Inspection on 29/11/04 for Ashlong House

Care Homes For Adults (18 ­ 65)Ashlong House141 Longfellow Road Worcester Park Surrey KT4 8BAAnnounced Inspection29th November 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) 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 2003 Yes NO 17/06/04 If 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 329th November 2004 09:30 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; home 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. The home is a detached house situated in a cul-de-sac off a quiet street in Worcester Park. Ashlong House is at present developing a new Statement of Purpose and Service User Guide. The home plans to provide support to people with learning disabilities with physical and mobility disabilities. The home is being prepared so that the bedrooms, bathrooms and communal spaces can meet the needs of this service user group. As this work is not yet complete the inspector will assess this at a planned visit when the new service users move into the home.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.) This inspection was announced and took place in the morning and early afternoon. At present the home supports one service user. The inspector was able to speak to the service user before she went off to an interview at Croydon College. Since the unannounced inspection that took place in June of this year three service users have moved out of the home and the acting manager has now been appointed as the home manager for Ashlong House. There were thirteen requirements set at the last inspection the majority of which were regarding the previous service users. The previous service users were people with learning disabilities who presented Challenging Behaviours and were also diagnosed with specific mental health conditions yet none of these service users had a care manager needs assessment carried prior to moving into the home. There were also a number of concerns and complaints raised by health care providers and local residents regarding serious incidents involving these service users. The management of the home felt that the home could no longer meet the needs of these service users and the service users placements were terminated. The home manager stated that the home now plans to change direction and focus on supporting people with learning disabilities with physical and mobility difficulties. The home manager has recently applied to the Commission for Social Care Inspection for a variation to increase the service user numbers on the homes registration from supporting five people with learning disabilities to nine people with learning disabilities some of who may have physical disabilities. A number of service users have visited the home with a view to moving in. The home manager stated that under no circumstances would any new service user be considered for admission into the home if they did not have a care manager needs assessment carried out first. The home manager stated that there are no plans to admit service users with predominant Challenging Behaviours. Due to this fact many of the previous requirements are no longer relevant. The inspector and the home manager agreed that it was not possible to fully inspect the home in its present transitional situation and that a further visit would be appropriate once new service users have moved into the home. As a result of this inspection there are eight requirements and one recommendation. Choice of Home. Ashlong HousePage 6 The home manager is developing a new Statement of Purpose this must accurately reflect the aims and objectives of the home and the home should only admit service users for whom the it is registered to provide support to. The home manager and the service user are currently developing the Service User Guide for the home this is work in progress and may need to be reviewed again once new service users move into the home. A number of service users from The Queen Elizabeth Foundation Centre, a Development Centre for people with learning disabilities/physical disabilities have visited the home with a view to possible placements. Individual Needs and Choices. The manager explained that the organisation has purchased a full set of policies and procedures from the consultancy company Cared4. These documents fully comply with the required standards as defined in appendix 2 of the National Minimum Standards. The inspector was shown the service users Lifestyle Plan (Cared4) this is very comprehensive and has been completed by the service user with the support of staff. The service user often leaves the home for a number of days she often goes to her Mothers home or to visit her friends who live in that area. This issue was discussed as part of the service users care manager review meeting. The homes manager stated that she is working closely with the service user, the service users mother, the police and the service users care manager to minimise any risk to the service user. The inspector was shown risk assessments carried out for the service user when she goes missing, guidelines for staff to follow should she go missing and the homes missing persons guidelines. The inspector and the manager discussed these guidelines and agreed that the guidelines for staff to follow in the event of the service user going missing and the missing persons guidelines should be incorporated into one procedure. Lifestyle. The inspector was shown the service users weekly activities record. The manager explained that the service user with the support of staff had drawn this up. Activities include iceskating, bowling, gym, visit to mum, lunch out and pubs. The manager stated that new service users would continue to attend activities that they enjoy when they are admitted to the home. Personal Healthcare and Support. The inspector examined the homes medication records these had a recent photograph of the service user and were up to date and accurate. The home manager employs the Boots blister pack system. The home manager plans to employ this system when new service users move in.Complaints and Concerns. There were a number of concerns and complaints regarding incidents involving previous service users that lived at the home. A meeting took place in August 2004 at the offices of Ashlong House Page 7 the Commission for Social Care Inspection where these concerns and incidents were discussed including the impact of these incidents on the local community and actions to be taken by the home to improve relationships with the local community. As a result of this meeting the manager set up an Open Day on the 1st October 2004 and a number of local residents attended to express their concerns, the inspector also attended. The manager has recently met with local residents and feels that the home and the local residents have developed positive communication and hopes that any future concerns can be resolved quickly. The manager also stated that the local councillor has played a supporting role in developing this positive communication. There have been no recorded complaints to the home or to the Commission for Social Care Inspection since the previous service users left the home. Environment. The home has nine bedrooms over two floors seven of which have en-suite facilities. Each floor has a living room, kitchen diner, laundry room and a bathroom. The front of the house is mainly used for car parking and has a small grassy area, the there are plans to develop the garden by knocking down an unused garage, there are plans to resurface the driveway to the home in order to improve mobility for wheelchair users. Builders with experience in converting care homes to the needs of service users with physical and mobility difficulties have been to the home and plans are in place to complete this work i.e. widening bedroom doorways and adding adaptations. All service users will be assessed prior to moving into the to ensure that all equipment such as hoists are in place. The home also has a lift that at present is out of commission. The manager stated that she would review the need for the lift should service user assessments identify this. The manager stated that no new service user would move into the home until this work is completed. These standards will be reviewed at the next visit to the home when new service users are admitted. Staffing. At present the home has one service user. The manager stated that since three service users moved out this Summer the home has retained its staff. Some of the staff however work in other Allied Care homes. Once the new service users move into the home staff will return to work at Ashlong house. The home manager showed the inspector evidence that six staff had completed Criminal Records Bureau Checks and that five staff have applied and are awaiting checks to be returned from the Criminal Records Bureau. The inspector has required that the home manager contact the Criminal Records Bureau to enquire when the staff Criminal Records Bureau Checks and to inform the Commission for Social Care Inspection when these have been received. Two new staff has started work at the home, the home manager stated that these staff are supported/shadowed on a one to one basis by an established member of staff at all times the home manager is required to continue this arrangement until their Criminal Records Bureau Check are received by the home.Conduct and Management of the Home. The manager has completed the Registered Managers Award to level 4, has a Degree in Health Care Studies and is currently completing a Diploma in Applied Psychology at the Tizard Centre. The manager has applied to the Commission for Social Care Inspection to be the registered manager for Ashlong House. She explained that she is awaiting registration information to Ashlong House Page 8 be transferred from the Wimbledon Commission for Social Care Inspection office to the Croydon office in order that she can move forward with her application. The manager has worked hard to develop positive communication between the home and local residents. The Area Manager has recently left the organisation the manager stated that she now has contact with another Area Manager and the Registered Provider if she needs support; and explained that the organisation is currently trying to recruit a new area manager. A requirement was set that the home manager sends copies of the Legionella Testing Certificate and the Landlords Gas Safety Certificates to the Commission for Social Care Inspection. As previously stated the inspector will visit the home again when new service users are admitted to the home. Given the homes previous history the inspector feels that the manager is moving in a positive direction and is confident that the manager will ensure that the new service users are properly assessed and placed. As has always been the case the manager has been consistent in her approach of keeping the Commission for Social Care Inspection informed of developments in the home. The inspector would like to thank the service user and professionals for their feedback, the home manager and all staff present on the day, for their time and willingness to facilitate the inspection process.Ashlong HousePage 9 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY 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 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 knowledge, 1 4 (1) a YA1 31/08/04 experience and qualifications of the management and staff can afford people in their care a safe, secure and comfortable quality of life. 7 14 (1) YA9 The Commission for Social Care Inspection must be informed prior to any new service user moving into the home. As stated.Action 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 10 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 home manager must ensure that the new Statement of Purpose accurately reflects the 1 4 (1) a YA1 aims and objectives of the home and the 31/01/05 home only admits service users for whom the home is registered to provide support to. 2 12(1) a & b YA9 The home manager must ensure that staff is given clear guidance to follow should the service user go missing. The home manager must write to the Commission for Social Care Inspection detailing how the home will ensure that 50 of the care staff in the home will achieve a care NVQ level 2 qualifications by 2005. 31/01/05318(1) aYA3331/01/05418(2) bYA34The home manager must ensure that the two new staff continue to be supported/shadowed As per on a one to one basis by an established requireme member of staff at all times until their Criminal nt. Records Bureau Checks have been received by the home. The home manager must contact the Criminal Records Bureau to enquire when the staff As per Criminal Records Bureau Checks will be requireme complete, the home manager must inform the nt. Commission for Social Care Inspection when these have been received. The home manager must ensure that copies of the homes Regulation 26 visits are sent to 31/01/05 the Commission for Social Care Inspection on a monthly basis. Page 11519(1)YA34626 (4)&(5)YA39Ashlong House 712(1) aYA42The home manager must ensure that copies of the Legionella Testing Certificate and the Landlords Gas Safety Certificate are 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.31/01/05814 (1)YA9As stated.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 * 1 YA41 The inspector recommends that the home manager contact the Cared4 consultancy company for support in locating this policy.* 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 Ashlong House YES YES YES Page 12 · 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: 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)YES YES NO NO NO YES NA YES NO NO YES NO NO YES NO NO NO 1 0 0 NO NO YES NO 8 X 29/11/04 09.15 4.5The 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 Ashlong House (Commendable) (No Shortfalls) (Minor Shortfalls) (Major Shortfalls) Page 13 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 14 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. 900.00 900.00 Range of fees charged From To £ £ (per week) NO Any charges for extras If yes, please state what the extras are 2 Key findings/Evidence Standard met? The acting manager has now been appointed as the homes manager for Ashlong House. The manager stated that due to the fact that the home now plans to admit people with learning disabilities/physical disabilities she is in the process of developing a new Statement of Purpose for the home. The manager must ensure that the new Statement of Purpose accurately reflects the aims and objectives of the home and the home only admits service users for whom the home is registered to provide support to. The manager showed the inspector the Service User Guide that she and the service user are currently developing for the home this is work in progress and may need to be reviewed again once new service users move into the home. The inspector informed the home manager that he will revisit the home once the new service users move in.Ashlong HousePage 15 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. 3 Key findings/Evidence Standard met? Since the last inspection in June of this year three service users have moved out of the home. There were a large number requirements set at the last inspection regarding these service users care managers needs assessments, risk assessments, staff guidelines, staff training and how the home would meet the needs of service users with learning disabilities who presented Challenging Behaviours and were also diagnosed with specific mental health conditions. There were also a number of concerns raised by health care providers and local residents. The management of the home felt that the home could no longer meet the needs of these service users. The home is currently registered to support five people with learning disabilities. The manager has applied to the Commission for Social Care Inspection to increase the service user numbers on the homes registration to support nine people with learning disabilities some of whom may have physical disabilities. The manager stated that a number of service users have visited the home with a view to moving in. The inspector was shown a care managers needs assessment and care plan for one prospective service user. The manager stated that under no circumstances would any new service user be considered for admission into the home if they did not have a care manager needs assessment carried out first. As previously stated in this report the manager is developing a new Statement of Purpose, the previous Statement of Purpose stated in the section Referrals and Admissions that service users are welcome to visit for short periods, meals and or overnight stays, six week trial period with re-assessments and a care review after six months. The manager stated that this is what she plans to do with all new prospective service users. The manager stated that there are no plans to admit service users with Challenging Behaviours. 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. 3 Key findings/Evidence Standard met? The manager stated that under no circumstances would any new service user be considered for admission into the home if they did not have a care manager needs assessment carried out first. A care manager needs assessment is required for all new service users so that the manager can identify how the home will develop staff training and practices to successfully meet the needs of the service users. At present only one service user resides at the home, the inspector was shown a care managers needs assessment, care plan, risk assessments, staff support guidelines and lifestyle plan completed for this service user.Ashlong HousePage 16 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. 3 Key findings/Evidence Standard met? The home manager stated that a number of service users have visited the home with a view to moving in. The majority of the service users that have visited the home have been from The Queen Elizabeth Foundation Centre this the home manager explained is a Development Centre for people with learning disabilities/physical disabilities where people live and attend classes/courses that would support them towards independent living. The inspector was shown a care managers needs assessment and care plan for one prospective service user. This service user has been to visit the home on four occasions and the manager stated that she has been to visit the service user at her present placement. 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. 3 Key findings/Evidence Standard met? The inspector was shown the service users Individual service contract and the terms and conditions. The service user has signed these.Ashlong HousePage 17 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. 3 Key findings/Evidence Standard met? The manager explained that the organisation has purchased a full set of policies and procedures from a consultancy company Cared4. These documents fully comply with the required standards as defined in appendix 2 of the National Minimum Standards. The inspector was shown the service users Lifestyle Plan (Cared4) this is very comprehensive and has been completed by the service user with the support of staff. Sections include; some good things about myself, where I live now and my life now. In all of these sections the service user has set her personal goals for the future. 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. 3 Key findings/Evidence Standard met? Currently the home caters for one service user. This standard will be reviewed at the next visit to the home. See previous standard.Ashlong HousePage 18 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. 3 Key findings/Evidence Standard met? Currently the home caters for one service user. The manager showed the inspector evidence that the service user attends part of the staff meeting. She stated that the new service users when admitted to the home will hold regular service user meetings and that issues identified by the service users will be brought by them to the staff meeting. The manager showed the inspector the Service User Guide that she and the service user are currently developing for the home. This is work in progress and may need to be reviewed again once new service users move into the home. 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. 2 Key findings/Evidence Standard met? The service user who lives at the home often leaves the home for a number of days. The manager stated that she often goes to her Mothers home or to visit her friends who live in that area. The inspector was shown evidence that this issue was discussed as part of the service users care manager review meeting. The manager stated that she is working closely with the service user and her mother, the police and the service users care manager to minimise the risk to the service user. The inspector was shown risk assessments carried out for the service user when she goes missing, guidelines for staff to follow should she go missing and the homes missing persons guidelines. The inspector and the home manager discussed these guidelines and agreed that the guidelines for staff to follow in the event of the service user going missing and the missing persons guidelines should be incorporated into one procedure. The manager must ensure that staff is given clear guidance to follow should the service user go missing. 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. 3 Key findings/Evidence Standard met? The manager explained that the organisation has purchased a full set of policies and procedures from a consultancy company Cared4. The inspector was shown the policy on Confidentiality. The manager stated that all staff had read and signed the homes previous policy on Confidentiality. She also stated that all staff are currently completing an induction into the new policies and procedures for the home, these are discussed in staff supervision. Staff will sign a staff compliance sheet in the Cared4 policies and procedures file when they have read and understood each policy.Ashlong HousePage 19 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? Currently the home caters for one service user. This standard will be reviewed at the next visit to the home when new service users are admitted.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. 3 Key findings/Evidence Standard met? On the day of the inspection the service user was on her way to Croydon College for an interview for a place on a leisure and tourism course. Previously she had employment in a hairdressers and a supermarket. The inspector spoke to the service user prior to her going to her interview, she explained that this is something that she would like to do, hopefully she would make new friends, she also goes to the gym and ice skating supported by staff on a regular basis.Ashlong HousePage 20 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? See standards 9 and 12 of this report. Currently the home caters for one service user. This standard will be reviewed at the next visit to the home when new service users are admitted.Standard 14 (14.1 ­ 14.6) Staff ensure that service users have access to, and choose from a range of, appropriate leisure activities. 0 Key findings/Evidence Standard met? Currently the home caters for one service user see standards 12 of this report. This standard will be reviewed at the next visit to the home when new service users are admitted.Standard 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). 3 Key findings/Evidence Standard met? The manager stated that the service user visits her Mother at weekends. The manager plans to purchase two minibuses for the home. She explained that new service users would be supported to visit relatives and their friends at their previous placement if they wished to do so. The manager stated that the visitor policy would be in the Service User Guide when it is completed.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). 3 Key findings/Evidence Standard met? The inspector was shown the service users weekly activities record. The manager explained that the service user with the support of staff had drawn this up. Activities include iceskating, bowling, gym, visit to mum, lunch out and pubs. The manager also stated that the service user enjoys clubbing and has been supported by staff to go to clubs. The manager stated that new service users would continue to attend activities that they enjoy when they are admitted to the home.Ashlong HousePage 21 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. 3 Key findings/Evidence Standard met? The manager stated that the current service user is very independent when it comes to what she likes to eat. She is supported to the local supermarket where staff support her to pick seven healthy meals for the week. The manager stated that she would use a menu plan when the new service users move in. This standard will be reviewed again at the next visit to the home when new service users are admitted.Ashlong HousePage 22 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? The present service user requires no support with personal care. This standard will be reviewed at the next visit to the home when new service users are admitted.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) 403 Key findings/Evidence Standard met? There were a number of occasions when the previous service users who lived at Ashlong House were taken to Accident and Emergency. Since these service users moved out in July of this year only one service user now lives at the home. There have no occasions since then of this service user attending Accident and Emergency. The manager stated that the current service user had been diagnosed with childhood epilepsy. The service user has attended hospital to assess this condition, the inspector was shown evidence that the Doctor found no evidence during examinations and teats to suggest that she has epilepsy now. In any case the majority of the staff team had been trained on epilepsy.Ashlong HousePage 23 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. 3 Key findings/Evidence Standard met? The manager showed the inspector the homes medication records these had a recent photograph of the service user and were up to date and accurate. The manager employs the Boots blister pack system. She stated that she plans to employ this system when new service users move in.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. 3 Key findings/Evidence Standard met? The inspector was shown the Care of Dying and Bereavement policy (Cared4). The manager stated that this would be given to prospective service users and relatives prior to moving into the home seeking their wishes upon dealing with aging, illness and death. The manager stated that this information would also be included in the service users Lifestyle Plan when fully completed.Ashlong HousePage 24 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 5 5 0 0 0 2 0 3 Key findings/Evidence Standard met? There were a number of concerns and complaints regarding incidents involving the previous service users that lived at the home. A meeting took place in August 2004 at the offices of the Commission for Social Care Inspection to discuss the management of the service users at Ashlong House and the impact the service was having on the local community. A number of concerns were discussed including the impact of these incidents on the local community and actions to be taken to improve relationships with the local community. As a result of this meeting the home manager set up an Open Day on the 1st October 2004 and a number of local residents attended to express their concerns, the inspector also attended. The manager stated that she has recently met with local residents and feels that the home and local residents have developed positive communication and hopes that any future concerns can be resolved quickly. The manager also stated that the local councillor has played a supporting role in developing this positive communication. There have been no recorded complaints to the home or to the Commission for Social Care Inspection since the previous service users left the home.Ashlong HousePage 25 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 YES03 Key findings/Evidence Standard met? The manager showed the inspector Sutton Multi Agency Procedures and Guidelines for the Protection of Vulnerable Adults, she stated that the home uses this as guidance. The inspector was also shown evidence that staff has had training on Adult Protection.Ashlong HousePage 26 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. 3 Key findings/Evidence Standard met? The home has nine bedrooms over two floors seven of which have en-suite facilities. Each floor has a living room, kitchen diner, laundry room and a bathroom. The front of the house is mainly used for car parking and has a small grassy area, however the home manager stated that there are plans to develop the garden by knocking down an unused garage. The manager also stated that there are plans to resurface the driveway to the home, as this would in its current condition prevent service users in wheelchairs comfortably accessing the community. The manager stated that builders with experience in converting care homes to the needs of service users with physical and mobility difficulties have been to the home and plans are in place to complete this work i.e. widening bedroom doorways and adding adaptations. The manager also stated that service users will be assessed prior to moving into the to ensure that all equipment such as hoists are in place. The home also has a lift that at present is out of commission the home manager stated that she would review the need for the lift should service user assessments identify the need. The manager stated that no new service user would move into the home until this work is completed. This standard will be reviewed at the next visit to the home when new service users are admitted.Ashlong HousePage 27 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 See previous standard. YES NO NO 9 7 0 0 Standard met? 3 9 XX X 0 0Ashlong HousePage 28 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. 3 Key findings/Evidence Standard met? There is currently one service user living at the home. Service users bedrooms viewed by the inspector are spacious comfortable and seven of the nine bedrooms have en-suite facilities. See standard 24.Standard 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. 3 Key findings/Evidence Standard met? Seven of the nine service user bedrooms have en-suite facilities there is a communal bathroom on each floor.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. 3 Key findings/Evidence Standard met? Each floor of the home has a lounge and a kitchen dining area. The home manager stated that there are plans to develop the garden area by knocking down an unused garage.Ashlong HousePage 29 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. 3 Key findings/Evidence Standard met? The manager also stated that service users will be assessed prior to moving into the home to ensure that all equipment such as hoists and moving equipment is in place. The home also has a lift that at present is out of commission the manager stated that she would review the need for the lift should service user assessments identify the need. The home manager stated that no new service user would move into the home until this work is completed.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. 3 Key findings/Evidence Standard met? The home was observed to be clean and hygienic on the day of the inspection.Ashlong HousePage 30 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. 3 Key findings/Evidence Standard met? The inspector examined the homes job description, it states what is expected of its employees in terms of their roles and responsibilities and the values that should underpin their conduct. Staff meeting take place at least once a month and minutes are taken of the meetings. At present the home has one service user. The manager stated that since three service users moved out this Summer the home has retained its staff. Some of the staff however work in other Allied Care homes in the local area. Once the new service users move into the home staff will work back at Ashlong house. 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. 3 Key findings/Evidence Standard met? The manager stated that all staff are currently completing an induction into the new policies and procedures for the home, these are discussed in staff supervision. Staff will sign a staff compliance sheet in the Cared4 policies and procedures file when they have read and understood each policy. The manager also stated that the home would develop a training programme that reflects the assessed needs of all new service users when they move into the home she also explained that she is endeavouring to recruit staff with at least two years experience in working with people with learning disabilities. This standard will be reviewed at the next visit to the home when new service users are admitted.Ashlong HousePage 31 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 X X X 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 XXX2 Key findings/Evidence Standard met? The home manager stated that none of the care staff have completed an NVQ qualification however she is seeking an organisation that will provide this for her staff team. The home manager must write to the Commission for Social Care Inspection detailing how the home will ensure that 50 of the care staff in the home will achieve a care NVQ level 2 qualifications by 2005.Ashlong HousePage 32 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 showed the inspector evidence that six staff had completed Criminal Records Bureau Checks and that five staff have applied and are awaiting checks to be returned from the Criminal Records Bureau. Two new staff has started work at the home, the manager stated that these staff are supported/shadowed on a one to one basis by an established member of staff at all times. The manager must ensure that the two new staff continue to be supported/shadowed on a one to one basis by an established member of staff at all times until their Criminal Records Bureau Checks have been received by the home. The manager must also contact the Criminal Records Bureau to enquire when the staff Criminal Records Bureau Checks will be complete and inform the Commission for Social Care Inspection when these have been received. This standard will be reviewed at the next visit to the home when new service users are admitted. 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. 3 Key findings/Evidence Standard met? The inspector was shown staff appraisal preparation forms. This includes strengths and needs assessments and training and development required.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 of regular staff supervision. As previously stated some of the staff work at other Allied Care homes due to the fact that there is only one service user living at the home, the manager stated that these staff receive supervision from management at these homes. The manager and the deputy manager supervise staff in the home. A staff training programme will be drawn up to meet the assessed needs of any new service users. This standard will be reviewed at the next visit to the home when new service users are admitted.Ashlong HousePage 33 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 acting manager has been appointed the new home manager since the last inspection. She has completed the Registered Managers Award to level 4, has a Degree in Health Care Studies and is currently completing a Diploma in Applied Psychology at the Tizard Centre. The home manager has applied to the Commission for Social Care Inspection to be the registered manager for Ashlong House; she was the registered manager for another Allied Care home and was registered at the Wimbledon Commission for Social Care Inspection office. The manager explained that she is awaiting her registration information to be transferred to the Croydon office in order that she can move forward with her application.Ashlong HousePage 34 Standard 38 (38.1 ­ 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? Ashlong house is at present going through a transition period, the manager plans to admit service users with physical/mobility difficulties. The manager has worked to develop positive communication between the home and local residents. She plans that the new service users when admitted to the home will hold regular service user meetings and that issues identified by the service users will be brought by service users to the staff meeting. The inspector was shown the Service User Guide that the manager and the service user are currently developing for the home this is work in progress and may need to be reviewed again once new service users move into the home. 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. 2 Key findings/Evidence Standard met? The inspector was shown service user, staff and relatives questionnaires (Cared4) that the manager plans to distribute when new service users move to the home. The Area Manager has recently left the organisation. The manager stated that she now has contact with another Area Manager and the Registered Provider if she needs support. The organisation is currently trying to recruit a new area manager. The inspector received a copy of the recent Regulation 26 visit carried out at the home, these should be sent to the Commission for Social Care Inspection on a regular monthly basis. The manager must ensure that copies of the homes Regulation 26 visits are sent to the Commission for Social Care Inspection on a monthly basis. 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). 3 Key findings/Evidence Standard met? The manager explained that the organisation has purchased a full set of policies and procedures from a consultancy company Cared4. These documents fully comply with the required standards as defined in appendix 2 of the National Minimum Standards.Ashlong HousePage 35 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. 3 Key findings/Evidence Standard met ? The inspector noted that all service users confidential information is kept in a locked cabinet in the office. The inspector noted that the service user had named people she would like to attend review meetings and Lifestyle Planning meetings. As previously stated the organisation has purchased a full set of policies and procedures from a consultancy company Cared4. A policy on Confidentiality is included however the home manager could not locate a policy on Service Users Access to Personal Files. The inspector recommends that the home manager contact the Cared4 consultancy company for support in locating this policy. 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. 2 Key findings/Evidence Standard met? The inspector examined the homes fire book. All fire call points are checked on a weekly basis, this has highlighted a technical problem; a Fire Services Engineer is rectifying this. The home at present holds weekly fire drills. The home manager explained that although there is only one service user living at the home at present this gives the staff the opportunity to practice the fire procedure. The inspector was shown the Portable Appliance Testing Certificate 24/04/04. The home manager stated that the Legionella Testing Certificate and the Landlords Gas Safety Certificate are held at head office. The home manager must ensure that copies of the Legionella Testing Certificate and the Landlords Gas Safety Certificate are sent to the Commission for Social Care Inspection. 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. 3 Key findings/Evidence Standard met ? The inspector did not have the opportunity to examine the homes annual accounts as the business and the trusts accounts department holds financial plan for the home centrally. The manager was advised of the requirement to notify the care commission if financial viability is in doubt at any stage and that copies of the homes accounts must be supplied to the commission if requested.Ashlong HousePage 36 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DateSignature Signature SignatureAshlong HousePage 37 Public reports It should be noted that all CSCI inspection reports are public documents.Ashlong HousePage 38 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 29th November 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possible We are working on the best way to include provider responses in the published report. In the meantime responses received are available on request.Action taken by the CSCI in response to provider comments: Ashlong House Page 39 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 accurateNONote: 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 12th January 2005, 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 planYESOther: enter details here Ashlong HousePage 40 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 41 Ashlong House / 29th November 2004Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000048490.V171905.R01© This report may only be used in its entirety. 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