Inspection on 06/06/05 for Ashtead House

This inspection was carried out on 6th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Ashtead House 11/07/07

Ashtead House 05/12/06

Ashtead House 24/10/05

Ashtead House 14/12/04

Ashtead House 20/09/04

Ashtead House 16/02/04

Similar services:

Thorndene

Sutton Lodge Nursing Home

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

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

CARE HOME ADULTS 18-65 Ashtead House 153 Barnett Wood Lane Ashtead Surrey KT21 2LR Lead Inspector Mr D Griffiths Unannounced 06 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. Ashtead House Version 1.10 Page 3 SERVICE INFORMATION Name of service Ashtead House Address 153 Barnett Wood Lane, Ashteaad, Surrey. KT21 2LR 01372 810330 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) Ashtead House Ltd Ms Sheila Cassidy CRH (PC) 10 Category(ies) of Learning Disability (LD) 6 registration, with number Physical Disability (PD) 4 of places Ashtead House Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: The age/age range of the persons to be accommodated will be 18 - 60 YEARS. Date of last inspection 14 December 2004 Brief Description of the Service: Ashtead house is a detached property set in its own grounds a short distance from local shops of Ashtead town centre. Accommodation is situated on the ground floor and first floor. All bedrooms are single occupancy ,five bedrooms on the first floor and five on ground floor. There is no lift to access the upper floor . One of the bedrooms on the ground floor is being used as a quiet room and containes the service users computor. There is a communal garden at the rear and parking for several cars at the front. The home is registered to ten people with mild to moderate learning disabilities and physical disabilities. Ashtead House Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first inspection of two to be undertaken in the Commission for Social Care Inspection Year April 2005 to April 2006. It was an unannounced visit and took place over a period of 7hrs. Lead Inspector Damian Griffiths was assisted throughout the inspection by Sheila Cassidy Manager representing Ashtead House. A tour of the premises took place and the inspector was able to meet three service users and three members of the staff at home who were happy to contribute to the inspection report. The service users confirmed that they would prefer to be described as service users. It is recommended that the reader should also look at the previous report that can be accessed by using the CSCI website details on the last page of this report. The inspectors would like to extend thanks to the service users, management and staff at Ashtead House for their time and hospitality. What the service does well: What has improved since the last inspection? The management met all the requirements made at the previous inspection. The Home now employs a maintenance man and has a maintenance log containing work needing to be completed and new carpets have been fitted throughout the home. Ashtead has been making progress with service user involvement and looking at the quality of the services they are providing. A quality assurance inspection has recently been completed by the service and a new standardised system of recording is now in place. The management expects that this will Ashtead House Version 1.10 Page 6 provide better consistency with all services records, policies and procedures that should be evident by the time the next inspection is due. Ashtead aims to be a home for life and as so has had to deal with a varied range of life events including death. The home has shown sensitivity and support to bereaved family, relatives and service users at Ashtead house. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ashtead House Version 1.10 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 Standards Statutory Requirements Identified During the Inspection Ashtead House Version 1.10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4 and 5 The home has clear details of the services they provide. The service users guide is written in pictorial form and would help existing and prospective services users to make an informed decision. New Service users are given time to adjust to their new environment and appropriate care is taken to support their needs. EVIDENCE: The Service is overhauling all its current documentation to a new system. This is a clearer and modern update that is all available on the IT system. It includes pictures of the home the interiors and grounds. The services users guide is complete however very bulky due to the inclusion of the pictorial explanations and was located, at the services users request, by the front door. The service users guide should be made available and in an accessible place. It is recommended that the service users guide be moved to a place in the living room area and that residents discuss what changes would be needed to make the service users guide more useful to them. The service users guide should contain information concerning each individual and be kept in their room. It is recommended therefore that this point needs to be discussed as an agenda point at the service users next house meeting. The most recent service user to move into Ashtead was due to an emergency situation. The correct procedures are being observed .The initial assessment was completed prior to admission and further assessments are being compiled Ashtead House Version 1.10 Page 9 from the health and social services practitioners to establish the suitability of Ashtead House as a long term home. The manager has explained that all Service users’ contracts are kept in a central location as part of the larger organisation of “Allied Care”. Service user contracts therefore are not available for inspection this is a requirement of the National Minimum Standards. Ashtead House Version 1.10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,8, and 9 Service users receive a full assessment of their needs and are encouraged to participate with all aspects of life at the home. Service users are supported to take assessed risks that are regularly reviewed. EVIDENCE: Three service user care plans were inspected and were shown to be informative and precise. One existing service user initial assessment was not available, therefore, the manager is required to provide another to ensure the current care plan is correct. The service users care plans included a wide variety of care needs ranging from management of challenging behaviour to providing intimate personal care or safe manual handling. Risk assessments were regularly updated as necessary and a record of challenging behaviour is kept. Specific details about how best to manage the service users challenging behaviour is provided to staff with clear information about what behaviour to expect. Service users confirmed that staff were consistent with the help they provide and will help them to realise their personal choices. One service user is able to work at a local leisure complex with the support of the home and the local employment services. Ashtead House Version 1.10 Page 11 Ashtead House Version 1.10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11,12,13,14,15,16 and 17. Service users are supported to use local education, employment and leisure facilities. Service users are able to stay in touch with family friends and privacy is respected with existing intimate relationships. EVIDENCE: Many of the services users were attending a range of activities open to the service users at Ashtead house. These include access to the local church, pub, cinema, various clubs and bowling. A bowling trophy has pride of place in the living room. The home supports a long-term relationship between residents and has supported them to overcome or accept difficulties with their relationship. All reasonable steps are taken to protect service users from exploitation. Risk assessments were observed to be realistic and sensitive to service users needs. Service users are assisted and escorted on holidays of their choice the home will provide at least one holiday a year to residents. Service users also have access to a caravan in Hastings free of charge. Ashtead House Version 1.10 Page 13 Ashtead House Version 1.10 Page 14 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, and 21. Staff provide sensitive and flexible personal support and care to maximise service users’ privacy, dignity, independence and control over their lives. EVIDENCE: Service users are able to keep in touch with their families with the support of their key worker who will personally assist them to achieve their goals, whether it concerns booking a holiday or arranging a trip out to the shops Some service users receive input from the District Nursing services and all service users have the choice of regularly visiting the chiropodist and at other times are able to access the services of an aroma therapist . Another service user was taken to visit the dentist. Sadly the recent death of a fellow service user required the sensitivity of staff to support the family and service users through this difficult time. Correspondence from the family indicated that the manager had ensured this was done in a respectful and dignified way. Ashtead House Version 1.10 Page 15 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 and 23 The manager has provided clear guidelines and timescales for the investigation of complaints. Service users consulted understands that they can complain and that there is a system in place if required. EVIDENCE: One complaint has been recorded since the last inspection made by a neighbour complaining about the noise, no further complaints have been registered. The manager has stated that the home has never received a complaint about noise before, but she has fully investigated the compliant and there has been no further reports of this nature. Most service users consulted were confident of their ability to make a complaint however less vocal service users stated that they needed assistance and this did not always occur. Service users are able to discuss complaints with individual members of staff or at regular house meetings. Staff have regular training and aware of Protection Of Vulnerable Adult (POVA) procedure. The manager stated that she has been unable to access the Surrey Multi-Agency Procedures on the Surrey Website but will contact the local area social care team for advice as recommended by the inspector. Ashtead House Version 1.10 Page 16 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)24,26,27 and 30. Limited improvements to the décor have been made. Repairs and redecoration limit the provision of a safe and comfortable environment for the service users. EVIDENCE: Since the last inspection the home have employed a maintenance man to carry out a program of repairs and redecoration. The maintenance log showed repairs that were also noted during the inspection, e.g., re-grouting the shower room tiles. Service users rooms inspected were well decorated and personalised, all have their own sink basins and door locks with additional lockable draw space. One ground floor room has two distinct areas providing the resident with ample space needed to maximise manoeuvrability and access. The room mentioned in the last report that required decoration and to be kept locked is now locked and undergoing redecoration. Bathrooms and toilets all in good condition bright airy and well decorated. The Communal areas however, due to the continued use, have sustained significant wear and tear. The manager is required to address these issues in particular a hazard on the stair caused by the length of curtains hanging loosely onto the stairs contributing to a potential trip hazard. Other areas for attention include: Ashtead House Version 1.10 Page 17 • • • • • • . Torn covers to be repaired or replaced on settee in the living room area. Clean carpets in all communal areas. New plastering to doorways to living room. Re-hang curtains on fire door exit or removal, advise from fire officer. Re-hang curtains in staff sleepover room. Washing the living room and the Landing ceiling and painting if required. Ashtead House Version 1.10 Page 18 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)34. The recruitment process has been shown to be adequate however there have been delays with the completion of Criminal Record Bureaux Checks for two long serving staff members. EVIDENCE: Criminal Record Bureaux Checks (CRB) evidenced for all staff except three including the new maintenance person. The manger confirmed that he is supervised throughout the home when working. The manager has stated that the details of two staff members who have been working at Ashtead House for three years have previously received a CRB check. The manager is required to show evidence of enhanced CRB checks for these members of staff. Ashtead House Version 1.10 Page 19 Conduct and Management of the Home The intended outcomes for Standards 39 – 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) 39 and 42. Effective quality assurance and quality monitoring systems, based on seeking views of service users have not yet been implemented however there is evidence that a new system has been put in place. The home complies with the Health and Safety requirements. EVIDENCE: The residents are able to voice their opinions monthly at the house meeting. To ensure that the views of all residents are noted a service users survey would help to confirm this in a way the would be simple to review. There was no evidence of any completed quality assurance or quality monitoring outcomes from service users. The manager is aware of the need to provide this information and, therefore, to confirm and establish all the good work achieved at Ashstead House. A requirement has been made for the management to comply and provide a quality audit before the next inspection. Regulations 26 reports have been received on a quarterly basis it is a recommended that these be made available monthly. Ashtead House Version 1.10 Page 20 The Home’s overall Health and Safety procedures were seen and showed that it had regular fire checks and drills and had a signed record of the fire officers’ inspection. There was also in evidence on record of temperatures for fridge freezers and cooker used, to ensure the correct and safe temperatures are achieved. The Environmental Health Officer has recently inspected the premises and there were no concerns recorded. The home has received a fire inspection of the premises recorded 01.11.04. 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. Where there is no score against a standard it has not been looked at during this inspection. 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 2 2 3 3 2 Standard No 22 23 ENVIRONMENT Score 3 2 Standard No 24 Version 1.10 Score 2 Page 21 Ashtead House INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 2 3 x Score 25 26 27 28 29 30 STAFFING 3 3 3 2 3 2 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score x x x 2 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 x 4 Standard No 37 38 39 40 41 42 43 Score x x 2 x x 3 x Ashtead House Version 1.10 Page 22 no 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 5 Regulation 5. (1)(c) Requirement The Registered Person must ensure that services users are in receipt of a standard contract for the provision of services and facilities provided by the registered provider. The Registered Person must ensure they do not employ a person at work at the care home unless she has obtained in respect of those persons the information and documents specified in paragraphs 1-9 of schedule 2 of the Care Homes Act 2001 The Registered Person must ensure that all parts of the home to which service users have access are so far as is reasonably practical free from hazards to their safety. The Registered Person must ensure that a system to review the quality of care offered by the home in consultation with the service users is completed with identifiable outcomes provided to all parties involved. Regulation 26 reports to be issued to CSCI on a monthly basis. Version 1.10 Timescale for action 29/08/05 2 34 19(1)(b) Schedule 2 04/07/05 3 24 13. (4)(a) 07/06/05 4 39 24(1)(a)( b)(2)(3) 01/12/05 5 42 26 07-07-05 Ashtead House Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Refer to Standard 24 Good Practice Recommendations That the carpets are cleaned on a rotational basis an all other recommendations as listed are added to the maintenance list to be completed as prioritised by the manager. No. 1. Ashtead House Version 1.10 Page 24 Commission for Social Care Inspection The Wharf. Abbey Mill Business Park Eashing Surrey. GU7 2QN 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. Extracts may not be used or reproduced without the express permission of CSCI Ashtead House Version 1.10 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!