate meals twice each week to meet the needs of residents of diverse ethnic backgrounds, seeking advice from staff with greater knowledge of appropriate recipes as required. Dishes from Africa and the Caribbean are available. Feedback about the quality of the food is mixed, some residents said it was OK and others said that some days were better than others. Kitchen equipment and food storage arrangements are adequate and records of kept of cold storage temperatures, and of the temperatures of cooked foods and delivered items. Samples of all meals served are held in the freezer for one week. The kitchen itself is in need of refurbishment as floor and wall tiles are damaged in some areas. A food hygiene and hazard analysis is not available. The chef on duty was unaware of any written assessment of kitchen hazards. Advice must be sought from the local authority environmental health department and a detailed analysis of kitchen and food preparation hazards undertaken and appropriate action taken as required. (See requirement 6) It is unclear whether dining table heights are appropriate for all residents who use a variety of wheelchairs and mobility aids. During the previous inspection it was noted that some residents were sitting at the dining table in a sideways position, as their wheelchairs could not fit under the table. (See requirement 3 & 4) One resident is listed on menu plans as needing a ‘Gluten-Free’ diet. Arrangements for this were examined and are sparse. There was only a small packet of gluten free flour, and this was stored with other food produce, risking cross-contamination. Discussion with the acting manager indicates that this diet is a family preference rather than a medical need (such as gluten intolerance) and the diet is based on advice from a family member who was supporting the resident in reducing his weight. When any issues of reducing or special diets are planned, advice must be taken from a GP and, if necessary, a dietician. This advice can be discussed with the resident and family (if the resident wishes them to be involved) and the agreed action must then be the basis for a specific nutritional care plan. (See recommendation 9 & requirement 2) Ashley Cooper House DS0000067468.V347242.R02.S.doc Version 5.2 Page 17 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. More must be done to ensure that resident gets appropriate support with their personal care, although healthcare is generally well supported and addressed. Staff must take better care to administer medications as prescribed and to record when they have done so. Senior staff must take better care to monitor how medication is being handled in the home. EVIDENCE: Residents are able to choose their own clothes and hairstyles in most cases. Some people are supported by staff or family to shop and buy clothing. A rota system is in place for use of the laundry facilities, each resident’s clothes are washed separately, and residents who are able to use the equipment themselves in some cases. Personal support is provided in the privacy of bathrooms and bedrooms. ‘Same gender’ staff support is not available as the majority of staff are female and the majority of residents are male. The AQAA (Annual Quality Assurance Ashley Cooper House DS0000067468.V347242.R02.S.doc Version 5.2 Page 18 Audit) also cites recruiting more men as a current aim so that residents can choose who provides their personal care. (See recommendation 10) Failure to consult a resident about personal care support needs has led to embarrassment for the resident and to staff being unclear of what support to offer and when to offer it. (See requirement 2) Times for getting up and going to bed are flexible. Health care records show that staff support residents to attend an appropriate range of health care appointments, including pro-active healthcare and health screening. A detailed account of the outcome of each appointment is maintained, unless the resident is able to attend the appointment themselves. The AQAA (Annual Quality Assurance Audit) states that residents are supported to make and attend annual health checks. All staff responsible for administering medication have undertaken medication training. Medication is administered by staff that are leading the shift. Medication is stored in a locked cupboard. At the time of this inspection, all prescribed medications are in stock. The acting manager stock checks on a regular basis to ensure continuous supply. Medication administration records show that there are a number of days when staff have not signed for prescribed medication. A spot check of dossette boxes indicates that medication has been administered correctly during the week of the inspection. It is unclear whether the earlier gaps in recording are as a result of staff failing to administer the medication or failing to sign when they have done so. Either is dangerous for residents. The stock checking system currently used has not included investigation of what stock should be available (to ensure that staff are administering correctly) and any gaps in recording. (See requirements 7 & 8) Ashley Cooper House DS0000067468.V347242.R02.S.doc Version 5.2 Page 19 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The complaints procedure meets with regulatory requirements but care must be taken to ensure that the actions taken when residents make a complaint are properly recorded. Procedures are in place to protect vulnerable adults and staff are trained to recognise abuse and how to respond. EVIDENCE: Policies and procedures about how complaints will be handled are in place and meet regulatory requirements. The record of complaints indicates that the last recorded complaint was in October 2006, when a resident made a complaint about the service to a visiting Occupational Therapist. The record shows that a meeting was held with the placing authority social worker and resident. The record does not state the outcome of the investigation. The acting manager said that the resident retracted the complaints and refused to attend any further meetings about it. The action taken and outcomes are not adequately recorded. (See requirement 9) There are adult protection procedures in place, although the local authority (Lambeth) adult protection procedures are not available. Staff should be familiar with these procedures to ensure that they take correct action. (See recommendation 11) Ashley Cooper House DS0000067468.V347242.R02.S.doc Version 5.2 Page 20 There have been no adult protection investigations since the last inspection visit. The AQAA (Annual Quality Assurance audit) states that all staff have received training in the P.O.V.A (the Protection Of Vulnerable Adults). Many residents require assistance to manage their financial affairs. This is often provided by families in terms of the collection of state benefits and management of savings, sometimes via court of protection protocols. Family members provide cash to be held in safe keeping by staff. This money is stored in a safe and is available for residents to spend when they wish. Appropriate records are maintained and checked regularly and receipts for purchased items are retained in all cases. A spot check of the cash balances, receipts and records for two residents provided evidence of accurate accounting. Ashley Cooper House DS0000067468.V347242.R02.S.doc Version 5.2 Page 21 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27, 28 & 30. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Considerable alteration must be completed to ensure that this home is suitably adapted to fully meet the needs of residents with a mobility need and building security must be assessed. EVIDENCE: The ground floor home provides residents with level access to the bedrooms, communal areas and garden. The premises are reasonably clean and decorated. As detailed earlier in this report, an occupational therapist assessed the suitability of the premises for people with mobility needs and has made many recommendations for improvement. Bathroom and shower facilities are in need of refurbishment and the main kitchen is inaccessible to most residents. Dining tables available are not suitable for people using some models of wheelchair. An action plan and schedule for these improvements is required. (See requirements 3 & 5) Ashley Cooper House DS0000067468.V347242.R02.S.doc Version 5.2 Page 22 Bedrooms are single occupancy and are accessed via a central hallway, along which the main communal area/dining room is also situated. Some of the bedrooms are personalised and some have access to the garden. Each bedroom is fitted with an emergency call alarm and has an appropriate door lock fitted. During the previous inspection it was noted that there was an unpleasant smell of urine in one bedroom. During this inspection, senior managers advised that further odour management issues had arisen as a result of continence needs and an alternative floor covering was on order for the bedroom. The communal lounge/dining area is large and not particularly comfortable. The only seating available is dining chairs. (See recommendation 12) External building security is of concern, as some bedrooms have patio doors that open directly onto gardens that are accessible from the road outside. The registered provider is looking at ways to improve perimeter fencing. Whilst this is being done it is essential that current risks are assessed and appropriate measures put in place to ensure the building is safe from intruders (for example, during hot weather when residents may leave these doors open). (See requirement 10) Ashley Cooper House DS0000067468.V347242.R02.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 & 36. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Senior roles and responsibilities are unclear and more care staff must undertake a vocational qualification in providing Care. There is also a need for better planning around team training and development. There is insufficient evidence of thorough staff recruitment checks and the frequency of staff supervision meetings has reduced. EVIDENCE: There are team leaders and senior support worker posts. Job descriptions and responsibilities are the same for both posts. These posts must be harmonised so that residents, staff and relatives are clear about the roles and responsibilities of senior staff. (See recommendation 13) Person specifications should be reviewed, as presently the senior posts person specifications do not require any experience in care or staff supervision. Given the complex care needs of the residents this is inappropriate. (See recommendation 14) Ashley Cooper House DS0000067468.V347242.R02.S.doc Version 5.2 Page 24 A part time administrator post is currently vacant, as are five support worker posts. A team of ‘bank’ workers who are familiar with the service and the residents currently meets staff shortages. A recruitment drive is underway at the time of the inspection to address this. The AQAA (Annual Quality Assurance Audit) states that of the sixteen strong team of care staff, seven have attained a National Vocational Qualification in Care (NVQ) at level 2 or above and two members of staff are working towards the award. There is a shortage of male staff and the gender mix of staff does not reflect that of the residents. This means that ‘same sex’ personal care is not provided and young male residents have, during previous inspections, expressed a desire to go out in the community, for example to the pub, with male staff instead of female. (See recommendation 10) There are two night waking staff on duty at night and a minimum of three members of staff on duty during the day (one of whom is a senior or team leader). Records of staff duty are in place. Staff are not paid for the time needed to take part in early morning handover meetings between shifts. These essential meetings are therefore brief. (See recommendation 15) Although there are records of training undertaken and a few planned training days, as noted during the previous inspection, there is no team training and development plan in place. The training and development plan should cover NVQ training, mandatory training, refresher courses and specific training in meeting the needs of the current residents, for example, training in epilepsy, diabetes, brain injury, communication and sensory impairment. (See requirement 11) Human resource policies and staff application information has been updated to state that the criminal offences that would exclude applicants from consideration, as recommended in the previous inspection report. In the previous inspection report, a requirement was made in regard to retaining evidence of staff induction training in accordance with Skills for Care guidelines. No new staff have been employed in the interim period so compliance with this requirement cannot be examined during this inspection. The service is in the process of recruiting new members of staff so compliance will be examined during the next inspection. Ashley Cooper House DS0000067468.V347242.R02.S.doc Version 5.2 Page 25 The AQAA states that a new induction record has been introduced to ensure effective monitoring and recording of staff induction. Recruitment records for two of the new bank staff were examined, and were found to be inadequate. Copies of references were missing. There is confirmation that both have satisfactory criminal records checks in place. A senior manager said that the full recruitment records were likely to be at the head office, as staff were not recruited directly to the service. (See requirement 12) Discussion with staff indicates that staff supervision meetings have not been held with the required frequency, as a result of the manager being absent and a senior member of staff also being on leave for an extended period. (See requirement 13) Ashley Cooper House DS0000067468.V347242.R02.S.doc Version 5.2 Page 26 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42. Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. There has been a lack of effective leadership of the home and the registered provider has failed to monitor the service during a period when additional support should have been provided to staff and residents. Health and safety monitoring has slipped and steps must be taken to ensure t the safety of residents. EVIDENCE: The registered manager has been on a period of extended leave since July 2007. At the time of the inspection it was unclear when he would be returning to work. Three days after the inspection the Commission was notified of his resignation. Ashley Cooper House DS0000067468.V347242.R02.S.doc Version 5.2 Page 27 A senior manager, present during part of this inspection, advised of a strengthening of the management arrangements, with urgent attention being directed towards care planning. Formal notification of the manager’s resignation and strengthened interim management arrangements were then provided to the Commission. A registered manger from another Sanctuary service will provide the senior member of staff in charge on a ‘day-to-day’ basis with additional managerial support, whilst recruitment of a new manager is underway. The post of registered manager must be filled as soon as possible to provide the home with necessary leadership and to begin the much-needed improvements of the service identified in this report. Many requirements and recommendations made in the last inspection report have not been addressed. (See requirement 14) The Commission has not received monthly visit reports in accordance with Regulation 26 since December 2006. Copies of the reports are not available in the home either. This means that the registered provider has not monitored the performance of the home properly. (See requirement 15) During the previous inspection it was noted that records suggest that fire evacuation drills have not been conducted with the required frequency. Again, during this inspection it is noted that there have been only two fire evacuation drills this year. The requirement made following the previous inspection is unmet. (See requirement 16) The previous inspection report also notes that the most recent fire authorities inspection report (24 March 2005) requires a fire plan to be developed. It is still unclear as to whether this has been developed. Staff could not locate a plan. Advice must be sought from fire authorities on an appropriate plan for service users with mobility needs in the event of a fire (including a fire at night). (See requirement 17) The building floor plan, available in the reception area of the home, does now stipulate bedroom numbers and the names of occupants, as recommended in the previous inspection report. Call alarm response times were tested and staff attended swiftly (within one minute). However, a bathroom emergency call alarm is broken. Staff were unaware when shown the broken cord. (See requirement 18) There is evidence that hoists and specialist bathing equipment, such as an easy access bath are safety tested regularly. Ashley Cooper House DS0000067468.V347242.R02.S.doc Version 5.2 Page 28 Hot water temperatures have not been tested since April 2007. This must be done more often to ensure safe operation of the valves that restrict the temperature of the water to within safe limits to prevent scalding. (See requirement 16) Ashley Cooper House DS0000067468.V347242.R02.S.doc Version 5.2 Page 29 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 1 2 2 3 1 4 2 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 2 29 X 30 2 STAFFING Standard No Score 31 2 32 2 33 3 34 1 35 2 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 1 1 1 X LIFESTYLES Standard No Score 11 2 12 2 13 2 14 2 15 3 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 1 2 1 X 1 X 1 X X 1 X Ashley Cooper House DS0000067468.V347242.R02.S.doc Version 5.2 Page 30 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 5 Requirement The registered person must revise the service users guide in accordance with recent changes in legislation. The timescale of 31/03/07 is not met. Evidence that action has been taken to meet this requirement must be supplied to the Commission by 2 YA2 YA6 15 The registered persons must ensure that residents know that their assessed and changing needs and personal goals are reflected in their individual care plans. The timescale of 31/03/07 is not met. Evidence that action has been taken to meet this requirement must be supplied to the Commission by 31/12/07 Timescale for action 31/01/08 Ashley Cooper House DS0000067468.V347242.R02.S.doc Version 5.2 Page 31 3 YA3 12(1) 13(4) The registered person must take action to address urgent and high priority recommendations made in the May 2005 occupational therapy report of the premises. The timescales of 31/01/06, 31/10/06 and 31/01/07 are not met. A detailed action plan and refurbishment programme must be supplied to the Commission by 31/01/08 4 YA9 12 13 5 YA17 13 23 The registered person must 31/12/07 ensure that staff enable residents to take responsible risks, ensuring they have good information on which to base decisions, within the context of the resident’s individual Plan and of the home’s risk assessment and risk management strategies. The registered person must 31/12/07 ensure that dining tables are of a type that is suitable to residents who use wheelchairs. The timescale of 31/03/07 is not met. Evidence that action has been taken to meet this requirement must be supplied to the Commission by 6 YA17 13 16 23(5) 7 YA20 13(2) The registered person must ensure that a hazard analysis is conducted of the kitchen and food storage areas and of food preparation and take any remedial action necessary. The registered persons must DS0000067468.V347242.R02.S.doc 31/01/08 31/12/07 Page 32 Ashley Cooper House Version 5.2 ensure that medicines are administered as prescribed. Justified stock checks must be conducted and a record kept of the outcome of these checks and action taken. The timescale of 31/12/06 is not met. Evidence that action has been taken to meet this requirement must be supplied to the Commission by 8 YA20 17 The registered persons must ensure that a record is kept of any medication administered to a service user. If a service user is self-medicating a prescribed item an appropriate record be kept and a risk assessment must be conducted. The timescale of 31/12/06 is not met. Evidence that action has been taken to meet this requirement must be supplied to the Commission by 9 YA22 17(2) The registered person must ensure that a record is kept of all complaints made by residents or their representatives or by persons working at the care home about the operation of the home, and the action taken by the registered provider in respect of any such complaint. The registered person must assess any risks relating to building security and ensure DS0000067468.V347242.R02.S.doc 31/12/07 31/01/08 10 YA24 12(1) 13(4 23 31/01/08 Ashley Cooper House Version 5.2 Page 33 11 YA35 YA32 18 that adequate measures are put in place to ensure the safety of residents, staff and visitors. The registered person must ensure that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of residents. The timescale of 31/01/07 is not met. Evidence that action has been taken to meet this requirement must be supplied to the Commission by 31/01/08 12 YA34 19 13 YA36 18(2) 14 YA37 8 15 YA39 26 The registered person must ensure that there is evidence of thorough checking during recruitment of staff in accordance with Regulation. The registered person must ensure that staff receive the necessary support and supervision to enable them to undertake their duties effectively. Supervision meetings must be held regularly and a record must be kept of agreed actions. The registered person must appoint a manager who is appropriately qualified and experienced and this manager must register with the Commission. The registered person must ensure that the home is visited in accordance with Regulation 26 at least once each month. The reports of the outcomes of DS0000067468.V347242.R02.S.doc 31/01/08 31/01/08 31/03/08 31/12/07 Ashley Cooper House Version 5.2 Page 34 16 YA42 23(4) these visits must be available in the service and supplied to the Commission. The registered persons must ensure that fire evacuation drills are conducted with the required frequency. The timescale of 31/12/06 is not met. Evidence that action has been taken to meet this requirement must be supplied to the Commission by 31/12/07 17 YA42 23(4) The registered persons must seek professional advice from the LFEPA on a suitable plan for evacuation in the event of a fire, given that some service users are moved from bed using a hoist. The timescale of 31/01/07 is not met. Evidence that action has been taken to meet this requirement must be supplied to the Commission by 31/12/07 18 YA42 12 13 19 YA42 12 13 The registered person must 31/12/07 ensure that the emergency call alarm system in place in the home is in good repair and is suitable to the needs of residents using it. The registered person must 31/12/07 ensure that hot water temperatures are tested regularly to ensure that hot water temperatures are within safe limits. Ashley Cooper House DS0000067468.V347242.R02.S.doc Version 5.2 Page 35 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 Refer to Standard YA1 YA6 YA8 YA8 YA8 Good Practice Recommendations The registered persons should produce a service users guide in a format that is suitable for people who find text only information inaccessible. The registered persons should develop care plans around areas identified in National Minimum Standard 2 ‘Needs Assessment’. The registered persons should encourage residents to chair house meetings and to take the minutes. The registered persons should store the minutes of house meetings in a communal area so that they are readily accessible to residents. The registered persons should ensure that residents are offered opportunities to participate in the day to day running of the home and to contribute to the development and review of policies, procedures and services. The registered persons should assist residents to find out about and contact advocacy services in the area. The registered persons should take steps to increase the number of staff who can be designated drivers of the house vehicle so that it can be used in a more spontaneous way in the evenings and at weekends. The registered person should provide a computer with internet access for residents. The registered person should seek advice from a GP about any special diets in place for any resident (such as ‘glutenfree’ or ‘reducing’ diets). The registered persons should take steps to recruit a sufficient number of male staff to ensure that same gender personal care support can be provided. The registered persons should obtain a copy of the local authority adult protection procedures and ensure that all staff are familiar with them. The registered persons should consider ways in which the communal areas of the home can be made more attractive and comfortable. The registered persons should harmonise the senior posts DS0000067468.V347242.R02.S.doc Version 5.2 Page 36 6 7 YA8 YA13 8. 9 10 YA14 YA17 YA18 11 YA23 12 YA28 13 YA31 Ashley Cooper House (senior and team leader) as the job descriptions and responsibilities are identical. 14 YA31 The registered persons should review the person specifications for senior posts and make experience of care and staff supervision a requirement. The registered persons should ensure effective staff communication in verbal handovers between shifts by making them part of the allocated shift time. 15 YA33 Ashley Cooper House DS0000067468.V347242.R02.S.doc Version 5.2 Page 37 Commission for Social Care Inspection Sidcup Office River House 1 Maidstone Street Sidcup DA14 5RH 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 Ashley Cooper House DS0000067468.V347242.R02.S.doc Version 5.2 Page 38 - 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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