Inspection on 26/06/06 for Asra House

This inspection was carried out on 26th June 2006.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Asra House 13/12/07

Asra House 11/04/05

Asra House 14/10/04

Asra House 18/05/04

Similar services:

Applegarth

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

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

CARE HOMES FOR OLDER PEOPLE Asra House 15 Asha Margh, Holden Street Leicester Leicestershire LE4 5LE Lead Inspector Lesley Allison-White & Keith Charlton Key Unannounced Inspection 09:30 26th June 2006 X10015.doc Version 1.40 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 DS0000006410.V286953.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 Older People. 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. DS0000006410.V286953.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Asra House Address 15 Asha Margh, Holden Street Leicester Leicestershire LE4 5LE 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) 0116 266 2727 0116 266 6051 ASRA Midlands Housing Association Mrs Husaina Hirani Care Home 38 Category(ies) of Old age, not falling within any other category registration, with number (38), Sensory Impairment over 65 years of age of places (3) DS0000006410.V286953.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. No person falling within category SI (E) may be admitted to the home when 3 persons of that category are already accommodated within the home. To be able to admit the named person of category OP named in variation application V26884 dated 4:11:05. 21st September 2005, 10:30am Date of last inspection Brief Description of the Service: Asra House is registered to accommodate up to thirty-eight older people and up to 3 people with sensory impairment. Asra House is part of the Asra Midlands Housing Association, which provides care for older persons with an Asian lifestyle. Asra House comprises of a series of self-contained flats on two floors with single and double rooms, joined by the communal areas, offices and a passenger lift to the upper floor. There is a large communal lounge on the ground floor, a quiet / private lounge for special family gatherings and a dining room adjacent to the kitchen. Asra House provides culturally appropriate prepared meals for the residents. Asra House has access to a minibus that is used for day trips. Asra House is purpose built and wheelchair friendly. Asra House has a pleasant aspect and is set back amongst trees surrounded by a garden area with seating area around the shrubs and plants. There are many places to shop and community facilities on the main road nearby. Asra House is in the heart of a multicultural community and there are ample places of worship and appropriate community amenities and activities. There is ample public transport to the local facilities and the city centre, which is ten-minute bus-ride from the home. Fees range from £270 to 370.00 and are subject to Social Services increments. DS0000006410.V286953.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector had the use of an interpreter to enable communication with residents to take place for this inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is on outcomes for residents and their views of the service provided. Inspection planning took three hours and consisted of a full review of the Inspection record. This is a tool used by inspectors, to record their planning. This involves any previous requirements or recommendations made, the Home’s service history record including notifications of accidents, events and incidents, any previous comments received from residents and relatives and previous correspondence between CSCI and the Home. The information was collated and analysed to form the plan of inspection focusing on the outcomes for Residents. This inspection was carried out unannounced and lasted for some seven hours in total with the Registered Manager present. The primary method of inspection used was ‘case tracking’ which involved selecting three residents and tracking the care they receive through review of their records, talking with them and/or observations of practices of care staff. The outcomes for residents were, given the various health conditions of residents, mainly judged on observations made at the visit. Three staff and ten residents were spoken with to obtain their views. In some cases an interpreter was used who spoke a number of Asian languages. The inspector did not have the opportunity to speak to relatives visiting the home later on the day of the inspection. Staff employed at Asra House are from an Asian background and are able to meet cultural and community language needs of individual residents. Individual staff records confirm a wide range of training is provided to staff at all levels in the home. Residents said that they liked their bedrooms and the home was kept clean and tidy and odour free. The accommodation inspected was generally in a good state of repair. Flats are roomy and include a spacious living, dining and kitchen area. All areas inspected were clean and well maintained. Residents said that they would go to the Registered Manager or senior staff if they had concerns and thought this would be sorted out. DS0000006410.V286953.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: There are two Complaints Procedures, which do not follow the same course of action, which could be confusing to complainants. DS0000006410.V286953.R01.S.doc Version 5.2 Page 7 A number of residents said that there were not many activities or outings though they were only bothered about not being able to go to the Temple to worship. A room was provided within the home that enabled worship to take place when ever the residents needed it. The Registered Manager said there were not enough drivers but she would look into organising taxis instead. Residents were very complimentary of the friendly care they received from staff. Staffing ratios appeared generally satisfactory. There are risk assessments for safe working practices in the home, although there was not one for the risk of burning to service users from uncovered radiators. The Registered Manager said this would be carried out shortly and sent to the inspector and action taken if a risk is identified. This has now been done. 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. DS0000006410.V286953.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000006410.V286953.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 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 robust admission process with clear information available describing the services of the house. EVIDENCE: The Registered Manager undertakes written assessments of prospective residents before entering the home. There was evidence of assessments. Current Residents living at the home came from many diverse Asian backgrounds. The majority of residents were Hindu’s and spoke Gujarati there were other residents from minority religions such as Punjabi (spoke Punjabi) or Muslims, (who spoke Gujarati) There were Asian residents from Tanzinia (Africa) who spoke Swahili. Staff was also from appropriate culturally diverse backgrounds that matched the residents needs and expectations. DS0000006410.V286953.R01.S.doc Version 5.2 Page 10 Residents were comfortable in attempting conversation with each other although their mother tongue was slightly different. Five different languages took place in conversations in the lounge. Service users spoken to confirmed that they had some involvement in the choice of home. There were no intermediate facilities offered at the home. (Standard 6). DS0000006410.V286953.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is successful in delivering health and personal care culturally appropriate to individual residents. EVIDENCE: Residents could remember having Care needs assessed and this was observed generally detailing how their care needs should be met. Overall care plans were of reasonable quality and content and were routinely evaluated on a monthly basis by a named key worker with evidence regarding risk assessments. Discussions took place with care staff about their knowledge of care plans and there was awareness of care plan contents. Service users were very complimentary of the friendly care they received from staff. DS0000006410.V286953.R01.S.doc Version 5.2 Page 12 The Registered Manager was asked to review the accident procedure, as there were instances where medical authorities were not alerted following a head injury to a service user. Residents told the inspector that the General Practitioner (GP) visited every Thursday to see residents as required. Residents explained that they were able to get help when required from staff. There was evidence of choices and continuity of care as wheel chair assessments at the hospital and was followed up by the home. The resident felt that they had a choice as to when the rose and choose what to wear. They told the inspector that they went out to the Dentist when required. The regular a GP was male but for anything personal a female nurse would come out. Residents’ used their wheel chair around the home and enjoyed the independence this gave. Many of the Women wore Sari’s (Female Asian clothing) of their choosing. The residents were well presented at all times during the inspection. Some residents’ case tracked was self- medicating. This meant that they took their medications when they needed to and stored them safely in their rooms. The staff that gave medicines was asked about this and they explained that they check on self- medication residents weekly to ensure that medication is being taken correctly. One resident had “their own way” of taking large tablets by breaking them in half and storing them in an unlabelled bottle. Controlled drugs were stored in the treatment room they were checked and fine. DS0000006410.V286953.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home succeeds in meeting the identified daily and social needs and the outcome is positive for the residents. EVIDENCE: A number of residents said that there were not many activities or outings though they were only bothered about not being able to go to the Temple to worship. The Registered Manager said there were not enough drivers but she would look into organising taxis instead. Evidence from the home clearly showed that a number of activities have taken place at various times during the year. Many of the residents said that members of their family visited regularly and took care of their social needs. One resident said that a son took them out weekly; another resident said that they were not bothered about going out to the religious festivals as they were “wobbly” but went out to Eid and celebrated with family at their home. (This resident was Muslim, which was a minority religion in this home). The resident spoke of the second lounge being used for prayers and religious song (known as Bhagen, which is chanted) the second lounge is used as DS0000006410.V286953.R01.S.doc Version 5.2 Page 14 desired by residents. Some residents said that since living at the home they had found special friends whose company they enjoyed. The residents from minority religions at this home were asked if there were any problems living together they replied “there are no arguments about religion and we all eat in the same dining room together.” One resident told the interpreter that when they visited the home they loved it and asked to stay. This resident had come from another home where they found the language (English), difficult to understand. Residents said that staff welcomed their visitors as the inspector left the home visitors entered and were made welcome by staff. Residents also spoke about their families who brought in treats for them to eat special meals on special occasions. They all spoke of the homes flexible attitude on this as it made them feel comfortable to be able to do this. Residents said the food was either good or very good. Food records did not always show a choice – the Registered Manager said that this was because food was freshly made and offering a choice was impractical and not requested by Residents. Asian and diabetic diets are catered for. A hot lunch of curries was being served and looked nutritious and appealing. The staff serving lunch was observed as again being very attentive and caring to individual residents needs. Both the dining and kitchen areas were maintained to high standards. The dining rooms had hand wash basins, soap and driers for staff and residents to use if they needed to. Some food was served using the hands as in a traditional home setting. Residents were observed enjoying their nutritious meal and fresh fruit was served which Residents dining appeared to enjoy. DS0000006410.V286953.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has procedures for dealing with complaints and protection however further training for staff will potentially give protection to residents. EVIDENCE: The Commission have received a complaint that the home is responding to. The Registered Manager is currently investigating a concern raised by an anonymous person regarding the behaviour of one staff member. Residents said that they would go to the Registered Manager or senior staff if they had concerns and thought this would be sorted out. Examination of the complaints procedure and associated records indicated that complaints are appropriately managed. There are two Complaints Procedures, which do not follow the same course of action, which could be confusing to complainants. Some staff members spoken to were fully aware of the correct reporting procedures for allegations /incidents of abuse. Other staff needed a better understanding for reporting systems outside of their own organisation. DS0000006410.V286953.R01.S.doc Version 5.2 Page 16 There are regular residents meetings where resident’s views are discussed and promptly acted upon. The minutes from these meetings are written in English and the majority of residents at the home do not use English as a first a language. It was suggested by the inspector that a taped copy of the meetings as per minutes are saved for residents to listen to at their leisure in an appropriate Ethnic language. DS0000006410.V286953.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with a safe, hygienic and comfortable environment. EVIDENCE: Residents said that they liked their bedrooms and the home was kept clean and tidy and odour free. The accommodation inspected was generally in a good state of repair. The Registered Manager said that internal paintwork to residents’ bedrooms was planned to be carried out this year to deal with scrapes and flaking paintwork. Communal areas were clean and well maintained. Flats are roomy and include a spacious living, dining and kitchen area. All areas inspected were clean and well maintained. DS0000006410.V286953.R01.S.doc Version 5.2 Page 18 Both the dining and kitchen areas were maintained to high standards. The dining rooms had hand wash basins, soap and driers for staff and residents to use if they needed to. The outdoor area is also well maintained with a seating area outside looking onto a lawn, trees and border plants. On the day of inspection the outside of the building was being painted. DS0000006410.V286953.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 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 satisfactory recruitment procedure. Despite the lack of recorded supervision the home succeeds in providing a competent staff team that meets the needs of and protects residents. EVIDENCE: Residents said that staff were friendly and quickly responded to their needs. Staff employed at Asra House are from an Asian background and are able to meet cultural and community language needs of individual residents. Individual staff records confirm a wide range of training is provided to staff at all levels in the home. The Registered Manager is to look into setting up a training matrix so that it will indicate at a glance where training is needed. A staff member confirmed they receiving training in a range of care issues and looking forward to taking the National Vocational Qualification (NVQ) level 2 level course. The Registered Manager confirmed the majority of staff have a NVQ level 2 or equivalent in care and new staff are provided with a certified induction programme ensuring residents are in safe hands. DS0000006410.V286953.R01.S.doc Version 5.2 Page 20 Staff recruitment records do not have copies of references or Application forms which are kept at head office – the Registered Manager was asked to ensure copies are kept in the home available for inspection. Despite the lack of recorded supervision the home succeeds in providing a competent staff team that meets the needs of and protects residents. DS0000006410.V286953.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is being run in the best interests of residents. EVIDENCE: The Registered Manager holds a nursing qualification and extensive management and care experience. On a daily basis she works very closely with residents and staff and is able to discharge her responsibilities fully. She attends training with her staff and provides regular staff appraisals and team meetings ensuring staff are supported. Comments received from service users and staff indicated they thought the Registered Manager was good at managing the service. DS0000006410.V286953.R01.S.doc Version 5.2 Page 22 There has been a Quality Assurance system carried out this year to check the service for service users – it was recommended that this process extend to relatives, District Nurses, GPs etc. There are staff meetings, which are documented. The Registered Manager acknowledged that these were not as regular as was needed and the frequency will increase. There have been regular service user meetings, which were documented in detail. There was also an acknowledgement that there has been no formal supervision of staff apart from formal appraisals and these will be introduced and carried out on a regular basis. There are risk assessments for safe working practices in the home, although there was not one for the risk of burning to service users from uncovered radiators. The Registered Manager said this would be carried out shortly and sent to the inspector and action taken if a risk is identified. This has now been done. Fire checks were thorough in that fire drills had been carried out on a three monthly basis, emergency lighting carried out on a monthly basis and fire bell testing had been carried out on the required weekly basis. Records showed the Fire Officer had recently visited and confirmed the fire risk assessment was fully satisfactory. The water temperature was tested in a bathroom and found to be 44c, complying with the National Minimum Standard of 43c. Temperatures are monitored on a monthly basis. The Registered Manager holds records of small transactions for resident’s money, which is well organised and secure. Window restrictors are on all windows to prevent the risk of accidents. DS0000006410.V286953.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 4 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 4 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X 3 DS0000006410.V286953.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? None 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. Standard Regulation Requirement Timescale for action 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 OP9 OP37 Good Practice Recommendations Need to review the suitability of the type of dispenser used for self-medication residents. To ensure documented evidence of staff supervisions. DS0000006410.V286953.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Northamptonshire Area Office 1st Floor Newland House Campbell Square Northampton NN1 3EB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © 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 DS0000006410.V286953.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!