Inspection on 17/06/04 for Ashtonleigh

Care Home For Older PeopleAshtonleigh4 Wimblehurst Road Horsham West Sussex RH12 2EDAnnounced Inspection17th June 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of Establishment Ashtonleigh Address 4 Wimblehurst Road, Horsham, West Sussex, RH12 2ED Email address Name of registered provider(s)/company (if applicable) Ashtonleigh Residential Care Home Limited Name of registered manager (if applicable) Miss Nicola Purtill Type of registration Care Home No. of places registered (if applicable) 30 Tel No: 01403 259217 Fax No:Category(ies) of registration, with (number of places) Old age, not falling within any other category (30) Registration number H110000938 Date first registered 30th July 2002 Was the home registered under the Registered Homes Act 1984? Do additional conditions of registration apply? Date of last inspectionDate of latest registration certificate 9th May 2003 YES NO 06/11/03 If Yes refer to Part CAshtonleighPage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 317th June 2004 08:00 am Mrs M McCourtID Code096572Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionAshtonleighPage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Providers Response Providers Comments Action Plan Providers AgreementAshtonleighPage 3 INTRODUCTION TO REPORT AND INSPECTION Every Establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI), is subject to inspection, to establish if the Establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the CSCI in respect of Ashtonleigh. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.AshtonleighPage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Ashtonleigh is a privately owned care home registered to accommodate up to thirty service users in the category of older people. The registered provider is Ashtonleigh Residential Care Home Ltd. Mr Chaytansing Gopal is the responsible individual and the registered manager is Mrs Nicola Purtill. The property is a large detached house, providing accommodation across three floors. It is situated in a quiet residential area near to the town centre of Horsham. There is a spacious and well-maintained garden to the rear of the house. The accommodation is provided in twenty single rooms and four double rooms. Eighteen of the rooms have en-suite facilities. There is a passenger lift available.AshtonleighPage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.)AshtonleighPage 6 Inspectors undertaking inspections for the year 2004/2005 are required to assess all standards over the two statutory inspections each year. During this inspection twenty out of the overall thirty-eight standards were assessed. Those standards that were not assessed have been scored with a zero. Two standards are not applicable and have been scored with a 9. The inspection identified the following: CHOICE OF HOME (STANDARDS 1 ­ 6) Three of the six standards were assessed. Two were met and one does not apply. Statement of Purpose and Service Users Guide were comprehensive and inclusive of all the points highlighted in the National Minimum Standards. The Statement of Terms and Conditions has recently been updated by the registered manager. HEALTH AND PERSONAL CARE (STANDARDS 7 ­ 11) Two of the five standards were assessed. Two were met. Care plans are in place and up-to-date. They are comprehensive and include risk assessments and relevant health care matters. The registered manager reviews them on a monthly basis. Specialised support and professional input are available when required. DAILY LIFE AND SOCIAL ACTIVITIES (STANDARDS 12 ­ 15) Two of the four standards were assessed. Two were met. Visitors to the home are welcomed. Some criticism of the food was received by the inspector, although food sampled was found to be well presented and wholesome. Menus are available for a four-week period. COMPLAINTS AND PROTECTION (STANDARDS 16 ­ 18) Three of the three standards were assessed. Two were met and one was partially met. Relevant policies and procedures are in place and one complaint received was dealt with in a thorough manner. Service users are pleased with quality of care provided by the home. Staff are aware of how to proceed with any adult abuse issues that may arise. ENVIRONMENT (STANDARDS 19 ­ 26) Four of the eight standards were assessed. Two were met, one was partially met and one does not apply. The home was clean, tidy and well maintained throughout. All fixtures and fittings were of a high standard and bedrooms were decorated to reflect personal taste. An assessment has not been carried out by an Occupational Therapist, however the home does provide additional facilities to assist with mobility and the registered manager is a qualified RMN. Staff need to be updated regarding infection control, and the water facilities should comply with the Water Supply Regulations 1999. STAFFING (STANDARDS 27 ­ 30) Two of the four standards were assessed. One was met and one was partially met. The registered manager should ensure recruitment records are in place prior to employment. Records show that all staff are training to NVQ level, and a comprehensive induction and foundation training is due to be implemented.AshtonleighPage 7 MANAGEMENT AND ADMINISTRATION (STANDARDS 31 ­ 38) Four of the eight standards were assessed. Two were met and two were partially met. The registered manager has the necessary skills and experience required to manage the home, and is able to demonstrate her capabilities well. Quality assurance systems need to be revised and implemented, and consideration should be given to planning residents meetings, in order to obtain feedback. Supervisions sessions, whilst in place should be held on a more regular basis.AshtonleighPage 8 Requirements from last Inspection visit fully actioned? If No please list belowNASTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for actionAction is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).Met (Yes / No)AshtonleighPage 9 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for actionRECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * The registered person should facilitate access to available advocacy services. Service users rights to participate in the political process is upheld, for example, by enabling them to vote in elections. Foul laundry should be washed at appropriate temperatures to control the risk of infection. Services and facilities should comply with the Water Supply Regulations 1999. The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users.1OP172OP263OP29AshtonleighPage 10 4 5OP33 OP36Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims and objectives and statement of purpose of the home. Care staff receive formal supervision at least six times a year.* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10.AshtonleighPage 11 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES YES YES YES YES YES NO NA YES YES YES NO YES YES YES YES NO YES YES YES 6 0 0 NO NO YES YES 10 1 17/06/04 08.00 4.75AshtonleighPage 12 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Care homes for older people have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.AshtonleighPage 13 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to service users an up to date Statement of Purpose setting out the aims, objectives, philosophy of care, services and facilities, and terms and conditions of the home; and provides a Service Users Guide to the home for current and prospective residents. The Statement of Purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the homes service users guide. Range of fees charged From (£) 315 To (£) 550Any charges for extras If yes, please state what the extras are: Key findings/EvidenceYES TOILETRIES, PAPERS, HARIDRESSING & TRANSPORT 3 Standard met?A Statement of Purpose is available at the home, although it was noted that it needs some slight adjusting, in order to update the name of the manager. The Service Users Guide is also available and includes the points as highlighted in Standard 1.2 of the National Minimum Standards.AshtonleighPage 14 Standard 2 (2.1 ­ 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 3 Key findings/Evidence Standard met? The registered manager has recently revised the statement of Terms and Conditions. The inspector considered it to be a comprehensive and clear document, which includes all of standard 2.2 of the National Minimum Standards. Standard 3 (3.1 ­ 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 0 Key findings/Evidence Standard met? This standard was not assessed at the inspection. Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 0 Key findings/Evidence Standard met? This standard was not assessed at the inspection. Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 0 Key findings/Evidence Standard met? This standard was not assessed at the inspection. Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff, to deliver short-term intensive rehabilitation and enable service users to return home. 9 Key findings/Evidence Standard met? The home does not accept anyone for intermediate care. Therefore this standard does not apply.AshtonleighPage 15 Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The service users health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. Service users, where appropriate, are responsible for their own medication, and are protected by the homes policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect.Standard 7 (7.1 ­ 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 3 Key findings/Evidence Standard met? The registered manager does assessments prior to admission, using the Spandex preassessment form. Assessments sampled by the inspector were up-to-date and relevant to care offered. Service users plans set out care needs and ensure all aspects of the health and social care are being met. A G.P. reviews care on a weekly basis, and the registered manager continues to review each month. Files sampled confirmed that this does indeed take place.AshtonleighPage 16 Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. No. of incidents where service users have been taken to Accident and Emergency during last 12 months No. of service users with pressure sores at time of inspection (from information taken from care notes) Key findings/Evidence X 0 Standard met? 3An external Dentist and Optician visit the home every six months, unless there are specific concerns, which are then dealt with on an individual basis. A Chiropodist attends the home every three months, although one service user attends the local hospital for her chiropody, out of choice. The registered manager is a qualified RMN and therefore seen as capable of assessing pressure sores. On the day of inspection there were no incidences of pressure sores. Risk assessments are carried out for individuals, and these were available to look at during the inspection. Generally one G.P. is used, although four service users continue to see a G.P. of their own choice. Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 0 Key findings/Evidence Standard Met? This standard was not assessed at the inspection. Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that service users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with, and examination by, health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 0 Key findings/Evidence Standard met? This standard was not assessed at the inspection.AshtonleighPage 17 Standard 11 (11.1 ­ 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 0 Key findings/Evidence Standard met? This standard was not assessed at the inspection.AshtonleighPage 18 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 0 Key findings/Evidence Standard met? This standard was not assessed at the inspection. Standard 13 (13.1 ­ 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users preferences. 3 Key findings/Evidence Standard met? The inspector spoke with four service users regarding the ability to entertain visitors at the home. All said that they could see friends and relatives whenever they chose, and that these visits could take place in a private place. Standard 14 (14.1 ­ 14.5) The registered person conducts the home so as to maximise service users capacity to exercise personal autonomy and choice. 0 Key findings/Evidence Standard met? This standard was not assessed at the inspection. Standard 15 (15.1 ­ 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet, which is suited to individual, assessed and recorded requirements, and that meals are taken in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? Some negative comments had been received by the inspector via comment cards, regarding the consistency of the quality of meals. However, the inspector sampled one meal, and on the day this was thought to be wholesome, nutritious and appetising. Ashtonleigh Page 19 Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users legal rights are protected. Service users are protected from abuse.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple, clear and accessible complaints procedure which includes the stages and time-scales for the process, and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days Key findings/Evidence X X X X 0 0 100 3Standard met?There is a clear and accessible complaints procedure in place. It has recently been updated to include the name change of the Commission for Social Care Inspection. There has been one complaint since the last inspection, and this ended in a satisfactory outcome.AshtonleighPage 20 Standard 17 (17.1 ­ 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 2 Key findings/Evidence Standard met? There are no details currently available to service users regarding advocacy groups. The registered manager said that she will look into finding information about local advocacy projects and ensure it is then made available to the service users. Elections have recently been held, however despite the registered manager completing and sending the electoral register for all accommodated at the home, only ten cards and two postal votes arrived in return. The registered manager said she is going to query why this was the case. Standard 18 (18.1 ­ 18.6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self-harm, inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists Key findings/Evidence Standard met? YES 0 3Comprehensive policies and procedures are in place at the home, and the West Sussex County Council Adult Abuse Procedures were also available. No incidents of abuse have been reported at the home, and service users spoken to were complimentary of staff employed. Comment cards received spoke highly of the level of care offered by the home. The inspector spoke to staff members and was confident that they were aware of abuse issues and how to deal with them should they arise.AshtonleighPage 21 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · · Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic.Standard 19 (19.1 ­ 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 0 Key findings/Evidence Standard met? This standard was not assessed at the inspection. Standard 20. (20.1 ­ 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 9 Key findings/Evidence Standard met? This standard does not apply. Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 3 Key findings/Evidence Standard met? Six toilets are accessible by all service users within the home. Where required there is additional equipment available, such as grab rails, raised seats and so on. Sixteen bedrooms have en-suite facilities. Sluices are provided and are separate from WC and bathing facilities.AshtonleighPage 22 Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons, including a qualified occupational therapist, with specialist knowledge of the client groups catered for, and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 3 Key findings/Evidence Standard met? Although the home has not been assessed by an Occupational Therapist, the registered manager, who is a qualified RMN, assesses all new placements. If there is a mobility concern, she will employ the professional opinion of a Physiotherapist to carry out an individual assessment. The home provides ramps to both the rear and the front of the property for wheelchair access.AshtonleighPage 23 Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite Key findings/Evidence This standard was not assessed at the inspection. Standard 24 (24.1 ­ 24.8) The home provides private accommodation for each service user which is furnished and equipped to assure comfort and privacy, and meets the assessed needs of the service user. 0 Key findings/Evidence Standard met? This standard was not assessed at the inspection. NO NO YES 20 15 4 3 Standard met? 0 X XX X X XAshtonleighPage 24 Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 0 Key findings/Evidence Standard met? This standard was not assessed at the inspection. Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. 2 Key findings/Evidence Standard met? The premises were clean, bright and well maintained. There was no odour present throughout the building. Laundry facilities are sited in the basement of the property. Hand washing facilities are also provided. On discussion with several staff members, only one was aware of the correct temperature required to thoroughly clean foul laundry to reduce the risk of infection. In addition it was unclear whether the services and facilities comply with the Water Supply Regulations of 1999. The registered manager agreed to look into this matter.AshtonleighPage 25 StaffingThe intended outcomes for the following set of standards are: · · · · Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the homes recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours X X X needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff Key findings/Evidence This standard was not assessed at the inspection. X X X No. staff hours allocated No. staff hours allocated No. of staff hours provided X X X X X X1 10 4 Standard met? 0AshtonleighPage 26 Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of the care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 Key findings/Evidence 0 1 Standard met? 3All ten staff members are completing either level 2 or 3 or NVQ. The registered manager is completing level 4. The home has access to three assessors. A comprehensive TOPSS induction file has been set up for each member of staff. It is anticipated by the registered manager that it will take up to six months to work through, and work completed will count toward NVQ. The inspector was of the opinion that the home had a high level of commitment towards training for staff. Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 2 Key findings/Evidence Standard met? The inspector sampled several files, and of those, one did not have two written references obtained prior to employment. All except one staff member have CRB checks in place. The one outstanding check has been requested and this has been noted on records kept by the registered manager. The registered manager told the inspector that all staff have a copy of the GSCC code of conduct and practices. On recruitment a pack is given to individual employees, which includes information on Health & Safety, Terms & Conditions and a Job Description. Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 0 Key findings/Evidence Standard met? This standard was not assessed at the inspection.AshtonleighPage 27 Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users financial interests are safeguarded. Staff are appropriately supervised. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 3 Key findings/Evidence Standard met? Mrs Purtill, the registered manager successfully attended her Fit Persons Interview with the Commission for Social Care Inspection in May 2003. She has approximately eight years managerial experience and is up-to-date with relevant training. Mrs Purtills nursing background, and in particular her experience of EMI patients, has equipped her with the relevant skills and knowledge required to manage this home. Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? This standard was not assessed at the inspection.AshtonleighPage 28 Standard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 2 Key findings/Evidence Standard met? The inspector was of the opinion that quality assurance needs improving and updating. Currently there is little in place that could measure the views of the service users regarding the aims, objectives and Statement of Purpose of the home. A questionnaire is sent to a selection of service users every two months, however, there is no format available to feed back information collated, and where people have made comments or suggestions, there is no record of any outcomes. On discussion the registered manager agreed to look into setting up regular resident meetings, which could also serve as a useful form of quality assurance. Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure there is effective and efficient management of the business. 3 Key findings/Evidence Standard met? Accountants are employed by the organisation to ensure the company is financially viable. Insurance cover is in place, displayed by the front door of the building. Standard 35 (35.1 ­ 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders Key findings/Evidence This standard was not assessed at the inspection. Standard met? 0 X X XAshtonleighPage 29 Standard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 2 Key findings/Evidence Standard met? Supervision is in place, although not as regular as recommended in the National Minimum Standards. Staff spoken to confirmed that training and development are discussed in their supervision sessions. On discussion with the registered manager, the inspector was told that formal supervision has only recently been started and therefore the process should improve with time. Standard 37 (37.1 ­ 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 0 Key findings/Evidence Standard met? This standard was not assessed at the inspection. Standard 38 (38.1 ­ 38.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 0 Key findings/Evidence Standard met? This standard was not assessed at the inspection.AshtonleighPage 30 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DateMrs Marie McCourtSignature Signature SignatureAshtonleighPage 31 Public reports It should be noted that all CSCI inspection reports are public documents.AshtonleighPage 32 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 17th June 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleAshtonleighPage 33 Action taken by the CSCI in response to provider comments: Amendments to the report were necessaryComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurate Note: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by N/A , which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required NOAction plan was received at the point of publicationAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planOther: enter details here AshtonleighPage 34 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I Mr Gopal of Ashtonleigh confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date signed Or D.3.2 I Mr Gopal of Ashtonleigh am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons: Director 24/06/2004 C. CopalPrint Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.AshtonleighPage 35 - 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. 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