CARE HOME ADULTS 18-65
Ashview 330 Main Road Duston Northampton Northants NN5 6NJ Lead Inspector
Stephanie Vaughan Unannounced Inspection 6th February 2006 08:30 Ashview DS0000063513.V281439.R01.S.doc Version 5.1 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 Ashview DS0000063513.V281439.R01.S.doc Version 5.1 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. Ashview DS0000063513.V281439.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Ashview Address 330 Main Road Duston Northampton Northants NN5 6NJ 01604 591179 01604 591179 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) Compass Care Limited Miss Ntokozo Hlongwa Care Home 3 Category(ies) of Learning disability (3), Mental disorder, registration, with number excluding learning disability or dementia (3) of places Ashview DS0000063513.V281439.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. No person falling within the category of MD, Mental Disorder excluding Learning Disability or Dementia, may be admitted into the home unless that person also falls within the category LD, Learning Disability ie Dual Disability. 11th July 2005 Date of last inspection Brief Description of the Service: Ashview is a residential home providing care to three young adults with learning disability and diagnosed mental health needs. The size of the premises contributes to the friendly informal atmosphere within the home. The home is located in a busy residential area of Northampton close to all main facilities and amenities. Ashview DS0000063513.V281439.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This second unannounced inspection was conducted over a period of three hours during which the inspector made observations and spoke to two residents. A limited tour of the premises was conducted which involved viewing the communal areas and a selection of the private accommodation. Case tracking is the method used during inspection where one resident was selected and all aspects of their care and experiences reviewed, including individual plans of care and associated documentation. Prior to the inspection a period of 30 minutes was spent in preparation, which included a review of previous inspection reports, previous requirements, the service history and comment cards received from residents and their representatives. Three comment cards were received from residents and these indicated a general level of satisfaction with the services provided at Ashview. Two comment cards were received from a resident’s representatives, which indicated varied levels of satisfaction with the service provided. Specific issues that were identified on the comment cards are addressed within the main body of the report. One requirement and one recommendation were made following the previous inspection and both of these have been met. What the service does well:
Residents confirmed general satisfaction with the services and facilities at Ashview and appeared well presented. Staff were seen to relate well to residents during the course of their duties. The Registered Manager is mindful of the need to ensure that the home is able to meet the needs and expectations of new residents and of the need to ensure that the new resident is able to integrate well with existing residents A sample of individual plans of care evidenced that personal support and health care needs are addressed appropriately.
Ashview DS0000063513.V281439.R01.S.doc Version 5.1 Page 6 Care plans evidenced the involvement of the individual resident in the care planning process and monthly review. Any restrictions placed on residents were seen to be in their best interests and supported by an appropriate risk assessment. Residents spoken to confirmed that they were involved in the decision making process within the home through regular meetings with staff and menu planning Residents confirmed satisfaction with the arrangements to support their individual lifestyles, access to the local community and the ability to develop friendships with other people outside the home and maintain links with their families Individual plans of care evidence that resident’s personal needs are being met and demonstrate respect for individual privacy and dignity. Residents’ healthcare needs are met and residents spoken to confirmed access to a range of specialist nurses and health care professionals. Staff and management respond appropriately to ensure the Protection Of Vulnerable Adults What has improved since the last inspection? What they could do better:
Food records should be further developed to ensure that an accurate record is maintained of what the resident has actually eaten, if this has deviated from the planned menu or has been brought in as a takeaway meal.
Ashview DS0000063513.V281439.R01.S.doc Version 5.1 Page 7 At present the Complaints Policy is located within a file in the managers office and within individual plans of care. Therefore the complaints policy is not easily accessible to residents or their representatives. One of the resident’s chest of drawers was damaged in that it had no handles to enable the drawers to be easily opened. Further enquiry indicated that the resident had broken the handles, however these had not been replaced The Registered Manager confirmed that shortages of staff could occur when staff are off sick, on training or on leave. Common practice is to acquire support staff from one of the other homes within the group or to provide agency cover. One of the comment cards received from a resident’s representative indicated that inspection reports were not accessible. These are currently filed within the office and therefore not accessible to residents or their representatives. Two issues relating to the safety of residents were identified and immediate requirements were issued at the time of inspection. The certificate frames, located within the hall were noted to have standard glass within the frames. One of these had been broken and sharp, loose glass remained within the frame. In addition the communal shower temperature was erratic with temperatures varying between very cold and very hot. 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. Ashview DS0000063513.V281439.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ashview DS0000063513.V281439.R01.S.doc Version 5.1 Page 9 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Prospective residents are assessed prior to admission to ensure that the home is able to meet their individual needs and expectations EVIDENCE: The home has had no new admissions since the last inspection. However at present there is one vacancy. The Registered Manager confirmed that arrangements were being made to place another resident in the home. However she is mindful of the need to ensure that the home is able to meet the needs and expectations of new residents and of the need to ensure that the new resident is able to integrate well with existing residents. Ashview DS0000063513.V281439.R01.S.doc Version 5.1 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 the following standard(s): 6&7 Residents are supported in their individual needs and choices. EVIDENCE: A sample of individual plans of care evidenced that personal support and health care needs are addressed appropriately. Residents have access to a range of appropriate health care specialists Care plans evidenced the involvement of the individual resident in the care planning process and monthly review. Any restrictions placed on residents was seen to be in their best interests and supported by an appropriate risk assessment. Residents spoken to confirmed that they were involved in the decision making process within the home through regular meetings with staff and menu planning. Ashview DS0000063513.V281439.R01.S.doc Version 5.1 Page 11 One resident confirmed that the management were currently seeking appropriate advocacy support and this was evidenced within the individual plan of care. Ashview DS0000063513.V281439.R01.S.doc Version 5.1 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 the following standard(s): 12, 13, 15, 16 & 17 Residents are supported to enjoy fulfilling lifestyles EVIDENCE: Residents confirmed satisfaction with the arrangements to support their individual lifestyles. Residents have an individual timetable of activities which include educational opportunities e.g. writing skills, photography and computer skills held at the local college and access to the local community for activities such as the cinema, local pubs and gym membership. Residents spoken to confirmed that they had developed friendships with other people outside the home and were supported to maintain links with their families. Following a recommendation made as a result of the last inspection risk assessments are now in place to reduce and manage the risks of bullying between residents. In addition residents confirmed that routines were flexible within the constraints of their planned activities.
Ashview DS0000063513.V281439.R01.S.doc Version 5.1 Page 13 Comment cards received from some residents indicated a limited satisfaction with the food at the home. On discussion with the residents during the inspection they were able to confirm that they had addressed these issues with management at the weekly meetings and that they were now satisfied with the food provided. Kitchen records are well maintained and the menus are specific to the preferences of individual residents whilst to continuing to offer a balanced diet. Residents confirmed that they could have an alternative to the menu if they wished and that they often had a take away at the weekend. However deviations from the menu and specific take away food are not currently recorded Ashview DS0000063513.V281439.R01.S.doc Version 5.1 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 the following standard(s): 18,19 & 20 Resident are supported to maintain their personal and health care EVIDENCE: Individual plans of care evidence that resident’s personal needs are being met and include respect for privacy and dignity. Residents appeared to be appropriately dressed and well presented. Management are mindful of the need to ensure that staffing is representative of the residents’ own race, gender and culture. Individual plans of care evidenced that residents’ healthcare needs are met and residents spoken to confirmed access to a range of specialist health care and specialist nurses. Medication was not reviewed on this occasion, however one incident was noted where a medication error had occurred and the appropriate action had been taken to ensure the safety of the resident involved. Staff responsible had been prohibited from administering medication until further training had been provided, which has since been conducted. Ashview DS0000063513.V281439.R01.S.doc Version 5.1 Page 15 Ashview DS0000063513.V281439.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Access to the complaints policy is limited, however residents are protected from abuse. EVIDENCE: The Commission for Social Care Inspection have received no recent complaints about Ashview. The home has a corporate complaints policy, which complies with the National Minimum Standards, however one comment card indicated that a residents representative was unaware of this policy. At present the policy is located within a file in the managers office and within individual plans of care. Therefore the complaints policy is not easily accessible to residents or their representatives. In addition one negative response card has been received relating to the management and care of a resident that has since moved to another home. The Commission for Social Care Inspection has sought further information regarding this and is awaiting responses in order to assess if any further action needs to be taken. Since the last inspection staff have received training in the Protection Of Vulnerable Adults and this is generally managed well. One recent allegation has been investigated and referred to care management, who have agreed that no further action is to be taken. The Commission for Social Care Inspection is awaiting a copy of the investigation report. The Commission for Social Care Inspection have been notified about a further incident, which has implications for the Protection Of Vulnerable Adults and is awaiting the outcome of an appropriate referral.
Ashview DS0000063513.V281439.R01.S.doc Version 5.1 Page 17 Ashview DS0000063513.V281439.R01.S.doc Version 5.1 Page 18 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26 & 30 The premises are suitable for the stated purpose, providing a comfortable environment suitable to the needs of residents EVIDENCE: Following an immediate requirement made at the last inspection the garden shed had been replaced to address the safety issues identified. The premises are subject to heavy wear and tear, however the hall and some of the bedrooms have been redecorated since the last inspection. In addition the glazed kitchen door has been replaced with a wooden door, following an incident involving a resident. Further improvements are planned for the near future, subject to planning permission. These include the provision of a conservatory to increase the communal space and improve the dining facilities, the addition of ensuite facilities to a resident’s room and improvements to the laundry. Other improvements include the provision of a protective case to protect a resident’s replacement television from damage and the resident from the associated risks. Ashview DS0000063513.V281439.R01.S.doc Version 5.1 Page 19 Individual rooms evidenced some personalisation, however this is limited due to the behaviours of some of the residents and is supported by risk assessment. One of the resident’s chest of drawers was damaged in that it had no handles to enable the drawers to be easily opened. Further enquiry indicated that the resident had broken the handles, however these had not been replaced. Residents are currently waiting for a replacement television for the lounge, following recent damage Ashview DS0000063513.V281439.R01.S.doc Version 5.1 Page 20 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33 Staffing levels are adjusted and maintained to meet the needs of residents. EVIDENCE: Both of the comment cards received from residents’ representatives indicated that they thought that there were not always sufficient staff on duty. However on the day of inspection there were two staff members, in addition to the Registered Manager to cater for two residents. Residents were able to continue with their planned activities and receive an appropriate level of support as specified within the individual plans of care. The Registered Manager confirmed that the home was currently operating with two care staff on duty during the day, with one waking staff at night. However shortages of staff can occur when staff are off sick or on leave. Common practice is to acquire support staff from one of the other homes within the group or to provide agency cover. Ashview DS0000063513.V281439.R01.S.doc Version 5.1 Page 21 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Resident’s benefit from the stability of having a Registered Manager however resident’s safety is not always safeguarded. EVIDENCE: Following the last inspection the Manager has been successful in her application to become Registered with the Commission for Social Care Inspection. One of the comment cards received from a resident’s representative indicated that inspection reports were not accessible. These are currently filed within the office and therefore not accessible to residents or their representatives. Two issues relating to the safety of residents were identified and immediate requirements were issued at the time of inspection. The certificate frames, located within the hall were noted to have standard glass within the frames. One of these had been broken and sharp, loose glass remained within the frame.
Ashview DS0000063513.V281439.R01.S.doc Version 5.1 Page 22 In addition the communal shower temperature was erratic with temperatures varying between very cold and very hot. Ashview DS0000063513.V281439.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME 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 3 ENVIRONMENT Standard No Score 24 3 25 X 26 2 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 3 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 X X 3 X 3 X X 2 X Ashview DS0000063513.V281439.R01.S.doc Version 5.1 Page 24 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 YA33 Regulation 18 (1) Requirement Staffing levels must be reviewed to ensure that staff absences are covered by suitably competent staff who have knowledge of the needs of the individual residents The glass within the picture frames must be made safe, by 14.00hrs. Immediate Requirement. The communal shower must be serviced to ensure that water temperatures are regulated and dispensed at safe temperatures. Immediate Requirement. Timescale for action 01/04/06 2 YA42 13 (4) 06/02/06 3 YA42 13 (4) 08/02/06 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
Ashview Refer to Standard YA17 YA22 Good Practice Recommendations Food records should be further developed to record what the resident has actually eaten Arrangements should be made to ensure that residents
DS0000063513.V281439.R01.S.doc Version 5.1 Page 25 3 4 YA26 YA39 and their representatives have greater access to the complaints policy Furnishings and fittings should be repaired without delay Arrangements should be made to ensure that residents and their representatives have greater access to the Commission for Social Care Inspection reports Ashview DS0000063513.V281439.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Northamptonshire Area Office 1st Floor Newland House Campbell Square Northampton NN1 3EB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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