Inspection on 14/12/06 for Ashley House

This inspection was carried out on 14th December 2006.

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

Other inspections for this house

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Ashley House 56 Forest Road Bordon Hampshire GU35 0XT Lead Inspector Ms Jan Everitt Unannounced Inspection 14th December 2006 09:00 X10015.doc Version 1.40 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 DS0000067403.V316602.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 Older People. 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 DS0000067403.V316602.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashley House Address 56 Forest Road Bordon Hampshire GU35 0XT 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) 01905 338626 Sanctuary Care Limited Mrs Margaret Powell Care Home 34 Category(ies) of Dementia - over 65 years of age (10), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (10), Old age, not falling within any other category (34), Physical disability over 65 years of age (5) Ashley House DS0000067403.V316602.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Ashley House is a care home that is registered to accommodate 34 people in the old age category. Of the 34 residents, the home can accommodate ten (10) older people with dementia, ten (10) older people with a mental disorder and five (5) older persons with a physical disability. The home’s ownership has recently been taken over by Sanctuary Care Ltd but the ethos and management of the home remains as it was with the previous organisation. The home is purpose built on two levels and is situated on the site of other assisted living accommodation. The home is subdivided into six clusters, each containing a small lounge and kitchenette area. All 34 rooms are single accommodation with en-suite facilities. There is a large communal dining area, which leads onto an attractive garden that has colourful shrubs and plants. This area provides seating for residents to enjoy the garden. The home is situated in a quiet residential area that is close to some local shops. Fees £385 - £508 Newspapers, Toiletries – Varied Hairdressing - £7.00 Chiropody (Free for Diabetics) - £10.00 Bingo - £1.00 Ashley House DS0000067403.V316602.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A site visit to Ashley House care home, which was unannounced, took place on the 14 December 2006. This report details the results of an evaluation of the quality of the service provided by Ashley House and brings together accumulated evidence of activity in the home since the last key inspection on 18 October 2005. The visit to Ashley House formed part of the process of the inspection of the service to measure the service against the key national minimum standards for the year 2006/7. The judgements made in this report were made from the visit to the home, information gathered prior to the visit from the link inspector, pre-inspection information submitted to the commission by the registered manager, information from the previous report, the service history correspondence, registration activity, touring the home and viewing records. The thematic probe was applied to standards 1, 2, 3 & 16 and specified, supplementary questions were asked of the service users/relatives, whose care the inspector tracked. A relative for one service user supported this. The results of this probe are documented in the main body of the report. People who use the service have been consulted with and this has been done by questionnaire surveys sent to service users, relatives, other visiting professionals including GPs, staff questionnaires and talking to service users and staff at the time of the inspection visit. There were five responses to the visiting relatives survey. One GP returned their comments and seven staff completed the surveys given to them by the inspector. The responses from the surveys were very positive and complimentary about the care and services given in the home. What the service does well: Ashley House DS0000067403.V316602.R01.S.doc Version 5.2 Page 6 The home is run for the benefit of its service users and provides good quality care in a homely environment and the home is well maintained and decorated to a high standard. Service users are consulted about any changes in the home and visitors, when spoken to, and from the questionnaire surveys returned, that they were always made welcome to the home and consulted on their relatives/friends care. The atmosphere in the home was relaxed and friendly and it being close to Christmas, very festive. The home continues to provide meaningful activities for the service users and service users stated that staff are friendly and got on well together. Service users spoken with said that they were always treated with dignity and respect and ‘nothing was too much trouble for the staff’. The inspector observed this during this visit. It was also stated that the manager and staff are approachable and all service users spoken to were very happy at the home. Staff stated that they enjoyed working at the home and that they were provided with regular training and updates in order for them to do their job effectively. They praised the manager and leadership within the home and are aware of the management structure within the staff group. The care planning system is to be commended and is person centred and approaches service user’s care holistically. The manager, having undertaken dementia training, is focused on ensuring that all aspects of the person’s being are taken into consideration when planning how to care for that service user. The questionnaires returned by the service users and the relatives indicated that they are confident that they can approach the manager and staff at any time to discuss any issues and worries and relatives have commented that they consider they care in Ashley House is ‘excellent’. The organisation provide appropriate training for staff and they report in the survey questionnaires that they receive regular supervision and appraisal, at which time, their training needs are discussed and planned. The staff comment on the surveys returned that they are happy working at the home and their employment contracts. They comment that the home provides ‘a great place for service users to live’ ‘a lovely home for staff to work in’ ‘our residents are very important to us’ ’I think we do well in respecting each resident as an individual’ ‘I like out home it is a home, comfy, safe and cheerful’. Ashley House DS0000067403.V316602.R01.S.doc Version 5.2 Page 7 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 DS0000067403.V316602.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ashley House DS0000067403.V316602.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, & 3. Standard 6 is not applicable to this service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The thematic probe survey was undertaken on standards 1,2 & 3. Potential service users have a needs assessment undertaken prior to moving into the home to confirm that the home can meet the service users needs. Information about the home is given to prospective service users/relatives to enable them to make informed choices about where they wish to live. All service users sign and agree to the statement of terms and condition of residency in the home. EVIDENCE: Ashley House DS0000067403.V316602.R01.S.doc Version 5.2 Page 10 Three service user’s records were tracked. Those service users chosen were a recent admission, a service user with a diagnosis of dementia and one service user that had been at the home for some time. The service user or/and their relative was asked questions from the thematic probe survey. Some service users were unable to respond or remember their admission, owing to their mental frailty but a visiting relative was able to give more accurate responses .and reported that she had received information about the home in the form of the service user guide and statement of purpose and her mother had been assessed at a visit to the home. The outcome from the thematic probe survey revealed that the home receives referrals from social services and for the privately funded service user, contact is made by them or their relative to arrange a visit or assessment. One service users spoken to had come to live at the home with his wife from out of the area, and it was his son who lived locally, and was familiar with the home, that had arranged this placement. He reported that he had ‘left it to his son’ and did not want any information before his admission. He reported that he and his wife are happy with the care although he has desires to return to his home to live. The manager reports that potential service users are able to visit and spend time in the home prior to their admission to familiarise themselves with the home and help them with their decision making of whether to be admitted to the home, and at which time they are given information about the home. One relative spoken with said that her mother had been a volunteer in the home many years ago and knew the home intimately and did not wish to consider anywhere else now that she needed care. The Statement of Purpose and Service User Guide now reflects the new ownership and is comprehensive and delivers all the information that the potential service user would need to make an informed choice. The inspector viewed these documents. She was informed that all potential service users receive a copy of this information. The inspector viewed a sample of contracts/terms and conditions of residency in service user’s personal files. The service user or their next of kin had either signed these. The fee was identified and also the room that the service user was to occupy. The manager reported that if fees are changed, all service users/advocate are informed by letter. Social services are informed for those who are being funded. The manager or deputy undertakes pre-admission assessments at the service users current address. The inspector viewed the care records of the three Ashley House DS0000067403.V316602.R01.S.doc Version 5.2 Page 11 service users. The pre-admission assessment was thorough and covers all aspects of personal, health and social care. The care plans are then drawn up with the support of this information and the care needs assessment from a social worker if they are involved with the admission. Ashley House DS0000067403.V316602.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service and viewing records. The manager has introduced a detailed; person centred care-planning system for service users. The health and social care needs of service users are appropriately met and documented. The home’s approach to the management and storage of service users’ medications was robust and secure. Service users are treated with respect and their right to privacy upheld. EVIDENCE: Ashley House DS0000067403.V316602.R01.S.doc Version 5.2 Page 13 The inspector tracked a sample of service users’ care plans. The home must be commended for the comprehensive person-centred care planning system that is being used at the home. Each contained pre-admission assessments from which care plans are instigated, patient specific information such as photos for identification purposes and daily records. Full risk assessments are undertaken for health and safety and include moving and handling. Nutritional and tissue viability risk assessments are also undertaken on service users and care plans written if a risk has been identified. The level of detail within each plan was felt generally to be very good, and there was evidence that the plans were being regularly reviewed and updated, and that the service users and their representatives are involved in the care planning and reviewing process, these being signed by the service user or relative. Social histories are collected for all service users, detailing past history, previous hobbies and recreational past times. This is part of the holistic approach to the assessment and care planning. Service users and relatives comment survey cards that were returned were very positive in their stated comments about the care they receive at the home. One relative spoken with said she was very happy with the care her mother was receiving and feels confident that the home keeps her fully informed about her changing care needs. The home is serviced by four GPs. The District Nurse attended the home whilst the inspector was visiting. She was attending to two service users and the inspector observed that she had a good rapport with the staff. Comment survey cards received from the GP who visit the home, was very positive and complimentary and stated that ‘the care provided in the home is exemplary and of an extremely high standard and am very happy for my patients to be admitted there’. The manager reported that the home is supported by the primary health team and that she was awaiting an occupational therapist assessment for a service user’s room who was about to be discharged from hospital and she wanted to ensure that any alterations or aids were in place before they returned home. The home also has access to a psychiatrist and the community psychiatric nurse. Ashley House DS0000067403.V316602.R01.S.doc Version 5.2 Page 14 The chiropodist attends the home 6 weekly and diabetics do receive a free service from the local community hospital for their foot care. The manager reported that the home has experienced difficulty in obtaining dentistry but this has now been resolved. Some service users choose to attend their own dentist in the community and this is supported by the home. The home’s medication system was audited as part of the inspection process. The deputy manager co-ordinates the robust systems the home has in place for the management of service users’ medication. The records were found to be well organised with clear, structured systems for ordering and receiving medications into the home. The return of medication to the pharmacist was well recorded and the records signed by the receiving pharmacist. The storage area for the medication is in a treatment room and holds a fridge for medication storage. The inspector observed that daily temperatures were being recorded. The medication is dispensed as part of a Monitored Dosage System (MDS), supplied by the local pharmacist, from which the manager reports, the home receives good support. Medication Administration Records (MAR) sheets were viewed and found to be completed accordingly. The home has appropriate policies and procedures in place with regard to medication. Staff receive training through the suppliers of the medication but the manager reported that the new organisation has a specific person to deliver this training in the future. All staff have received training in medication and will assist with the medicine rounds regularly. The training records support that training has taken place and the inspector observed the administration of medicines, which were being undertaken in accordance with the procedures. The inspector observed that service users preferences as to their daily activities of living are documented as part of the assessment process. It was observed by the inspector that one couple living in the home had chosen to have two separate rooms and this had been documented as a choice following admission. The inspector observed that service users were not being rushed to go about their activities of daily living. Staff were observed to be knocking on doors before entering service user’s rooms and generally there was a good rapport between staff and service users, with carers being over heard giving service users choice and respecting their wishes. Service users, who were spoken with, and comments from the service user survey, praised the staff highly and considered them to be very supportive. By observation it was apparent to the inspector that staff were familiar with the service users’ needs. Ashley House DS0000067403.V316602.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The cultural, religious and recreational needs of service users are met and the home matches service users expectations. Service users are able to keep contact with family and friends and visitors are always welcome. The home respects service user wishes on whom they do or do not wish to see. Service users exercise their own choice and have control over their own lives. Meals at the home are wholesome and appealing and are served in pleasant surroundings with a choice of food available to service users. EVIDENCE: The home employs an activities co-ordinator who works 20 hours per week and the home must be commended for the activities organised for service users, Ashley House DS0000067403.V316602.R01.S.doc Version 5.2 Page 16 these include bingo, reminiscence sessions, baking, arts and crafts and quiz’s. The activities co-ordinator also works on a 1 – 1 basis with service users and is currently supporting service users to make up a history album using old photographs and input from the service users family. These albums are put together with photographs in chronological order of the service user’s life. For those with a dementia, it is hoped that this will prompt memories and stimulate social interaction with others. The inspector evidenced this when visiting a service user’s room, the service user was looking through her album and was willing to discuss the photographs with the inspector. The coordinator intends to do this with other service users if they so wish. One service user, when making up her album, commented ‘I feel like I am meeting them again’. The home had performed their Christmas pantomime the previous evening to the visit. The home was busy getting ready for Christmas and the previous evening had been a huge success with the staff performing and the service users and families attending. There had been refreshments and it was evident from talking to residents and visitors that everyone had enjoyed the evening. All visitors are required to sign the visitor’s book and it was possible to see that there is a regular stream of visitors to the home at varying times. 2 visitors were spoken to during the inspection and they confirmed that they were always made to feel welcome and that there were no restrictions on visiting. At the time of this visit the vicar was attending the home to give a service in the ‘bar area’ that has been created to emulate a local pub; beer taps and optics included. The inspector spoke to the vicar at this time and she reported to visit the home regularly and to have good relationships with them and is available at any time should they request her presence. The manager reports that the staff put a lot of effort and time into the activities in the home and the service users are generally very responsive and enjoy participating. Service users exercise their own choice and have control over their own lives. Service users are encouraged to bring in their own personal possessions to personalise their rooms. This was confirmed by service users and by observing items in service users rooms. The home employs a catering service to provide meals at the home and service users are consulted about the menu at the home and all those spoken to stated that meals were good, they stated that there was always a choice at meal times and that there was always enough food available. Service users are able to have snacks at any time and hot and cold drinks available throughout the day and night. Ashley House DS0000067403.V316602.R01.S.doc Version 5.2 Page 17 The inspector observed the lunchtime meal. This was presented well with a variety of vegetables. The inspector observed three service users choosing to have something other than what was on the menu. Ashley House DS0000067403.V316602.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and their relatives are confident that their complaints are listened to and taken seriously and acted upon. Service users are protected from abuse. EVIDENCE: The home has a complaints procedure that it stated in the Statement of Purpose of which all service users/relatives have a copy. There has been one complaint logged since the last inspection and this has been resolved with the relative by the manager at an arranged meeting at the home. The outcome of this complaint has changed the practice when responding to an emergency situation. The thematic probe survey for this standard, undertaken by the inspector, revealed that service users were aware of the complaints procedure and considers they have sufficient information in the procedure to know how to complain. Ashley House DS0000067403.V316602.R01.S.doc Version 5.2 Page 19 Relative’s survey comments and service users survey comments both report that they would speak to the manager if they had any complaints. One service user reported ‘I do not have any complaints about the home’, another service user commented that they had never felt the need to make a complaint but stated that they would speak to a member of staff, or the manager, if they had any concerns. One relative survey comment indicated their lack of knowledge of the complaints procedure. This communication was anonymous and therefore the inspector could not explore this further. Staff spoken with, and the staff survey, confirmed that staff are aware of the complaints procedure and would know how to respond to a service user if they were to complain or wished to complain. The home has an adult protection procedure for which all staff have received training. The inspector discussed this with the manager who demonstrated her awareness and knowledge with the procedure for reporting abuse. The staff survey analysis indicated that staff are aware of abuse and would know what action to take and to whom they would report this to if they witnessed, or there was alleged, abuse to any service user. Staff training records demonstrate that staff are made aware of the adult protection procedure and what constitutes abuse. Ashley House DS0000067403.V316602.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a clean, safe and well-maintained home. EVIDENCE: The inspector toured the building and it being her first visit, all rooms were visited. The communal areas were well lit and all areas were furnished to a high standard. The home must be commended for the way the small lounge areas, which can be used to take meals, have been created and decorated to make a very homely environment. Attached to these areas is a small kitchen area that has facilities for making tea. Ashley House DS0000067403.V316602.R01.S.doc Version 5.2 Page 21 There is a larger dining area, which is also used for activities and service users spoken to were full of praise for the facilities available and were proud of their home. All service user’s bedrooms have been personalised and are furnished to a good standard. Many of the service users have been able to bring with them items of furniture of their choice from home. An inventory of this is maintained in the service user’s records. The atmosphere in the home was warm and welcoming and service users have plenty of space of wander and sit in different areas if they so wish. Service users have access to safe and comfortable outdoor facilities in the finer weather. The laundry at the home is operated by dedicated laundry staff and has 2 industrial washing machines and a tumble drier. The inspector observed that laundry was well presented and service users reported that they were very satisfied with this service. There is a clear laid down procedure for washing commodes and the home was clean throughout with no unpleasant odours. Staff receive training in infection control that is cascaded down from senior staff. Questionnaires are completed by staff to test knowledge. The inspector observed that staff were following procedures for the prevention of infection control and hand-washing facilities were available throughout the home. Ashley House DS0000067403.V316602.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has mix of staff that have a range of skills and there were sufficient numbers of staff on duty to meet the needs of service users. The home’s staff recruitment selection policy and practices are robust. Service users benefit from a staff team that has had sufficient training to meet the needs of service users and are competent and qualified to meet service users’ needs. EVIDENCE: The homes staffing rota showed that there are a minimum of 5 staff members on duty each morning, 4 staff on duty in the afternoon and 2 awake members of staff at night, the night staff are backed up by a team leader or the homes manager who sleeps in and is available for support or advice during the night. The pre-inspection information stated that the home is requiring 265 hours bank/agency staff in the past eight weeks. The manager reports that she is recruiting staff at the current time. She also reported that the new providers Ashley House DS0000067403.V316602.R01.S.doc Version 5.2 Page 23 are re assessing the staffing levels and that she hopefully will be able to increase the number of staff by one on each shift in the new year. The inspector observed that the home was calm and staff were not rushing about in their duties and therefore there was no indication that the home did not have sufficient staff. Service users’ surveys supported this by stating that a member of staff is always available when they need them. Staff members spoken to stated that they were not rushed and had sufficient support to carry out their duties. The pre-inspection information stated that 13 of the staff have already obtained their NVQ 2 qualification, representing 50 of the care staff numbers. Staff training records showed that staff have completed training in Health and Safety, fire, medication, equal opportunities, moving and handling, 1st aid, adult protection, food hygiene, dementia care, person centred care, incontinence, use of hoists, risk assessment and infection control. Staff spoken to confirm that they had received this training and stated that their induction training was comprehensive and they were confident that they could meet the needs of service users. Care workers surveys also confirmed that they had undertaken various training activity. The home has an induction programme in place that all newly appointed staff undertaken. An example of this was seen by the inspector and comes in the form of a workbook and is based on the Skills for Care programme. The member of staff had completed this and skills were signed off as they had achieved them. Six of the seven staff surveys returned to CSCI stated that they had received induction training. The inspector viewed the training matrix that recorded an appropriate selection of training. The manager reported that training did slow down when the new providers took over but this has improved and training is booked for early 2007. The inspector viewed a sample of recruitment records for recently recruited staff. All the information required to be recorded was found in the files including 2 references and a record of CRB/POVA checks. There were clear job descriptions for staff and these gave details of individual roles and responsibilities. Ashley House DS0000067403.V316602.R01.S.doc Version 5.2 Page 24 Ashley House DS0000067403.V316602.R01.S.doc Version 5.2 Page 25 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users benefit from strong leadership in the home, which is managed by a person who is of good character and is able to discharge her responsibilities fully. The home is run in the best interests of service users and the views of service users as to how well the home is performing is taken into consideration. Service users financial interests are safeguarded. The health, safety and welfare of the service users and staff are promoted and protected. Ashley House DS0000067403.V316602.R01.S.doc Version 5.2 Page 26 EVIDENCE: The registered manager has been in post for three years and has gained her Registered Manager’s Award and that together the National Certificate in Dementia Care, is committed to providing person centre care for all categories of service users in residence. The manager has a deputy in post, who has also gained her national certificate in dementia care. The home has recently been taken over by another organisation but the manager reported to the inspector that the day-to-day management of the home has not changed and the service users, have been informed of this change, have not been affected by it. The manager reported that following the transition period she now receives good support from the organisation and her operational manager, who are very responsive to her requests for resources to allow her to deliver a consistently good standard of care and ensure good outcomes for service users. The manager demonstrated a good knowledge of her duties and is particularly interested in dementia care and is focused on staff training in this area to ensure that service users are at the centre of all the activities of daily life in the home. Staff at the home were aware of the management structure of the home and it was confirmed that staff and service user meetings are held on a regular basis. Staff spoken to were very supportive of the manager and it was obvious to the inspector that they respect her position. The home actively seeks the opinions and views of service users and their relatives/friends on how the home meets it’s stated philosophy of care. This is undertaken by questionnaires and also by the manager being available and around the home to talk to service users. The inspector viewed the results and analysis of the latest service user satisfaction survey. The results were very good and these together with outcomes from actions taken from any suggestions or negative comments were published and distributed for service users and relatives to view. This survey is undertaken annually. The manager is hoping to expand the home’s capacity for accommodating more service users who have mental frailty in old age. In anticipation for this Ashley House DS0000067403.V316602.R01.S.doc Version 5.2 Page 27 a great deal of staff training has taken place. The organisational training officer for dementia care has visited the home and given a talk to staff, relatives and friends about dementia and the care of those who suffer from this degenerative illness. The manager reported that the talk was received very positively and was well attended and generated many questions. The policies and procedures for the new organisation have been introduced. The pre-inspection information stated that the home supports two service users to manage their money. The inspector viewed the records and receipts of transactions, which are held individually. The balance sheet and monies agreed. The inspector evidenced that records have been audited monthly. Certificates were seen for annual tests of fire fighting equipment, fire alarms, boilers, PAT (electrical equipment testing) and for the lift and hoists and these were all in date. The fire log was inspected and all relevant testing is carried out within the specified timescales. The Hampshire fire has visited the home and rescue service and the report of May 06 did not document any recommendations. The inspector identified that the annual fire training was due. The manager evidenced that this training is taking place in February 07 but reported that she undertakes regular fire drills and regular training in-house. Ashley House DS0000067403.V316602.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 Older People 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 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Ashley House DS0000067403.V316602.R01.S.doc Version 5.2 Page 29 Are there any outstanding requirements from the last inspection? NO 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. Standard Regulation Requirement Timescale for action 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 DS0000067403.V316602.R01.S.doc Version 5.2 Page 30 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 DS0000067403.V316602.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. 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