Inspection on 27/07/07 for Ashpark House

This inspection was carried out on 27th July 2007.

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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ashpark House 06/07/06

Ashpark House 02/02/06

Ashpark House 14/06/05

Ashpark House 23/11/04

Ashpark House 02/06/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Ashpark House Peldon Road Abberton Colchester Essex CO5 7PB Lead Inspector Diane Roberts Key Unannounced Inspection 27th July 2007 09:00 Ashpark House DS0000017754.V349301.R01.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 Ashpark House DS0000017754.V349301.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Ashpark House DS0000017754.V349301.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashpark House Address Peldon Road Abberton Colchester Essex CO5 7PB 01206 735567 01206 735567 ashparkhouse@btconnect.com www.alliedcare.co.uk Ashpark House Limited 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 Lynette Carter Care Home 11 Category(ies) of Learning disability (11), Learning disability over registration, with number 65 years of age (1) of places Ashpark House DS0000017754.V349301.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Persons of either sex, under the age of 65 years, who require care by reason of a learning disability (not to exceed 11 persons) One named person, over the age of 65 years, who requires care by reason of a learning disability, whose name was provided to the National Care Standards Commission in October 2003 The total number of service users accommodated in the home must not exceed 11 persons 6th July 2006 3. Date of last inspection Brief Description of the Service: Ashpark House is a detached house with large, enclosed grounds, in the north Essex village of Abberton, south of Colchester. Its a rural, village location and was originally bought as a vacant property. It has been decorated throughout in a style appropriate for the type of residents it is intended for. Ashpark House is registered for 11 residents with learning disabilities, one of whom is over 65 years old. It is divided into two distinct units, one upstairs and one downstairs. All rooms are single occupancy, seven are ensuite and all have good views over the grounds of the home. The home has a large garden to the rear of the home. Fees currently range from £1000.00 to £1800.00 depending on needs/staffing requirements. Additional costs are made for toiletries, hairdressing, chiropody and some activities. Ashpark House DS0000017754.V349301.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out as part of the annual inspection programme for this home. The registered manager was available on the fieldwork day of the inspection. The inspection focused upon all of the key standards. A partial tour of the premises was undertaken. Evidence was also taken from the Annual Quality Assurance Assessment completed by the management of the home and submitted to the CSCI. It was possible to meet several residents whilst visiting the home but it was not possible to obtain full feedback. Residents were happy to show me their rooms. 3 staff were spoken to during the inspection. Seven feedback/comment sheets were received from relatives and friends and feedback was also received from 6 healthcare professionals. These comments were taken into account when writing the report. The manager has completed a very basic annual quality assurance assessment for the CSCI, which does not demonstrate a comprehensive management approach to the development of the services in the home and improvement of outcomes for residents. What the service does well: Residents are generally happy living at the home and the residents and the staff team interact well. A good level of healthcare is provided for residents and they have access to specialist services. Staff management medication for residents efficiently and medication is kept under review. The home is kept in good order and the meals provided at the home are good and suitable for the resident group. The manager ensures that new staff are properly recruited and all the required checks are in place before they start work. Ashpark House DS0000017754.V349301.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ashpark House DS0000017754.V349301.R01.S.doc Version 5.2 Page 7 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 Ashpark House DS0000017754.V349301.R01.S.doc Version 5.2 Page 8 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The assessment system helps to ensure that the team at the home can meet the needs of the residents they admit and the information available would allow people to make an informed decision about the home. EVIDENCE: The manager has a pre-admission assessment system in place. Since the last inspection, only one new resident has been admitted and this assessment documentation was inspected. The manager undertakes these assessments and where possible may also take another member of the staff team with her. Transition periods are encouraged to help residents settle in well and to ensure that the home will be able to meet their needs. The admission assessed was an emergency and did not allow for a transition and full assessment. Other records seen evidenced that this was not the norm. The assessment was seen to be detailed and covered the required subject areas. Input had been obtained from the referring home and records were clear as to the resident’s level of ability and support required. Behaviour issues were identified along with associated risks. Good detail was also obtained on communication methods and personal preferences. From the assessment the team should be Ashpark House DS0000017754.V349301.R01.S.doc Version 5.2 Page 9 able to assess whether they would be able to meet the residents needs. Although an emergency admission, the resident was admitted on a trial basis and records showed regular review meetings with the staff at the home and the placing team. Since the last inspection the manager has reviewed both the statement of purpose and service users guide. The content of these documents is satisfactory and the format appropriate for the resident group in relation to their abilities. Ashpark House DS0000017754.V349301.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Significant shortfalls in residents care plans and a very limited use of person centred planning does not demonstrate that residents’ needs are met in a proactive and progressive way by the team at the home. EVIDENCE: The care planning system in the home was reviewed. The recording systems require a significant amount of work to bring them up to an acceptable standard so that the residents’ current care package is fully reflected and that positive outcomes are achieved. The majority of care plans were either seen to be out of date or were not in place at all. Care plans were not in place that reflected the residents current needs, the level of support they needed, what the staff were trying to achieve with the resident and the result and evaluation of the inputs by staff. Some Ashpark House DS0000017754.V349301.R01.S.doc Version 5.2 Page 11 assessments were seen to have been completed over three years ago and did not reflect the current needs of the resident. Although yearly reviews had taken place on some care plans, although the homes policy is six monthly, these were seen to be limited and contained little evaluation of the care provided. Occasionally the care plan did reflect current need but this was seen to be more by luck because there had been no changes. One resident, who had been in the home some months, had no care plans in place and the care plans from the resident’s old home were on file. On review of these, with the manager, she confirmed that they were not appropriate as the care and behaviour of the resident had change significantly for the better, since admission but there were no records to evidence this or the current approach by staff to progress this further. Several of the records in place do not show that the team have a person centred approach, as they were not individual to the resident nor did they contain sufficient detail. The manager confirmed that the daily routines, weekly timetables and other documents were the same for each resident. It would be expected that each resident would have a different daily routine. Other records demonstrate that the daily routine does not reflect what is actually happening with the resident and they also do not cross reference and reflect the resident activities timetable. Care records were seen to contain limited information on residents’ preferences although staff could account verbally for this and obviously know the residents well from this point of view. Daily records are maintained and these reflected behaviour, dietary intake and sleep patterns. Some valuable information was recorded on some occasions that would help to inform the care plan for the resident but as the care plans are not updated, the information may be lost. This poor approach to the care planning for residents does not reflect what the manager states in the Statement of Purpose. The manager also states in her annual quality assurance assessment that ‘care plans are reviewed six monthly’ but then goes on to state that they could do better by ‘ensuring that care plans are reviewed on a regular basis’. Some healthcare professionals who commented said that ‘they had concerns that care plans were not followed by the team at the home or kept up to date’. Others said that the team at the home worked well with them’. One positive thing is that the manager does state the care plans and risk assessments need to be developed. Other records and from healthcare professionals comments show that review meetings are held. Minutes often produced by the placing team/reviewing officer, which the team put in the care plan file but do not use to up date the residents individual plan. From discussion with staff there is an indication that review guidance is followed but there is little written evidence of this. Risk assessments, although in place and up to date, were not all individual to the resident and it could be questioned as to how valuable some of these are. Ashpark House DS0000017754.V349301.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are able to access a range of activities. Further person centred work on aspects of resident’s daily lives may enable them to have a wider choice, develop more skills and improve outcomes. Food provision at the home is satisfactory. EVIDENCE: The residents at the home attend a range of activities dependant on individual abilities and behaviour challenges. The funding of some residents allows for higher one to one staffing levels and enables some residents to go out of the home on a more regular basis. Individual and group activities take place but the residents care plans and records do no always link into the activities planned or identify residents goals to achieve further independence. Residents do spend time in the home’s activity room but records do not always indicate Ashpark House DS0000017754.V349301.R01.S.doc Version 5.2 Page 13 what activity they are doing. Equipment in the room would indicate that some positive personal development activities are taking place such as awareness with money, but again records are limited. Records seen show that residents are undertaking a range of activities, such as day centres, cinema, walks, shopping, eating out, swimming, gardening and limited household tasks. At the current time none of the residents are able to undertake any employment. At the day centres residents take part in cookery classes, art and craft and computers. One resident who is able to attend college has chosen their own courses for later this year and this includes communication and music. Care plans need to improve to show a more person centred, developmental approach to activities as well as providing a much needed social outlet. One healthcare professional who commented said that the home could improve by ‘encouraging residents with more domestic skills to develop their independence’. A visitor commented that ‘ the staff encourage my friend to get involved in things that enhance his/her life and they take time to understand peoples’ needs’. Residents access the local community and do visit local shops and pubs etc. The home has held a fete in the past, which was attended by people from the village. The team at the home have two vehicles, one with a tail lift, which they can use to take residents out and about. One resident is able to go out regularly with another local provider on a contracted one to one basis. Holidays for residents are limited at the current time with only a small group of staff willing to undertake this role. This relates to a dispute between the provider and the staff over payment for what can be long shifts, with staff looking after residents for long periods of time due to their needs during the day and night. The management should review this situation to help ensure positive outcomes for residents. The home has an open visiting policy and some of the residents do have regular contact with family members. One resident has a volunteer visitor from Mencap who visits the home and others do meet up with residents from other homes within the provider group. Families and friends are actively invited to events at the home. Residents, where possible, do have their own keys to their rooms and some were happy to show me around their rooms. Healthcare professional who commented said that ‘interaction between the staff and residents was good and that the home had a good atmosphere’. Residents have a variety of meals and where possible are involved in the shopping. Due to some behavioural challenges, access to some foods has to be limited. Care records need to improve to reflect these approaches to care fully and identify residents up to date preferences and dietary needs. Where required the monitoring of food intake is detailed. Care plans also could reflect Ashpark House DS0000017754.V349301.R01.S.doc Version 5.2 Page 14 residents’ personal goals in relation to cooking at and food management at the home. Some residents are able to go out with staff and eat in the community. Food stocks were satisfactory and varied and the menus seen were appropriate for the resident group at the home. Residents have been helping to grow a variety of vegetables and herbs at the home, which is positive. Ashpark House DS0000017754.V349301.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ healthcare needs are generally met in a proactive way and medication management is good. EVIDENCE: Records show that residents’ healthcare needs are generally being met. Records show that residents have input from a wide range of healthcare professionals, although guidance in the care notes is not always dated so it is not possible to assess how up to date the information is. Care plans for some residents were not up to date with regard to healthcare needs and some were not in place at all. Where required residents dietary intake is monitored and records show that residents are weighed regularly. Residents’ have access to local doctors and where possible visit the surgery. Records show a proactive approach to care and visits are also made to local Consultants in Learning Disability. Ashpark House DS0000017754.V349301.R01.S.doc Version 5.2 Page 16 From observation and records, residents have access to physiotherapists, local district nursing services, dental services, opticians and continence advice. Visiting healthcare professionals spoken to on the day of the inspection, commented positively on the staff team and said they worked well with them and communication was good. The team uses a monitored dosage system to manage residents’ medication. The systems were reviewed and found to be managed well with neat clear records in place. Records show that residents have regular medication reviews from either their doctor or Consultant. Records also show that where medication is being reduced good monitoring records are in place to evidence the effect of the reduction. Ashpark House DS0000017754.V349301.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Systems are in place to help ensure that residents will be listened to and their rights protected but shortfalls in staff training may compromise this. EVIDENCE: The manager has a complaints procedure in place. A standard format is displayed and the manager has started work on a pictorial format now that she has more picture formats to draw upon. The complaints procedure can also be found in the service users guide. The manager reports 9 complaints since the last inspection. These all relate to complaints from local residents regarding noise coming from the home relating to one resident. This issue has now been addressed. The manager keeps appropriate records and responds to these issues. Relatives who commented said that they knew how to raise any concerns with the home. The manager has up to date adult protection procedures in place and this includes local guidance. Since the last inspection 2 adult protection referrals have been made and the CSCI correctly notified. Both relate to staff behaviour toward residents. One was found not to be substantiated due to lack of evidence and the other is currently ongoing. The management of the home have responded properly to these matters and residents obviously feel confident to raise concerns/complaints with the manager. Ashpark House DS0000017754.V349301.R01.S.doc Version 5.2 Page 18 On review of the training records, for staff working in the home, there is a significant shortfall in relation to staff training on this subject. This should be addressed in light of the recent referrals. Training records do show that all the staff are up to date with dealing with challenging behaviour. Ashpark House DS0000017754.V349301.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have a pleasant environment to live in that meets their needs. Some systems in the home need to improve to ensure resident and staff safety. EVIDENCE: A partial tour of the home was undertaken with the manager. Standards of décor and furniture were generally acceptable. Residents’ bedrooms were personalised and many had their own items of furniture. Where possible residents choose their own décor in their rooms and some are helped by staff. Corridors in the home, apart from reception, were seen to be stark and reflected poorly on the home. The manager reported that these are due to be decorated and pictures etc will be put up. Recent refurbishment work has been undertaken in the upstairs kitchen and some bedrooms have been recently decorated. Specialist equipment is available throughout the home and includes hoists, padding, rails etc. Specialist wheelchairs are also in use. Ashpark House DS0000017754.V349301.R01.S.doc Version 5.2 Page 20 The home has a large garden to the rear, which consists mainly of lawn with some shrubs to the edges. More could be made of this facility, which could involve residents. Relatives who commented said that the home had a nice atmosphere and was ‘homely’. Maintenance certificates for the fixtures and equipment in the home were inspected at random and found to be in order. The manager needs to ensure that she has evidence that remedial work, identified on certificates, has been attended to. Arrangements in relation to fire safety were reviewed. A risk assessment is in place, which is due for review in September 2007. Records show that weekly tests of fire alarms have not been carried out since the end of June. The manager stated that she was aware of this but had not addressed the matter. Regular fire drills had been carried out. The company have a infection control procedure in place but it is recommended that local guidance is obtained from the Community Infection Control Team. Staff cover aspects of infection control training through induction and on LDAF courses. The manager should obtain advice and consider the need for such training, as she states that the proprietors do not supply this. Ashpark House DS0000017754.V349301.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst recruitment and staff retention is generally good, shortfalls in staff training and staff managment could adversely affect the quality of services provided to residents. EVIDENCE: The staff team at the home is quite stable although there has been some turnover of staff in the last year. At the current time there is no agency use, which is positive for residents. Rotas show that 5/6 staff are working each shift during the day and the managers office hours are additional to this. The deputy manager has office time to help ensure that care records are up to date. At night 2 awake night staff are on duty. Staffing levels tend to be 5 on each shift during the day at weekends. The range of activities provided over the weekend period is limited and this could relate to the slightly lower staffing levels. During the week staff do take residents to and from day care centres etc and out to appointments. It is felt that the staffing levels are currently satisfactory to meet residents’ needs but this should be kept under review as Ashpark House DS0000017754.V349301.R01.S.doc Version 5.2 Page 22 not all residents’ needs are identified in their care plans. Some of the staff have permits to work in the country that expire later this year. This may adversely affect the staff at the home and the manager needs a proactive approach to this issue so that resident care is not affected. Relatives and healthcare professionals both commented positively on the staff team saying that they were ‘polite, friendly and helpful’. The manager has recruitment policies and procedures in place. The recruitment of new staff was inspected and files checked at random. All the required checks and documentation was seen to be in place and interview records are also kept. It is recommended that the application form allows for a longer employment record and the interview records evidence that gaps in employment have been explored. The manager does have copies of the GSCC Code of Conduct but does not have any evidence that these are issued to new staff. Records show that nearly all the staff have achieved NVQ qualifications at level two or above. This is to be commended and the manager should give consideration as to how to use the skills that the staff team have to improve outcomes for residents. Records show that the NVQ assessor visits the home regularly. A training matrix, submitted to the CSCI shows that the manager has a training programme in place and that whilst compliance levels with manual handling training are good there are shortfalls with fire safety, food hygiene and health and safety. This needs to be addressed. Attendance at specialist study days, that relate to the care needs of the residents at the home, is also limited and could be improved upon to help ensure positive outcomes for residents. The manager now has the information on the Skills for Care induction programme but has yet to use this with new staff. The manager has a staff supervision system in place but on review there is an inconsistent approach with some staff having significantly less that others. Good records are kept when supervision has been carried out. The manager holds staff meetings but records show that these are not regular with only one being held in the last year. Minutes are kept and show that these include resident care information/review along with general information pertinent to staff. It may be of value to separate these two meetings and use the care review one to update care plans and inform staff. Meetings should be held more regularly. Ashpark House DS0000017754.V349301.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Management at the home is stable but work is needed to develop systems so that the home develops with residents and other interested parties comments in mind and to ensue that outcomes for residents are positive. EVIDENCE: The manager has been in post for one year now, having worked in the home in other capacities in the past. The manager is suitable experienced and has not been registered with the CSCI. This inspection shows that the manager does need to tighten up on the management and monitoring systems in the home. There also needs to be more communication with staff through supervision and meetings. Utilising staff skills appropriately may help the manager to address Ashpark House DS0000017754.V349301.R01.S.doc Version 5.2 Page 24 some of the shortfalls in the home that can affect outcome for residents. These issues are also reflected in the proprietor’s audits on the home. The manager interacts well with residents and does have their interests at heart. There is clear evidence that she is prepared to appropriately advocate on their behalf and help to sort out personal issues that come to light over finances, placement and family matters. Since the last inspection the quality assurance systems in the home have developed further although the manager, in her annual quality assurance assessment, says that they need to improve by developing a quality assurance system. The manager needs to have a better understanding of the company’s quality assurance system and how this relates to the management systems in the home and the care provided. The company carry out a variety of audits on the premises, residents’ finances, medication etc. These reflect the theme of this inspection report. Satisfaction surveys are used and these have changed over the year and have only recently been sent out. The manager analyses these with another manager in the company and plans to produce results. These were subsequently submitted to the CSCI and showed that half of the residents are unable to take part and the other half are generally happy with the services provided. The results do not give extra comments made by residents and consideration should be given to this so that the detail is available. Surveys should be developed so that feedback is sought from relatives and visiting professionals. The manager has just started to hold residents meetings on a monthly basis and minutes are kept. Only one meeting has been held so far. A range of issues are discussed that include, holidays, new residents, staff, bedroom redecoration, college courses and birthday celebrations. These are good records and should be used to inform the quality assurance systems in the home as an additional tool. The minutes show that residents are able to freely express themselves and have choice with regard to aspects of the home and are aware of internal changes to staff etc. The manager has a health and safety policy in place and has completed risk assessments for the home in February 2007, which are comprehensive. No COSHH issues were noted on touring the home. Health and safety training for staff could be improved upon. Accident records were clearly maintained and detailed. Accident levels were low with more incidents occurring. Ashpark House DS0000017754.V349301.R01.S.doc Version 5.2 Page 25 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 X 2 3 3 X 4 X 5 X 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 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 2 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 X 2 X 2 X X 2 3 Ashpark House DS0000017754.V349301.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes 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 YA6 Regulation 12, 14 and 15 Requirement Each resident must have an up to date plan of care in place that identifies their current needs and how those needs will be met. This must be kept under review and where possible involve the resident or a representative. Care plans should reflect that residents have a right to make decisions regarding their care and more information on personal preference/choice must be provided. Risk assessments must be written for the individual and management of risk reflected in their care plan. This is partly a repeat requirement. Residents’ activity programmes should be reviewed/reassessed to ensure that their needs are being met and their abilities optimised. Appropriate records need to be maintained to evidence this. Care plans must accurately reflect residents current healthcare needs and how those needs will be met. Timescale for action 31/10/07 2 YA7 12 and 15 31/10/07 3 YA9 12 and 13 31/10/07 4 YA12 14 and 16 31/10/07 5 YA18 12, 14 and 15 31/10/07 Ashpark House DS0000017754.V349301.R01.S.doc Version 5.2 Page 27 6 7 YA23 YA35 13 12 and 18 8 YA39 24 All staff must be trained in adult 31/10/07 protection matters and kept up to date with current policy All staff must attend training on 30/11/07 fire safety, food hygiene and health can safety and where require attend updates. This is a repeat requirement. The quality assurance system in 30/11/07 the home needs to develop further and the manager needs to have a better appreciation as to the use of such systems. This is a partial repeat requirement. 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 2 3 4 5 Refer to Standard YA6 YA12 YA24 YA30 YA34 Good Practice Recommendations Consideration should be given to developing a more person centred approach to care planning. A review of staffing should be undertaken to ensure that residents have access to holidays. Regular checks should be made on the fire safety systems in the home. The manager should seek advice regarding infection control training for staff and provide training as appropriate. The staff application form should be reviewed to ensure that there is enough space for employment history, interview records should evidence that gaps in employment have been explored and staff should be issued with the GSCC Code of Conduct. Staff should attend additional specialist training that relates to the specialist needs of residents so that outcomes can improve. 6 YA35 Ashpark House DS0000017754.V349301.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ashpark House DS0000017754.V349301.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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