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Inspection on 25/03/09 for Ashley Cooper House

Also see our care home review for Ashley Cooper House for more information

This inspection was carried out on 25th March 2009.

CSCI found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

Key inspection report CARE HOME ADULTS 18-65 Ashley Cooper House 25 Hillyard Street Brixton London SW9 0NJ Lead Inspector Sonia McKay Unannounced Inspection 25 & 31st March 2009 09:30 th Ashley Cooper House DS0000067468.V374960.R01.S.doc Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Ashley Cooper House DS0000067468.V374960.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Ashley Cooper House DS0000067468.V374960.R01.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) Mrs Moharajia Dwarka Care Home 16 Category(ies) of Physical disability (16) registration, with number of places Ashley Cooper House DS0000067468.V374960.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (CRH - PC) to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Physical disability - Code PD The maximum number of service users who can be accommodated is: 16 31st March 2008 Date of last inspection 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.V374960.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 Star. This means the people who use this service experience Good quality outcomes. Whilst this service remains rated as Adequate there is improvement. This inspection was carried out over two days. The methods used to assess the quality of service being provided were: • • • • • • • • • Talking with the registered home manager and deputy manager Looking at the ‘Annual Quality Assurance Audit’ completed by the home manager (this document is sometimes called an ‘AQAA’ and it provides the Commission with information about the service) A tour of the communal areas of the home and some of the bedrooms Looking at records about the care provided to three of the residents Talking with residents during the two day inspection Reading the surveys that twelve residents kindly completed for the Commission before the inspection Looking at records relating to recent staff recruitment and training Looking at the way medicines are handled by staff in the home Looking at issues that the Commission has been notified about since the last inspection and how they were handled The Commission would like to thank all who kindly contributed their time, views and experiences to the inspection process. What the service does well: Prospective residents have the information they need to help them make an informed decision about moving to the home. Procedures are in place for a thorough assessment of needs before admission to the home and prospective residents are offered a chance to experience life in the home before they decide to move in. The home is clean and comfortable and most areas are adapted to meet the needs of people who use mobility aids. Comments from current residents include:“All staff treat me well” “Yes, of course staff listen to me!” “ Staff tidy up my room, day by day” Ashley Cooper House DS0000067468.V374960.R01.S.doc Version 5.2 Page 6 “If I am not happy about something I tell my key worker or the manager” “Before coming to Ashley Cooper house, I spent the whole day there and they asked me what my goals were” “I can put my ideas in my care plan, I am very happy with it! I can tell my key worker about things I would like to do”. Risk assessment is used to make staff aware of any risks and how to dangers and as a basis for increased independence. Residents enjoy the meals and their menu ideas are listened to and acted upon. Residents can maintain their friendships and relationships whilst living in the home. Residents receive personal care in the way that they prefer and require and their health needs are recognised and addressed. Medication is administered safely by trained staff. Residents views are listened to and acted upon and they are protected from abuse and neglect. Steps are taken to involve the residents in the running of the home and systems are in place to promote health and safety. What has improved since the last inspection? The residents guide to the home is now produced in a more accessible format making it easier for a wider range of people to understand. The manager is experienced and qualified and she is having a positive impact on the home and in improving the quality of care provided. A resident said “The new manager is good, she’s doing well. It’s much better here now. There’s more to do and more outings”. Residents have been consulted about things they would like to do whilst living in the home. There are now more things for people to do. Managers are doing more to monitor how well medication is being administered by staff. A full staff team is recruited. Ashley Cooper House DS0000067468.V374960.R01.S.doc Version 5.2 Page 7 Recruitment procedures provide residents with adequate protection and staff are supervised more often. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Ashley Cooper House DS0000067468.V374960.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ashley Cooper House DS0000067468.V374960.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 4. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective residents have the information they need to help them make an informed decision about moving to the home. The information is produced in a more accessible format making it easier for a wider range of people to understand. Procedures are in place for a thorough assessment of needs before admission to the home and prospective residents are offered a chance to experience life in the home before they decide to move in. EVIDENCE: The statement of purpose and service users guide have been revised since the new manager has been appointed. These documents now contain the legally required information and the service user’s guide is available in a more accessible format; with pictures and symbols to make it easier to understand. This is good for people who might find text only documents hard to understand. There are no new residents since the last inspection visit and there are currently two vacant placements. The home manager is currently marketing these vacancies. Ashley Cooper House DS0000067468.V374960.R01.S.doc Version 5.2 Page 10 The home manager describes the admissions procedure in the AQAA. Placing authorities must supply a full community care assessment of a persons care needs during the referral process. This enables the home manager to see if the placement is appropriate before beginning the homes own assessment process that involves obtaining any specialist reports or hospital discharge summary. The manager visits the person referred and also invites them to visit the home. If placement seems appropriate the resident is then invited for an overnight stay. This gives them an opportunity to experience life in the home before they make a decision to move in for a trial period. Ashley Cooper House DS0000067468.V374960.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is adequate information about the care needs of each person. There is also information about their life goals and aims. There is a need to consult each resident and to develop person centred plans for each area of care and support required. Each of these plans must be agreed with the resident concerned. Risk assessment is used to make staff aware of any risks and how to dangers and as a basis for increased independence. EVIDENCE: There is a staff office with locked cupboards where confidential written information is stored. Each resident has a file of information about their care. Records relating to the care of three of the current residents were examined. The manager assesses that care planning is an area that can be improved, and the staff are in the process of completing a new format of care plans for each resident. Ashley Cooper House DS0000067468.V374960.R01.S.doc Version 5.2 Page 12 Care plans seen during this visit were in various stages of completion. Some of the new style plans are in place and some are blank, pending completion by key workers. Some plans had been agreed and signed by the resident concerned and some had not. Current residents have wide ranging needs, in addition to a mobility need. Some also have a learning disability and/or need help with communication and help to manage their emotions. There are some new and detailed written guidelines for staff to follow when working with individual residents and these guidelines must now be developed in to care plans with each resident so that they (or their relatives/advocate) can be properly consulted and sign the care plan as evidence of their consultation and agreement. The range of care plans available should also include a wider range of topics, for example support that a person needs to safely manage their personal finances and cultural needs. There is information about people’s life history and their future plans and aims. These documents are written in the first person, as if the resident had written them themselves. This is good. Feedback from a placing authority social worker is positive. A recent placement review indicates substantial improvement in the resident’s quality of life and all actions agreed at a prior placement review had been addressed. A key worker system is in operation. This means that each resident has an allocated member of staff (or two) to help them plan their care and make their appointments. Residents are consulted about their choice of key workers from within the team. A resident said, “I can put my ideas in my care plan, I am very happy with it! I can tell my key worker about things I would like to do”. The manager plans to improve the service by ensuring that all residents have access to an advocacy service within the next twelve months. Information about local advocacy groups is also now available in the communal lounge. There is also a move towards making written care plans more person centred. Each resident has a general health and safety risk assessment. Risks relating to care, activities and any emotional needs are also included in the written information. The three sets of records examined showed that risks are reviewed regularly. Ashley Cooper House DS0000067468.V374960.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: 12, 13, 15, 16 & 17. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are more things for people to do and residents can maintain their friendships and relationships whilst living in the home. Residents enjoy the meals and their menu ideas are listened to and acted upon. Some residents now have less opportunity to cook independently and this should be addressed as the main kitchen is not accessible. EVIDENCE: During the last inspection a requirement was issued for residents to be consulted about the activities they wanted to take part in as there was a shortage of supported activity for some people. Evidence seen during this inspection indicates that this issue was discussed in group meetings and in one to one meetings between residents and their key worker. Ashley Cooper House DS0000067468.V374960.R01.S.doc Version 5.2 Page 14 Residents were observed to be engaging in a variety of activities over the course of this inspection. Some are able to organise their own social lives and they have friends and family visiting. Residents are able to maintain their personal relationships whilst living in the home. Some residents need staff support to access the community safely and to organise their activities and leisure. The home is close to public transport. The house vehicle has been repaired and the home manager is arranging for staff from within the team to be insured to drive it. This vehicle is used for outings and to drop people to college and daycentres. Dial-a-ride taxis are also booked by staff. During previous inspections it has been noted that there is not enough to do in the home. On this occasion residents and staff were seen to be spending time watching television, playing board games and also musical instruments (a keyboard). Some residents have televisions, music systems and computers and computer games in their own rooms. Some attend college and daycentres and three people are being supported to look for employment. There is now a pool table in a small communal room and more games and materials in the activities cupboard. A resident said “The new manager is good, she’s doing well. It’s much better here now. There’s more to do and more outings”. Some residents go away on holiday regularly. This includes trips overseas to see family. The residents pay for these trips themselves and the holidays are not staffed by staff from the home. Residents have house meetings. These meetings are recorded and often there is discussion about activities and meals. There is evidence that the manager acts on issues raised in these meetings and there are plans to increase the amount of community based activities organised by the home over the next year. Placement review feedback from a local authority social worker is positive, “There is profound and qualitative improvement. A weekly plan of structured activity and the resident is much more active in the community”. The manager assesses that residents could be better supported to undertake more housekeeping in accordance with their ability. There are communal gardens. There are garden parties and barbeques in good weather. Ashley Cooper House DS0000067468.V374960.R01.S.doc Version 5.2 Page 15 Residents said they enjoyed the meals served and they are each asked what they would like to eat each day. There is a rolling menu with several choices for each meal. There are late night snacks available if required. There is a chef and he also prepares packed lunches for people to take to college or daycentre. Meals include fresh fruit and vegetables and a record is kept of what each person eats. Some residents require feeding assistance and this is given by staff who were observed to be patient and attentive. There is a catering style kitchen with a serving hatch into the communal dining room/lounge. The kitchen is not adapted to be used by people with wheelchairs or other mobility aids. There used to be small cooking areas in the central hallway. Some residents liked to prepare some of their own meals and have dinner parties. The cooking areas have been deemed too much of a fire risk and have now been removed. One resident said she misses the opportunity to cook for herself and her friends. Residents can still make themselves cold snacks and hot and cold drinks. It is recommended that consideration be given to how residents can be supported to maintain and develop their food shopping and cooking skills. Ashley Cooper House DS0000067468.V374960.R01.S.doc Version 5.2 Page 16 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents receive personal care in the way that they prefer and require and their health needs are recognised and addressed. Medication is administered safely by trained staff. EVIDENCE: There are written guidelines for how people wish and need to be supported to maintain their personal care. Some residents do this independently or with verbal prompting and/or advice from staff, others need full assistance including use of hoists and other mobility and bathing aids. Assistance is provided in the privacy of bedrooms and bathrooms. A resident said that his support with personal care was very good. According to daily logs the condition of each resident is monitored and appropriate referrals made to relevant health professionals. Ashley Cooper House DS0000067468.V374960.R01.S.doc Version 5.2 Page 17 Annual health checks are completed. Staff supports residents to attend appointments at hospitals, dentists, opticians. Health action plans are in place and records are kept of people’s weight and, if appropriate, any seizures they may experience. A resident said, “If I feel ill, I tell the staff and they make me an appointment” Some residents have been advised to do daily physiotherapy. Guidelines are available in bedrooms and staff were observed to encourage people to do their daily exercises and to assist when necessary. This helps people to increase and maintain their mobility. A district nurse attends to administer insulin to one resident. A refrigerated medication cabinet is available for storing the insulin and regular temperature checks are taken to ensure correct storage. All of the residents need some form of staff assistance to take their medication. None are self medicating at this time. The medication procedures were examined. Medication is supplied from the pharmacist in blister pack and stored securely. MAR (Medication Administration records) sheets were found to be accurately completed with signatures present for all medicines administered. A spot check of one medication indicated the correct amount in stock. There is information about common side effects and staff are all trained before they are allowed to administer the medication. Although there were no gaps in the MAR sheets and medicines in stock were accounted for, the home needs to refine the procedures for checking medication monthly. This was the subject of a requirement in the previous inspection report. The new deputy manager had just completed an audit of medication. This must be done regularly to ensure medication is being administered properly by staff at all times. The manager plans to improve the handling of medication by introducing specific medication care plans and also to look at risks relating to self medication. Ashley Cooper House DS0000067468.V374960.R01.S.doc Version 5.2 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents views are listened to and acted upon and they are protected from abuse and neglect. EVIDENCE: A complaints system is in place and posted in the communal areas of the home. Residents who commented in surveys and in person said they know how to make a complaint or raise a concern and feel able to do so. According to the log viewed no complaints were received since the last inspection. Resident’s group meetings and key worker meetings provide a suitable forum for individuals to express concerns. Records indicate that concerns are listened to and acted upon. The home manager plans to improve the information about how to make a complaint to make it more accessible to people with a learning disability. The home manager appropriately referred one incident to the local authority under adult safeguarding procedures. There was an investigation and a member of staff was dismissed. As recommended in previous inspection reports, a copy of the local authority safeguarding procedures is now available for staff reference. Ashley Cooper House DS0000067468.V374960.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is clean and comfortable and most areas are adapted to meet the needs of people who use mobility aids. EVIDENCE: The home is reasonably clean and comfortable. All bedrooms, bathrooms and communal areas are situated on the ground floor of the building. There are door opening devices on the front door and into bedroom hallways. This makes it easier for people in wheelchairs to move around the building. There is CCTV to the exterior parts of the building as a security measure. There is also a large level access rear garden and front garden protected by security fencing. Ashley Cooper House DS0000067468.V374960.R01.S.doc Version 5.2 Page 20 The communal lounge is more homely now and there is more furniture. There is a programme of redecoration in place and the carpets have been replaced since the last inspection. Bathrooms are adapted and a range of assistive bathing facilities are available, as recommended by an occupational therapist. Bedrooms are all single occupancy and many are highly personalised. Residents said that they are comfortable in their rooms and that their rooms are warm enough. Emergency call alarms are in place and were working properly during the inspection. Clinical waste is stored correctly and there are a sufficient number of bathrooms and WCs with adequate hand-washing facilities. The kitchen is not accessible and this should be considered in any refurbishment. Ashley Cooper House DS0000067468.V374960.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A full staff team is recruited and there is now a need to co-ordinate team training and development to ensure that each member of staff is trained to meet each person’s individual needs. Recruitment procedures provide residents with adequate protection and staff are supervised more often. EVIDENCE: The new home manager has just finished recruiting new staff to the home and now the team better reflects the cultural diversity and gender composition of the resident group. There were a sufficient number of staff on duty during this inspection and the staff on duty were as listed on the staffing duty rota. There is a part time administrator to help with paperwork and there is a deputy manager and two senior support workers. Ashley Cooper House DS0000067468.V374960.R01.S.doc Version 5.2 Page 22 There are currently four members of staff on duty during the day and two at night. Staff meetings are held regularly and, as required in the previous inspection report, the frequency of staff supervision meetings has now increased. Recruitment records for three new members of staff were examined. Records and checks required by regulation were in place and staff had not started work in the home before a POVA First check was obtained. Staff receive a combination of in house and mandatory training as an induction to working in the home. Induction records were not available and the manager said that new staff were currently still working through the booklets with either herself or the deputy manager. Some recently appointed staff were attending a staff induction session during this inspection. The manager is in the process of organising individual training profiles for each member of staff. This information is being added to a team training matrix that will better enable the manager to develop a team training and development plan. This must be done to ensure that staff each receives the right sort of training and periodic refresher courses. Training is booked via the head office and also via a local team for adults with a learning disability. There is progress in developing a qualified staff team. Out of twenty staff, ten have attained a vocational qualification at NVQ level 2 or above and the remaining staff are either studying, waiting for certificates or waiting to start training. Ashley Cooper House DS0000067468.V374960.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 & 42. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager is experienced and qualified and she is having a positive impact on the home and in improving the quality of care provided. Steps are taken to involve the residents in the running of the home and systems are in place to promote health and safety. Record keeping must be improved to ensure that residents are protected from abuse. EVIDENCE: The newly appointed registered manager has 22 years experience of residential care. She is qualified in care and management and also has a nursing background. She is familiar with local resources and services. Ashley Cooper House DS0000067468.V374960.R01.S.doc Version 5.2 Page 24 There is positive feedback about her management of the home. Residents who commented said they would raise issues with her if they had a problem. Line management within the home is clear. There are two senior support workers, a deputy manager and a manager. The manager is supervised by the area manager, who also undertakes monitoring visits of the service. The majority of requirements and recommendations from the previous inspection report have been addressed. The provider has a management training and development programme and the manager and deputy have attended conferences. The area manager visits the home each month and undertakes quality monitoring in accordance with Regulation 26. The reports of the outcomes of these visits are held in the home. There is a quality assurance plan that involves consulting residents about their experiences in the home and asking them to complete surveys. There are plans to increase the range of stakeholders surveyed to include local authority care managers and relatives. There is a record of visitors to the home. There is a record of cash and valuables held in staff safekeeping and purchase receipts are retained. Inventories of the personal possessions of each resident are not yet complete. This must be done to ensure that ownership is clear and to provide residents with adequate protection. A record of the personal items of furniture brought into the home by each resident is a legal requirement. There are regular fire evacuation drills and fire fighting equipment checks. Hoists and wheelchairs are visually checked and periodically professionally checked. The kitchen has been checked by local authorities and there is a good standard of hygiene. Fire safety authorities visited the home in 2008 and made a list of requirements. The home manager said that there is progress in addressing these requirements. Ashley Cooper House DS0000067468.V374960.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X 3 3 X Version 5.2 Page 26 Ashley Cooper House DS0000067468.V374960.R01.S.doc 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 YA6 Regulation 15 Requirement Residents (or their representatives) must be consulted about planned care and from this consultation there must be a written plan as to how each of their needs, in respect of health and welfare, are to be met. The plans must be available to residents and kept under review. Residents must also be notified of any revision. The registered person must ensure that there is 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 30/04/08 is not met. There must be a record of the furniture that each resident brings into the home. Timescale for action 31/07/09 2. YA35 18 31/07/09 3. YA41 17(2) 31/07/09 Ashley Cooper House DS0000067468.V374960.R01.S.doc Version 5.2 Page 27 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. Refer to Standard YA6 YA17 Good Practice Recommendations Staff should consider a wider range of needs when developing care plans with each resident. For example, how cultural needs are to be met. Residents should have the opportunity to be more involved in cooking and food shopping as part of developing their independent living skills. Ashley Cooper House DS0000067468.V374960.R01.S.doc Version 5.2 Page 28 Care Quality Commission London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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