Inspection on 25/08/06 for Ashmill

This inspection was carried out on 25th August 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 16 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ashmill 23/06/09

Ashmill 23/04/09

Ashmill 06/02/08

Ashmill 22/11/05

Ashmill 02/06/05

Ashmill 07/01/05

Ashmill 01/07/04

Ashmill 26/01/04

Ashmill 07/08/03

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

CARE HOME ADULTS 18-65 Ashmill 141 Millfield Road Handsworth Wood Birmingham West Midlands B20 1EA Lead Inspector Joe O’Connor Unannounced Key Inspection 25th August 2006 10:30 Ashmill DS0000016719.V302668.R02.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ashmill DS0000016719.V302668.R02.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ashmill DS0000016719.V302668.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashmill Address 141 Millfield Road Handsworth Wood Birmingham West Midlands B20 1EA 0121 358 6280 0121 358 6280 ashmill141@hotmail.com Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Tuula Marjukka Khan Alison Shaughnessy Care Home 18 Category(ies) of Physical disability (18) registration, with number of places Ashmill DS0000016719.V302668.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years Date of last inspection 22nd November 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. The fee for this home is £650.00-£950.00 per week. Additional charges include those for aromatherapy, hairdressing and chiropody. Ashmill DS0000016719.V302668.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection took place over a day and the fieldwork was unannounced. Three service users who live in the home were present and were able to provide some comments about life in the home. The Inspector also spoke to three members of staff. Comments were also received from a healthcare professional on a CSCI survey form. A partial tour of the premises was completed. Care records including care plans, risk assessments and daily reports were also sampled. Other records examined included staff recruitment and training and those for health and safety. Additional information was also examined from the pre-inspection questionnaire that is sent out to the home before the fieldwork including any significant events. Some observations of care practices were undertaken. To see how the service has performed since the last inspection then the report should be read with the unannounced inspection report 22 November 2005. What the service does well: Two service users provided comments about what they thought about the home. One service user said, “ I like it here people the staff talk to me as an adult”. Another service user said with the aid of an electronic keyboard, “ I get on well with the staff and am given choices in what I want to do”. Service users are encouraged and supported to access activities in the community. One service user said he had been to college studying computers and had passed two exams. Another service user is involved in supporting people who have difficulty in communicating verbally and is an expert on using electronic communication keyboards. There are number of service users from different cultural backgrounds and they have been to the cinema to watch Asian films while another has been to the Chinese New Year celebrations every January. Two service users spoke positively about the food that was offered and stated they were able to choose from a menu. There are a number of service users who must have Halal food due to their Muslim faith. Observations at the time of this inspection indicated the service users were receiving friendly and positive support from staff. Ashmill DS0000016719.V302668.R02.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Service users care plans were in need of reviewing which should be undertaken every six months or sooner to update any changes in their needs. The care plans will need to reflect individual’s preferences with regard to whether they prefer a male of female carer to support them when managing their personal care. There must be clearer information about the contact service users have with healthcare professionals as there was no evidence available confirming whether they were being seen by a chiropodist. Manual handling assessments must also be reviewed. It is recommended that the service users have their healthcare requirements set out in an individual health action plan. The manager must make sure that when new service users are admitted to the home that it has in place a detailed assessment completed either by a social worker or the service. A social work review must be arranged as set out in the local authority’s guidelines for arranging reviews. This is to make sure the service can still meet the needs of the service user and that the service user is happy with the placement and the support provided by staff. Staff recruitment records need to be maintained to a better standard and have important information available such as CRB checks, two references and training completed by staff. Interviews must be written on appropriate documentation and not on pieces of paper. The staff induction records need Ashmill DS0000016719.V302668.R02.S.doc Version 5.2 Page 7 further development in line with guidelines on staff training issued by an organisation known as Skills for Care. A service user and two staff members commented there was a need for more staff at the weekends so they could do more activities. Minutes of meetings for service users and staff must be made available for inspection. 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 DS0000016719.V302668.R02.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Ashmill DS0000016719.V302668.R02.S.doc Version 5.2 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 the following standard(s): 1, 2, & 3 Quality outcome in this area is adequate. This judgement has been based on available evidence including a visit to the service. The statement of purpose and service user guide must be reviewed and updated to include information regarding the weekly fees charged by the service. Improvements are needed in ensuring new service users are only admitted following a needs led assessment completed prior to admission. The needs of the current group of service users are being met but improvements are needed in ensuring statutory reviews are completed ensuring the suitability of the placement for new admissions. EVIDENCE: The service has a statement of purpose and service user guide which will need reviewing and amending to include information relating to the weekly fees charged by the service as set out in the recently amended Care Homes Regulations 2001 from 1 September 2006. The service users have a copy of the service user guide in their bedroom. Three service users care records were examined during this inspection. One included a service user who had been admitted to the service in December last year. There was evidence of an initial care plan that had been completed by a social worker and was detailed in what kind of support the service user required. However, there was no copy of a social worker assessment nor that the service had undertaken their own needs led assessment. It was also noted the service user did not have a social work review which was supposed to have occurred during January this year. Ashmill DS0000016719.V302668.R02.S.doc Version 5.2 Page 10 Three service users were able to provide comments about life in the home. One said, “ I like it here staff relate to me as an adult and are really supportive”. Another commented, “I’m getting on ok here and have seen other places but this one is the best”. Comments were made by a service user with the assistance of an electronic keyboard and eye movements to say that he got one well with staff and was happy with the support he was receiving. Observations made during this visit indicated service users were dressed in clothing appropriate for their age and climate of the day. Staff interaction between the staff and service users was positive and friendly. Ashmill DS0000016719.V302668.R02.S.doc Version 5.2 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 the following standard(s): 6, 7, 8, & 9 Quality outcome in this area is poor. This judgement has been based on available evidence including a visit to the service. Significant improvements are required in ensuring service users care plans and risk assessments are reviewed and updated to reflect how individual needs are to be met and how any identified risks should be managed. Service users are involved in making decisions about the running of the home but there is no up to date record to confirm the frequency of monthly meetings EVIDENCE: Three service users care records were examined during this inspection. One care plan sampled referred how the service user communicated and that he used an electronic keyboard. Another care plan sampled stated that the service user was a Muslim and must have a Halal diet. The care plan referred to the individual’s preferred time for getting up and going to bed. It was good to see that one care plan referred to the service user being able to speak a number of languages other than English. However, when examining the care plans some of the information recorded was out of date. For example one referred to a service user requiring assistance to be fed with peg tube, which was no longer the case. The service user had a pressure relief mattress but this was not referred to in the service users care plans. It was noted the care plans were overdue a review. Ashmill DS0000016719.V302668.R02.S.doc Version 5.2 Page 12 Two service users records examined had individual risk assessments and these included the use of bed rails, which was a requirement from the previous inspection. However a service user who had been admitted to the service in December 2005 did not have a risk assessment or one for manual handling. Two service users stated they were involved in meetings every month to talk about future activities and changes to the menus. However, there were no up to date minutes available for these meetings to confirm the frequency of these. Observations at the time of this inspection found staff encouraging a number of service users to choose what they wanted to eat and it was apparent where service users chose to prefer spend time alone in their bedrooms. Service users’ personal monies were not examined during this inspection but the preinspection questionnaire stated social services were acting as appointees for three service users while one had their financial affairs managed by a solicitor as power of attorney. It also stated seven service users were supported to manage their own finances and everyone have their own bank account. One of the service users was very keen to talk about the work he was involved in supporting people with disabilities in using communication devices and had made a number of presentations as part of disability awareness training. He expressed an interest in being involved in the Commission’s work on service user involvement. Ashmill DS0000016719.V302668.R02.S.doc Version 5.2 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 the following standard(s): 12, 13, 15, 16 & 17 Quality outcome in this area is adequate. This judgement has been based on available evidence including a visit to the service. Service users have access to activities in the community but the daily records do not provide a true reflection of how they spend their leisure time. Service users are not subjected to any unnecessary restrictions in place where there are positive relationships with staff. Service users are offered a choice of meals that are nutritious and meet individual cultural and medical requirements. EVIDENCE: The service employs a day service co-ordinator and at the time of this inspection three service users were involved in a craft activity, which they seemed to be enjoying. A number of service users receive organised day services from the local authority. A member of staff was arranging for a group of service users to go out to West Midlands Safari Park. One service user said he had been to college before the end of the summer break and was involved in computer work and had passed two exams. Another service user spoke of his recent celebrations for his birthday where he went out to local pub for a drink and later went nightclubbing. However, the service user said he did not have the opportunity to go to the pictures something which he enjoyed doing. Another service user said he had been to college participating in ECDL Ashmill DS0000016719.V302668.R02.S.doc Version 5.2 Page 14 computer. A number of service users have their own computers and have access to Sky TV. One member of staff commented that three Asian service users one of them who is Chinese have been involved in activities that reflect their cultural background. Two of the service users have been to a cinema to watch Asian films while the third always attends the Chinese new year celebrations in Birmingham City Centre every January. An examination of service users’ daily records found these lacked detail and did not reflect in full how service users spent their leisure time and the activities they had been involved in. The records also did not make reference to service users responses to care and support being offered, received and declined. It was also noted two service users commented that there were times when they could not go out at the weekends due to staff shortages. Two service users stated they had regular contact with their families and both had their own telephone in their bedroom. Another service user said he has members of his family visit him everyday. Observations during this inspection indicated there were positive relationships between staff and service users with no unnecessary restrictions apparent. Copies of menus were provided for the previous four weeks indicated service users were being offered a choice of healthy meals. Two service users spoke positively about the meals provided and they could choose what they want from a menu. One service user confirmed he was provided with a Halal diet, as he is a Muslim. A tour of the kitchen found that Halal foods were being stored separately. There was evidence of ingredients in stock for another service user to have Chinese meals. Discussion with the cook on duty found she had a good understanding around individual service users dietary requirements. An examination of the food cupboards, refrigerators and freezers found these were well stocked food items purchased from reputable suppliers. One service user’s care records examined found he had eating and drinking guidelines developed by a Speech and Language Therapist who recommended that the food needed to be textured with the use of thickeners. The service user commented he had his food liquidised but did not want this and had agreed to have it textured. Ashmill DS0000016719.V302668.R02.S.doc Version 5.2 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 the following standard(s): 18, 19, & 20 Quality outcome in this area is adequate. This judgement is based on available evidence including a visit to the service. Service users receive support with their personal care that generally meets their cultural requirements but the care plans must make their gender care preferences clear. Service users records do not always provide a clear picture as to how their healthcare needs are being addressed. The management of medication is to a good standard with minor improvements needed to promote and maintain service users good health. EVIDENCE: Three users care records indicated that only two had a manual handling assessment and included information as to how many carers were required in transferring. These were overdue a review. An examination of the daily records indicated where service users had support with their personal care including a shower or a bath. The service accommodates a pre-dominantly male service user group. There are three Asian men one of whom is Chinese, along with another male who is Afro Caribbean. The remaining group of male service users are White English with the exception of one who is of South African origin. There are five female service users. In discussion with the senior carer on duty and an examination of the staffing group in the pre-inspection questionnaire, appropriate gender Ashmill DS0000016719.V302668.R02.S.doc Version 5.2 Page 16 care support is provided. There are Asian female staff that are able to communicate with one of the service users in their language, which is Punjabi. There is a white female member of staff who is able to speak Punjabi as well. There are also African and Afro Caribbean staff employed by the service. It was noted however; that service users’ care plans did not have any references to their preferred choice of gender care support. The service has a positive approach in supporting service users with regard to developing and maintaining personal relationships. There are guidelines in place for staff informing them how any relationships should be promoted and supported. Tracking of information relating to service users healthcare requirements was difficult. There was some evidence where service users had contact recent contact with a GP, Dentist and Optician. There was no clear information however, confirming how their foot care was being managed. There were guidelines in place for one of the service users with regard to management of diabetes and how long their blood sugar levels should be monitored. Other information seen confirmed service users recently had medication reviews and one had seen a Speech and Language Therapist who had drawn up eating and drinking guidelines that referred to service user requiring thickened drinks. Comments were received from a District Nurse who stated that while generally staff were aware of the needs of service users, “sometimes wounds are left too long before the district nurse is contacted. Information available during this visit was difficult to track with regard to service users healthcare requirements, that it is recommended the manager develops for each service user an individual health action plan. This should set out how individual healthcare requirements are to be addressed and set out and the professionals involved in their care. The management of medication was found to be to a good standard with some minor improvements. An examination of the Medicines Administration Records (MAR Charts) indicated there were no gaps in recording and there were no discrepancies in balances of medication administered. It was noted that a service user who required medication “when required” (PRN) did not have a written protocol for when it should be used. There were certificates on display in the building, which showed the number of staff who had completed accredited medication training. It was also noted inhalers had not been signed in on the MAR sheet. A requirement from the previous inspection for the service users wheelchair to be cleaned and maintained to an acceptable standard had only been partially addressed, as a number appeared to be still dirty below the seats. Ashmill DS0000016719.V302668.R02.S.doc Version 5.2 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 the following standard(s): 22 & 23 Quality outcome in this area is adequate. This judgement has been based on available evidence including a visit to the service. Service users are able raise any concerns with the manager and are confident these will be addressed. Service users must have better protection through a more robust recruitment practice. EVIDENCE: The CSCI had received a concern from a former member of staff relating to care practices with a service user and the service’s recruitment process. The manager prior to this inspection did provide satisfactory evidence to indicate that there were no reaches in regulations and therefore no further action was taken. There is a complaints procedure, which needed updating as it referred to the National Care Standards Commission, which no longer exists. Two service users spoken with stated they would be able to resolve any issues with the manager and felt confident the manager would address their concerns. There is a copy of the current multi agency guidelines published by Birmingham Social Care & Health. A member of staff who had recently been recruited to the service provided satisfactory responses to questions relating how issues of poor practice would be addressed. It was noted that when examining staff recruitment records there was no details confirming whether staff had details of their CRB checks, which the manager must address as a matter of urgency Ashmill DS0000016719.V302668.R02.S.doc Version 5.2 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 the following standard(s): 24 & 30 Quality outcome in this area is good. This judgement has been based on available evidence including a visit to the service. Service users live in a clean, tidy environment that is also accessible for their mobility requirements. EVIDENCE: The premises was generally clean and tidy at the time of this inspection, although some foul odour was present in one of the bedrooms which the manager must take steps to address. A partial tour of the premises and an examination of the pre-inspection questionnaire found some improvements had been made to the building since the last inspection. New floor covering had been installed in one of the showers that had also been re-decorated. Three bedrooms had been re-decorated along with parts of the communal areas. One service user said she was pleased with how her bedroom had been decorated and chose the colour scheme herself. Two service users commented they thought the building was clean and tidy. The main kitchen area was clean and tidy but it was noted that the coloured chopping boards were worn and in need of replacing. The service has procedures in place for the control of infection. Ashmill DS0000016719.V302668.R02.S.doc Version 5.2 Page 19 Ashmill DS0000016719.V302668.R02.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, & 35 Quality outcome in this area is adequate. This judgement has been based on available evidence including a visit to the service. Service users interests must be better protected through a more robust recruitment process. Service users are supported by staff, who are offered and participate in training enabling them to undertake their duties effectively. EVIDENCE: Two staff spoken with raised concerns about the current staffing levels during the weekends where due to sickness three members of staff would be off resulting in the manager having to come in and cover shifts. This has resulted in limited opportunities for service users to have activities. Both staff members stated the management had provided questionnaires for staff to be able to raise their concerns. The staff members concerned stated the manager and the owner were looking at a range of incentives for staff to work at the weekends including a rise in their salary. An examination of the staff rota for the previous four weeks indicated that there were seven staff on duty during the morning and four in the evenings during the week and at the weekend. The preinspection questionnaire stated that since the last inspection five members of staff including the deputy manager had left the service. A new part time senior carer had recently been recruited although another will be needed to cover one senior carer who stated she would be on maternity leave following this inspection. Ashmill DS0000016719.V302668.R02.S.doc Version 5.2 Page 21 An examination of the pre-inspection questionnaire stated that 57 of the care staff working for the service were qualified to NVQ Level 2 or above. However, there were no up to date training records to confirm this. Certificates were seen of training completed by staff including topics such as manual handling and food hygiene. The pre-inspection questionnaire stated that future training planned would be adult protection, first aid, fire safety, disability, health and safety, infection control and equal opportunities. A sample of staff recruitment records for one current staff member and recently employed care staff were found to be unsatisfactory. Three files seen did not have evidence of CRB Checks and one file had only a single reference, which was not even from their previous employer. Another file had a record of the interview completed on a blank piece of paper and there was no photograph or other proof of identity. Each file seen had an induction checklist but this will need further development ensuring staff are inducted adequately. One of the care staff commented that a service user had been involved in the recruitment of newly appointed staff but the service user concerned was not available to confirm this. The staff file examined for one of the current staff members did not have evidence of recent or updated training certificates. Ashmill DS0000016719.V302668.R02.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 & 42 Quality outcome in this area is adequate. This judgement has been based on available evidence including a visit to the service. Improvements are needed with regard to the management of staff recruitment and care records, which should be up to date. Service users are able to provide their views on life in the home at regular intervals. Service users’ health and safety is promoted and maintained to a satisfactory standard protecting their interests. EVIDENCE: The manager was on sick leave at the time of this inspection. A manager from another service owned by the Registered Provider was present. The manager was co-operative and any comments were received positively. He acknowledged the areas that were in need of improving particularly with regard to the recruitment records for staff and the quality of the service users’ care plans. A representative for the Registered Provider visits the service every month and reports for these are always sent to Commission. There was evidence where service users and staff were spoken with during the course of their visits. Ashmill DS0000016719.V302668.R02.S.doc Version 5.2 Page 23 Service users and relatives are able to provide comments about the service through satisfaction surveys. Two completed by service users commented that staff should always keep the home clean tidy during the weekend. One relative commented they would like the service to have a family room. While generally the records were up to date and locked in a secure facility, work is needed in ensuring the staff recruitment and training records are fully up to date. Records with regard to health and safety were satisfactory. There was evidence confirming when the fire alarms had been tested every week and the emergency lighting every month. The risk assessment for the prevention of fire was in need of reviewing. A fire drill had occurred since the last inspection and staff had recently completed fire safety training. There was documented evidence confirming where lifting equipment had recently been inspected and tested along with the electrical and gas equipment. An examination of the accident book found one had occurred since the last inspection and this along with other incidents affecting the welfare of service users had been notified to the CSCI. Ashmill DS0000016719.V302668.R02.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 2 3 2 4 N/A 5 N/A INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 N/A 26 N/A 27 N/A 28 N/A 29 N/A 30 3 STAFFING Standard No Score 31 N/A 32 3 33 3 34 2 35 2 36 N/A CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 2 2 N/A LIFESTYLES Standard No Score 11 N/A 12 2 13 2 14 N/A 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 N/A 3 N/A 3 N/A 2 2 N/A Ashmill DS0000016719.V302668.R02.S.doc Version 5.2 Page 25 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 YA1 Regulation 4(1) Schedule 1 5(1) Requirement Timescale for action 25/10/06 2. YA2 14(1) 14(2) The Registered Person must ensure the Statement of Purpose and Service User Guide is reviewed and amended in line with recent amendments to the Care Homes Regulations 2001. These must include information such as the fees charged by the service. The Registered Person must 25/10/06 ensure new admissions to the service are only admitted following receipt of a community care assessment. Failing that the Registered Person must ensure an assessment is completed within seventy two hours of admission. The Registered Person must ensure reviews for new admissions are undertaken with the funding authority in order to determine the suitability of the placement. 25/10/06 3. YA3 14(1)(2) Ashmill DS0000016719.V302668.R02.S.doc Version 5.2 Page 26 4. YA6 15(1)(2) 5. YA7 12(3) 6. YA9 13(4) 7. YA13 YA12 12(3)(4) 8. YA18 23(2) The Registered Person must ensure service users all service users’ care plans have been developed, reviewed and amended to show a complete picture as to how their individual needs should be met. There must be evidence of service users’ involvement. The Registered Person must ensure there is up to date minutes of service users meetings available for inspection to confirm how service users contribute to the running of the service. The Registered Person must ensure all service users risk assessments are completed and reviewed ensuring any identified risks are robustly managed. The Registered Person must ensure service users daily recording reflect more clearly how service users spent their leisure time including their responses to activities offered, participated in and declined. All equipment including wheelchairs used by residents must be maintained in a clean condition. Outstanding Requirement. Timescale 22 December 2005 not met. The Registered Person must ensure service users’ care plans refer to their gender care preferences. The Registered Person must ensure clear documentation is available to confirm service users’ contacts with healthcare professionals. 25/10/06 25/10/06 25/10/06 25/10/06 26/10/06 9. YA19 12(1)(2) 25/10/06 Ashmill DS0000016719.V302668.R02.S.doc Version 5.2 Page 27 10. YA23 13(6) The Registered Person must ensure staff recruitment records contain evidence confirming CRB/POVA checks. 25/10/06 11. YA34 9(2)(b) Schedule 2&3 12. YA35 The Registered Person must 25/10/06 ensure staff recruitment records include the following Two references (One must be from most recent employer) Confirmation of CRB & POVA checks. A record of the interview process Current photograph. 18(1)(a)(i) The Registered Person must 25/10/06 ensure it develops a staff training matrix that includes training completed so far and identifies any gaps in learning and for any updated mandatory training required. Individual staff training records must also be updated and include evidence of qualifications. 17(2) Schedules 2, 3 & 4 13(2) The Registered Person must 25/10/06 ensure the service users care records and staff recruitment records are up to date. The Registered Person must 25/10/06 ensure service users who require medication when required (PRN) have a written protocol in place confirming why this is required. The Registered Person must 25/10/06 ensure all external preparations and inhalers are labelled with date of opening. 13. YA41 14. YA20 15. YA20 13(2) Ashmill DS0000016719.V302668.R02.S.doc Version 5.2 Page 28 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 YA19 Good Practice Recommendations It is recommended that the Registered Provider develop Individual Health Action Plans that set out how service users healthcare requirements should be met and by whom. Ashmill DS0000016719.V302668.R02.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Birmingham 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 © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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