Inspection on 26/06/07 for Ashville House

This inspection was carried out on 26th June 2007.

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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ashville House 27/11/07

Ashville House 28/12/06

Ashville House 04/07/06

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOME ADULTS 18-65 Ashville House 117 Ashville Road Leytonstone London E11 4DS Lead Inspector Ms Harina Morzeria Unannounced Inspection 26th June 2007 10:00 Ashville House DS0000064958.V340075.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ashville House DS0000064958.V340075.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ashville House DS0000064958.V340075.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashville House Address 117 Ashville Road Leytonstone London E11 4DS 020 8281 2236 F/P 020 8281 2236 patiencemabena@aol.com Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) April Rai Ltd Ms Shelley Okwuosa Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places Ashville House DS0000064958.V340075.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 28th December 2006 Brief Description of the Service: Ashville house is a privately run care home registered for three adults, providing long-term placements to people with mental health problems. The home provides services to both men and women. At the time of the inspection three service users were living at the home, one male, two female. It is a two-storey terraced house, which contains a lounge cum small dining area plus kitchen and a small staff office. There is a small garden to the rear. All bedrooms are single, two of which are situated on the first floor with the other on the ground floor. There are two toilets and one bathroom, all situated on the first floor. The building is therefore not suitable for someone who has mobility difficulties. The home is staffed on a 24-hour basis in order to provide care and support to the service users. Physical health needs are met by the local GP and other specialist professionals when needed. Service users attend day centres, clubs and community facilities, and are also involved in domestic chores within the home as much as possible. The registered person provides a Statement of Purpose that sets out the objectives and philosophy of the service. A Service Users Guide is also available which includes a summary of the Statement of Purpose and provides information about the home. All residents are given a copy of the guide. The fees charged range from £730 to £900 per week. Ashville House DS0000064958.V340075.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection visit was unannounced. The support worker on shift assisted the inspector initially and was later joined by the manager. During the visit the inspector spoke to two service users who were both in. One other service user was attending the day centre. A tour of the home took place and staff and care records were inspected, as well as individual service user files. Representatives of service users were contacted by phone to comment on the service provided at Ashville House. The inspector discussed the outstanding requirements with the manager during this inspection. Although some requirements have been met, new timescales were set for compliance for repeated requirements. The manager is aware that failure to meet requirements impacts upon the well-being of the service users and that enforcement action may be taken by the Commission for Social Care Inspection to secure compliance. What the service does well: What has improved since the last inspection? What they could do better: Ashville House DS0000064958.V340075.R01.S.doc Version 5.2 Page 6 The manager and staff generally provide a service which meets the service users’ needs but they must ensure that the service user plans detail all the needs of service users, including their changing mental health needs. Risk assessments must be reflective of key risks and include risk management strategies. It is also important to link the risk assessments to the service user plans. The recording systems must be improved including care plans, daily logs and reviews of care plans and show how care plans are being achieved. Service users must be provided with culturally varied and balanced meals. All staff must attend mental health awareness training in order to equip them to understand and meet the needs of the particular group of people they are caring for and the staff must have the skills and competencies to provide appropriate care, which meets service users’ needs. The homes premises must be suitable for its stated purpose, accessible, safe and well maintained to meet service users’ individual and collective needs. The manager must demonstrate a clear sense of direction and leadership which staff and service users understand and can relate to the aims and purpose of the home. The registered persons to ensure that a lone working risk assessment is undertaken in order to protect staff and service users when staff are working alone. Efficient systems must be in place to ensure there is routine monitoring of the service by a responsible individual carrying out monthly Regulation 26 visits and providing a quality assurance and monitoring process to ensure efficient running of the home. Staffing levels must be kept under review, so that there are sufficient staff on duty at all times to ensure the protection of service users and staff. The manager and staff need to consider how they can achieve the highest standard of care as set out in the Commission’s Key Lines of Regulatory Assessment (KLORA). Ashville House DS0000064958.V340075.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ashville House DS0000064958.V340075.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ashville House DS0000064958.V340075.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A Statement of Purpose and a Service Users’ Guide are available and include the information service users need to make an informed choice about where to live. Prospective service users’ needs are assessed in conjunction with the multidisciplinary team. Prospective service users know they and their relatives can spend time in the home to find out what it would be like to live there. Residents have a written contract with the home. EVIDENCE: The above standards were checked at the previous inspection and were again discussed during this visit. The inspector is satisfied that sufficient information is available for prospective service users and their representatives to make informed choices about where to live. There have been no new admissions to the home since the last inspection. Evidence was seen at the previous inspection that information was gathered from referring agencies prior to the most recent service user being admitted to the home. Ashville House DS0000064958.V340075.R01.S.doc Version 5.2 Page 10 Initial enquirers are sent a copy of the Statement of Purpose and Service Users’ Guide and a standardised referral form is completed. Prospective service users are then invited to visit the service if it is suitable for them to visit. The consultant psychiatrist reviews their care on a regular basis. These professionals are involved when prospective service users are being considered for admission to the home. All the service users have contracts, which are signed by the manager, the placing authority, and the service user. Ashville House DS0000064958.V340075.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Each service user has a care plan. However, these must be detailed and tailored to meet individual needs. Service users are consulted and involved in decisions affecting their lives and are reassured that information held on them is handled in line with the home’s policy on confidentiality. Service users are involved in negotiating their daily routines and objectives and are encouraged to live life to their full potential subject to a risk assessment. However, risk assessments must be reflective of key risks and include risk management strategies. It is also important to link the risk assessments to the service user plans. EVIDENCE: The service users had a care plan, which shows what they can do and what they like. For one service user this included details of specific conditions affecting the service user and how staff should deal with the service user when they display this behaviour. Ashville House DS0000064958.V340075.R01.S.doc Version 5.2 Page 12 Evidence was seen on file of one-to-one key worker sessions being held with the service users with good records kept of the discussions. However the care plans did not include details of each persons mental health condition or identify any goals or specify any ways of working with the service users should they display a breakdown in their mental health condition. There wasn’t a behaviour management plan outlining particular behaviours relating to individual service users and the action to be taken by staff in the event of this behaviour being displayed. There were no clear guidelines on managing challenging, aggressive or sexualised behaviour. This was discussed with the manager and a requirement has been made. The manager and key worker review service user plans monthly. The service users spoken to on the day of the inspection expressed the view that they are given good support from the staff in making decisions about their lives. The service users are involved and consulted on various aspects of life in the home. Evidence was seen of service user meetings held with minutes recorded. At this forum service users bring suggestions and contribute to life in the home e.g. activities, furnishings, menus and health and safety. Service users also express their views informally and in key-worker sessions. General risk assessments are carried out in discussion with service users and relevant specialists. These are recorded in the individual plan. These identify risks for the service users and indicate ways in which the risks can be reduced. There was a specific risk assessment for one service user however this was not evident on other files. Hence the risk assessments need to be extended further to cover all areas of risk. For example, breakdown in their mental health condition, smoking, aggressive and sexualised behaviour as well as other behaviours as identified from the person’s background. This would ensure that staff are fully aware of the risks posed by individuals living in the home and what action will be required to minimise identified risks and hazards, enabling all service users to lead independent and safe lives. There is a policy in place in the event of a person going missing from the home and staff spoken to were aware of it. Residents’ records and other information are stored in a lockable cabinet in the office and staff are aware of issues of confidentiality. However the manager is required to draw up an Access to Files policy. It remains unclear whether verbal requests could be made, which is in contradiction to the Data Protection guidelines which establish that written requests are required when requesting access to files. Ashville House DS0000064958.V340075.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16, 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Opportunities for social and leisure pursuits and personal development are actively promoted and supported by staff for all service users to enable them to participate in the wider community in which they live. Service users are provided with varied and nutritional meals, staff promote healthy eating, however more effort needs to be made to provide diverse meals to cater for individual needs. Visitors are made to feel welcome in the home and service users are supported to maintain and establish family links and friendships. EVIDENCE: Two service users were spoken to and confirmed that they are asked about what they want to do on a daily basis and are involved in making decisions about daily activities. All the service users are independent and come and go as they please. The routines for daily living are flexible and the service users Ashville House DS0000064958.V340075.R01.S.doc Version 5.2 Page 14 are able to make choices in major areas of their life. The routines, activities and plans are individually focused and can be quickly changed to meet their needs. The service users said that they are able to lead very independent lifestyles. The most recent service user has gained a lot of confidence, better self esteem and is being supported by staff to apply for and attend college to acquire a qualification in fashion and design. In addition, staff and service users told the inspector that occasional day trips around London had been organised by the home. The service users also enjoyed a weeks break in Jersey just prior to the inspection. These trips are planned with the service users and clearly enjoyed by them. The manager and staff actively promote the rights of the service users to make informed choices, providing links to specialist support when needed. Family and friends are welcomed and their involvement in daily routines and activities is encouraged with the service users’ agreement. Often the service users take the opportunity to go out individually with their families. One service user’s family are actively involved in the service user’s life and visit the home on a regular basis, with the service user also spending time at the family home frequently. The inspector had an opportunity to speak to the relative on the day of the inspection. They were positive about the care provided in the home. The recording systems generally in the home must be improved to evidence how the service users’ care needs are being met and their day to day to functioning in terms of their mental needs to be better reflected. The service users confirmed that they are offered a healthy diet and generally enjoy their meals which they choose daily. They assist staff with meal preparation. However, one service user spoken to and the relative stated that they were unhappy about the lack of culturally varied food. The inspector has advised them to discuss this issue with the manager and be actively involved in planning the menu and selection of meals. A requirement has been made that service users are offered a choice of suitable meals, which meet their dietary and cultural needs and which respect their individual preferences. Ashville House DS0000064958.V340075.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Service users are prompted and encouraged to take responsibility for their own personal care. Their physical and emotional health needs are met. A medication procedure is in place which is followed by staff and offers protection to service users. EVIDENCE: By viewing the care records and in discussion with the support worker and manager, the inspector noted that staff do not carry out any personal care tasks for the service users, although they require prompting and close supervision from the staff. The service users confirmed that they are able to lead an independent lifestyle and are able to wash and dress by themselves. The service users’ health needs are identified in the assessment documents, and their health is well monitored. Any problems identified are dealt with quickly by taking the person to the GP in the first instance and follow-up action Ashville House DS0000064958.V340075.R01.S.doc Version 5.2 Page 16 taken promptly if required, for example, via consulting the specialist mental health team. Staff support the service users to attend any health appointments. Evidence was seen on individual files that all medical appointments attended by service users are logged. A record is maintained of current medication for each service user and medication is supplied in dosset packs. The medication administration records were checked which are accurately maintained by the staff working in the home. Two staff have completed medication administration training with one staff booked on a course in July. The inspector recommends that the manager develops clear guidance for the staff, outlining the signs and symptoms to recognise and what follow up action will need to be taken when a service user’s mental health starts deteriorating. Emergency numbers should be readily accessible to staff if assistance is required to deal with an individuals mental health breakdown. Ashville House DS0000064958.V340075.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager and staff make every effort to sort out any problems or concerns and make sure that the service users feel confident that their complaints and concerns are listened to and will be acted upon. The staff have completed training in Adult Protection/ Abuse Awareness in order to ensure that there is a proper response to any suspicion or allegation of abuse but this is not supported by a robust adult protection policy and procedure. EVIDENCE: The home has policies and procedures for dealing with complaints and the records examined showed that one complaint was received which was recorded with details of investigation, any action taken and the outcome for the complainant. One resident spoken to about what they would do if they were unhappy with anything in the home said that they would speak to the manager or their key worker. The complaints policy is displayed in the corridor, with information about how to contact the Commission, if the complainant remains dissatisfied with the outcome of any investigation. There is a written policy and procedure for dealing with allegations of abuse and whistle blowing. However this does not accurately reflect the procedures to be followed if an allegation is made. The policy also must reflect Local Authority Adult Protection procedures. The manager and must obtain a copy of Ashville House DS0000064958.V340075.R01.S.doc Version 5.2 Page 18 the adult protection procedures from the host authorities who place service users in the home and link their policies to others. Staff, as part of their induction are taken through the adult protection guidelines of the home and have now received detailed training in Adult Protection/ Abuse Awareness. The member of staff spoken to was aware of the action to be taken if there were concerns about the welfare and safety of service users. Ashville House DS0000064958.V340075.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29,30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The service users live in a comfortable environment which allows them to have a family type lifestyle however more needs to be done to improve the environment. Sufficient shared spaces are available but cramped. The home is clean but more needs to be done to keep the premises hygienic. EVIDENCE: The house is in keeping with the other properties on the street and a tour of the premises showed that it is adequately decorated and furnished in a homely manner. It is an ordinary, two bed roomed family house with a downstairs front room which has been converted into a third bedroom hence all three service users occupy single rooms. None of the rooms have en-suite facilities. There is a small kitchen, living and dining area downstairs. Ashville House DS0000064958.V340075.R01.S.doc Version 5.2 Page 20 The garden can be accessed from the living room as well as the staff office. It was bare with a large, uneven concreted area which is unsuitable for use. A plastic chair was placed in the garden for use by a service who smokes. It was raining on the day of the inspection and discussion took place about how the home is going to comply with the no smoking regulation which will be enforceable in care homes as well. The kitchen has been refitted since the last inspection. The fixtures, fittings and furniture are all domestic in nature, and in keeping with this type of home. There is a programme to improve the decoration in the home and some work has been done with the redecoration of the living room, painting and the kitchen. However, the whole house is in need of re-decoration particularly the bathroom and toilets which are bare and institutional in design. The service users said that they liked their rooms and felt comfortable and safe in the home. However, upon viewing one service user’s room the inspector noted that the cabinet in his room was broken meaning he could not store his clothing adequately. The manager must carry out a full review of all the fittings and furniture in the house as well as service users’ bedrooms and ensure that they have adequate facilities and storage space for personal items. The home is adequately furnished and decorated downstairs. The living room is cramped as it has a small dining table situated here as well as settees which limit the space available. None of the service users need any specialist equipment. They are able to maintain a significant level of independence and the home remains suitable for meeting the needs of the service users currently residing in the home. The home is generally clean but requires a deep and thorough clean. Ashville House DS0000064958.V340075.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32, 33, 34, 35,36 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. There is a recruitment policy and procedure in place which is followed when recruiting staff but all staff must have job descriptions which clearly outline their roles and responsibilities. Appropriate staff training in relation to mental health issues must be provided so that service users know that the staff are suitably trained and understand how to meet their needs. Evidence must be provided that staff receive regular supervision. The staffing levels are not sufficient to ensure that service users are safeguarded at all times. EVIDENCE: At the time of inspection a support worker was present and assisted with the inspection process. The manager arrived later and so the inspector was able to verify the homes recruitment process. The inspector examined the procedure for recruiting staff. Staff files showed that they have been recruited according to the recruitment procedure and have been vetted before being employed. Ashville House DS0000064958.V340075.R01.S.doc Version 5.2 Page 22 However all staff must have accurate job descriptions so that they are clear regarding their role and what is expected of them. Evidence was seen that the staff have attended various training courses which included first aid, food hygiene, moving and handling, adult protection and medication administration training. Two members of staff have completed their NVQ level 2 qualification and are now enrolled on NVQ level 3 courses. One member of staff is currently doing NVQ level 2 training. This is good practice. It was noted that staff were not provided with training that was specific to the needs of the service user group e.g. managing challenging behaviour and mental health awareness. This is of significant concern to the Commission, as the service is registered to provide care only to this client group. However experienced or qualified staff may be in social care they must have an understanding of mental health issues in relation to the diagnosis and the needs of the service users accommodated in the home. This training must be arranged by the manager urgently. The service users spoken to stated that the staff are kind and caring towards them and know what they need. A requirement was set at the previous inspection that staff must receive structured supervision at least a six times per year. The staff member spoken to said they do get supervision and the inspector was informed by the manager that staff members do receive supervision. Some sessions were recorded but there needs to be evidence that regular supervision is provided to staff which is accurately reflected on their files. The manager is aware that formal supervision is important as it allows the staff time and space to reflect on their practice with their manager. Recording of the supervision is important, as it provides a retrospective picture of development and change. The manager is required to attend a supervisory training course in order to deliver effective supervision to the staff. Evidence was seen that staff appraisals have taken place. Upon discussion with the manager about staffing levels, the inspector was informed that only one member of staff plus the manager (who is only present sometimes) work from 8 a.m. to 2 p.m. and then one other member of staff does the afternoon shift continuing through to do the night shift(sleeping in) and the next morning shift. Hence only two full time care support staff and one part-time member of staff who covers weekend and annual leave are employed. The reason given for this was that the service users are very independent and are able to carry out most of their tasks by themselves but require prompting, hence only one staff is present with one other person on call at all times. Ashville House DS0000064958.V340075.R01.S.doc Version 5.2 Page 23 The inspector noted that the manager is not present in the home on a daily basis. This means that there isnt a responsible person in charge of the dayto-day management and running of the home which is left largely to the staff. This is not acceptable practice and the registered manager must be present in the home on a daily basis to provide support and supervision and by occasional hands on care, leading by example. The staffing levels must be kept under review and adjusted according to the service users changing needs. The registered person is required to undertaken a risk assessment to identify and minimise the risks to service users and the staff when a member of staff works alone. Ashville House DS0000064958.V340075.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40, 41, 42, 43 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The manager of the home is not qualified, and has basic management skills to run the home. The residents’ rights and best interests are safeguarded by the home’s recordkeeping policies and procedures. Service users’ and staff health, safety and welfare are promoted and protected, however more needs to be done. EVIDENCE: The manager of the home has not yet completed her NVQ level 4 qualification and hopes to achieve this by December 2007 . However, she has a mental health background and basic management skills to run the home. She didnt have previous management experience but is generally competent and knowledgeable to care for the people who use the service. The service is Ashville House DS0000064958.V340075.R01.S.doc Version 5.2 Page 25 planned to be user focused, to take account of equality and diversity issues, and generally works in partnership with families of people who use the service and professionals. The manager is improving and developing systems that monitor practice and compliance with the plans, policies and procedures of the home. More work is needed in this area. She is aware that the home must be run in line with its stated purpose. Through interviewing the manager, the inspector was satisfied that the home is managed in an open and positive way. The manager is aware of the need to promote safeguarding and has developed a health and safety policy that generally meets the health and safety requirements and legislation. As stated elsewhere in this report more work needs to be done to develop an adult protection policy and procedure which staff must be aware of and implement. The requirement relating to this has been made under the relevant section of this report. Certificates were in place to indicate that checks were carried out in line with the current Regulations. Fire safety regulations are being followed. On the day of the inspection all fire doors were kept closed. Records are generally up-to-date although some gaps were found in recording and entries are not always clear. There was no evidence that monthly unannounced (Regulation 26) visits are being carried out by the responsible individual, which was a requirement made at the last inspection. This means that there is a lack of monitoring about the running of the home from the responsible individual. As stated at the previous inspection the home’s monitoring visits must be robust and effective in reviewing the homes performance and offering solutions where problems and issues are highlighted. The whole must ensure that a competent person care is out these visits. Service users and staff were asked their views about the running of the home. They made positive comments about the way the home is managed. Since the last inspection some essential work on policies and procedures, working practices, and Health & Safety checks have been completed. The Registered Manager must ensure that staff are aware of all the policies and procedures and implement them in their daily practise. Care homes have to have a quality assurance system in place, which includes seeking the views of service users, their families and other stakeholders. The inspector was informed that service users’ views have been sought and more is required to be done as stated. This system should result in the production of a Ashville House DS0000064958.V340075.R01.S.doc Version 5.2 Page 26 yearly report, which is then used as a basis for service improvement. This is a joint responsibility between the owner and the Registered Manager. The responsible individual must ensure that a quality assurance system is implemented with in the stated timescales and a report made available to the CSCI. Ashville House DS0000064958.V340075.R01.S.doc Version 5.2 Page 27 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 3 2 3 3 3 4 3 5 3 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 2 25 2 26 3 27 2 28 3 29 3 30 2 STAFFING Standard No Score 31 2 32 2 33 3 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 2 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 3 2 3 3 2 2 Ashville House DS0000064958.V340075.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 14/15 Requirement An individual care plan must be drawn up in consultation with each service user detailing how the service user’s needs in respect of his/her mental health and welfare are to be met. The care plans must be reviewed and updated as required in line with the National Minimum Standards for Care Homes for Younger Adults (previous timescale of 31/03/06 not met) The registered manager must ensure that all service users’ file evidence fully completed risk assessments which are linked to the individual care plans. (previous timescale of 31/03/06 not met) The registered manager must develop an Access to Files policy that outlines the procedure for information/files to be reviewed by service users and/or their advocates. (previous timescale of 31/03/06 not met) The service users must be offered a choice of suitable meals, which meet their dietary and cultural needs and which respect their individual DS0000064958.V340075.R01.S.doc Timescale for action 30/09/07 2. YA9 14 30/09/07 3. YA10 12 30/09/07 4 YA17 16 30/09/07 Ashville House Version 5.2 Page 29 preferences. 5. YA24 YA25 23 The registered manager must carry out a full review of all the bedrooms, the fittings and furniture and ensure that these are suitable for the stated purpose, safe and well maintained and meet service users’ individual and collective needs. Sufficient and suitably refurbished toilets and bathrooms must be available to meet service users needs. The premises must be kept clean, and hygienic throughout in accordance with relevant legislation. The registered manager must ensure that the staff have clearly defined a job descriptions and understand their own and others roles and responsibilities. All staff must attend mental health awareness training in order to equip them to understand and meet the needs of the people they are caring for. Staff must have the skills and competencies to care for the particular group of people they look after. All staff must receive regular, recorded supervision with their manager in addition to regular contact on day-to-day practice. Efficient systems must be in place to ensure there is routine monitoring of the service by the proprietor, carrying out monthly Regulation 26 visits and providing a quality assurance and monitoring process to ensure efficient running of the home. (previous timescale of 31/03/06 not met) DS0000064958.V340075.R01.S.doc 30/09/07 6 YA27 16 30/09/07 7 YA30 12/13 30/09/07 8 YA31 18 30/09/07 9 YA32 YA35 18 30/09/07 10 YA36 18 30/09/07 11 YA39 24/26 30/09/07 Ashville House Version 5.2 Page 30 12 YA42 18(a) 13 YA43 10 The registered person to ensure that a lone working risk assessment is undertaken in order to protect staff and service users when The manager must demonstrate through her working pattern that she is in day-to-day control of the service in order to bring about improvements in the service. 30/09/07 30/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA19 Good Practice Recommendations The inspector recommends that the manager develops clear guidance for the staff, outlining the signs and symptoms to recognise and what follow up action will need to be taken when a service user’s mental health starts deteriorating. Emergency numbers should be readily accessible to staff if assistance is required to deal with an individuals mental health breakdown. Ashville House DS0000064958.V340075.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ashville House DS0000064958.V340075.R01.S.doc Version 5.2 Page 32 - 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!