Inspection on 12/08/08 for Ashwood

This inspection was carried out on 12th August 2008.

CSCI found this care home to be providing an Adequate service.

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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

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Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOME ADULTS 18-65 Ashwood 34 Woodfield Crescent Kidderminister Worcestershire DY11 6TU Lead Inspector Dianne Thompson Unannounced Inspection 12th August 2008 09:30 Ashwood DS0000070094.V369392.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 Ashwood DS0000070094.V369392.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. Ashwood DS0000070094.V369392.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashwood Address 34 Woodfield Crescent Kidderminister Worcestershire DY11 6TU 01562 741455 01299 896531 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) Coseley Systems Limited Mr Paul Sankey Care Home 8 Category(ies) of Learning disability (8), Physical disability (8) registration, with number of places Ashwood DS0000070094.V369392.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (Code PC) the service users of the following gender: Either Whose Primary care needs on admission to the home are within the following categories: Learning Disabilities (LD) 8 Physical disabilities (PD) 8 The maximum number of service users to be accommodated is 8. 2. Date of last inspection 31/5/07 Brief Description of the Service: Ashwood is located in a residential area of Kidderminster approximately half a mile from the town centre. The building is a large, detached property that has been adapted for its present use as a care home. Coseley Systems Limited purchased Ashwood and became the registered provider in February 2008. The registered manager remained unchanged. Ashwood is registered to provide residential care, for a maximum of eight adults with learning disabilities and physical disabilities. People who use the service are accommodated on the ground and first floor of the premises in two single bedrooms and three double bedrooms. The building does not have a lift. Ashwood has an enclosed rear garden and patio. The aim of the service is to help people enjoy an ordinary lifestyle by promoting their independence, developing their living skills by encouraging individual activities and the use of community resources and facilities. Ashwood provides a residential care service for a maximum of twelve people with learning disabilities. Details of fees for living at Ashwood are agreed on an individual basis as stated in the Service User Guide. The reader may wish to Ashwood DS0000070094.V369392.R01.S.doc Version 5.2 Page 5 contact the service for up to date fee information. Ashwood DS0000070094.V369392.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was an unannounced inspection visit to see what the service was like for the people who live at Ashwood. It was the first inspection since Coseley Systems Ltd. became the owner. Time was spent talking to some of the people who live at Ashwood and some of the staff working there. We looked at some of the records, policies and procedures. We talked to other people to get their views about the service. The manager completed an Annual Quality Assurance Assessment (AQAA) and sent this to the Commission for Social Care Inspection (CSCI). The AQAA is where the manager tells us about the service provided at Ashwood and the ways they plan to make the service better. We looked at parts of the premises. Information gathered from other sources, such as surveys, monthly visit reports and information sent to the CSCI has been included in this report. What the service does well: The service can provide information to help people and their families to make decisions about their future care needs. People can visit and have short stays to help with these decisions. People are given help and support to make choices in their daily lives. Lots of different activities are provided and people can choose to take part if they want to. Staff help people to do things and to try new activities. Ashwood makes sure that suitable staff are employed and that all checks are made to keep people safe. People are helped to keep in touch with their families and friends. Visitors are made welcome in the relaxed and friendly home. People can choose what they want to eat from the healthy menu. Alternative options to the main menu are provided, and people can have snacks and drinks at all times. Surveys say that people are happy with the care that is given by staff at Ashwood. Ashwood DS0000070094.V369392.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: The statement of purpose and service user guide must be updated so people have up to date information. Details of the ways each person communicates would help all staff learn what words or different sounds mean. Daily records should be kept in a way that makes sure personal details are kept private. All care plans must be reviewed and updated as required so that staff can work to up to date information. All risk assessments must be reviewed and updated as required to make sure everyone is kept safe. All health care monitoring must be done as needed to help people keep well and comfortable. All routine dental appointments must be made to make sure everyone has regular checks. Each person’s medication listed in their care plans should have a date when people start to take it, when there are any changes, and when the medication is stopped. This makes sure all records are correct. The service must make sure that money is available so staff can buy what is needed. A dishwasher would make sure all dishes are washed cleanly. The manager should write staff training and development assessments so that training courses and staff development is planned. Ashwood DS0000070094.V369392.R01.S.doc Version 5.2 Page 8 Staff must attend training courses so their skills and knowledge are maintained and developed. This will help them support people who use the service in ways that are up to date. The manager must give staff support with regular supervision and staff meetings so that everyone works together and in the same way. The gas safety certificate is out of date and needs to be renewed. Regular fire drills must be done to help keep people living and working at Ashwood safe if there was a fire. Names of all people must be written down to make sure that everyone takes part in fire drills. 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. Ashwood DS0000070094.V369392.R01.S.doc Version 5.2 Page 9 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 Ashwood DS0000070094.V369392.R01.S.doc Version 5.2 Page 10 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 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Information is available about the service and what can be provided to help people and their families making decisions about their future care needs. People are given opportunities to visit and assessments are completed before people move in to make sure their individual needs can be met. EVIDENCE: Policies and procedures are in place for assessing potential people to live at Ashwood. Information about the service is included in a Statement of Purpose and Service User guide and is available for all enquirers and residents. This information is available in alternative formats to make it more accessible, such as symbols. The Statement of Purpose and the Service User Guide are to be updated to reflect the new ownership of Ashwood. The manager says that the new company Coseley Systems Limited has given new contracts to everyone who lives at Ashwood. The manager says in the service’s AQAA that a ‘comprehensive pre-admission assessment is in place for future referrals.’ The admissions procedure states that full community care assessments are required and in addition Ashwood Ashwood DS0000070094.V369392.R01.S.doc Version 5.2 Page 11 complete their own assessments. We saw that community care assessments and service assessments had been completed for the files examined. Care plans are written from the information gathered during assessments, visits and discussions with families and other interested parties. Surveys confirm that families and carers have been consulted and included in the assessment process. Ashwood DS0000070094.V369392.R01.S.doc Version 5.2 Page 12 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, 9 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Care plans provide staff with information about individual’s assessed needs, although this information may not always be up to date because the plans are not reviewed regularly. People who use the service are supported in making decisions about their lives and are provided with opportunities to participate in various aspects of life in the home. Risk assessments work to show how risks are to be reduced and how independence is promoted and maintained. People who use the service and staff may be put at risk where risk assessments are not reviewed regularly. EVIDENCE: Care plans for three people were checked. Care plans set out the action to be taken by care staff, although some care plans have not been regularly reviewed. Of the three care plans examined we saw that one care plan was Ashwood DS0000070094.V369392.R01.S.doc Version 5.2 Page 13 reviewed 18/4/08, but another care plan was last reviewed in January 2006. The third care plan examined had been reviewed 18/1/07 although the agreed frequency of review for this person was recorded as every six months. Where a care plan had been reviewed a cover sheet records the date the review took place, for example 29/8/07, but this conflicts with individual sheets where original dates of care plans have been recorded. All pages should be dated and signed when care plans are updated. Care plans describe the needs of each person including their daily living needs, health and personal care, physical well-being, social interests and relationships, religious and cultural needs and any other specific areas. We saw examples of preferred personal care routines such as support to get up and to go to bed. It is unclear if these routines have remained unchanged for the past two years as the records indicate that no review has taken place. Staff complete records with people who use the service to make sure everyone is involved as much as possible in their everyday lives and choices, including the running of the service. Daily records for each person are kept in one file in the dining room cupboard. The manager was advised that this is not a confidential way to keep records. People communicate in different ways. We talked with one person who tried to communicate during the inspection. Staff explained what this person’s various sounds and gestures meant. This information was not available in the person’s care plan. A descriptive list of words and sounds people use to communicate would be beneficial to staff (particularly new and agency staff) to help with understanding the different ways people communicate. Each person is allocated a key worker to oversee his or her care. Key workers support people on a one-to-one basis. Information about each persons ageing and death preferences are recorded. Risk assessments are completed to keep people safe and include additional support guidelines for staff to follow where this is needed. We saw that risk assessments have not been reviewed regularly and may put people at risk if any changes to the original assessment need to be made. We saw that a risk assessment for road safety was dated 19/5/04 with road safety training for one person completed in 2002. In talking with staff it is evident that support currently provided by staff is not consistent to that identified in the care plan or the risk assessment. The assessment should be reviewed together with the assessment of the individual’s road safety skills. Behaviour management plans indicate that staff are to monitor changes but there is no evidence to show how or where is this recorded. If a specific monitoring form is to be used, the risk assessment should signpost the reader to this. We saw behaviour guidelines referring to aggressive behaviour dated 2006 that had a staff signature sheet with it to confirm staff had read the Ashwood DS0000070094.V369392.R01.S.doc Version 5.2 Page 14 guidelines. This was out of date in that signatures did not reflect that some staff have left and new staff have been employed by the service. The manager has identified in the service’s AQAA the need to ‘improve care plans’ and ‘research more comprehensive individual risk management system’. It is of concern however, that this was the situation at the last inspection and reviews have not been completed for two or more years for some people. Ashwood DS0000070094.V369392.R01.S.doc Version 5.2 Page 15 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): 12, 13, 15, 16, 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People are supported and encouraged to take an active part in their choice of activities. Everyone is encouraged and supported to maintain links with their families and to develop friendships. Dietary needs are well catered for with a varied and healthy menu provided. EVIDENCE: People living at Ashwood are encouraged and supported to make choices about activities and daily living with as much control over their lives as they are able. People make choices about how to spend their day and examples of this were observed throughout the inspection visit. Three people were at home at the time of the inspection, and other people returned from their various day activities later in the afternoon. Ashwood DS0000070094.V369392.R01.S.doc Version 5.2 Page 16 The range of activities provided includes the Odell Centre, sewing and embroidery, out for meals to a local pub, Orchard Street Centre, Recycling Centre, shopping, out in the community, using sensory items, music, art and crafts. The manager said that regular meetings are held with people who use the service. Through a discussion about Equality and Diversity during a recent meeting one person said they would like to go to church. People who use the service talked about the things they like to do. One person said they ‘like to help wash up and mop the kitchen and dining room’ and another person said they like to ‘listen to the radio’. Surveys confirm that people are able to choose what they want to do during the day, although one person indicated they ‘can only go out at weekends if there are extra staff on duty’. People are supported to have a holiday each year and a holiday to Butlins in Minehead is planned for early September 2008. Care records show that regular contact with friends and family is supported. People who use the service are able to see their visitors in private, and surveys confirm that they are made welcome. We saw that support has been given to help a person re-establish contact with a relative. We saw records that show how this support was provided, and that letters and photographs were sent 18/4/08. The service provides meals that are varied and nutritious, with different choices available where preferred. A four weekly menu is regularly completed. People are consulted about their choice of food and diets, and support is given for people who find it difficult to eat and need help. Snacks and drinks are available throughout the day. Lunch during the inspection consisted of choices of ham toastie and crisps; sausages, mashed pots and gravy; and meatballs on toast. These were all individually chosen and demonstrate the flexibility of the menu. Ashwood DS0000070094.V369392.R01.S.doc Version 5.2 Page 17 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. Care plans give information about each person’s health care needs, but they are not being reviewed regularly and this could mean that staff do not have all the information they need to ensure consistent healthcare. Ashwood has a medication policy and procedure for staff to follow to ensure that all medication is administered and stored safely for the protection of everyone who uses the service. EVIDENCE: Care plans provide information about the health care support needed by everyone who lives at Ashwood. This includes details of personal care needs and the ways people prefer to be supported. We saw that for some people physical checks are being completed where people have particular health related issues such as weight and physical functions. Records of these are not completed consistently for everyone. For example, we saw one weight chart with the direction ‘to be weighed every 3 months’ crossed out. Details of recorded weight checks are inconsistent. The Ashwood DS0000070094.V369392.R01.S.doc Version 5.2 Page 18 last entry 26/7/08 shows a weight loss of 6lb, but there is no record of any action or monitoring in response to this. The manager states in the service’s AQAA that ‘improved healthcare monitoring system is to be introduced’. It is of concern however, that this was the situation at the last inspection and changes have not been introduced for two or more years for some people and may affect the health and well being of people who use the service. We saw information about an individual’s dietary needs that details possible allergies. In the care plan an entry dated 27/11/07 referred to diet and meals, ‘staff to implement and report any improvement or worsening and review in 2 months time’. An entry dated 4/12/07 stated ‘replace with Soya milk’. Records did not show any monitoring or review process or how the decision to replace with Soya milk had been reached. In reading through the daily records for the same person we saw an entry dated 16/7/08 ‘ate well and plenty of drinks’. Later that evening the record shows ‘9.30 p.m. very agitated and windy/bloated. Back rubbed’. There is no information to show that this concern has been followed up, investigated or any possible link to diet established for the discomfort suffered. People have good access to medical support through their Primary Health Care Team (PCT) as required. This includes physiotherapist, dietician, dentist and doctors. A record of visits to the doctors or other medical professionals is kept, although routine dental appointments have not been maintained for some people. Some routine health checks have been completed such as well person, medication reviews and psychiatry appointments. We saw staff engage with people in a respectful way, making sure that dignity and self-esteem was important for each person. Although communication with some people who use the service for visitors may be difficult, people appeared to be comfortable and at ease in their surroundings. Surveys confirm that staff treat people well and listen to what people say. A policy and procedure is in place for the administration of medication. The manager said that medication training courses are to be arranged for some staff. Specific medication training related to epilepsy had been provided for some staff during August. A ‘consent to medication’ form is included in care plans and the person using the service or their representative has signed these. The manager was advised that the consent forms should be reviewed when care plans are reviewed. The administration of prescribed medication was observed during the inspection visit. This was well managed and all procedures were followed. Medication is stored securely and given to people at the right time and full records are kept which show this. A record of current medication is included in care plans. The manager was advised that dates when medication starts and Ashwood DS0000070094.V369392.R01.S.doc Version 5.2 Page 19 dates of any changes should be recorded as well as the date the medication was stopped. Ashwood DS0000070094.V369392.R01.S.doc Version 5.2 Page 20 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 good This judgement has been made using available evidence including a visit to this service. People have access to easy to understand information about how to complain and staff support people to express their views and any concerns they may have. There are suitable procedures in place for the management of complaints and to make sure that people who use the service are protected from abuse. EVIDENCE: Ashwood has a complaints policy and procedure which is accessible to people who live at the home and their relatives. The manager says in the service’s AQAA that views of people who use the service are listened to and that a clear and comprehensive policy about adult protection is included in their staff training. Surveys confirm that people who use the service know how to respond if they have any complaints. Staff use the complaints procedure to support people should they wish to make a complaint. Survey responses show that people are aware of the complaints procedure and that no complaints have been made. The manager confirms in the service’s AQAA that no complaints have been made to the service. We have not received any complaints or safeguarding concerns about Ashwood. The service has a complaints book that records both compliments and any complaints that are made. There are specific policies and procedures in place to guide staff on the protection of vulnerable adults from abuse and on ‘whistle blowing’ for staff. Ashwood DS0000070094.V369392.R01.S.doc Version 5.2 Page 21 Staff training in abuse awareness and protection of vulnerable adults is to be arranged for this year. Staff confirmed they are aware of the procedures and understand the implications of concerns, complaints and protection issues. Financial policies and procedures are in place. An independent appointee was made for some people in April 2008 and this meets a recommendation of the previous inspection. Staff support people with weekly budgeting and information is recorded on finance record sheets. Appropriate financial systems such as petty cash facilities should be developed as soon as possible so the service or people who use the service are not disadvantaged. Ashwood DS0000070094.V369392.R01.S.doc Version 5.2 Page 22 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, 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who live at Ashwood enjoy a safe and homely living environment that is spacious and kept clean. The service will benefit from the planned redecoration and refurbishment of the building. EVIDENCE: Ashwood is located in a residential area of Kidderminster approximately half a mile from the town centre. The building is a large, detached property that has been adapted for its present use as a care home. Coseley Systems Limited is now the registered provider having purchased Ashwood earlier this year. Ashwood is registered to provide residential care, for a maximum of eight adults with learning disabilities and physical disabilities. Ashwood DS0000070094.V369392.R01.S.doc Version 5.2 Page 23 People who use the service are accommodated on the ground and first floor of the premises in two single bedrooms and three double bedrooms. The building does not have a lift. Ashwood has an enclosed rear garden and patio. The aim of the service is to help people enjoy an ordinary lifestyle by promoting their independence, developing their living skills by encouraging individual activities and the use of community resources and facilities. We looked at parts of the premises. Ashwood is clean and tidy throughout. The bedrooms are a good size, suitably furnished and personalised by people living at the home. Policies and procedures for infection control are in place and staff are provided with disposable gloves and aprons. All cleaning materials are locked in the laundry room. The manager states in the service’s AQAA that staff have completed training in Infection Control although the training records show that some staff have yet to complete this. Work is due to take place in two weeks time (while everyone is on holiday) to refurbish the home and redecorate some areas. This will include replacing the exterior doors to the lounge, redecorating and a new kitchen floor fitted. An external office facility is planned for later in the year. The provision of a dishwasher would make sure all dishes are cleanly washed. This would be beneficial to the people who live at Ashwood and should be considered during the planned refurbishment of the building. Ashwood DS0000070094.V369392.R01.S.doc Version 5.2 Page 24 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): 32, 34, 35, 36 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Staff are committed to providing good care but they need to be supported through regular staff meetings, supervision and training. Recruitment policy and practices make sure that suitable staff are employed. All necessary checks are made to make sure that everyone living at Ashwood is kept safe. EVIDENCE: Ashwood has a committed staff team. People commented in surveys that they were generally satisfied with the service and the staff. Staff appeared to have good relationships with people who use the service. Survey comments include ‘staff are kind’ and ‘staff listen’. Recruitment policies and procedures have been reviewed and updated to reflect the new ownership of the service. Staff have been given new contracts of employment. The revised recruitment policy and procedure makes sure that everyone completes an appropriate application form and that suitable references are obtained including one from most recent employers. Ashwood DS0000070094.V369392.R01.S.doc Version 5.2 Page 25 Appropriate criminal records and other checks are undertaken before appointments are confirmed. Staff records were examined for three people and included recent staff appointments. All required information was seen and included confirmation of identity, security checks and suitable references. All staff are required to work a probationary period. Staff spoken to confirmed that safety checks had been completed before they started their employment. The manager confirms that all new staff complete an induction period when they start their new job. An induction checklist was seen for one new member of staff that shows progress so far. The manager identifies in the service’s AQAA that each member of staff is to have a training programme based on their individual training and development assessments. It is of concern however, that this was the situation at the last inspection and the staff training assessments and training plans have not been completed. The manager confirmed that mandatory staff training is to be arranged as soon as possible. A new member of staff has recently completed training in infection control and fire safety, but for some staff previous fire safety training was last completed in 2006. The manager has recently recruited staff that are NVQ qualified which means that six people from the staff team of ten are now NVQ qualified. There are no current arrangements in place for the remaining members of the staff team to complete their NVQ training. The manager said that staff meetings have not taken place very often as people have been covering shifts due to staff shortages, staff sickness and annual leave. The manager plans to hold more regular meetings now that new staff have been recruited and the service is fully staffed. Minutes of these meetings will be kept and made available during future inspection visits. Similarly, staff supervision to cover all aspects of care practice staff has not taken place regularly. Staff surveys asked if the manager met with them to provide support and discuss how they were working? The responses were mixed in that half of the surveys said ‘often’, and the other half saying ‘sometimes’ or ‘never’. This is a reflection on the lack of regular staff supervision and staff meetings. It is of concern however, that this was the situation at the last inspection and there is no evidence of improvement. We talked with staff that said that the ‘change of provider has been ok’ and ‘the new providers are nice, helpful and supportive’. Ashwood DS0000070094.V369392.R01.S.doc Version 5.2 Page 26 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, 39, 42 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 work to provide a service to meet people’s needs, but regular supervision and staff meetings would help staff feel more supported and make sure people work in a consistent way. The new provider will monitor Ashwood in various ways to make sure that the health and welfare of people using the service is protected. EVIDENCE: The manager Mr Paul Sankey has many years experience working with people with learning disabilities. Management responsibilities are shared with a senior member of staff. They are involved in organising day-to-day activities, health and safety promotion, staff supervision and induction. Ashwood DS0000070094.V369392.R01.S.doc Version 5.2 Page 27 The Annual Quality Assurance Assessment (AQAA) was completed and submitted to the CSCI prior to the inspection visit. The AQAA is where the manager tells us about the service provided at Ashwood and the ways they plan to improve the service. The completion of the AQAA was discussed with the manager. Mr Sankey was advised that the information contained in the AQAA was very brief and did not fully reflect the service being provided. Coseley Systems Limited currently employs a consultant to conduct monthly visits to monitor the service and how it is being run. These visits include interviews with staff and people living in the home. We saw from the reports that an audit of relevant parts of the service, including records, environment, complaints received, finance and safety has been completed. Any actions that may be needed to address shortfalls are specified. In the service’s AQAA the manager states that ‘a Quality Assurance document is now available via the new provider’ and will be implemented. Records show that checks of water temperature and storage, fridge, freezers and electrical appliances are completed. The gas safety certificate is out of date and needs to be renewed. Fire records show that regular safety checks are completed but the date of the last recorded fire drill shows 2007. The manager was advised that a fire drill must be completed as soon as possible. The CSCI was notified that a fire drill was completed on 16/8/08. The manager was further advised that the record of drills form should be revised so that names of all people present during drills are recorded to monitor attendance. The manager says that he spends a lot of his time working hands-on to give priority to the people who use the service. Mr Sankey must give priority to the planning and organisational work that is required to manage this service. The management of Ashwood needs to make sure priority is given to updating all care plans, risk assessments, staff supervision and staff training. Surveys confirm that the manager and staff are approachable and provide the help people need. Ashwood DS0000070094.V369392.R01.S.doc Version 5.2 Page 28 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 2 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 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 2 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 3 X 2 X 2 X X 2 X Ashwood DS0000070094.V369392.R01.S.doc Version 5.2 Page 29 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. 2. 3. Standard YA6 YA9 YA35 Regulation 15.2 (a) (b) 13.1 (a) (b) 18.1 (a) Requirement Care plans must be reviewed regularly and updated as changes occur. Risk assessments must be kept under review and updated as any changes occur. A staff training and development programme must be put into place to make sure that the needs of the people who use the service can be met by suitably trained and qualified staff. Timescale for action 12/02/09 12/02/09 01/02/09 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. Refer to Standard YA6 YA6 Good Practice Recommendations When care plans are updated all pages should be dated and signed to make sure information is clear and consistent. A descriptive list of words and sounds people use to communicate would be beneficial to staff (particularly new and agency staff) to help with understanding how people communicate. DS0000070094.V369392.R01.S.doc Version 5.2 Page 30 Ashwood 3. 4. 5. 6. YA7 YA19 YA20 YA20 7. 8. YA30 YA42 Daily records for each person are currently kept in one file in the dining room cupboard. The manager was advised that this is not a confidential way to keep records. Routine dental appointments should be maintained for all people who use the service. Consent to administer medication forms should be reviewed with care plans. The dates when medication is to start, when any changes occur and when the medication is discontinued should be recorded on the medication information sheet in people’s care plans. A dishwasher to make sure all dishes are washed cleanly should be considered during the planned refurbishment of the building. The gas compliance and safety certificate is out of date and needs to be renewed. Ashwood DS0000070094.V369392.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection West Midlands Office West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 Ashwood DS0000070094.V369392.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. 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