Inspection on 29/03/07 for Ashwood House

This inspection was carried out on 29th March 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Ashwood House 08/02/06

Ashwood House 17/08/05

Ashwood House 24/02/05

Ashwood House 15/06/04

Ashwood House 03/03/04

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 Ashwood House 217 Winchester Road Southampton Hampshire SO16 6UA Lead Inspector Tracey Horne Key Unannounced Inspection 29th March 2007 09:30 Ashwood House DS0000036881.V329612.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 House DS0000036881.V329612.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 House DS0000036881.V329612.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashwood House Address 217 Winchester Road Southampton Hampshire SO16 6UA 023 8077 7451 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) ashwood.house@tiscali.co.uk Wessex Regional Care Limited Mr Paul Wright Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Ashwood House DS0000036881.V329612.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th January 2006 Brief Description of the Service: Ashwood House is located on the outskirts of Southampton on a busy main road. The home provides care and support for up to five people who have a learning disability. Currently all the service users are male. The aim of the home is to support residents to develop social, daily living and independence skills to become integrated into the community. Twenty-four hour staff support is provided. The house is detached and it has a sitting room, dining room, spacious kitchen and shower room on the ground floor. Bedrooms are situated on the first floor and are single rooms, which are spacious and have been personalised to each service users own preference. Access to the first floor can be gained by one flight of stairs. There are no en-suite facilities, however there is a bathroom on the first floor, which is accessible from all the bedrooms. Car parking is available to the side of the house and there is a large well-maintained garden to the rear, which offers privacy. The manager confirmed the fees for service users living in the home range between £1257.61-£1672.16 per week. Ashwood House DS0000036881.V329612.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of the inspection was to assess how well the home is doing in meeting the key National Minimum Standards (NMS) and Regulations. The findings of this report are based on several different sources of evidence. These included: an unannounced visit to the home, which was carried out on the 28th March 2007 between 09.30 and 14.30, during which the inspector (Mrs Tracey Horne) was able to have discussions with service users the staff on duty and the registered manager. The opportunity was taken to look around the home, view records, procedures and talk with service users and staff. Observe were made regarding the interaction between service users and staff. All of the service users spoken with were very complimentary about the care, encouragement and support they receive. The people living in the home prefer to be referred to as service users, therefore the rest of this report will reflect this. The staff on duty during this visit felt they were very well supported to do their job. The inspector received a pre inspection questionnaire from the registered manager prior to this visit, which provided further evidence of how the service is meeting the Key National Minimum Standards. The Commission for Social Care Inspection (CSCI) sent feedback forms to the home prior to this site visit, four service users forms were completed and returned and one member of staff returned their comment card to the CSCI prior to this site visit. All regulatory activity since the last inspection was reviewed and taken into account including notifications sent to the Commission for Social Care Inspection. What the service does well: The staff are caring, respectful and are mindful of peoples need for privacy and dignity. They encourage individuality and independence within the limits dictated by the service user’s needs. Service users feel supported to make decisions about their lives and are fully involved in planning what happens in their lives. Service users enjoy living in their home which is clean and has a relaxed, homely atmosphere. Service users are encouraged to participate in the local community as they wish. Staff time is organised so that service users may go out on trips on an individual basis or spend time doing activities with staff support in the home. Ashwood House DS0000036881.V329612.R01.S.doc Version 5.2 Page 6 The home has an open and good process in place for dealing with complaints, concerns and compliments. One service user said “I would tell my keyworker if I was not happy.” The home has a process for recruiting new staff which safeguards the people living in the home. Staff said that they felt very supported by the manager and other team members, are encouraged to obtain qualifications (60 0f staff are working towards, or have achieved a National Vocational Qualification (NVQ) this exceeds the NMS.) and said communication is very good. All service users spoken with said they feel safe and comfortable at the. The registered manager has provided strong leadership since his appointment and developed a team that work well together to support service users to achieve their individual goals and aspirations. What has improved since the last inspection? What they could do better: During this site visit one concern was noted. Risk assessments had not been reviewed regularly, therefore a requirement was made to ensure that: Risk assessments must be reviewed regularly to minimise any identified risk occurring to any one living and working in the home. Service users may benefit from staff attending specific training to further understand individual’s specific needs. The manager has already identified when completing maintenance checks that certain areas of the home would benefit from being re decorated and that worn carpets in communal areas need to be replaced. Ashwood House DS0000036881.V329612.R01.S.doc Version 5.2 Page 7 The manager is aware of the areas in which improvements need to be made and is keen to improve the standards within the service further. 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 House DS0000036881.V329612.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 Ashwood House DS0000036881.V329612.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): 2. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home has a comprehensive admission procedure that ensures a placement will only be offered to service users whose needs can be met. EVIDENCE: The current service users have lived in the home since it was opened. The registered manager has had no experience of assessing or admitting a new service user but he said he felt the most important aspect of anyone new moving in would be that they fitted in with the current service users and that the service could meet their needs. The home currently have one vacancy, and the manager explained the process he would follow before admitting a service user to the home which included meeting the person, completing an assessment and by getting as much information as possible about the person’s needs. The manager said time would be needed to make sure the service user wanted to move to the service, this would be achieved through a planned move that included visits to the home and possibly short stays before a placement was offered. Ashwood House DS0000036881.V329612.R01.S.doc Version 5.2 Page 10 The home had a policy and procedure for the admission of a new service user. These confirmed the process described by the registered manager and stressed the need for a planned admission to be made. Ashwood House DS0000036881.V329612.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 & 9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users are involved in improving and reviewing their care plans and feel they are consulted about decisions which effect their lives. While risk assessments are in place to enable service users to take risks as part of an independent lifestyle, they were not reviewed regularly. EVIDENCE: The manager had identified that care plans needed improving to be more person centred for the individual. Staff said they received internal training to enable this to be achieved, and evidence was seen in the two care plans of this improvement taking place. The inspector looked at two care plans with each service user it referred to. Service users confirmed they were aware of their care plan and were working with staff to include photographs to make it more personal to them. Ashwood House DS0000036881.V329612.R01.S.doc Version 5.2 Page 12 Care plans were clear, detailed and kept under regular review by service users and staff signing to say the information is correct. Information such as photographs of people who are important to the individual and places of interest, likes and dislikes, dreams and aspirations, how to communicate with individuals and how to interpret their actions were clearly written in the plans. One service user said he had agreed specific guidelines with staff which are clear to as to how they can best support him, these were clearly stated in his care plan. One service user stated in their feedback for to the CSCI that ‘ I have a care plan, and a key to their room, and have meetings.’ One service user said he had an interest in fishing, and that staff will be arranging this as soon as the weather is warmer as he doesn’t like the cold. Staff keep records which show what each service user has done during the day. Records seen included details of social activities taken part in and work towards life skills (such as cooking, cleaning and looking after pets) and changes in behaviour. Through observation it was evident that service users are able to make decisions about their lives. Service users said they are able to choose how they spend their time, when they get up, go to bed and when they want to eat. Each service user has an activities chart which includes details of what activities the individual will be doing each day. One service user was eager to tell the inspector what he was going to be doing during that day, this was reflected in the activities chart. One service user sees an advocate and according to the visitors book the last visit to see him was a few days before this site visit. Regular house meetings are held and a record is kept of what service users discussed. The manager said he would like to introduce the idea of either a service user or an independent person chair the meetings. There was evidence that annual reviews take place. Service users said they felt that staff understood them This was also evident through discussion with staff who were allocated as the service user’s key worker. Risk assessments seen were drawn up on an individual basis and the emphasis on independence and positive outcomes supports service users to achieve their goals and aspirations but they are not reviewed regularly, therefore a requirement was made for all risk assessments to be updated and reviewed regularly, this will show that risks have been identified and minimised and will ensure the safety of people living and working in the home. Ashwood House DS0000036881.V329612.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 excellent This judgement has been made using available evidence including a visit to this service. Service users feel able to make choices about their life style, and are supported to develop their life skills. Social, educational, cultural and recreational activities meet individual’s expectations. EVIDENCE: One service user commented in their comment form to the CSCI, ‘I go out shopping & I like living here.’ Another service user wrote ‘ I have lots of things to do like going shopping for food, swimming, I go to the pub and walking.’ Daily records showed that all service users have a varied and active social life. Service users are supported to access a range of leisure and educational activities where they have the opportunity to develop friendships. These are arranged on an individual needs according to the individual’s own personal preferences. Service users are involved in the following activities within the home/premises: board games, arts & craft, bingo, social BBQ’s, quiz Ashwood House DS0000036881.V329612.R01.S.doc Version 5.2 Page 14 nights and cooking. Service users are involved in the following activities within the wider community: ‘Minstead lodge’- where one service user works as part of a horticultural project, making compost and planting, city college/computing, pottery, cinema, QE2 centre- where service users have the opportunity to do water sports such as canoeing, swimming/cycling and luncheon cub. Service users felt able to pursue their hobbies and interests. One service user said they had just started to go horse riding. One service user is starting to make a scrapbook to keep his memorabilia in. Equality and diversity is promoted in the home and good examples of this were available. Service users are supported to express their individuality through a range of social activities and are members of specific interest groups. Service users are active in their local community and attend local groups, clubs and use the local shops, pubs and restaurants. Service users are encouraged to maintain relationships that are important relationships to them. Records showed service users being supported to maintain links with families and friends. One service user said he visits a friend in Winchester about once a fortnight, and users spoken to said they could invite friends to the house when they like. One service user said staff support him (by driving) him to see his girlfriend, and she visits him regularly at the home. The manager said that visitors are welcome at any time, one service user confirmed this. Staff said that families usually rang first to make sure the service user was going to be in. The registered manager said that relatives were invited to attend annual reviews so they could be involved in care planning if the service user wants. Staff were observed knocking on bedroom doors before entering. They address service users by the name the individual prefers, as stated in their care plan. Service users were seen to be able to move freely round the home. When the inspector arrived at the home one service user answered the door. One service showed the inspector around the home and one service user was feeding his pet birds. One service user was in his bedroom watching television. Support is given to service users to take responsibility for household tasks and be involved in all aspects of running the home. Healthy and varied meals are provided and service users said they enjoyed helping with the cooking. Details of specific dietary needs are recorded in care plans as well as individual needs and preferences. Meals and meal times are flexible and fit in around service users activities. Service users spoken to said they liked the food. Ashwood House DS0000036881.V329612.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users receive health & personal care on an individual basis. The home practices the principles of respect, dignity and privacy. EVIDENCE: Service users’ individual needs and preferences regarding their personal care are recorded in their care plans which are being improved to be more person centred. Service users said they receive the support they need and that staff ‘always help’ them. The staff said they knew service users very well and were able to describe the support that individuals needed. Care plans show that emotional needs are considered individually and strategies for support are in place for those who need it. One service user said that he has worked with staff to produce guidelines for him as he can get agitated and upset sometimes. Service users said they could talk to staff if they are upset or worried about things. Ashwood House DS0000036881.V329612.R01.S.doc Version 5.2 Page 16 Each client is supported to maintain their health and well being by having their own General Practitioner (GP). Support is given to keep GP’s appointments as well as dental and podiatry appointments. Specialist healthcare professionals are involved when necessary for service users with specific health needs, systems are in place to monitor and review these. It was evident that the manager had researched and was knowledgeable about specific healthcare needs and has provided training for staff as part of meetings to inform staff of specific disorders. One service user stated in their CSCI survey ‘staff listen to me, I have a care plan, and a key to my room, and have meetings and lots of things to do like going shopping for food, see my doctor and dentist.’ The care plan included a photograph of the doctor and the surgery so that the service user could recognise the building and person as the surgery and their doctor. At the time of this visit, one service user was responsible for managing their own medication their care plans reflected this. A risk assessment was in place. The policy for the home stated that only staff assessed as competent by the registered manager could administer medication. The pre inspection questionnaire recorded that all current staff had completed this process. The inspector saw records of this assessment that had been completed with staff this year. The manager said he will be arranging safe administration of medication for training as well. The home has an arrangement with the local pharmacist for medication to be supplied in a monitored dosage system. This was stored, together with creams and lotions in a locked cupboard. The registered manager said he has requested lockable storage for each bedroom, as currently all medication is stored and administered in a lockable kitchen cupboard. One service user who self administers their medication has storage in their bedroom. The medication administration record had been completed for the morning’s medication. Records were also kept of any non-prescribed medication. Ashwood House DS0000036881.V329612.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): Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Service users feel able to air their views and make complaints. The policies and procedures used in the home, and the training staff have received protect service users from the risk of abuse. EVIDENCE: One member of staff stated in their feedback form to the CSCI that ‘Service users receive very good support and are always given the opportunity to air their views or choices, this is done through their keyworkers, weekly service user meetings or they can request a meeting to discuss any issues or concerns they may have.’ A copy of the complaints procedure was displayed on the notice board in the hall way and in the statement of purpose. The registered manager was able to show how a recent complaint from a service user had been dealt with appropriately. Records showed the manager informing the care manager as the complaint had an impact on funding. As a result the manager requested the care manager attend the service users forthcoming review. Service users were asked about how they complained and made their concerns known. They said they knew who they could talk to and said that staff and the manager listen to them and sort out their problems. During the visit service users spoke openly with staff about any questions or concerns they had, staff were quick to respond, and explained most of the time service users need reassure about what is happening during the day. Staff acting promptly and consistently elevated any anxieties. Ashwood House DS0000036881.V329612.R01.S.doc Version 5.2 Page 18 Staff spoken to said they were familiar with the home’s adult protection and whistle blowing policy as well as Hampshire County Council’s policy on adult protection. Staff said they were aware of their responsibilities within them. The registered manager said that staff have attended training regarding adult protection issues, and the manager has referral an issue to social services for investigation, which has been completed. Records of the outcome are held on file. Care plans, risk assessments and intervention plans are in place for managing challenging behaviour. Staff and service users were aware of them. Records showed staff have received appropriately to carry out such interventions and the homes policy had clear guidelines. Service users are all supported with their finances, they can have access to their money when they wish. Receipts and written records of transactions are kept. Monies held on behalf of two service users were sampled both were accurate. Ashwood House DS0000036881.V329612.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users benefit from some areas of the home being refurbished to provide a homely, comfortable and safe environment to live in, however the carpet in the dining room and hall way needs to be replaced to provide a totally safe environment for service users. The home is clean and hygienic. EVIDENCE: The pre inspection questionnaire states that a new suite and shower have been installed downstairs to make a ‘wet room’ and flooring in the toilets has been replaced. The bathroom, toilet and wet room have been decorated and the kitchen has new flooring. A tour of the premises was undertaken with the assistance of one of the service users. The home was found to be comfortable, clean and safe. A system is in place to report repairs and improvements needed. Bedrooms seen were suitably decorated with adequate furniture and personalised to reflect the preferences and needs of the individuals occupying Ashwood House DS0000036881.V329612.R01.S.doc Version 5.2 Page 20 them. There was adequate communal space and these areas were clean and comfortable. Risk assessments were in place for the environment and staff are suitably trained, for example; in Health and Safety, Food Hygiene and Fire Safety and first aid. The inspector saw that the hall way and dining room walls carpet were worn and in poor condition. The manager has already identified when completing maintenance checks that certain areas of the home would benefit from being re decorated and that worn carpets in communal areas need to be replaced as it could become a trip hazard, and one service user uses a walking stick to aid him. The manager said that the carpets will be replaced and the walls will be painted as he had already requested this work be completed by the organisation. Staff said they have completed infection control training, and were aware of the home’s policies and procedures of hygiene issues. The inspector saw records of staff training and the member of staff who was cooking confirmed they were up to date with food hygiene training. The home’s radiators and pipe work are safe ensuring that all potential hot surfaces are kept to low temperature. Ashwood House DS0000036881.V329612.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): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are supported by staff who are trained, skilled and in sufficient numbers to meet individual’s and group needs. Staff support the smooth running of the home in line with their terms and conditions of employment. EVIDENCE: The staff spoken to during the inspection were confident and competent. Staff were clear about their roles and responsibilities, and said the manager provides clear direction and is organised. They said they enjoyed their work and showed an in depth knowledge of the individual needs of service users. The manager said he used to be a teacher and uses this skill to provide information to staff regarding specific areas which benefit service users and is aware that further training is needed to continue this awareness. Staff spoke about service users in a sensitive and positive manner and were seen interacting in this way. Staff have the skills to communicate with all the service users on an individual needs basis. For example picture symbols are used in the home to describe various activities a service user will be participating in. Ashwood House DS0000036881.V329612.R01.S.doc Version 5.2 Page 22 The home has a suitable recruitment and selection procedure in place. The manager stated in the PIQ that five staff have been employed since he last inspection. The records of two recently employed staff were and demonstrated that this was followed appropriately. All staff had the necessary checks prior to beginning work in the home. The home have two full time vacancies (one of which is for a senior position. The manager explained he will be interviewing in April 2007 for these vacancies. In the mean time the home use two agencies to provide staff cover, the manager said the agency try to provide the same staff to provide consistency for service users and staff. Staff said that a minimum of two staff are on duty. The rotas showed that a minimum of two staff were on duty that day. This did not include the manager who does work with staff to provide supervision and support, and enables staff to spend one to one time with service users. The manager said he has sufficient time allocated to full fill his managerial role to ensure that the home is managed appropriately. One member of staff provides sleep and one waking cover during each night shift. The staff undertake the cooking and cleaning with the service users assisting where possible. No separate ancillary staff are employed at the home. The manager included a training matrix with the PIQ which showed that all staff are qualified in all the mandatory training such as, Health and Safety, Fire and First Aid. Staff confirmed that they receive support from the manager and their colleagues via meetings, training and supervisions. The manager confirmed that staff work to the Learning Disability Award Framework (LDAF) induction standards in line with national guidelines for good practice. Currently 5 of the 8 staff in the home are either working towards, or have achieved an NVQ level 2 or above this exceeds the NMS of 50 of staff being qualified to an NVQ. Staff spoke highly of the training. Ashwood House DS0000036881.V329612.R01.S.doc Version 5.2 Page 23 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): Quality in this outcome area is Good This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect, the qualified, competent manager is developing a more effective quality assurance system. EVIDENCE: The registered manager is a qualified social worker and teacher, and is seeking advice from the Social Care Skills Council regarding whether he has to complete the Registered Manager’s Award (RMA) or not due to his degree in social care. From records seen and staff views on this inspection, it was evident he has developed monitoring systems for all aspects of the day to day running of the home and is providing strong leadership to the staff team. Ashwood House DS0000036881.V329612.R01.S.doc Version 5.2 Page 24 service users expressed confidence in the manager and felt able to talk to him and be listened to and staff felt he is approachable, supportive and good at his management role by providing clear direction. Service users said they are consulted on a daily basis and at house meetings where their views are listened to and acted on. The current systems used to find out what service users think of the service are being improved, the organisation are developing a quality assurance system which is going to be introduced at the end of March 2007. Annual reviews are held which are attended by service users, their keyworker, the home manager, service users relatives and care managers who are all able to contribute to the evaluation of care provision. The providers complete a monthly audit of care and provide a written record (Regulation 26 notice) to evidence how the service is performing. One service user accesses a local advocacy service and all four service users were supported by staff to complete the CSCI survey prior to this visit and confirmed that staff wrote what they wanted them to. The pre-inspection questionnaire recorded that appliances and equipment were serviced regularly. A number of records and certificates were checked at the visit and were found to be in order. These confirmed the dates given in the pre-inspection questionnaire. In addition, staff completed their own in-house checks on equipment. For example, staff checked that fire alarms were working on a weekly basis and completed a visual check of fire extinguishers every month. Staff records showed that staff were able to complete health and safety training such as first aid, moving and handling and food hygiene on a rolling programme. Their individual training needs were identified through monitoring, supervision and appraisal, and the provider had timescales for all health and safety training refresher courses. The registered manager said that fire training was given and staff confirmed this and explained the procedure. Regulation 37 forms are sent to the commission to inform us of events detrimental to the well being of service users. The home has policies, procedures and risk assessments in place to promote the health and safety of service users and staff. Ashwood House DS0000036881.V329612.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 4 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 4 33 X 34 4 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 X 2 x LIFESTYLES Standard No Score 11 4 12 4 13 4 14 4 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 3 x 4 X 3 X X 4 x Ashwood House DS0000036881.V329612.R01.S.doc Version 5.2 Page 26 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA9 Regulation 13.4(b,c) Requirement Risk assessments must be updated and reviewed regularly, to show that risks have been identified and minimised, to ensure the safety of people living and working in the home. Timescale for action 28/05/07 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 Ashwood House DS0000036881.V329612.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 House DS0000036881.V329612.R01.S.doc Version 5.2 Page 28 - 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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