Inspection on 13/12/07 for Ashley House

This inspection was carried out on 13th December 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ashley House 11/11/08

Similar services:

Thorndene

Sutton Lodge Nursing Home

Wingham Court

Bethany Lodge

17 John Street

Red Oaks

Clare House Nursing Home

Broad Oak Manor Nursing Home

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

CARE HOME ADULTS 18-65 Ashley House 120 Aldwick Road Bognor Regis West Sussex PO21 2PB Lead Inspector Sheila Gawley Key Unannounced Inspection 13th December 2007 09:00 Ashley House DS0000070236.V353410.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 House DS0000070236.V353410.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 House DS0000070236.V353410.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashley House Address 120 Aldwick Road Bognor Regis West Sussex PO21 2PB 01243 823058 01243 841975 tlockyer@grooms-shaftesbury.org.uk www.grooms-shaftesbury.org.uk Grooms-Shaftesbury 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 Trudy Karen Lockyer Care Home 16 Category(ies) of Physical disability (16) registration, with number of places Ashley House DS0000070236.V353410.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection New service. Brief Description of the Service: Ashley House is a large property located in the coastal town of Bognor Regis, within a reasonable distance of the town centre and the sea. The home offers full care to people with severe physical difficulties, also some with learning difficulties. Sixteen single bedrooms provide accommodation, none of which are en-suite, however, there are assisted bathrooms throughout. The accommodation, which is on the ground floor only, consists of three units, each with their own dining/sitting areas. There is a large activities area in the centre of the building. The provider is Grooms Shaftesbury who is currently in the development stage with a housing association to commission a new building. The fees charged are £728 -£947. Ashley House DS0000070236.V353410.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit as part of the inspection process took place on the morning of 13 12 07. The lead inspector S. Gawley was joined by the Pharmacy inspector G Yates. The deputy manager and the registered manager facilitated the inspection. The commission was in receipt of an Annual Quality Assurance Assessment (AQAA) and any documents required on the day were made available. Twelve residents were accommodated on the day of inspection. Three residents were case tracked, their care plans and Medicine administration charts were inspected and they were also spoken to. They expressed satisfaction with all aspects of the home saying that staff were very caring and that the food was very good. All residents spoken to throughout the day stated great satisfaction in the care they receive, that they are always treated in a respectful manner. Staff were spoken to, as was one relative on the telephone. The Commission was in receipt of three comment cards, one from a resident, one from a relative and one from a professional and one relative was spoken to on the telephone Staff were observed offering care in a respectful and encouraging manner. The atmosphere in the home was very relaxed and sociable. People who use this service experience a good lifestyle. Equality and diversity issues are identified. What the service does well: The pre admission assessment and settling in period is well managed. Residents are supported to develop links in the local community. The home uses person centred lifestyle plans, with good health and personal care information. Residents have the opportunity to be involoved in the daily running of the home and to have a voice and make choices. Ashley House DS0000070236.V353410.R01.S.doc Version 5.2 Page 6 Residents get the opportunity to choose their menus. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ashley House DS0000070236.V353410.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 House DS0000070236.V353410.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): 2, Resident’s individual aspirations and needs are assessed. People using this service experience good outcomes in this area because needs are fully assessed prior to admission. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents are fully assessed prior to admission. They are invited to visit the home. They are allocated a member of staff to liase with them and act as temporary keyworker during this visit,in order to help their stay to be comfortable. A resident spoken to expressed satisfaction with the admission process and said she settled in well. Prior to admission staff are given any training or information needed to equip them with the necessary skills to assist clients in an appropriate manner. All residents have a contract that sets out the responsiliblites of the provider and the client and each resident is supported to carry out an idividual personal plan which explores a whole range of needs and plans for the future. Ashley House DS0000070236.V353410.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Residents know their assessed and changing needs and personal goals are reflected in their individual Plan, they can make decisions about their lives and can take risks as part of an independent lifestyle. People using this service experience good outcomes in this area because they make decisions about their lives. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three residents were case tracked, their care plans were examined and the residents were spoken to. Residents spoken to stated that they make decisions about their lifestyle and are free to come and go. These decisions were seen recorded in their care plans. Ashley House DS0000070236.V353410.R01.S.doc Version 5.2 Page 10 Risk assessment is in place and Residents are allowed to take risks, many selfmedicate and those able to take care of personal needs are allowed to do so. A resident spoken to stated that her needs are met exactly as she wishes them to be met. Equality and diversity issues are identified and addressed. Ashley House DS0000070236.V353410.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Residents are able to take part in age, peer and culturally appropriate activities and are part of the community. Residents engage in appropriate leisure activities and have appropriate personal, family and sexual relationships. Residents’ rights are respected and responsibilities recognised in their daily lives. People using this service experience good outcomes in this area because they can participate and contribute to the local community. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a range of activities in the home. Activities coordinators are not employed as all staff interact with the residents and help with outings and activities. There is a large games room, which offers snooker. There is a large sunroom to the front of the building where residents can sit. Residents are facilitated in attending college, workshops and daycentres and to Ashley House DS0000070236.V353410.R01.S.doc Version 5.2 Page 12 go on trips and shopping. Residents were spoken o about their activities, one volunteers in the Scope charity shop, one attends film club weekly. There are shopping trips and special supper evenings. A relative spoken to on the telephone stated that his brother is taken to a day centre three times a week which involves the home taking three trips daily, one morning and evening to drop off and pick up and one at lunch time to assist in care. One resident stated that he preferred to do his own thing and usually went to the pub in the afternoons. One resident did say that he would like trips farther away than the local shops but there is not always the staff to facilitate this. Ashley House DS0000070236.V353410.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18-20 Residents receive personal support in the way they prefer and require and residents’ physical and emotional health needs are met. Residents retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. People using this service experience good outcomes in this area because the resident directs personal support. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Personal support required is noted in the care plans and residents confirmed they receive support as they wish. The Registered Manager stated that the home has difficulty accessing physiotherapy but one resident who was recently assessed by the physiotherapist stated that the care staff are following the therapists instructions on exercises. Ashley House DS0000070236.V353410.R01.S.doc Version 5.2 Page 14 Several residents have complex healthcare needs and this is clearly deatailed in care plans and involves regular input from outside professionals. Staff spoken to stated that the home is run in the interests of the residents and is very friendly but sometimes feel pressured to provide all care due to staff shortages and the frequent use of agency staff. The safe handling of medication was assessed by a pharmacist inspector, who looked at the medication records, procedures, and storage, talked to care staff and watched medicines being given to one person. This home has had some problems in the safe handling of medication. Action has been taken to correct these and systems have been put in place so that any future problems can be quickly identified and dealt with. People who live in this home are given the choice to independently look after their own medicines. A number of people chose to hold and administer some or all of their own medicines. People’s ability to safely hold and administer their medication and any risks to other people living in the home had not been fully assessed. This could be putting people in this home at an unnecessary risk. Other people chose to have their medicines given to them by the care staff. These people receive their medicines safely and in a way that takes into account their specific needs. Ashley House DS0000070236.V353410.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Residents feel their views are listened to and acted on. Residents are protected from abuse, neglect and self-harm. People using this service experience good outcomes in this area because they are protected from harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The residents spoken to stated that they felt their opinions were sought, and they were listened to. Residents and a relative spoken to stated that they are aware of the complaints procedure and that they could complain if they wish. Four complaints were recorded since the last inspection and these were dealt with appropriately. The Registered Manager has attended a road show on safeguarding adults provided by Social and Caring Services for an update on new procedures. There was evidence on safeguarding adults training in staff files and staff spoken to stated that they were aware of procedures to follow in the event of an allegation. The home is good at reporting to the commission any incident that may pose a risk to the health and safety of residents. Ashley House DS0000070236.V353410.R01.S.doc Version 5.2 Page 16 Ashley House DS0000070236.V353410.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 Residents live in a homely, comfortable and mostly safe environment. The home is mostly clean and hygienic. People using this service experience adequate outcomes in this area because upgrade of furnishings and décor is needed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The organisation has for some years been trying to commission a new build. They have now in conjunction with Martlett homes and a housing association identified a site and a design is in place, which has been contributed to by the residents. The organisation is awaiting the approval of the plans. The accommodation is arranged in three units each with their own assisted bathing facilities and kitchen diner facilities. Not all radiator covers are covered Ashley House DS0000070236.V353410.R01.S.doc Version 5.2 Page 18 and the registered manager stated that this decision is risk assessed. Should a resident be admitted to a room and the risk of burning was identified, then that radiator would be covered. Doors do have automatic door closure devices. The hallways have been decorated but the wallpaper in some rooms is worn as was the bed and the woodwork. The registered manager stated that this would be addressed. Some beds and furnishings were shabby and the registered manager stated that these items were the personal possessions of the residents. A relative spoken to stated that the home was getting a new bed for his brother. The premises were on this occasion neat, clean and free from offensive odours. The exception was the carpeting on one corridor, which is badly stained from wheelchair use. Ashley House DS0000070236.V353410.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): 32,34,35,36 Residents are supported by competent and qualified staff, but there is a reliance on agency who may not be aware of all residents needs. Residents are protected by the homes recruitment policy and practices and staff supervision. Some training is not up to date. People using this service experience adequate outcomes in this area because agency staff may not be aware of all needs and all training is not up to date. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents spoken to stated that a caring competent staff meets their needs with exception of when there is a heavy reliability on agency staff. One relative comment card also stated that basic needs only were met that staff did not have time for extras. A general practitioner commented that the care staff usually have the skills and experience to meet social and health care needs. One resident stated that he would like to get out more, not just to the Ashley House DS0000070236.V353410.R01.S.doc Version 5.2 Page 20 local shops but trips to nearby towns. Staff spoken to also stated that they have been short staffed and sometimes one regular staff is on with two-agency carers. One other resident stated that the agency staff “do not have a clue”. The Registered Manager stated that there has been some long-term sick leave, she is currently recruiting three new carers and has altered the rota to ensure regular staff cover more shift and has created a handover time. The majority of staff have National Vocational Qualification Level 2 or above. Training files were seen and they showed that not all training is up to date. All staff have had fire training and moving and handling and all but two staff have had recent safeguarding adults training. COSHH, infection controls. Food hygiene and first aid were not up to date. Staff stated that they receive training on issues specific to the residents such as disability equality, stoma care and continence. The home has robust recruitment procedures in place and staff files inspected contained all the documentation required and had evidence of two references, Criminal Records Bureau Clearance and POVA check. Staff are appropriately supervised and the Registered Manager has increased this to monthly to support staff. This was seen in staff files and confirmed by staff. There are regular staff meetings. Ashley House DS0000070236.V353410.R01.S.doc Version 5.2 Page 21 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, 42,43 Residents’ benefit from a well run home. Residents are confident their views underpin all self-monitoring, review and development by the home. The health safety and welfare are protected although there are gaps in training. Residents’ benefit from competent and accountable management. People using this service experience adequate outcomes in this area because there are times when the home is short staffed and training is not up to date This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager is said to be approachable and to have an open door Ashley House DS0000070236.V353410.R01.S.doc Version 5.2 Page 22 policy. There is good organisational support from the operations manager who attended the home on the day. The manager has DipSw , NVQ4 and registered managers qualifications. During the last year extensive organisational mangement essentials training has been undertaken. The manager has a knowledge of the organisations policies and procedures, current strategic and financial plans. Residents spoken to stated that the home is run in their best interests and that their opinions are sought and listened to. Their recent request to have more staff on earlier as more of them are going out to college now was met, as was their request to review the visiting policy. Not all training to ensure the health and safety of residents and staff is up to date. All staff have had fire training and moving and handling and all but two staff have had recent safeguarding adults training. COSHH, infection control food hygiene and first aid were not up to date. All accidents and incidents are reported appropriately. There is an induction programme for staff to complete. The home has the support and financial planning of a large organisation and insurance cover is in place. Ashley House DS0000070236.V353410.R01.S.doc Version 5.2 Page 23 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 X 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 2 25 X 26 2 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 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 2 X 3 X 3 X X 2 X Ashley House DS0000070236.V353410.R01.S.doc Version 5.2 Page 24 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 YA9 Regulation 13(4) Requirement So as to reduce the risks to people the risk assessments for people who look after their own medicines must be reviewed and updated to include how you are supporting people in this activity. The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. Timescale for action 11/01/08 2 YA42 13(3) (4)(5)(6) 18(1) (c) (i) 31/01/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Ashley House DS0000070236.V353410.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 House DS0000070236.V353410.R01.S.doc Version 5.2 Page 26 - 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!