Inspection on 27/11/07 for Ashville House

This inspection was carried out on 27th November 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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ashville House 26/06/07

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 27th November 2007 10:00 Ashville House DS0000064958.V355310.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.V355310.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.V355310.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 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.V355310.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 26th June 2007 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 service users are given a copy of the guide. The fees charged range from £730 to £900 per week. Ashville House DS0000064958.V355310.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit was the second key inspection of this home, following a first inspection in June 2007. The manager was present throughout the inspection. Two service users were briefly spoken to. All areas of the house were seen. Staff, care and other records were checked. Care staff were observed carrying out their duties. Feedback surveys were sent to the service users, relatives and staff and responses were received from the staff and two service users. A meeting took place on the 7th of August 2007 to discuss the Commissions concerns about the service and a management review was held on the 20th September 2007 to consider enforcement action. The inspector is pleased to report that the manager and staff have worked hard to meet all the requirements stated at the last inspection, resulting in an improved environment and outcomes for the service users. What the service does well: What has improved since the last inspection? All service users’ files evidence fully completed risk assessments which are linked to the individual care plans. An access to files policy is available which outlines the procedure for access to information/files to be viewed by service users and/or their advocates. A full review of all the bedrooms, the fittings and furniture has been carried out and these are now suitable for the stated purpose and for maintaining the safety and well being of the service users’ individual and collective needs. Individualised care plans have been 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 are reviewed and updated as required in line with the National Minimum Standards for Care Homes for Younger Adults. Sufficient and suitably refurbished toilets and bathrooms are available to meet service users’ needs. The premises are kept clean and hygienic throughout in accordance with relevant legislation. Ashville House DS0000064958.V355310.R01.S.doc Version 5.2 Page 6 The staff now have clearly defined job descriptions and understand their own and others roles and responsibilities. All staff have attended mental health awareness training in order to equip them to understand and meet the needs of the people they are caring for. All staff receive regular, recorded supervision with their manager in addition to regular contact on day-to-day practice. A lone working risk assessment is undertaken in order to protect staff and service users when working alone. The manager has begun to 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. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ashville House DS0000064958.V355310.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ashville House DS0000064958.V355310.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2, 3, 4, 5. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Information is obtained to enable the staff team to decide whether or not the home can meet the prospective service user’s needs. The required information would be gathered on a prospective service user and they and their relatives could spend time in the home to find out what it would be like to live there. Information is available to enable the staff team to meet service users’ basic needs. Service users have individual contracts or a statement of terms and conditions with the home, so that they are clearly aware of the services that the home can offer. EVIDENCE: The Statement of Purpose and the Service User Guide were examined. These contain up to date information about the service provided in the home so that prospective service users have the information they need to make an informed choice about where to live and whether their needs will be met by the home they enter. The complaints procedure is also included. Therefore appropriate Ashville House DS0000064958.V355310.R01.S.doc Version 5.2 Page 9 information about the home is available to prospective service users and their relatives. The home always carry out their own assessment of a prospective service user. These assessments cover all of the required areas and include health and culture. A report from the relevant health professionals is also obtained for the prospective service user. The individual and their relatives are invited to visit the home and trial visits/stays take place with the prospective service user. If it were agreed that this person would like to live at the home then a transition plan would be developed. Therefore sufficient basic information would be gathered on a prospective service user to enable the staff team to identify their needs. Contracts are in place for all service users, which are signed by the manager, the placing authority and the service user. Ashville House DS0000064958.V355310.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9,10 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Each service user has a care plan which is 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. EVIDENCE: At the time of the inspection, three service users were accomodated in the home. There have not been any new admissions to the home since the last inspection. All three service user’s plans were checked by the inspector. An initial assessment is carried out by the manager following a referral and another assessment of need is undertaken during the introductory period. The Ashville House DS0000064958.V355310.R01.S.doc Version 5.2 Page 11 findings from these assessments feed into an initial service user plan which is finalised in to a detailed care plan once the trial period for each individual is over. All the service users have appropriate professionals involved in their future care. Through discussion, the inspector was satisfied that the staff were aware of the service users’ individual needs and were ensuring that they provided appropriate care to each individual, which is reflected in an individualised care plan. The care plans examined for the three people using the service are comprehensive, individualised and person centred, based on each person’s specific needs, outlining how these will be met by staff. The care plans give details of how each person likes and needs to be supported. There was evidence to show that the service users have been involved in the development of their care plans. Evidence was seen of one to one discussions held with the service users showing that staff work consistently with the service users to achieve their goals. Evidence was seen that for all three service users, the care plan describes the person’s behaviours, why they may exhibit these behaviours and what to do if they have a mental health breakdown. This will ensure that all staff have correct and full information about individuals and how to work with them. Evidence was seen that the key worker reviews the service user plans monthly and updates them with the service user if there are any changes. The service users spoken to on the day of the inspection said 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 the most recent service user meeting shows discussions such as outings, holidays, Christmas menu planning, decorations etc. Informal ways of seeking people’s views are also used such as during outings or when undertaking activities in the home. Suggestions are also sought about activities, furnishings and health and safety. 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. The inspector was informed that all known risks have been risk assessed and evidence was seen on file that risk assessments are in place. 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. Service users’ records and other information is stored in a lockable cabinet in the office and staff are aware of issues of confidentiality. Ashville House DS0000064958.V355310.R01.S.doc Version 5.2 Page 12 Ashville House DS0000064958.V355310.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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of 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 and individual preferences are catered for. Visitors are made to feel welcome in the home and service users are supported to maintain and establish family links and friendships. EVIDENCE: Service users have access to a range of activities and staff were seen to work hard to motivate people to become involved in their chosen activities. Currently all the service users are independent, choosing to carry out their own activities. Ashville House DS0000064958.V355310.R01.S.doc Version 5.2 Page 14 One of the service users attends the day centre once a week and is being actively encouraged by the staff to increase this to two days. However, she prefers to spend time indoors but does go out with the staff to local shops, walks and other outings the home organise. All the service users’ have individual activity plans, for example, one service user has enrolled at college studying design and IT. She also goes independently to the local church on Sundays. Another service user attends the day centre, goes out with the staff as well as independently to access various community facilities and frequently visits his family who live locally. The routines for daily living are flexible and the service users can make choices in major areas of their life. The routines, activities and plans are individually focused and can be quickly changed to meet the individuals changing moods, needs, choices and wishes. At a recent meeting the service users decided to go to the West End to see the Christmas decorations and are then going to Harrods for tea. In the autumn the whole house went for a long weekend to Blackpool. One service user was involved in planning Diwali celebrations and they all had a chat about the celebration and had Indian food if they wanted. On Fridays, the service users who are all from different Ethnic backgrounds plan and prepare food from their own background, which they enjoy preparing with staff support. The manager and staff are aware of and actively promote the rights of the service users to make informed choices, providing links to specialist support when needed. This includes developing and maintaining family and personal relationships. Family and friends are welcomed and their involvement in daily routines and activities is encouraged with the service users’ agreement. The service users are offered a key to their own bedroom which can be locked from inside and outside. The key to the front door of the home is offered subject to a risk assessment. At the time of inspection none of the service users had the front door key but did have the keys to their own rooms. A community risk assessment is in place and staff interact with service users constantly so that they are aware of the risks to service users when out in the community and are aware of the company they keep so that they can be given appropriate to advice when going out. Each service user has responsibilities for their personal space as well as making a contribution to a communal activity, which is agreed with them. As part of promoting their rights, service users have access to advocacy services, and they are given advice about how to access these services. The service users also have social workers and families who can advocate on their behalf. They are also aware that they can have access to independent advocacy services if they wish to contact them. Staff prepare and cook meals with involvement from the service users and the menu for the week ahead is discussed at the weekend. However, the menu is Ashville House DS0000064958.V355310.R01.S.doc Version 5.2 Page 15 very flexible as most of the service users change their minds on the day and are therefore offered alternatives. The kitchen is accessible to the service users at all times and appropriate food stocks are purchased with the involvement of the service users. They accompany staff to do the shopping. Service users can choose when and where to eat but usually eat in the dining area. The menus are reflective of what has actually been eaten by the service user on a particular day. The staff involved in handling food have completed food hygiene training to promote the health and safety of the service users. However, they need to attend refresher food hygiene training which has been booked for January 2008. Visitors are encouraged to visit at any reasonable time and are encouraged to see their relative/friend in the lounge or their bedroom in privacy if needed. Often the service users go out with their families. The recording systems in the home have improved greatly and daily records reflect what the service users have done on a daily basis, their moods and how they are working towards their goals. Ashville House DS0000064958.V355310.R01.S.doc Version 5.2 Page 16 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): 18,19,20,21 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users are prompted and encouraged to take responsibility for their own personal care. The service users’ physical and emotional health care needs are monitored and this ensures that service users’ needs are recognised and met. The medication policies and procedures are clear. Staff have undertaken medication training in order to ensure the safety of the service users. EVIDENCE: Service users receive personal support in a way they prefer, with encouragement provided to enable them to carry out their own personal support tasks in a way that maintains their independence, privacy and dignity. There was evidence that service users’ needs, based on assessments, were recorded and they were carried out to promote their health, safety and welfare. Ashville House DS0000064958.V355310.R01.S.doc Version 5.2 Page 17 Staff have completed training in working with people with mental health issues and are therefore able to observe changes in the general and specific healthcare needs of service users and make interventions as appropriate to ensure their health and safety needs are met appropriately. Staff have now received specific mental health training in order to recognise and deal with mental health breakdown. The service users were all registered with a GP and records seen indicated that they had input from other health professionals such as the dentist, chiropodist and the opticians. On the day of the inspection one of the service users was accompanied by a staff member to attend a blood test. Another service user had been supported to see a consultant psychiatrist and outcomes are noted. The manager stated that as far as possible service users are given the opportunity to independently attend their appointments, as part of taking responsibility for their own healthcare. However, at the time of the inspection all three service users required support from staff to attend any health care appointments. Records were maintained where service users attended health related and professional appointments. Service users may see professionals privately in their rooms or in one of the offices. Emergency contact numbers are available for staff in the event of any emergency. A medication policy and procedure are in place. Staff handling medication, have had training in the handling and administration of medication, with further training specifically targeted to deal with service users with mental health needs and includes specific training regarding medication interactions and reactions as well as side effects of many of the anti psychotic drugs taken by service users with mental health needs. However, upon examining the medication records, the inspector noted that although the medication for one service user had been administered the Medication Administration Record was not signed by the member of staff. This appeared to a single error but is not acceptable practise. All MAR sheets must contain required entries and must be signed by the staff member responsible for medication at the same time. The manager must ensure that accurate records are kept of all medicines received, administered and leaving the home or disposed of in order to ensure that there is no mishandling. Ashville House DS0000064958.V355310.R01.S.doc Version 5.2 Page 18 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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of 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. A safeguarding adults policy and procedure is in place. Staff working in the home have received training in safeguarding adults in order to ensure that there is a proper response to any suspicion or allegation of abuse. EVIDENCE: The home has policies and procedures for dealing with complaints. The complaints log was examined and no complaints have been recorded since the last inspection. The complaints procedure is that all complaints verbal and written would be recorded with details of investigation, any action taken and the outcome for the complainant. One service user spoken to about what he would do if they were unhappy with anything said that they would speak to the manager or the 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. The policy and procedure for dealing with allegations of abuse and whistle blowing has been updated and this was discussed with staff at a recent staff meeting. A copy of all the relevant Local Authority Adult Protection protocols is kept in the home for the guidance of staff. Ashville House DS0000064958.V355310.R01.S.doc Version 5.2 Page 19 All staff working in the home have received training in safeguarding adults and staff are aware of the action to be taken if there were concerns about the welfare and safety of service users in order to ensure that there is a correct response to any suspicion or allegation of abuse. The staff team are aware of their duty to balance the rights and choices of people living in the home, with a legal duty to safeguard and protect service users. There have been no complaints or allegations drawn to the attention of the Commission. Ashville House DS0000064958.V355310.R01.S.doc Version 5.2 Page 20 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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides a comfortable environment for service users, with wellmaintained communal spaces. Service users bedrooms are suited to individual tastes/preferences and promote their independence. The décor, furnishings and fittings in the home are of a good standard and the home is clean and hygienic. EVIDENCE: The house is in keeping with the other properties on the street and a tour of the premises showed that since the last inspection it has been redecorated 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. Ashville House DS0000064958.V355310.R01.S.doc Version 5.2 Page 21 There is a small kitchen, living and dining area downstairs. On the day of the visit the home was clean, tidy and in good decorative order. Service users contribute to the maintenance of some aspects of the communal areas as well as their private spaces. Only three service users are accommodated at the home. One service user showed his room to the inspector which has now been re-decorated and personalised with suitable furniture which has been repaired or replaced. He was pleased with the room and said that he works closely with staff to make sure it remains clean and tidy. The kitchen flooring has been refitted since the last inspection and the general appearance of this area is much improved. The fixtures, fittings and furniture are all domestic in nature, and in keeping with this type of home. The programme to improve the decoration in the home has now been completed including the fitting of a new bathroom suite and toilets. This means the home looks homely, comfortable and welcoming. The service users said that they liked their rooms and felt comfortable and safe in the home. The only outstanding environment issues are the re-placement of carpets, which is scheduled to be completed in the New Year and the garden. 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. The inspector was informed that the garden is scheduled to be updated when the weather improves. The manager is going to install a smoking shed which is on order from a company and will be installed next year in order to comply with the no smoking regulation. A good standard of cleanliness was found in all parts of the home. Laundry facilities were satisfactory and policies for the control of infection were in place. Service users are involved in doing their laundry as part of maintaining their independent living skills and most were quite happy with this. None of the service users currently accomodated need any specialist equipment at present. Ashville House DS0000064958.V355310.R01.S.doc Version 5.2 Page 22 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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users receive care and support from a committed and motivated staff team. The staff team are receiving training that is appropriate to the needs of service users. Staffing levels are adequate to meet the individual needs of the service users. The procedures for the recruitment of staff are robust in order to provide safeguards for people living in the home. EVIDENCE: It was clear from informal discussions and feedback received that staff were motivated and committed to the service user group. All staff now 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(to be updated in January 2008), safeguarding adults and medication administration training and introduction to Ashville House DS0000064958.V355310.R01.S.doc Version 5.2 Page 23 mental health via “Lifecare”. The manager is hoping to en-roll staff to attend further advanced mental health training via Waltham Forest College. One member of staff has completed their NVQ level 2 qualification and is now enrolled on an NVQ level 3 course. One member of staff has completed NVQ level 3 training and is commencing a degree in social work. Another member of staff has also enrolled for NVQ Level 2 training. This is good practice. 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. Staff feedback received and staff records show that they do now get supervision on a monthly basis. Supervision is recorded and shows that the staff get time and space to reflect on their practice with their manager providing a retrospective picture of development and change. Evidence was seen that staff appraisals have taken place. The manager is aware that although staffing levels may be sufficient at the present time these must be kept under continuous review and adjusted according to the service users’ changing needs. The registered manager is now present in the home on a daily basis to provide support and supervision and covers shifts to provide hands on care. The registered person has undertaken a risk assessment to identify and minimise the risks to service users and the staff when a member of staff works alone. A lone person working risk assessment has been carried out and staff are aware of actions to take in an emergency when working alone. This must always be kept under review as differing situations may arise needing different reactions from the staff team. The recruitment files seen contained all the requirements of Schedule 2 of the Care Homes Regulations 2001. The manager demonstrated a good understanding of equality and diversity issues throughout the recruitment, induction and training process as well as daily practice issues. Evidence was seen that service users’ cultural needs are identified and met by staff. The daily records are now reflective of discussions held with service users and how staff are progressing with the individual care plans. Ashville House DS0000064958.V355310.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): People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users live in a home which is well-run and are supported by a manager who is experienced and registered with the Commission For Social Care Inspection. Service users’ rights and best interests are safeguarded by the home’s recordkeeping policies and procedures. Service users’ and staff health, safety and welfare are adequately promoted and protected. EVIDENCE: The manager is experienced and has managed the home since it was registered. She is a registered mental nurse ( RMN ) and is in the process of completing the Registered Managers Award. The managers work hard to provide a safe and stimulating environment for the service users. The service users’ health, safety and welfare are met by the staff working in the home. Feedback from service users was that the service is provided in a consistent and caring manner and that the service users are happy. Ashville House DS0000064958.V355310.R01.S.doc Version 5.2 Page 25 The manager promotes equal opportunities, has good people skills and understands the importance of person centred care and effective outcomes for people who use the service. The manager ensures that staff follow the policies and procedures of the home, however a requirement has been made in order to ensure that staff robustly follow the medication administration procedures. All records are held securely. Service users would be able to have access to their records upon request. All of the necessary health and safety policies and procedures are in place and the required health & safety checks are routinely carried out to ensure that a safe environment is provided for the service users. The home has a consistent record of meeting relevant health and safety requirements and legislation, and closely monitoring its own practice. Records are generally of a good standard and are routinely completed. The manager ensures risk assessments are completed and taken into account in planning the care and routines of the home. Individual risk assessments for each service user are in place which are regularly reviewed and updated and attached to each care plan as required. The home’s policies and procedures were readily accessible in the office and the staff team have signed each policy as they have read and discussed them. Staff were aware of where policies and procedures and other information was stored and confirmed a selection of these had been discussed during induction and staff meetings and supervision. Regular fire drills are carried out. The fire drill record sheet includes information about the time of the fire drill and who was present. This information can then be used to check that fire drills are being carried out at different times of the day and night and also that all staff and service users have taken part in fire drills over a period of time. A fire safety procedure is in place. The fire equipment was checked by a the fire service on 10/9/07. Hot water temperatures are tested each month and also checked each week to ensure that they do not exceed the specified 43°C. An environmental health check was completed on 13/11/07 and the home received a three staff rating(good). A formal quality assurance and monitoring system based on seeking the views of the service users, to measure success in achieving the aims and objectives of the home is in place. The registered person has begun the consultation process and is aware that the views of the service users’ family, friends and advocates and all other professionals involved in the care of the service users are also sought about how the home is achieving the goals for the service users. This information will then be available in an annual report. Ashville House DS0000064958.V355310.R01.S.doc Version 5.2 Page 26 A range of records were looked at. There was evidence that actions were taken to promote the health and safety of service users and this included staff training in health and safety and individual training records reflect this, safety signage, fire drills and procedures, risk assessments on safe working practice topics, fire training for staff and the maintenance of updated gas and electrical certificates. COSHH risk assessments are carried out. Ashville House DS0000064958.V355310.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 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 3 3 3 3 3 3 3 3 Ashville House DS0000064958.V355310.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? No 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 YA20 Regulation 13 Requirement The manager must ensure that accurate records are kept of all medicines received, administered and leaving the home or disposed of in order to ensure that there is no mishandling. Timescale for action 31/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Ashville House DS0000064958.V355310.R01.S.doc Version 5.2 Page 29 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.V355310.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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