Inspection on 17/06/04 for Ashlong House

Care Homes For Adults (18 ­ 65)Ashlong House141 Longfellow Road Worcester Park Surrey KT4 8BAUnannounced Inspection17th June 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Ashlong House Address Ashlong House, 141 Longfellow Road, Worcester Park, Surrey, KT4 8BA Email address alliedcareltd@aol.com Name of registered provider(s)/company (if applicable) Throwleigh Lodge Name of registered manager (if applicable) Ms Maureen Millar Type of registration Care Home No. of places registered (if applicable) 5 Tel No: 020 8330 2708 Fax No: 01483 740 569Category(ies) of registration, with (number of places) Learning disability (0), Sensory impairment (0) Registration number G030000622 Date first registered 4th December 2003 Was the home registered under the Registered Homes Act 1984 as amended? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 4th December 2003If Yes refer to Part CAshlong HousePage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 317th June 2004 10:00 am James O`HaraID Code120406Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionJenny Hamilton, Acting Manager.Ashlong HousePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards for Care Homes for Adults (18 ­ 65) 1. Choice of Home 2. Individual Needs and Choices 3. Lifestyle 4. Personal and Healthcare support 5. Concerns, Complaints and Protection 6. Environment 7. Staffing 8. Conduct and Management of the Home Part C: Part D: D.1. D.2. D.3. Compliance with Conditions ( if applicable) Providers Response Providers Comments Action Plan Providers AgreementAshlong HousePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 as amended. This document summarises the inspection findings of the CSCI in respect of Ashlong House. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Adults (18-65) published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The following inspection methods have been used in the production of this report. The report is based on the findings of the specified inspection dates.Ashlong HousePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Not inspected on this visit.Ashlong HousePage 5 PART ASUMMARY OF INSPECTION FINDINGSInspectors Summary (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) Ashlong House opened in March 2004 to provide care to service users in the category of learning disabilities. This unannounced inspection is the first inspection carried out by the Commission for Social Care Inspection, the home was inspected against the National Minimum Standards. Since the home opened there has been a settling in period for the service users at the home, there have been a number of incidents reported by the home to the Commission for Social Care Inspection concerning service users Challenging Behaviours and Mental Health issues. The home is currently addressing these issues with support from Mental Health professionals. There are currently three service users living at Ashlong House. The home has ended the placement of one service user whose needs they felt could not be met. There were a number of concerns noted on the day of the inspection. The home is registered to provide care in the category of learning disabilities. The current Statement of Purpose states that the home provides twenty-four hour support for up to nine adults with learning disabilities and also accepts referrals including individuals with Mental Health needs and Challenging Behaviour. There was no evidence to suggest that the any of the staff team is experienced in working with people with Mental Health conditions. Furthermore the Statement of Purpose does not state which Mental Health conditions the home caters for or how it will meet these service users needs. None of the service users admitted to the home had had a Full Care Managers Needs Assessment prior to moving into the home therefore the needs of the service users could not be addressed or planned for. Staff training on Mental Health is planned for September 2004 however given that the needs of service users were not fully assessed prior to admission to the home the full extent of training cannot be identified.Ashlong HousePage 6 Risk assessments of the impact of service users with Challenging Behaviours and Mental Health conditions on current or any prospective new service users need to be in place, no new service user should be admitted to the home until this has been completed and copies of these risk assessments sent to the Commission for Social Care Inspection. There was no evidence to suggest that risk assessments for service users with Mental Health needs had any input from Mental Health professionals. There was no evidence to suggest that guidelines in place for staff to support the service user with Mental Health needs had any recorded input from professionals who would have an insight into the individual need of the service user and there Mental Health conditions. Due to the unpredictable behaviours of service users, staff should be made fully aware of any risks and necessary protocol should be in place to avoid harm to service user, staff and visitors. There was no evidence to suggest that the home is seeking recruit staff with relevant mental health experience in order to meet the needs of the service users, however the acting manager stated that she plans to recruit staff with this experience. The home must provide evidence to the Commission for Social Care Inspection of how it will train staff to meet the needs of service users with learning disabilities who are diagnosed with a specific mental health condition. The inspector feels that the home initially set off on the wrong foot by not ensuring that each service user had full care managers needs assessments, this left the home not knowing what the needs of the service users were. By meeting the requirements set in this report the home would go some way to meeting the needs of the service users. During the inspection process the inspector was assured by the acting manager that the home plans to recruit and train staff that will reflect the assessed needs of the service users living at the home. The inspector appreciates that the acting manager has been consistent in her approach of keeping the Commission for Social Care Inspection up to speed on developments in the home and is certain that this communication will be maintained. The inspector would like to thank the service users, the acting manager and all staff present on the day, for their time and willingness to facilitate the inspection process.Ashlong HousePage 7 Requirements from last Inspection visit fully actioned? If No please list belowNASTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for actionAction is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).MET (YES/NO)Ashlong HousePage 8 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001, and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action The acting manager must ensure that the Statement of Purpose accurately reflects the aims and objectives of the home and only admits service users for whom the 1 4 (1) a YA1 31/08/04 knowledge, experience and qualifications of the management and staff can afford people in their care a safe, secure and comfortable quality of life. The home must provide evidence to the Commission for Social Care Inspection of 2 18 (1) a YA1 how it will meet the needs of service users 31/07/04 with learning disabilities who are diagnosed with a specific mental health condition. A full care management assessment must be carried out prior to any service user moving to 14 (1) a & the home. The Mental Health conditions of 3 YA1 31/07/04 d service users must be obtained and the placing authority must be satisfied that the home can meet the needs of the service user. Prior to any new service users being placed at the home. Immediate414 (1) a & dYA2The manager must ensure that all present service users have a full care manager needs assessment.513 (1) bRisk assessments for service users with Mental Health needs should have the input of Mental Health professionals.Ashlong HousePage 9 613 (1) bThe home must complete risk assessments of the impact of service users with Challenging Behaviours and Mental Health conditions on current or any prospective new service users, no new service user must be admitted to the home until this has been completed and copies of these risk assessments sent to the Commission for Social Care Inspection. The Commission for Social Care Inspection must be informed prior to any new service user moving into the home. The acting manager must ensure that guidelines for the support of the service user with Mental Health needs are completed with the involvement of Mental Health professionals. The manager must ensure that the home develops a Protection of Vulnerable Adults Policy for the home using Suttons Councils Protection of Vulnerable Adult Policy as guidance. The home must seek recruit staff with relevant mental health experience in order to meet the needs of the service users. The home must provide evidence to the Commission for Social Care Inspection of how it will train staff to meet the needs of service users with learning disabilities who are diagnosed with a specific mental health condition. Due to the unpredictable behaviours of service users, staff should be made fully aware of any risks and necessary protocol should be in place to avoid harm to service user, staff and visitors. The home must produce a Service Users Guide relevant to the home so that prospective service users have the information they need to make an informed choice about where to live.Prior to any new service users being placed at the home. As stated.714 (1)813 (1) bImmediate922 (1)31/07/041018 (1) a31/07/041118 (1) c31/07/041213 (4) a, b & c.Prior to any new service users being placed at the home.135 (1)31/08/04Ashlong HousePage 10 RECOMMENDATIONS Identified below are areas addressed in the main body of the report which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard ** Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. YA10 refers to Standard 10.PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other enter details here `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: YES YES YES YES NO NO NO NA YES NO YES NO NO YES NO NO NO NO NO YESAshlong HousePage 11 Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total No. of care staff employed (excluding managers) Total No. of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs)3 0 2 NO NO YES YES X 0 17/06/04 10:00 4The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Adults (18-65) have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No Shortfalls) (Minor Shortfalls) (Major Shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Ashlong HousePage 12 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · Prospective service users have the information they need to make an informed choice about where to live. Prospective service users individual aspirations and needs are assessed. Prospective service users know that the home they 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.Standard 1 (1.1 ­ 1.4) The registered person produces an up to date statement of purpose setting out the aims, objectives and philosophy of the home, its services and facilities and terms and conditions; and provides each service user with a service users guide to the home. The statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the service users guide. X X Range of fees charged From To £ £ (per week) NO Any charges for extras If yes, please state what the extras are 1 Key findings/Evidence Standard met? The acting manager is currently amending the homes Statement of Purpose. The current Statement of Purpose states that the home provides twenty-four hour support for up to nine adults with learning disabilities and also accepts referrals including individuals with Mental Health needs and Challenging Behaviour. However the home is registered to provide care in the category of learning disabilities. At present the home is registered to support five service users, the home has submitted an application to register a further four places to the Commission for Social Care Inspection. The acting manager must ensure that the Statement of Purpose accurately reflects the aims and objectives of the home and only admits service users for whom the knowledge, experience and qualifications of the management and staff can afford people in their care a safe, secure and comfortable quality of life. A full care management assessment must be carried out prior to any service user moving to the home. From this assessment the Mental Health conditions of service user must be obtained and the placing authority must be satisfied that the home can meet the needs of the service user. The home must provide evidence to the Commission for Social Care Inspection of how it will meet the needs of service users with learning disabilities who are diagnosed with a specific mental health condition. The home must produce a Service Users Guide relevant to the home so that prospective service users have the information they need to make an informed choice about where to live.Ashlong HousePage 13 Standard 2 (2.1 ­ 2.8) New service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user, using an appropriate communication method and with an independent advocate as appropriate. 1 Key findings/Evidence Standard met? There are currently three service users living at Ashlong House. The home has ended the placement of one service user whose needs they felt could not be met. None of the service users at the home had a care manager needs assessment completed prior to moving into the home. The inspector was shown an assessment for one service user that was carried out by the registered manager (now the HR manager for Allied Care) this was lean in content and referred to the service users Challenging Needs briefly in a tick box. There was no reference to the service users Mental Health needs. A full care managers needs assessment is required so that the manager can identify how the home will develop staff training and practices to successfully meet the needs of the service users and the impact of these needs on other service users living in the home. The manager must ensure that all present service users have a full care manager needs assessment prior to any new service users being placed in the home. Standard 3 (3.1 - 3.10) The registered person can demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 1 Key findings/Evidence Standard met? The manager stated that the specialist needs of the service users included Epilepsy, Diabetes, Asthma, Prada Willi Syndrome, Mental Health conditions and Challenging Behaviours. The inspector examined the staff training Matrix for the home. Some staff has completed training on Epilepsy and Aspergers Syndrome, training is planned facilitated by Securi-Care on Managing Challenging Behaviour over two days on the 18th and 28th June 2004 and Autism the 24th June 2004 a number of staff has recently attended training on Vulnerable Adults. The manager stated that training for staff on Mental Health is planned for September 2004 however given that the needs of service users were not fully assessed prior to admission to the home the full extent of training cannot be identified. See Requirement set in standard 32.Ashlong HousePage 14 Standard 4 (4.1 - 4.5) The registered manager invites prospective service users to visit the home on an introductory basis before making a decision to move there, and unplanned admissions are avoided wherever possible. 1 Key findings/Evidence Standard met? One service user moved from another home is the service another was an emergency placement that has expressed her wish to live at the home. As previously stated in this report none of the service users has had care manager needs assessment completed prior to moving into the home. The manager is currently amending the homes Statement of Purpose, the inspector examined the section on Referrals and Admissions that states that service users are welcome to visit for short periods, meals and or overnight stays, six week trial period with reassessments and a care review after six months. The manager stated that this is what she plans to do with all new prospective service users. Also See Standard 1 of this report. Standard 5 (5.1 - 5.5) The registered manager develops and agrees with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user. 0 Key findings/Evidence Standard met? Not inspected on this visit.Ashlong HousePage 15 Individual Needs and ChoicesThe intended outcomes for the following set of standards are: · · · · · 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.Standard 6 (6.1 ­ 6.10) The registered manager develops and agrees with each service user an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the home, and how these services will meet current and changing needs and aspirations and achieve goals. 1 Key findings/Evidence Standard met? The inspector was shown the service users Care Plan Objectives. These had been completed by the home based on service users individual needs, how to meet needs, goals to be achieved, how to achieve goals, by whom and potential timescales. These were in sections Personal Care, Behaviour Management, Activities/Day care, Community Assessment, Household Duties and General Health Needs. However as previously stated in this report none of the service users has had care manager needs assessment completed prior to moving into the home. From this assessment the needs of service user would be obtained and home should agree with each service user an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the home and how these services will meet current and changing needs and aspirations and achieve goals. Standard 7 (7.1 ­ 7.7) Staff respect service users right to make decisions, and that right is limited only through the assessment process, involving the service user, and as recorded in the individual Service User Plan. 0 Key findings/Evidence Standard met? Not inspected on this visit.Ashlong HousePage 16 Standard 8 (8.1 ­ 8.5) The registered manager ensures that service users are 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. 0 Key findings/Evidence Standard met? Not inspected on this visit.Standard 9 (9.1 ­ 9.4) Staff enable service users to take responsible risks, ensuring they have good information on which to base decisions, within the context of the service users individual Plan and of the homes risk assessment and risk management strategies. 1 Key findings/Evidence Standard met? The inspector was shown completed risk assessments. The manager and key-worker for each service user have completed these. There has been no involvement by Mental Health professionals recorded in risk assessments carried out for those service users with Mental Health needs. Risk assessments for service users with Mental Health needs should have the input of Mental Health professionals. The home should complete risk assessments on the impact of service users with Challenging Behaviours and Mental Health conditions on current and any prospective new service users, no new service user must be admitted to the home until this has been completed. The Commission for Social Care Inspection must be informed prior to any new service user moving into the home. Standard 10 (10.1 ­ 10.6). Staff respect information given by service users in confidence, and handle information about service users in accordance with the homes written policies and procedures and the Data Protection Act 1998, and in the best interests of the service user. 0 Key findings/Evidence Standard met? Not inspected on this visit.Ashlong HousePage 17 LifestyleThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 11 (11.1 ­ 11.4) Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 0 Key findings/Evidence Standard met? Not inspected on this visit.Standard 12 (12.1 ­ 12.6) Staff help service users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities. 0 Key findings/Evidence Standard met? Not inspected on this visit.Ashlong HousePage 18 Standard 13 (13.1 ­ 13.5) Staff support service users to become part of, and participate in, the local community in accordance with assessed needs and the individual Plans. 0 Key findings/Evidence Standard met? Not inspected on this visit.Standard 14 (14.1 ­ 14.6) Staff ensure that service users have access to, and choose from a range of, appropriate leisure activities. Key findings/Evidence Standard met? Not inspected on this visit.0Standard 15 (15.1 ­ 15.5) Staff support service users to maintain family links and friendships inside and outside the home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary). 0 Key findings/Evidence Standard met? Not inspected on this visit.Standard 16 (16.1 ­ 16.11) The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 0 Key findings/Evidence Standard met? Not inspected on this visit.Ashlong HousePage 19 Standard 17 (17.1 ­ 17.9) The registered person promotes service users health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 0 Key findings/Evidence Standard met? Not inspected on this visit.Ashlong HousePage 20 Personal and Healthcare SupportThe intended outcomes for the following set of standards are: · · · · 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 homes 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.Standard 18 (18.1 ­ 18.11) Staff provide sensitive and flexible personal support and nursing care to maximise service users privacy, dignity, independence and control over their lives. 0 Key findings/Evidence Standard met? Not inspected on this visit.Standard 19 (19.1 ­ 19.5) The registered person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. No. of incidents where service users have been taken to Accident & Emergency during last 12 months No. of service users with pressure sores at the time of inspection (from information taken from care notes) 801 Key findings/Evidence Standard met? There were eight recorded incidents where service users have been taken to Accident & Emergency/Hospital since the home opened in March 2004. One service user has been admitted to Accident & Emergency on issues relating to her diabetes. Another service user with Mental Health needs has attended hospital or called paramedics on a number of occasions voluntarily on issues relating to her Mental Health. The inspector was shown guidelines to support the service user when she displays Challenging Behaviours, absconds or threatens staff. However as in the risk assessments there has been no recorded input from Mental Health professionals who have an insight into the individual need of the service user and her Mental Health conditions. The acting manager must ensure that guidelines for the support of the service user with Mental Health needs are completed with the involvement of Mental Health professionals.Ashlong HousePage 21 Standard 20 (20.1 ­ 20.14) The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the homes policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. 0 Key findings/Evidence Standard met? Not inspected on this visit.Standard 21 (21.1 ­ 21.8) The registered manager and staff deal with the ageing, illness and death of a service user with sensitivity and respect. 0 Key findings/Evidence Standard met? Not inspected on this visit.Ashlong HousePage 22 Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: · · Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm.Standard 22 (22.1 ­ 22.7) The registered person ensures that there is a clear and effective complaints procedure, which includes the stages of, and timescales for, the process and that service users know how and to whom to complain. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days 3 0 0 0 3 0 0 3 Key findings/Evidence Standard met? The manager stated that there have been four recorded complaints. The inspector was shown the homes complaints record book. The stated that complaints about noise were made by a neighbour verbally however the manager has not been able to contact him in person to resolve these.Ashlong HousePage 23 Standard 23 (23.1 ­ 23. 6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, or inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policy. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists NO02 Key findings/Evidence Standard met? The manager explained that seven staff has recently attended training on Adult Protection run by Allied Care. The manager explained that she has requested a copy of Suttons Councils Protection of Vulnerable Adult Policy so this can be employed in the home. The manager must ensure that the home develops a Protection of Vulnerable Adults Policy for the home using Suttons Councils Protection of Vulnerable Adult Policy as guidance.Ashlong HousePage 24 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 24 (24.1 ­ 24.13) The homes premises are suitable for its stated purpose; accessible, safe and well maintained; meet service users individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. 0 Key findings/Evidence Standard met? Not inspected on this visit.Ashlong HousePage 25 Standard 25 (25.1 ­ 25. 11) The registered person provides each service user with a bedroom, which has useable floor space sufficient to meet individual needs and lifestyles. Total no. of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1st April 2003) ­ single bedrooms below 10 sq.m usable space or additional compensatory space Total no. of wheelchair users accommodated for in rooms at least 12 sq.m Total no. of wheelchair users accommodated for in rooms less than 12 sq.m Total no. of shared rooms at least 16 sq.m Total no. of shared rooms below 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total no. of single bedrooms Number of single bedrooms with en suite Total no. of double bedrooms Number of double rooms with en suite Key findings/Evidence Not inspected on this visit. YES NO NO X X X X Standard met? 0 X XX X X XAshlong HousePage 26 Standard 26 (26.1 ­ 26.4) The registered person provides each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. Key findings/Evidence Not inspected on this visit. Standard met? 0Standard 27 (27.1 ­ 27.6) The registered person provides service users with toilet and bathroom facilities which meet their assessed needs and offer sufficient personal privacy. 0 Key findings/Evidence Standard met? Not inspected on this visit.Standard 28 (28.1 ­ 28.3) A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. 0 Key findings/Evidence Standard met? Not inspected on this visit.Ashlong HousePage 27 Standard 29 ( 29.1 ­ 29.8) The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the homes stated purpose and the individually assessed needs of all service users. 0 Key findings/Evidence Standard met? Not inspected on this visit.Standard 30 (30.1 ­ 30.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 0 Key findings/Evidence Standard met? Not inspected on this visit.Ashlong HousePage 28 StaffingThe intended outcomes for the following set of standards are: · · · · · · 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 homes 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.Standard 31 (31.1 ­ 31.7) The registered manager ensures that staff have clearly defined job descriptions and understand their own and others roles and responsibilities. 1 Key findings/Evidence Standard met? The inspector was shown the staff job description and person specification, there was no reference to staff working with service users with Mental Health in either. The acting manager stated that she plans to develop a new staff job description and person specification around the specific needs of the homes. Given that some of the service users have mental health conditions the home must seek recruit staff with relevant mental health experience in order to meet the needs of the service users. Standard 32 (32.1 ­ 32.6) Staff have the competencies and qualities required to meet service users needs and achieve Sector Skills Council workforce strategy targets within the required timescales. 1 Key findings/Evidence Standard met? The acting manager stated that three staff has registered to complete NVQ level 3. The acting manager has completed the NVQ level 4 and Registered Managers Award and the deputy manager has completed NVQ level 3. The inspector was shown the Allied Care Induction Pack these are in the process of completion as the home opened in March this year. The home must provide evidence to the Commission for Social Care Inspection of how it will train staff to meet the needs of service users with learning disabilities who are diagnosed with a specific mental health condition.Ashlong HousePage 29 Standard 33 (33.1 ­ 33.11) The home has an effective staff team with sufficient numbers and complementary skills to support service users assessed needs at all times. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. Personal Care No. service users High needs No. service users Medium needs No. service users Low needs Total no. of hours needed No. of staff with NVQ level 2 or above No. of Trainees registered on Sector Skills Council training programme 2 1 0 X 0 No. of full time equivalent Staff with nursing qualification (where applicable) No. staff hours allocated No. staff hours allocated No. staff hours allocated Total Hours Provided X X X X Nursing X X X001 Key findings/Evidence Standard met? The manager stated that the present staffing level is three staff on early shifts, three staff on late shifts and two staff on at night also at the week-end there is an extra floating staff. See Requirements.Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 2 Key findings/Evidence Standard met? The manager stated that all staff had applied for Criminal Record Bureau Checks and these would be available for inspection at the announce inspection.Ashlong HousePage 30 Standard 35 (35.1 - 35.8) The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 1 Key findings/Evidence Standard met? See standard 3.Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. 3 Key findings/Evidence Standard met? The inspector was shown evidence that staff have supervision at least once every month.Ashlong HousePage 31 Conduct and Management of the HomeThe intended outcomes for the following set of standards are: · · · · · · · 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 homes policies and procedures. Service users rights and best interests are safeguarded by the homes 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.Standard 37 (37.1 ­ 37.4) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Registered manager qualified to level 4 NVQ in Management and care [by 2005]. YES3 Key findings/Evidence Standard met? The Registered Manager holds a level 5 NVQ in Management and Care however she is now the human resources manager for Allied Care. The acting manager has completed the Registered Managers Award and NVQ level 4. The acting manager has applied to the Commission for Social Care Inspection to be the registered manager for the home.Standard 38 (38.1 ­ 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? Not inspected on this visit.Ashlong HousePage 32 Standard 39 (39.1 ­ 39.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in achieving the aims, objectives and statement of purpose of the home. 0 Key findings/Evidence Standard met? Not inspected on this visit.Standards 40 (40.1 ­ 40.6) The homes written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Adults (18-65). 0 Key findings/Evidence Standard met? Not inspected on this visit.Standard 41 (41.1 ­ 41.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 0 Key findings/Evidence Standard met ? Not inspected on this visit.Ashlong HousePage 33 Standard 42 (42.1 ­ 42.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 1 Key findings/Evidence Standard met? Due to the unpredictable behaviours of service users, staff should be made fully aware of any risks and necessary protocol should be in place to avoid harm to service user, staff and visitors.Standard 43 (43.1 ­ 43.7 ) The overall management of the service (within or external to the home) ensures the effectiveness, financial viability and accountability of the home. 0 Key findings/Evidence Standard met ? Not inspected on this visit.Ashlong HousePage 34 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceRegulatory Inspector Second Inspector Regulation Manager DateSignature Signature SignatureAshlong HousePage 35 Public reports It should be noted that all CSCI inspection reports are public documents.Ashlong HousePage 36 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on enter date(s) of inspection here and any factual inaccuracies: Please limit your comments to one side of A4 if possibleAction taken by the CSCI in response to provider comments: Ashlong House Page 37 Amendments to the report were necessaryNOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateNONOYESNote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by 2nd August 2004, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request.You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planNOYESNOOther: enter details here NOAshlong HousePage 38 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I of confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Ashlong HousePage 39 - 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. 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