Inspection on 27/11/06 for Ashley Cooper House

This inspection was carried out on 27th November 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 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 02/10/07

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 27th November 2006 09:00 Ashley Cooper House DS0000067468.V318953.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ashley Cooper House DS0000067468.V318953.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ashley Cooper House DS0000067468.V318953.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) Mr A McFarlane Care Home 16 Category(ies) of Physical disability (16) registration, with number of places Ashley Cooper House DS0000067468.V318953.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th December 2005 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 service users 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. Prospective service users are given a copy of the Service Users guide that gives information about the home and the services provided. A copy of the most recent CSCI inspection report is available in the reception area. Fees range from £850.00 to £995.00 per week and depend on the individual care needs of each service user. Ashley Cooper House DS0000067468.V318953.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was carried out in six hours over one day. The purpose of this inspection was to examine key areas of service not examined during a brief random inspection carried out on 30th August 2006. The inspection involved discussion with the registered home manager and four people living in the home, examining the care arrangements in place for three service users, looking at records, observation of activities and a partial tour of the premises. What the service does well: What has improved since the last inspection? The main entrance doors are now electronically controlled and better suited to meet the needs of service users with mobility issues. Service users who are able, now have an electronic key and can enter and leave the home with ease. Service users have been consulted about their preferred routines for personal care (for example bathing and showering) and comprehensive plans are in place of how these preferences will be achieved. There is better consultation with service users about their interests and leisure pursuits and staff are discussing these issues regularly on a one to one basis with each person living in the home. There is progress in training the staff in the specific needs of individual service users. Ashley Cooper House DS0000067468.V318953.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ashley Cooper House DS0000067468.V318953.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ashley Cooper House DS0000067468.V318953.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 & 5. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Prospective service users have the information they need to make an informed choice about moving to the home, but some service users may benefit from more accessible information. Individual aspirations and needs are assessed during a resettlement process that provides an opportunity to visit and to’ test drive’ the home before making a decision to move in. However, not all identified needs are adequately planned for. Each service user has a written contract detailing their terms and conditions of occupancy. Extensive environmental refurbishment is required to ensure that the home is suitable to meet the needs of service users with a physical disability and staff must be better trained to meet the specific needs of individuals accommodated. EVIDENCE: The statement of purpose document contains all of the required information about the services provided. Ashley Cooper House DS0000067468.V318953.R01.S.doc Version 5.2 Page 9 There is also a guide for people using the service. This contains a summary of the purpose of the home and a description of the services provided. Text only information is not accessible to some of the service users who have a learning disability. The service users’ guide should be produced in a format that is more an accessible. (See recommendation 1) Regulations about the service user’s guide have been amended to require greater detail to be included about the standard package of services provided in the care home, the terms and conditions which apply to key services, fee levels and payment arrangements. The guide is also required to state whether the terms and conditions (including fees) would be different in circumstances where a service user’s care is funded, in whole or in part, by someone other than the service user. Any notice of an increase of fees is to be accompanied by a statement of the reasons for such an increase. (See requirement 1) Prospective service users have an opportunity to visit the service before making a decision to move in and the registered provider obtains a detailed community care assessment of need from the placing authority before completing their own assessment, records of which are held on file. Initial care plans are developed with each new service user and are based on information contained in the care management assessment, the homes own needs assessment and discussion with the service user. However, care plans do not address each specific area of identified need in some cases. For example, cultural needs and methods of communication. (See requirement 3 & recommendation 2) Contracts of occupancy are in place and include details of the bedroom to be occupied under the agreement. An occupational therapist assessed the accessibility of the premises to service users in May 2005. The detailed report of the findings of this assessment was supplied to the CSCI. Recommendations are prioritised in the report: 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: Ashley Cooper House DS0000067468.V318953.R01.S.doc Version 5.2 Page 10 • • • • • • • • • Detailed assessment of needs (equipment and therapeutic) to be completed prior to admission Activities profiles for each service user to be completed prior to admission and an increase in the range of activities available in the home Labelling all mobility equipment used by individual service users 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 now automated. This is a major improvement for service users, some of whom now hold an electronic key fob that allows fully independent access. Discussion with the home manager indicates that an additional OT inspection of the physical environment was carried out in September 2006. The report of which is not available at the time of the inspection. The registered provider has indicated that necessary changes identified will be carried out in 2007. This report and subsequent action plan must be supplied to the Commission. (See requirement 2) Ashley Cooper House DS0000067468.V318953.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 & 10. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Although care plans have improved, more must be done to ensure that service users assessed and changing needs and personal goals are reflected in their individual plans. Service users are consulted about decisions in the home and can make decisions about their own lives where possible. Some service users may benefit from the assistance of an advocate. Service users are supported to take risks as part of an independent lifestyle. Information is handed handled appropriately. EVIDENCE: Written care plans and risk assessments formats have been revised, standardised and improved. Each individual care file now has a consistent format and comprehensive information about care needs and personal preferences. However, care plans are not sufficiently goal oriented and do not focus on skills, development and achieving identified aims and objectives Ashley Cooper House DS0000067468.V318953.R01.S.doc Version 5.2 Page 12 identified in reviews. There is also inadequate information about specific needs, for example, cultural needs. (See requirement 3 & recommendation 2) Given that the majority of service users 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 5) The majority of service users require assistance to manage their financial affairs. Family members provide the support in most cases. The suitability and effectiveness of this support is reviewed during annual care reviews with the placing authority. Service user house meetings are held regularly. This provides service users with an opportunity to discuss house issues and make decisions together. One service user is interested in chairing a meeting. This would be good practice and may encourage others to take a more active role in this potentially powerful forum. (See recommendation 3) 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 service users if they were stored in a communal area. (See recommendation 4) A service user satisfaction questionnaire has been developed and distributed. Service users have received feedback about this consultation in house meetings and in a summary document. Individual missing persons procedures are in place and service users have taken part in personal safety training and been provided with personal attack alarms if they wish. This is useful for service users who access the community independently. Records are stored securely and the home is registered for storage under Data Protection legislation. Ashley Cooper House DS0000067468.V318953.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): 11, 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. There are increased opportunities for service users to engage in education and leisure activities and to be part of the local community. Further improvement could be achieved with increased access to the house vehicle. Service users are able to maintain friendships and relationships. Although there is improvement the lack of adaptation restricts independent use of some of the areas of the home. Meals are healthy and service users enjoy the meals. EVIDENCE: Most service users require staff support to access community activities and resources. The majority of service users attend a variety of day centres and college courses. Some service users attend faith meetings with the support of their families. One service user visits a hydro pool and another attends weekly basketball sessions at a local leisure centre. Ashley Cooper House DS0000067468.V318953.R01.S.doc Version 5.2 Page 14 The home manager said that staff are supporting service users to make better use of local authority transport for people with physical disabilities and service users also use local public transport services. There is a house vehicle, but a shortage of drivers restricts its use at times. Only two staff are currently licensed and insured to drive the vehicle, and one is the home manager. (See recommendation 6) During the last key inspection, several service users expressed dissatisfaction with the range of activities available. Two requirements were made as a result. One in regard to improving the range of activities available in the home and the other in regard to supporting greater access to activities in the community. The staff have addressed these requirements be consulting service users about group activities during house meetings and by using the monthly key worker meetings to consult individual service users about preferred activities. During the summer there has been a house barbeque and disco. There is also a range of arts and crafts materials and board games available. A service user said, “The activities are OK”. Another service user said “I am going to a music class today, I enjoy playing the drums”. Another was preparing to attend a college course in IT, and another was going to the local shopping centre with a member of staff using public transport. A bank staff has been appointed as an in-house activities co-ordinator. This is not ideal and it would be better that a permanent member of staff undertake this key responsibility. (See recommendation 7) A small music centre and television is available in the communal lounge/diner. The majority of service users watch television and listen to music in their own bedrooms. There are two payphones available. There is no computer or Internet access. Service users have been requesting Internet access for some time. (See recommendation 7) 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 inaccessible to service users with mobility needs. (See requirement 2) Ashley Cooper House DS0000067468.V318953.R01.S.doc Version 5.2 Page 15 Small hob cooking facilities and fridges are available along the central hallway for service users who are able to use them. One service user enjoys preparing meals for her guests. The record of meals served to a service user who requires a pureed meal are now kept, as required in the previous inspection report. Records of the main meals served showed that a range of meals are served. A four-week rolling menu programme is advertised in the communal lounge. The chef prepares culturally appropriate meals twice a week as the service accommodates service users from diverse ethnic backgrounds. Seeking advice from staff with greater knowledge of appropriate recipes as required. Dishes from Africa and the Caribbean are available. A number of the service users are Muslim and the chef ensures that Halal meat is available. 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. A food hygiene report and hazard analysis are not available. Advice should be sought from the local authority food hygiene department. (See recommendation 8) On the day of the inspection service users who were at home during the day had a lunch of either a choice of freshly prepared sandwiches and salad, sardines on toast or omelettes with various fillings. There was a choice of fresh fruit or yoghurt for dessert. A service user said, “The chef is good, he makes a really good pizza!” The chef and staff on duty interacted well with service users during the mealtime and care staff provided any necessary assistance with eating. Some service users require specialist plates and cutlery to enable independence and these items are available and in use. However, some service users cannot sit with their wheelchairs under the dining tables and have to position their wheelchairs sideways to the table. This is not suitable or safe. (See requirements 2 & 4) Ashley Cooper House DS0000067468.V318953.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Service users receive support with personal care and their personal preferences and routines are discussed and recorded. Physical and emotional health needs are met but medication is not handled safely and there must be improvement in stock checking and recording. EVIDENCE: Service users are able to choose their own clothes and hairstyles in most cases. Some people are supported to shop and buy clothing. Laundry procedures have been reviewed as required in the previous inspection report and this has improved the efficiency of the laundry system and reduced the instances of clothing becoming mixed up. A rota system is in place with each service user having a different day for laundry and each service users clothes are washed separately. And each service user has an inventory of clothing on file. Each service user has a written plan detailing their individual support needs and preferences with regard to personal care and personal hygiene. A Ashley Cooper House DS0000067468.V318953.R01.S.doc Version 5.2 Page 17 schedule of preferred bath and shower times is also available. The requirement made in the previous inspection report is therefore met. 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 service users are male. (See recommendation 9) Times for getting up and going to bed are flexible. Work undertaken as a result of recommendations made in the occupational therapist report will have significant impact on ensuring that service users have the technical aids and equipment they need for maximum independence. (See requirement 2) Health care records show that staff support service users 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. 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. Examination of records shows that medication collected from the pharmacy each month is not recorded and medication stock checks completed by the home manager are not thorough enough, for example, a stock check carried out on 18/11/06 simply says “Pills checked and found to be incorrect” another entry says “Staff not signing”. There is no record of what medication is incorrect, which service user is affected and what action was taken as a result. This is unsafe. (See requirement 5) Examination of MAR (Medication Administration Record) charts during this inspection showed that staff do not sign for some prescribed items, for example, mouthwashes used by a service user during personal care. (See requirement 6) Ashley Cooper House DS0000067468.V318953.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users feel their views are listened to and acted on and they are protected from abuse, neglect and self-harm. EVIDENCE: Service users have opportunity to discuss concerns during regular house meetings and key work A comments/complaints book is available in reception and more detailed records of complaints are stored confidentially, as recommended in the previous inspection report. There has been one complaint made since the last inspection. A service user made an allegation about poor service. There were adult protection implications and the registered manager contacted the local authority and placing authority social worker as required. The service user met with his social worker and the complaint was found to be unsubstantiated. The complaint was dealt with promptly. A representative of the registered provider regularly checks the record of complaints during monthly monitoring visits to the service. The complaints procedure is available in the service users guide and is also posted in a communal area. Ashley Cooper House DS0000067468.V318953.R01.S.doc Version 5.2 Page 19 A service user said “ If there is something wrong I talk to the staff”. There is ongoing staff training in adult protection and POVA (Protection of Vulnerable Adults). 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 10) Many service users 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 service users 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 service users provided evidence of accurate accounting. Ashley Cooper House DS0000067468.V318953.R01.S.doc Version 5.2 Page 20 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): 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 service users with a mobility need. EVIDENCE: The ground floor home provides service users with level access to the bedrooms, communal areas and garden. The premises are reasonably clean and well decorated. Building security is a concern, as passers by can gain easy access to open bedroom doors. (See requirement 7) 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 service users. Dining tables available are not suitable for people using some models of wheelchair. An action plan and schedule for these improvements is required. Ashley Cooper House DS0000067468.V318953.R01.S.doc Version 5.2 Page 21 (See requirements 2 & 4) 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. An audit of bedroom furnishings and fittings has been completed, as required in the previous inspection report. During a partial tour of the premises it was noted that there was an unpleasant smell of urine in one bedroom. This is unacceptable. (See requirement 8) The communal lounge/dining area is large and not particularly comfortable. The only seating available is the dining table chairs. (See recommendation 11) Ashley Cooper House DS0000067468.V318953.R01.S.doc Version 5.2 Page 22 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 adequate This judgement has been made using available evidence including a visit to this service. There are sufficient numbers of staff on duty. Senior staff roles and responsibilities are not clear and although there has been good progress with vocational training, training to meet all areas of specific individual needs is not yet in place. Recruitment records are complete and staff are supervised regularly. EVIDENCE: There are two team leaders and two senior support worker posts (one vacant). Job descriptions and responsibilities are the same for both posts. These posts must be harmonised so that service users, staff and relatives are clear about the roles and responsibilities of senior staff. (See recommendation 12) 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 service users this is inappropriate. (See recommendation 13) Ashley Cooper House DS0000067468.V318953.R01.S.doc Version 5.2 Page 23 A part time administrator post is currently vacant. There is a shortage of male staff and the gender mix of staff does not reflect that of the service users. This means that same sex personal care is not provided and service users have, in the past, expressed a desire to go out in the community, for example to the pub, with male staff. (See recommendation 9) 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. There are currently three full time support worker vacancies and one senior support worker vacancy. This shortfall in staffing is covered by bank or agency staff. 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 14) There are twelve members of staff (excluding the home manager). Three members of staff have completed an NVQ 3 (National Vocational Qualification in Care). Six members of staff have completed an NVQ 2 and one member of staff is currently undertaking the course. One member of staff has completed an NVQ 4. There is progress in providing training in meeting the specific needs of the current service users. Six members of staff have attended training in challenging behaviour and training is scheduled in understanding brain injury and associated challenging behaviours. Six members of staff have also attended raining in substance misuse. Training records supplied during this inspection show that staff receive training in: • First Aid • Infection control • Health and safety awareness • Fire safety • Equality and diversity • Risk assessment • Moving and handling • Vulnerable adults • Learning disabilities (LDAF) • Medication administration Some staff also receive training in Supervision. Ashley Cooper House DS0000067468.V318953.R01.S.doc Version 5.2 Page 24 Although there are records of training undertaken there is no training and development plan in place. The training and development plan should cover NVQ training, mandatory training and refresher courses and specific training in meeting the needs of service users. For example, epilepsy, diabetes, brain injury, sensory impairment and communication support. (See requirement 11) Enhanced criminal records checks and full recruitment records are in place for all existing staff, as required in the previous inspection report. Human resource policies and staff application information do not state what criminal offences would exclude applicants from consideration. (See recommendation 15) 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 three new members of staff so compliance will be examined during the next inspection. (See requirement 9) Supervision records examined show that staff have regular and recorded supervision meetings. Ashley Cooper House DS0000067468.V318953.R01.S.doc Version 5.2 Page 25 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 adequate This judgement has been made using available evidence including a visit to this service. The manager is experienced and qualified and there are systems in place to measure the quality of the services provided, including surveying the views of service users. Urgent occupational therapy recommendations have not been addressed and this has serious implications for the health, safety and welfare of the service users. Building security must be improved and there must be better planning for fire evacuation emergencies. EVIDENCE: The registered manager has extensive experience, a social work qualification and RMA (Registered Managers Award). Ashley Cooper House DS0000067468.V318953.R01.S.doc Version 5.2 Page 26 There is a quality assurance system in place and the home has been visited on a monthly basis by a representative of the responsible individual as required by Regulation 26 of The Care Homes Regulations 2001. The home manager confirmed that policies and procedures are in place in all areas specified by national minimum standards, however as Sanctuary Care took over the managing of the home in 2005 there is a staged introduction of new policies and procedures in progress at this time. Building and equipment safety certification and checks seen include: • Hot and Coldwater temperature test records • Small electrical appliances safety test certificate dated January 2006 • The gas appliances safety test certificate dated August 2006 • The mains electrical wiring test certificate dated May 2004 • Fire alarm call points weekly test records • Hoists and shower chairs test records • Alarm call testing Records suggest that fire evacuation drills have not been conducted with the required frequency. Only four drills have been conducted since May 2005. (See requirement 13) Environmental and fire risk assessments are reviewed annually. The most recent fire authorities inspection report (24 March 2005) requires a fire plan to be developed. Although there are fire evacuation instructions in place discussion with the home manager indicates that there has been no consideration of the needs of service users who need to be moved using a hoist (for example, out of bed during the night). The building floor plan does not stipulate bedroom numbers or the names of occupants. (See recommendation 16) 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 12) The gas appliance safety certificate was issued in August 2006. Mains electric circuitry has been safety checked in 2005. The test certificate covers a five-year period. Small electrical appliances had been safety tested in January 2005. A fire risk assessment and building floor plan are available. Thermostatic hot water safety control mechanisms are fitted to hot water outlets to prevent scalding and temperatures are tested and recorded each week. Ashley Cooper House DS0000067468.V318953.R01.S.doc Version 5.2 Page 27 Requirements with health and safety implications are also made elsewhere in this report. (See requirements 2 & 7) Ashley Cooper House DS0000067468.V318953.R01.S.doc Version 5.2 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 2 3 2 4 3 5 3 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 2 25 3 26 3 27 2 28 2 29 2 30 2 STAFFING Standard No Score 31 2 32 2 33 2 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 2 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 3 X 3 X X 2 X Ashley Cooper House DS0000067468.V318953.R01.S.doc Version 5.2 Page 29 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 Timescale for action 31/03/07 2. YA42 YA18 YA3 YA16 YA24 12(1) 13(4) 3. YA6 YA2 15 The registered person must revise the service users guide in accordance with recent changes in legislation. The registered person must 31/01/07 take action to address urgent and high priority recommendations made in the May 2005 occupational therapy report of the premises. A detailed action plan and refurbishment programme must be supplied to the CSCI Southwark office. The timescales of 31/01/06 and 31/10/06 are not met. Although there is progress in implementing some areas of the OT report. The timescale for supplying a detailed action plan is extended. The registered persons must 31/03/07 ensure that service users know that their assessed and changing needs, including cultural and communication needs and personal goals are reflected in their individual plans. DS0000067468.V318953.R01.S.doc Version 5.2 Ashley Cooper House Page 30 4. YA17 YA29 13 23 5. YA20 13(2) 6. YA20 13(2) 7. YA24 YA42 12(1) 13(4) 23 8. YA24 YA30 16(2)(k) 9. YA35 18(1) 10. YA35 YA32 18 The registered persons must ensure that dining tables are of a type that is suitable to service users who use wheelchairs. The registered persons must 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 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. Steps must be taken to ensure that the security of the premises is improved (front of building). Previous timescales of 16/07/05, 28/05/06 and 31/10/06 are not met. The registered persons must ensure that all areas of the home are free from offensive odours. The registered persons must ensure that all new staff undergo structured staff induction training within six weeks of appointment and foundation training within six months. 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 service users’. This DS0000067468.V318953.R01.S.doc 31/03/07 31/12/06 31/12/06 31/03/07 31/12/06 31/12/06 31/01/07 Ashley Cooper House Version 5.2 Page 31 11. YA42 23(4) 12. YA42 23(4) plan must be supplied to the Commission by The registered persons must ensure that fire evacuation drills are conducted with the required frequency. 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. 31/12/06 31/01/07 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. 6. Refer to Standard YA1 YA6 YA8 YA8 YA8 YA13 Good Practice Recommendations The registered persons should produce a service users guide in a format that is suitable for service users 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 service users 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 service users. The registered persons should assist service users to 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. The registered persons should seek advice about hazard analysis from the local authority food hygiene department. 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. DS0000067468.V318953.R01.S.doc Version 5.2 Page 32 7. 8. 9. YA14 YA17 YA18 Ashley Cooper House 10. 11. 12. 13. 14. 15. YA23 YA28 YA31 YA31 YA33 YA34 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 (senior and team leader) as the job descriptions and responsibilities are identical. 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. The registered persons should revise human resources policy and job application information to include criminal offences that will exclude an applicant from consideration. The registered persons should ensure that building floor plans include names and room numbers. 16. YA42 Ashley Cooper House DS0000067468.V318953.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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.V318953.R01.S.doc Version 5.2 Page 34 - 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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