Inspection on 31/03/08 for Ashley Cooper House

This inspection was carried out on 31st March 2008.

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 16 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 02/10/07

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 27/09/2008.

CARE HOME ADULTS 18-65 Ashley Cooper House 25 Hillyard Street Brixton London SW9 0NJ Lead Inspector Richard Turner & Mary Magee Key Unannounced Inspection 31st March 2008 10:00 Ashley Cooper House DS0000067468.V361610.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.V361610.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.V361610.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) vacant post Care Home 16 Category(ies) of Physical disability (16) registration, with number of places Ashley Cooper House DS0000067468.V361610.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 2nd October 2007 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.V361610.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors completed this unannounced key inspection. It lasted for eight hours. Thirteen service users met with the inspector over the period. Five were spoken to individually. Present at the service was the acting manger, the administrator, and three support workers. A selection of personnel records relating to service users and staff were viewed. A tour of the premises was conducted, all communal areas and the majority of bedrooms were viewed. What the service does well: What has improved since the last inspection? Improvements have taken place to ensure the premises are safer. A railings has been fitted to the front perimeter of the home to prevent intruders gaining entry. The new door entry system is providing more security for service users and staff. Suitable dining tables are supplied to enable wheelchair users access tables more comfortably. Adaptations are ongoing to bathroom and shower areas, the majority of shower rooms are now completed and offer comfortable safe and accessible shower facilities. The home has made improvements to how health and safety is promoted. A fire risk assessment was completed for the premises with appropriate floor plan of evacuation procedures. Fire evacuation procedures take place in accordance with the risk assessment. Attention is paid to maintaining the premises and equipment up to acceptable standards with regular monitoring of hot water temperatures, environmental health and safety checks. Ashley Cooper House DS0000067468.V361610.R01.S.doc Version 5.2 Page 6 Improvements are found in care planning and risk assessments for individual service users, more work is required here to ensure that appropriate formats are used and that involve service users or their representatives. 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.V361610.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.V361610.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 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The organisation has developed a guide that includes details of the new provider organisation. Service users are unaware of the services available as they have not received a copy of the service user’s guide. Neither is it available in the format that is accessible to service users. Written care plans and risk assessments are developed for service users. EVIDENCE: A copy of the service user’s guide was supplied to the Commission. The guide is not complete as there is some essential information such as complaint’s procedure absent. The Statement of Purpose was not available for examination. When checking with service users if they had received the necessary information service users all three-service users confirmed that they were unaware of the guide. The requirement stated in the previous inspection report is restated. See Requirement 1 No new service users have been admitted since the previous inspection, it was not possible to evaluate this Standard, the requirement stated in the previous inspection report remains. See requirement 2 . Needs assessments are in place for all service users, a selection of these were viewed. Also now in place are assessments for service users where this information was absent on the last inspection. Ashley Cooper House DS0000067468.V361610.R01.S.doc Version 5.2 Page 9 Observations were made of how service users’ needs are met. Thirteen individuals met with the inspectors over the day. Five were spoken to in depth. For the majority of service users the home is meeting their needs and aspirations. The assessment completed on admission for one service user demonstrates that the support needs were identified and care plans were developed to respond to these. But there are strong indications that these care needs now are in excess of that can be provided by the home. This appears to impact on the other service users and on the staff team’s capacity to manage these needs. The home needs to address this concern and review the placement needs of the service user. According to information seen a referral was made to the care management team requesting an urgent review. Ashley Cooper House DS0000067468.V361610.R01.S.doc Version 5.2 Page 10 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 adequate. This judgement has been made using available evidence including a visit to this service. Service users have their needs assessed and develop care plans to respond to these , but there is little involvement by service users/representatives or their relatives in this development. Risks are identified and managed appropriately. The home is improving provision in how service users are consulted on aspects of life but not sufficiently. EVIDENCE: Case tracking was to evaluate the support and care delivered to two service users. Care plans are in place for both service users but according to service users there has been little individual input. Evaluations take place but these are not accurately reflecting changes that arise or that make a difference to service users’ lives. The risks associated with delivering care and support are held with care plans, records seen show them to be up to date but there are areas where improvements are needed. These need to be reviewed regularly. Statutory reviews have been completed too for seven of the service users. According to the acting manager referrals were made to the local authority requesting the remaining reviews to be completed. Significant effort has been Ashley Cooper House DS0000067468.V361610.R01.S.doc Version 5.2 Page 11 made to review service users’ needs, but it is understood that the new provider is about to implement a complete new care planning process. This will be the responsibility of the new manager to take forward. Special consideration will need to be given at this time to involving service users in constructing and developing care plans that are appropriate. The requirement stated in the previous inspection is restated to address this shortfall. There are signs of improvement in the quality of life experienced by service users. Now the findings are that service users are participating more in some aspects of life at the home. One service user (wheelchair user) assisted in greeting visitors and answering the front door. He was enjoying a good rapport with staff in the front office. Another service user told the inspectors of her progress in using the kitchen facilities and encouragement received in support of developing independent living skills. Staff confirmed that the service user has progressed well and uses these new culinary skills to entertain visitors. Service user meetings have begun where forums are in place for individuals to put forward their views. Minutes of a recent service users’ meeting were viewed. The organisation has set up a national forum representing the voice of service users with disabilities. One of the service users has volunteered and attends this forum. He spoke of his role and looks forward to the meetings. Ashley Cooper House DS0000067468.V361610.R01.S.doc Version 5.2 Page 12 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 15 16 17 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home offers a wide range of healthy home cooked food that service users enjoy. The quality of life experienced by service users varies. Appropriate provision is not made for ensuring that all service users have opportunities for engaging in preferred activities. EVIDENCE: For some service users the lifestyle experienced is good, a variety of interests are pursued through college and club attendance. However there are limited facilities available in the home. Activity planners for service users are outdated and not reflecting their choices or needs, neither are they coordinated with care plans sufficiently. Some service users have little stimulation, or engagement in activities. This is an area that requires greater focus for development. A requirement is stated. Dining tables have been provided that are appropriate and allow service users using a variety of wheelchairs to access the tables comfortably. Ashley Cooper House DS0000067468.V361610.R01.S.doc Version 5.2 Page 13 Catering is now in house. The chef demonstrated the improvements made. A hazard analysis is completed and on display. Environmental health inspected the facilities and awarded a three star rating. The variety and quality of food served is good. At lunch a selection of food was on offer and displayed on the menu board in the dining room. The chef was observed preparing freshly the meals. Individual choices were responded to appropriately and served. Service users spoke well of the meals served and find that they enjoy them. They satisfy their cultural and dietary needs. Ashley Cooper House DS0000067468.V361610.R01.S.doc Version 5.2 Page 14 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 good, This judgement has been made using available evidence including a visit to this service. Service users receive appropriate support to manage health care needs and they are generally well met in this area. Medication procedures are good but more effective audit systems are needed. EVIDENCE: At the earlier part of the day some service users were receiving support with personal care. Doors were closed and staff observed privacy and dignity. The views of service users interviewed indicated that they are satisfied with the willingness of staff to assist them as required. Facilities such as walk in showers now available also contribute to the improvements found in this area. According to records seen of daily events the conditions of service users are monitored and appropriate referrals made to relevant health professionals. Annual health checks are completed. Staff supports service users to attend appointments at hospitals, dentists, opticians. The medication procedures were examined. Medication is supplied from the pharmacist in blister pack. MAR sheets were found to be accurately completed Ashley Cooper House DS0000067468.V361610.R01.S.doc Version 5.2 Page 15 with signatures present for all medicines administered. A senior staff member provided a copy of the recording sheet used for auditing medicines received into the home. 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. It is restated. Ashley Cooper House DS0000067468.V361610.R01.S.doc Version 5.2 Page 16 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. The home has an effective complaints procedure in place. Staff receive appropriate training on safeguarding adults. EVIDENCE: A complaints system is in place, according to the log viewed no complaints were received since the last inspection. For service users those consulted find that their views are encouraged and feel free to raise issues. Service users meetings provide a suitable forum for individuals to express concerns. A service user representative sits on the national forum and influences and informs planning. The home has received no allegation of abuse or neglect. Records in AQQA supplied confirm training in safeguarding adult’s procedures. A recommendation was made in the previous inspection report in relation to local authority adult protection procedures being obtained. These are still not available at the home. Ashley Cooper House DS0000067468.V361610.R01.S.doc Version 5.2 Page 17 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 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The premises offers a clean and odour free environment. Improvements are being made to the interior of the premises, with bathing facilities now available that are accessible to wheelchair users. EVIDENCE: Improvements have been made in a number of areas in relation to the environment. The perimeter of the building has been protected by the installation of metal fencing to the front. At the entrance lobby an automatic closing door is in place. The ground floor of the home provides service users with level access to the bedrooms, communal areas and garden. The premises are clean and odour free Appropriate furniture has been supplied to enable service users using wheelchairs access to dining tables. Communal kitchen areas are adapted to enable service users access light cooking facilities. Ashley Cooper House DS0000067468.V361610.R01.S.doc Version 5.2 Page 18 The dining are now has a comfortable sofa, the acting manager told of the plans to divide up the dining are and have a section where comfortable seat ing will be available for all. Refurbishment to bathroom and shower areas is still in progress, virtually completed with all bathrooms providing wet room facilities suitably designed and adapted for the disabled. The requirement stated in the previous inspection remains until work has been completed. Bedrooms viewed appeared comfortable, and were personalised. A number of bedrooms have been fitted with new floor covering depending on preferences. Ashley Cooper House DS0000067468.V361610.R01.S.doc Version 5.2 Page 19 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): 32 34 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users’ needs are not always met by appropriate numbers of suitably qualified staff. Staff are not receiving the training and development needed to equip them with the necessary skills for the role. Supervision and support is inconsistent for staff. EVIDENCE: Appropriate staffing levels were not on duty when the inspection began. According to staffing rota four support staff were rostered for duty. Three support staff were on duty instead, it was evident that staff were overstretched in providing for the needs of service users. The necessary support and supervision was not evident for the staff team. The team leader was not taking the lead in ensuring that staffing levels were appropriate. Two members of staff took morning breaks, this demonstrated a lack of supervisory skills by the team leader. Records held show that supervision is inconsistent and infrequent. The requirement stated in the last inspection report is restated. According to the acting manager (she come on duty later) the team leader is expected to call on bank staff members to cover any vacancy that arises. The team leader had not pursued this. A requirement is stated. The registered Ashley Cooper House DS0000067468.V361610.R01.S.doc Version 5.2 Page 20 person must ensure that staffing levels are in such numbers as are appropriate to the needs and number of service users. 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. A recommendation made in the previous inspection report is restated. 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 from previous inspection. Record keeping is not good, records of training are out of date. Although there are some records of training undertaken and a few planned training days, there is no team training and development plan in place. Neither is there evidence that an induction is completed. 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. The AQAA states that a new induction record has been introduced to ensure effective monitoring and recording of staff induction. The evidence gained is not supporting this statement. One new staff member was employed since the last inspection. Evidence of an induction programme was not available. The training and development plan should cover induction, 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. The requirement stated in previous inspection remains unmet. All three support staff were spoken to. Two of the staff have worked with service user group for many years and appeared knowledgeable on their needs. Recruitment records for three members of staff were examined, and were found to be inadequate. There was confirmation that all three have satisfactory criminal records checks in place. A copy of a second reference was missing from one file. A copy of passport was absent from another file, also photograph. The acting manager said that the full recruitment records were held at the head office. The files held at the home do not contain a front sheet to evidence that all the necessary checks are completed satisfactorily. The head office needs to send evidence of the recruitment procedures to the Commission. The requirement stated in the previous inspection is restated. Ashley Cooper House DS0000067468.V361610.R01.S.doc Version 5.2 Page 21 Ashley Cooper House DS0000067468.V361610.R01.S.doc Version 5.2 Page 22 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 41 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements are continuing in the promotion of the health and safety of service users and staff with the majority of issues now addressed appropriately. The home has been affected by the absence of a permanent manager and there is clearly a lack of leadership. Record keeping is not reliable and records are often inaccessible. EVIDENCE: The home has made improvements but all indications are that it is still not a well run home. The lack of a full time competent manager is reflected in many of the shortfalls found in the service. The arrangements in the interim of another home manager offering part time management has provided some consistency in the service. Notification was given to CSCI that a new manager is appointed and due to start work 7th April 2008. The requirement in relation Ashley Cooper House DS0000067468.V361610.R01.S.doc Version 5.2 Page 23 to management remains until confirmation is received that the new manager is in post. Service user participation in the home’s development has improved. The views of service users are encouraged. Service user meetings take place regularly; the new national service user forum that involves a volunteer from the home is operating. Copies of Regulation 26 visit reports are sent to CSCI. These demonstrate that on each visit consultation takes place with service users and staff to find out how the service is performing. The home has made efforts to promote the health and safety of service users and staff. A fire risk assessment is in place with floor plans for evacuation. Regular fire evacuation procedures take place. Essential equipment such as fire alarms and fire detecting equipment are serviced regularly. Hot water temperatures are monitored, although it was difficult to find the records as some were misfiled. The adaptations made to the environment have ensured more accessibility for service users to all areas but especially with the bathing facilities. It was not possible to check if the alarm bell is working efficiently as the record was unavailable. This was the subject of a requirement in the previous inspection report, it is restated in this report. A new administrator took up post thee weeks prior to the inspection. He assisted where possible but recognised the problems in the system used. The record keeping is not good, records are difficult to find and are often misfiled. This must improve. A requirement is stated. . Ashley Cooper House DS0000067468.V361610.R01.S.doc Version 5.2 Page 24 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 2 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 2 25 X 26 X 27 X 28 3 29 3 30 3 STAFFING Standard No Score 31 2 32 2 33 X 34 1 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 2 2 X LIFESTYLES Standard No Score 11 2 12 2 13 2 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 3 X 2 2 X Ashley Cooper House DS0000067468.V361610.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation 5 Requirement The registered person must revise the service users guide in accordance with recent changes in legislation. The timescale of 31/01/07 is not met. 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. 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 majority of the work is now completed. Timescale of 31/01/08 extended to allow for completion. The registered person must ensure that service users are consulted about their interests DS0000067468.V361610.R01.S.doc Timescale for action 30/04/08 2 YA2 YA6 15 30/04/08 3 YA3 YA24 12(1) 13(4) 30/04/08 4 YA11 YA12 YA13 16 (2) m, n 30/06/08 Ashley Cooper House Version 5.2 Page 26 5 YA20 13(2) and opportunities for personal development, and make arrangements to enable them engage in appropriate activities. The registered persons must ensure that regular audits /stock checks of medication are conducted and a record is kept of the outcome of these checks and action taken. The timescale of 31/12/06 and 31/12/07 is not met. 30/04/08 6 YA33 18 (1) a The registered person must 30/04/08 ensure that staffing levels on duty are maintained in such numbers as are appropriate to the needs and number of service users The registered person must ensure that there is evidence of thorough checking during recruitment of staff in accordance with Regulation. Evidence must be available at the care home 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 31/01/07 & 31/01/08 is not met. 30/06/08 7 YA34 19 8. YA35 18 30/04/08 9 YA36 18(2) The registered person must ensure that staff receives the necessary support and supervision to enable them to DS0000067468.V361610.R01.S.doc 30/04/08 Ashley Cooper House Version 5.2 Page 27 undertake their duties effectively. Supervision meetings must be held regularly and a record must be kept of agreed actions. Unmet in timescale of 31/01/08 10 YA37 8 The registered person must appoint a manager who is appropriately qualified and experienced and this manager must register with the Commission. Confirmation was received that the new manager is due to take up post on 7th April 2008 The registered person must ensure that record keeping improves, and that records required by regulation are available and filed appropriately The registered person must 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. Unmet in timescale of 31/12/07 07/04/08 11 YA41 17 (1) (2) n (3) 30/04/08 11 YA42 1213 30/04/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA1 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 DS0000067468.V361610.R01.S.doc Version 5.2 Page 28 2. YA6 Ashley Cooper House Assessment’. 3. 4. YA8 YA8 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 person should provide a computer with internet access for residents. 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 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 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 persons should obtain a copy of the local authority adult protection procedures and ensure that all staff is 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 ensure that residents are DS0000067468.V361610.R01.S.doc Version 5.2 Page 29 5. 6. YA14 YA18 7. YA31 8. YA31 9. YA33 10. YA13 11. YA23 12. YA28 13. YA8 Ashley Cooper House 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. 14. YA8 The registered persons should assist residents to find out about and contact advocacy services in the area. Ashley Cooper House DS0000067468.V361610.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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.V361610.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!