CARE HOME ADULTS 18-65
Ashmill 141 Millfield Road Handsworth Wood Birmingham B20 1EA Lead Inspector
Joe OConnor Unannounced 2 June 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ashmill E54 S16719 Ashmill V229350 020605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Ashmill Address 141 Millfield Road Handsworth Wood Birmingham B20 1EA 0121 358 6280 0121 358 6280 info@ashmill.net Mrs Tuula Marjukka Khan Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Alison Shaughnessy Care Home 18 Category(ies) of Younger Adults, Physical Disability registration, with number of places Ashmill E54 S16719 Ashmill V229350 020605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Residents must be aged under 65 years. Date of last inspection 7 January 2005 Brief Description of the Service: Ashmill is registered to provide personal care and support to 18 adults with a physical disability, who have been assessed as requiring full assistance with daily living tasks. The service is staffed twenty four hours a day including two waking night staff. The full range of medical services, leisure and social activities are provided for the service users. A number of adaptations are in place in order to meet the assessed needs of the service users. Service users are encouraged and supported to maintain links with their families and the local community. The service is situated in the Handsworth Wood area of Birmingham in a quiet residential road. It is close to local amenities and there is parking available at the front of the premises. Ashmill E54 S16719 Ashmill V229350 020605 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over one day. The Inspector had opportunity to talk to five service users, one relative and three members of staff. Care practices were observed, interactions and support from staff. A limited tour of the premises was undertaken. Service users care plans and risk assessments were inspected. Staff recruitment and training records were also examined and a number of health and safety records were also sampled. The Inspector had opportunity to talk to the Registered Manager and her deputy. What the service does well:
Five service users were able to provide their views on life in the Home. The comments received were very positive about the manager and staff team. One service user stated, “It’s a lovely well run home”. Another commented, “I can be my own boss and can go to bed and get up when I want”. “ My parents come to see me and they are happy with how I am being looked after”. “ It is a really homely place”. A relative visiting at the time of this inspection stated, “ My son isn’t institutionalised and the staff put the service users first”. Staff were observed to provide friendly and positive support to service users that enabled them to understand their preferences. There is a homely relaxed atmosphere, which the service users appreciate. Staff had knowledge and understanding of service users needs and were committed to improving the service users quality of life. Care plans showed how needs of the service users were met. Service users have access to a range of appropriate activities in the community such as the Cinema, local pubs, shopping and day trips out to Blackpool and Stratford Upon Avon. There is a vehicle available to service users that is accessible for their needs. A number of service users attend courses at college and a number go to day services provided by the Local Authority. Service users are able to access various healthcare professionals including a GP, District Nurse, Optician, Dentist and Chiropodist. Positive links are maintained with these and service users also have access to specialist support from an Occupational Therapist, Speech and Language Therapist and Physiotherapist. Service users are provided with a nutritious menu that promotes healthy eating and specific dietary requirements are known and catered for including diabetic diets and cultural requirements are also addressed. At the time of this inspection two service users required halal food as due to their Islamic faith. Staff training is completed regularly, enabling staff to perform their duties and included accredited training in handling medicines as well as specialist training in areas such as epilepsy and challenging behaviour. Staffing levels are maintained to numbers that meet the needs of the service users.
Ashmill E54 S16719 Ashmill V229350 020605 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better:
Risk assessments are in place that covers the movement and lifting of service users. However, these must be reviewed and include action to be taken in the event of a fall and the type of lifting equipment and type of sling to be used. Individual risk assessments must be in place for those service users who display any challenging behaviour. Clear guidance must be in place so all staff understands how any behavioural difficulties should be managed. A pre-admission assessment record will need to be developed when prospective service users are visiting the service as part of getting to know the other service users, staff and manager. This should also form the basis of an initial assessment to ensure the service confirms the suitability or unsuitability of the placement for prospective service users. Service users do have monthly meetings but the manager must ensure
Ashmill E54 S16719 Ashmill V229350 020605 Stage 4.doc Version 1.30 Page 7 minutes for these are typed up and available to service users, staff and for future inspections. The quality audit programme where service users, relatives and visitors views are sought must also include staff so they can have the opportunity to comment about the management and running of the home. Staff recruitment records need some improvement to ensure they protect the interests of the service users. A job interview assessment format must be developed so that evidence is documented of the prospective candidate’s performance during the interview and is used as a means of assessing their suitability or unsuitability for the advertised post. Staff records must also have essential information for each member of staff such as their contact details, N.O.K. and the hours they work. Staff meetings must occur every month and minutes of these must be in a typed format and available to staff and for future inspections. The frequency of staff supervision is unsatisfactory and the manager must ensure these occur every two months and should be documented. The relationship between staff and service users is positive, friendly and professional. However, the manager must make clear to staff that if there are any concerns or grievances with regard to work issues then these should be discussed solely in one to one supervision or in a group meeting. These should not be aired in front of service users which is unprofessional and likely to create unnecessary concern and anxiety. There is need for an up to date fire drill to be completed, the last one had occurred in August 2004. Fire drills must occur every six months. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ashmill E54 S16719 Ashmill V229350 020605 Stage 4.doc Version 1.30 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Ashmill E54 S16719 Ashmill V229350 020605 Stage 4.doc Version 1.30 Page 9 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2, 3, 4, 5 Service users needs are assessed prior to admission to the service covering all aspects of their daily living activities. The needs of the current group of service users are being met through the maintenance of detailed care records and with a committed staff team who have knowledge of individual needs. Prospective service users are able to visit the home prior to admission but evidence of these visits must be documented. Service users have a statement of terms and conditions that informs them of what they are paying for when they are admitted to the Home. EVIDENCE: One service user’s records found that he had not been living in the home long and there was evidence of an assessment completed by a social worker along with additional information provided by a rehabilitation hospital that covered information such as communication, physical and how the service user was to sit in a chair and bed. In conversation with the service user he confirmed that a social worker had been involved in identifying his current placement. The service user had visited prior to admission but there was no record of the visit. Service users needs were met at the time of this inspection. A sample of three care plans confirmed there were detailed records in place to confirm how the needs of each individual were to be met. The atmosphere was relaxed and welcoming and several service users provided the following comments. “ I’ve lived here for six years and its
Ashmill E54 S16719 Ashmill V229350 020605 Stage 4.doc Version 1.30 Page 10 fantastic, really homely”. “ I can be my own boss”. “Staff are friendly and we all get on well together”. “ The manager will listen to us if we have a problem and will sort it out”. One relative commented that she visited her son at different times during the week and found all of the service users to be well cared for. Observations found that there were positive interactions between staff and service users. When sampling service users records there was evidence to confirm that there were written statement and terms and conditions along with three way contracts provided by the Local Authority. Ashmill E54 S16719 Ashmill V229350 020605 Stage 4.doc Version 1.30 Page 11 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8, & 9 How service users needs are to be met are set out in detailed care plans. These cover service users’ likes and dislikes and how these should be met. Staff encourage service users to make decisions with regard to their daily routine through monthly meetings and on a day to day basis. Service users have risk assessments including how service users are to be moved and lifted. These were in need of some improvement to state action to be taken in the event of any falls and the type of equipment to be used. Individual risk assessments do not have any strategies for the prevention of any aggressive behaviour towards staff and service users. EVIDENCE: Each service user has a detailed care plan that covers all aspects of their daily living activities. The care plans contained information around service users’ preferences and dislikes, as well as their daily routines. One service user was keen to show a copy of his care plan that included a photograph and details about his leisure interests such as collecting Star Wars Memorabilia. Other care plans sampled referred to how service users with non verbal communication were using electronic keypad equipment. Another service user stated that she had her own care plan that referred to having a controlled diet due to diabetes. At the time of this inspection the management team were updating the care plans as part of the six month review period and it as evident that they were
Ashmill E54 S16719 Ashmill V229350 020605 Stage 4.doc Version 1.30 Page 12 working towards developing them in a more individual and personalised format. Risk assessments were in place including those for manual handling. These were found to require some improvement to cover action to be taken in the event of any falls and the equipment to be used. It was noted from a sample of one individual service user’s record that there had been a number of incidents when he had been physically and verbally aggressive towards staff when he was being assisted with personal care. There were no risk guidelines or strategies in place to direct staff in how the individual’s behaviour was to be managed. In discussion with service users and staff it was evident that service users are encouraged to make choices about their daily lives. Two service users stated that the manager looked after their money and they were happy with this arrangement. One service user spoke about how the manager had consulted with her about the need to have assistance with transferring from her wheelchair to the bed but had got into difficulties and now needed to be transferred by a hoist. The service user was initially concerned about losing some of her independence but acknowledged the need to be safe. All five service users spoken with confirmed there was a choice of meals available and that staff would find an alternative if they declined what was on the menu. There are monthly service user meetings in place where they can talk about any menu changes and future activities. Ashmill E54 S16719 Ashmill V229350 020605 Stage 4.doc Version 1.30 Page 13 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 15,16 &17 12, 13,14, Service users are able to access activities in the community with staff support. Service users maintain good relationships with staff and have contact from relatives and friends. There are no unnecessary restrictions affecting service users daily routine. Service users have access to wholesome nutritious meals with a varied menu that promotes healthy eating. EVIDENCE: Two service users stated they attended a college during the week for courses in computers. There is a vehicle available for transport. A number of service users attend daycentres provided by the local authority. From a sample of service users’ records there was evidence to confirm where they had been undertaking trips to the cinema at Star City and several had recently seen the recent Star Wars film. In conversation with the service users they also stated that they were able to go out shopping with staff and go out for meals and recently went to Stratford Upon Avon and had also gone to Blackpool. One service user said he was going to Lourdes with his sister. The manager stated that a holiday was being planned this year for a number of service users to go to Tenerife. Daily recording of service users referred to how they spent their leisure time.
Ashmill E54 S16719 Ashmill V229350 020605 Stage 4.doc Version 1.30 Page 14 A sample of service users records found that they are able to maintain contact with members of their family. Observations at the time of this inspection found there were positive relationships between the service users and staff, with no unnecessary restrictions apparent. Staff were aware of service users’ routines and these were respected. A number of service users confirmed that they had keys to their bedroom. There is a menu that is updated weekly. A record is maintained of what service users have eaten. Service users stated that they had a choice of what they wanted to eat and would be offered an alternative if they did not like what was on the menu. The refrigerator, freezers and larder were found to be well stocked. One service user spoke of her own specific dietary requirements in to manage her diabetes and that staff were aware of this. There was evidence on a number of service users’ records of eating and drinking guidelines that were developed by a Speech and Language Therapist. Ashmill E54 S16719 Ashmill V229350 020605 Stage 4.doc Version 1.30 Page 15 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 & 20 Service users receive support with personal care and choose when they require assistance. Service users are able to access community and specialist primary healthcare services through good recording systems. Medication management is of a good standard promoting good health. EVIDENCE: Each service user has a named keyworker. Service users stated that apart from having to get up and go to their day services or medical appointments, they were able to get up and go to bed when they pleased. It was evident from talking to two service users that they were aware of their own health conditions and what treatment was required as both had to attend a clinic for dialysis. A sample of daily recording provided examples of where personal care tasks had been completed. There was documented evidence to confirm when service users had seen healthcare professionals such a GP, Dentist, District Nurse, Chiropodist, Optician. Further evidence confirmed that specialist support and intervention is accessed from Occupational Therapist, Speech and Language Therapist and Physiotherapist. Each service user has a manual handling assessment but these will require some development in ensuring that they state what action is to be taken in the event of a service user falling and the type of equipment to be used. They were also found to be in need of reviewing. Ashmill E54 S16719 Ashmill V229350 020605 Stage 4.doc Version 1.30 Page 16 Medication management was of an acceptable standard. There was evidence on the Medicines Administration Records (MAR charts) that these were being recorded appropriately and without gaps. There was also evidence that prescriptions had been photocopied prior to dispensing. The majority of care staff employed have completed accredited medication training. The supplying pharmacist recently completed a medication audit and recommended that a new medicines storage trolley is purchased which the manager stated was being addressed. Ashmill E54 S16719 Ashmill V229350 020605 Stage 4.doc Version 1.30 Page 17 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 & 23 A complaints procedure is in place for service users that is written in an accessible format. Service users feel staff listen to their views and concerns and these are responded to by the manager. Staff receive appropriate training in the protection of vulnerable service users backed up by appropriate policies and procedures. EVIDENCE: There is a complaints policy and procedure that is written in an accessible format for service users. Neither the service nor the Commission have received any complaints during the last twelve months. Service users stated that they would be able to go to the manager if they had any complaints or concerns. In discussion with staff and from a sample of staff training records, it was found they had undertaken training in the abuse of vulnerable adults and challenging behaviour. Two staff interviewed provided satisfactory responses that they would be able to challenge poor practice and report any incidents to the manager. There is an adult protection policy and procedure including a copy of the Multi Agency Guidelines published by Birmingham City Council. The management of service users’ personal allowance was not assessed but will be looked into at the next visit. Ashmill E54 S16719 Ashmill V229350 020605 Stage 4.doc Version 1.30 Page 18 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 & 30 The premises is maintained and cleaned to an acceptable standard. Service users are able to move freely around the premises without any apparent hazards. Service users health and safety is maintained through staff observing appropriate infection control practices. EVIDENCE: A partial tour of the premises was undertaken at the time of this inspection. The premises were found to be clean, tidy and smelled fresh. There is a handyperson who is employed to undertake repairs and tests the alarms and emergency lighting on a day to day basis. Service users expressed satisfaction with the cleanliness of the premises. Staff were observed to wear protective clothing when working in the kitchen and there are procedures in place for the control of infection. There is a separate laundry area that was found to be clean and tidy with appropriate commercial washing and drying equipment being used. Ashmill E54 S16719 Ashmill V229350 020605 Stage 4.doc Version 1.30 Page 19 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 34, 35, & 36 Service users are supported by staff that are competent and qualified to meet their needs. Current staffing levels meet the needs of the service users. Staff recruitment records generally meet the requirements of the regulations ensuring protection for the service users but some improvements are required. Staff are offered and provided training that enables staff to undertake their duties in meeting the needs of the service users. Staff supervision does not meet the required level of frequency. EVIDENCE: Staff demonstrated an understanding around the needs of the current service users and provided positive interactions with service users. Three staff stated they were qualified at NVQ Level 2. The levels of staffing were found to be adequate at the time of this inspection. In discussion with the manager it was found that five members of staff were pregnant and that she was taking action to cover their maternity leave. Two new members of staff who were undertaking night waking duties had commenced employment. At the time of this inspection three new members of staff were being inducted by the manager. Ashmill E54 S16719 Ashmill V229350 020605 Stage 4.doc Version 1.30 Page 20 Discussion with service users and staff stated that there were enough staff on duty, although one member of staff commented that there were occasions when they would be short of staff during the mornings. This issue was discussed with the manager who stated that none had raised this as a concern previously but would be willing to review the staff rota during the morning period. Another matter raised with the manager concerned one service user’s comments that he had on occasions heard certain members of staff make negative comments in front of other service users about issues such as their salary and having to cover shifts for colleagues on sick leave. While the majority of service users spoken with were complimentary about their relationships with staff, the manager must ensure that staff refrains from discussing any grievances about employment matters with service users, as it is unprofessional and should only be discussed in individual staff supervision or staff meetings. The manager and her deputy responded positively with regard to these comments made. Staff recruitment records were to a certain extent satisfactory with evidence of proof of ID, CRB check, birth certificate, passport, job application form, statement of fitness to work, contract, photo and two references. However, it was noted that there were no basic details for each staff member including N.O.K, hours worked and when they commenced work. It was also noted that the staff records had no evidence of any assessments being undertaken during the interview process, to evidence the suitability or unsuitability of the prospective applicant. There was evidence on the staff records sampled that they had received training in areas such as fire safety, manual handling, health and safety, food hygiene and first aid. Staff had also received training in epilepsy, challenging behaviour, adult protection and accredited medication training. Certificates of training courses completed were on file. There was evidence that staff had completed a written induction. The frequency of staff supervision was found to be unsatisfactory and the manager must ensure that they receive supervision every two months. Ashmill E54 S16719 Ashmill V229350 020605 Stage 4.doc Version 1.30 Page 21 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 39, 41 & 42 Service users live in a home that is run by a competent management team. There is an open and relaxed, friendly atmosphere that benefits service users and staff. Service users, relative’s views and opinions are sought through six monthly quality audits. The records were generally up to date for the safety service users. The welfare and safety of service users is promoted and maintained with some minor improvements required. EVIDENCE: The Registered Manager and her deputy demonstrated an awareness and detailed knowledge of the service users in their care. At the time of this inspection the manager had yet to complete training towards the Registered Managers Award. The atmosphere was found to be relaxed and friendly which benefits the service users. Five service users stated that they would be able to approach the manager if there were any concerns. One service user expressed her opinion that it was a well run home. A relative of one service user stated that she visits the home at different times of the day unannounced and has always found the staff to be open and friendly. Staff stated that the manager
Ashmill E54 S16719 Ashmill V229350 020605 Stage 4.doc Version 1.30 Page 22 and deputy were approachable and supportive. They also said there were monthly staff meetings however, there was no evidence to confirm that these were occurring monthly as minutes of the meetings had not been typed up. This was also the case with the meetings for service users. A representative of the Registered Person visits every month and a report of their visit is sent to the Commission. The manager provided a copy of an audit report between January 2005-June 2005, where 17 anonymous satisfaction questionnaires were given to service users of which 11 were returned and the comments were found to be positive. 13 satisfaction questionnaires were sent to 13 relatives of which 3 were returned and 4 were sent out to visitors including professionals and 1 was returned. Again the comments about the quality of care in the home were positive. The quality audit must be extended to the development of anonymous satisfaction surveys for staff. The records were found to be generally up to date and were locked in a secure facility. Records with regard to health and safety were found to be satisfactory. There was evidence to confirm that the fire alarm was being tested weekly and the emergency lighting every month. The equipment for the detection and extinguishing fires had been inspected and serviced, as had the call alarm system. There is a risk assessment in place for the prevention of fire. It was noted that a fire drill had not occurred since August 2004 and action must be taken to address this. The main kitchen was found to be clean, tidy and there was evidence that the temperatures for the refrigerators and freezers were being recorded every day. The accident book was examined and it was good to see that there were no accidents that had occurred since the last inspection. Ashmill E54 S16719 Ashmill V229350 020605 Stage 4.doc Version 1.30 Page 23 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 3 2 3 Standard No 22 23
ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 3 3 3 2 x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score x 2 3 2 3 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Ashmill Score 2 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 2 2 x 2 2 x E54 S16719 Ashmill V229350 020605 Stage 4.doc Version 1.30 Page 24 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 4 Regulation 14(1)(2) Requirement The Registered Person must ensure that it develops a preadmission assessment tool that also acts as record for any trial visits. The Registered Person must ensure that risk assessments must be in place for service users display challenging behaviour. Strategies must be in place for staff as to how this should be managed. The Registered Person must ensure that manual handling assessments are reviewed. They must also state the action to be taken in the event of a fall and the type of equipment to be used. The Registered Person must ensure that all staff raise any grievances within individual supervison or staff meetings. These must not be discussed with or in front of service users. This is unprofessional and is not in the service users interests. The Registered Person must ensure it develops an assessment tool for use during staff recruitment interviews to Timescale for action 2 August 2005 2. 9 13(4) 2 July 2005 3. 18, & 9 13(4)(6) 2 July 2005 4. 32 12(5)(a) From 2 June 2005 5. 34 19(1)(a) (i) Schedule 2 2 July 2005 Ashmill E54 S16719 Ashmill V229350 020605 Stage 4.doc Version 1.30 Page 25 6. 34 19(1)(a) (i) Schedule 2 provide evidence of the suitablity or unsuitability of the candidate. The Registered Person must ensure that staff recruitment records have information with regard to staff details including: Contact details, N.O.K. The hours worked and National Insurance number. 2 July 2005 7. 36 8. 37 9. 38 10. 38 11. 39 12. 42 The Registered Person must ensure that all staff working in the home receive supervision at least six times during the year. 9(1)(2)(b) The Registered Person must (i) ensure the Registered Manager achieves qualification to the Registered Award. Outstanding Requirement 12(5)(a) The Registered Person must ensure that service users meetings are held every month and that minutes of these are available for inspection. 12(5)(a) The Registered Person must ensure that staff meetings occur every month and minutes of these are available for inspection. 24(1) The Registered Person must ensure that anonymous satisfaction surveys are available for staff so they can comment on aspects of life in the home within the quality audit process. 13(4) The Registered Person must 23(4)(e) ensure that arrangements are made for a fire drill. These should be undertaken every six months. 18(2) 2 August 2005 30 Decemeber 2005 From 2 June 2005 From 2 June 2005 2 August 2005 2 July 2005 and every six months from this date. 13. Ashmill E54 S16719 Ashmill V229350 020605 Stage 4.doc Version 1.30 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Ashmill E54 S16719 Ashmill V229350 020605 Stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection Birmingham & Solihull Local Office 1st Floor, Ladywood House 45-46 Stephenson Street Birmingham, B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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