Inspection on 19/01/06 for Burnt Ash Hill, 94

This inspection was carried out on 19th January 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 found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Burnt Ash Hill, 94 28/02/07

Burnt Ash Hill, 94 23/06/05

Burnt Ash Hill, 94 31/03/05

Burnt Ash Hill, 94 14/06/04

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Edenvale

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Chatsworth Care - Dawson House

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Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Burnt Ash Hill, 94 London SE12 0HT Lead Inspector Lisa Wilde Announced Inspection 19th January 2006 10:00 Burnt Ash Hill, 94 DS0000053308.V277250.R01.S.doc Version 5.1 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 Burnt Ash Hill, 94 DS0000053308.V277250.R01.S.doc Version 5.1 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. Burnt Ash Hill, 94 DS0000053308.V277250.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Burnt Ash Hill, 94 Address London SE12 0HT 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) 020 8851 3824 Aurora Charity Mrs Comfort Amoateng Care Home 6 Category(ies) of Learning disability (0), Physical disability (0) registration, with number of places Burnt Ash Hill, 94 DS0000053308.V277250.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for 6 people with a learning disability of whom 2 are over 65 years. 23rd June 2005 Date of last inspection Brief Description of the Service: Burnt Ash Hill offers a care home to a maximum of six women and men with learning disabilities, who might also have other support needs. The overall aim is that of providing a service driven by the needs, abilities and aspirations of the service users. The home declares its core values to be: individual approaches, equal opportunities, inclusion and shared values. Burnt Ash Hill aims to achieve this by basing the service on a thorough assessment of needs, delivered in collaboration with external agencies. Staff would seek to advance the rights to privacy, dignity, independence, security, civil rights, choice and fulfilment in all aspects of their work and of the environment. The provider is an organisation named: ‘The Aurora Charity’, which also runs other homes. A chief executive and a service manager, to whom all the staff are ultimately accountable, direct the service. The day-to-day running of the home is delegated to a care manager. The premises are a large house, adapted to meet the needs of the residents group. All residents have their own bedroom. The ground floor is fully accessible to people using wheelchairs. The area is residential; it is served by public transport and has a selection of local shops. At the time of this inspection there were no vacancies. Burnt Ash Hill, 94 DS0000053308.V277250.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day in January 2006. The inspector met with seven of the eight current service users, staff, the actingmanager and a senior manager of the organisation who was visiting at the time. Following the inspection the inspector telephoned some relatives, to find out what they thought of the service. Service users said that they were happy and liked living at the home. They liked their rooms and said that staff were very nice. Relatives said that the place was wonderful, that they were more than happy and wouldn’t want their relatives to live anywhere else. They thought their children were happy which was all that they wanted. The inspector found the staff to be knowledgeable of the needs of the service users and committee to offering a high standard of care. All of the requirements and recommendations from the last inspection had been met and only three were identified during this inspection. In the last two inspections the majority of the National Minimum Standards had been met. What the service does well: What has improved since the last inspection? This was the first inspection of this service by this inspector so it was harder to say what had improved. There were not many problems identified at the last inspection but previous requirements and recommendations that had been met by this inspection show that staffing has been increased significantly to make Burnt Ash Hill, 94 DS0000053308.V277250.R01.S.doc Version 5.1 Page 6 sure that there are enough people around to meet service users needs at all times. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Burnt Ash Hill, 94 DS0000053308.V277250.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Burnt Ash Hill, 94 DS0000053308.V277250.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 The home was committed to a full assessment of residents’ needs before they were offered a place at the home so that they could be sure the home could meet their needs before they moved there permanently. EVIDENCE: The evidence in this area was the same as at the last inspection. No new resident had come to live at the home since 1998. The policy of the organisation in relation to any future admissions was that prospective residents would need to receive a full assessment, by the appropriate professionals. Only then the home would confirm the offer of a place, if the home could meet the identified needs and aspirations. Burnt Ash Hill, 94 DS0000053308.V277250.R01.S.doc Version 5.1 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 & 10 Service users have their needs and goals written down in their care files with detailed action plans in place to show staff how those needs are to be met and goals achieved. Service users are fully involved in the drawing up of these plans and when they are reviewed, to make sure that as their needs and wishes change, staff change their way of working so the support they are offered is flexible. Certain parts of the care file, including the part that describes service users’ wishes and goals in their own words have not yet been completed. Service users have access to all files as they are stored and used in the dining area which is where service users and staff generally sit. While this is obviously an attempt to make service users comfortable with their own files (which is to be commended) it does mean that confidential information is not being handled entirely appropriately. EVIDENCE: All service users have a care plan and two of the service users showed theirs to the inspector. There were detailed guidelines for staff about how to support service users and a life plan that described all areas of a service users life. There were more formal care plans in place outlining staff action to show how Burnt Ash Hill, 94 DS0000053308.V277250.R01.S.doc Version 5.1 Page 10 certain goals were to be met. Certain parts of the life plans had not yet been completed, as the manager said that this style of person centred planning was fairly new to the service and certain staff had been on leave. (See Requirement 1) Service users files were stored in a cupboard in the lounge, which was in use and open at the time of the inspection. Service users had access to this cupboard so that they could see their own files. Staff were using and writing in the files at the table in the lounge. There is staff office but it is at the top of the house and did not appear to be used regularly. (See Requirement 2) Burnt Ash Hill, 94 DS0000053308.V277250.R01.S.doc Version 5.1 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 17 Staffing levels have been increased which means that now service users can enjoy their mealtimes without being rushed to finish because their are not enough staff on duty. EVIDENCE: There were previoue requirements that the registered provider must ensure that residents receive adequate support so that they can enjoy relaxed and unrushed mealtimes and the registered provider must: - Conduct a thorough review of the staffing levels against each resident’s needs, behaviour, actions, aspirations and the ethos of the home. - Prepare a statement of what they consider minimum suitable staffing levels. - Ensure that at all times suitably skilled staff are working at the home in such numbers as are appropriate for the health, welfare and support needs of residents. - Ensure that staffing levels are consistent with an assessment of safer working practices for residents and staff. The previous inspector had seen the staffing review and at this inspection staffing levels had been increased to a minimum of two staff at all times, with three at busier times. Staff and the manager said that in emergency situations Burnt Ash Hill, 94 DS0000053308.V277250.R01.S.doc Version 5.1 Page 12 sometimes there is only one member of staff on duty for a while but this only when staff call in sick at short notice and no cover can be arranged. Staff reported that the increased staffing is a significant improvement and they felt that there were now enough staff on duty at all times. Burnt Ash Hill, 94 DS0000053308.V277250.R01.S.doc Version 5.1 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were assessed as all the key standards were assessed as met at the last inspection. EVIDENCE: Burnt Ash Hill, 94 DS0000053308.V277250.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Neither of these standards were assessed as both were assessed as met at the last inspection. EVIDENCE: Burnt Ash Hill, 94 DS0000053308.V277250.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 28 & 30 The communal areas of the home are comfortable and clean throughout. The place is decorated in a homely manner and service users are involved in choosing the colour schemes and furniture. EVIDENCE: At the time of the inspection the communal areas of the home were clean and hygienic throughout. There is a kitchen with attached dining area and a separate lounge. All areas are large enough and creates spaces for service users to choose who they spend time with outside of their rooms. There was a previous requirement that the registered provider must ensure that garden furniture is adequate to ensure both comfort and protection from the sun. This had been done but was not in use at the time of the inspection as it was still too cold to use the garden. There are plans to create a patio area in the garden to allow service users to use it more frequently in summer. Burnt Ash Hill, 94 DS0000053308.V277250.R01.S.doc Version 5.1 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 & 33 The home is not yet meeting the target of 50 of the care being provided by staff who hold the NVQ Level 2 in Care, or equivalent. This means that service users are not receiving care and support from the most qualified staff team possible. Now that staffing levels have been increased, the staff team is effective and service users have their needs met when they need to be by there being enough staff on duty at all times. EVIDENCE: Currenlty two out of five care staff are undertaking or hold the NVQ Level 2/3 in Care, which doesn’t quite meet the target for 50 of staff holding this qualification. (See Requirement 3) There was a previous recommendation that a minimum of two staff are on duty to support residents at busy times. This would include the late afternoon/evening, when residents are getting ready to go out in the morning and weekend days, (if most residents are not away). As stated previously there has been a staffing review and there is now a minimum of two staff on duty at all times. Weekly rotas showed that this staffing level is in place each day, including weekends. Burnt Ash Hill, 94 DS0000053308.V277250.R01.S.doc Version 5.1 Page 17 The personnel records are not held at the home but at head office with other home’s records. An inspector will assess all these records together at date point following this inspection. Burnt Ash Hill, 94 DS0000053308.V277250.R01.S.doc Version 5.1 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 & 39 Although the current Registered Manager is on extended leave the acting manager showed her ability to effectively manage the service in her absence. The Registered Manager is due to return to the service a few weeks after this inspection. The organisation monitors the service effectively through regular inspections, service user surveys and discussions with family and other stakeholders. Development plans are drawn up and reviewed annually to make sure that the home improves in ways that are based on the views of people who use the service. EVIDENCE: There has been an acting manager in place for a few months now to cover the Registered Manager’s extended leave. The Registered Manager is due to return a few weeks after this inspection. The Registered Manager is currently undertaking the NVQ Level 4 in Care and Registered Managers’ Award Level 4. Burnt Ash Hill, 94 DS0000053308.V277250.R01.S.doc Version 5.1 Page 19 The organisation conducts at least annual service user/family/stakeholder surveys and audits of its service. It draws up a development plan based on the views of service users and their families and reviews this plan every year. A senior manager was conducting the monthly internal check at the time of this inspection and it was seen to be thorough and detailed, picking up on daytoday and longer-term issues for the home. These reports and any incident reports are sent though as required to the Commission. Health and safety and financial audits take place with external accountants auditing the organisation’s accounts. Burnt Ash Hill, 94 DS0000053308.V277250.R01.S.doc Version 5.1 Page 20 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 X 23 X ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X X 2 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X 3 X 3 X X X X Burnt Ash Hill, 94 DS0000053308.V277250.R01.S.doc Version 5.1 Page 21 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 YA6 Regulation 15 (1) & (2) 17 (b) Requirement The Registered Manager must ensure that all areas of the service users’ life plans are completed The Registered Manager must ensure that all service users information is stored and handled in a confidential manner. The Registered Individuals must ensure that at least 50 of staff hold the NVQ Level 2 in Care, or equivalent. Timescale for action 31/03/06 2. YA10 07/02/06 3. YA32 18 (1) (c) (i) 31/03/06 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 Burnt Ash Hill, 94 DS0000053308.V277250.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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 Burnt Ash Hill, 94 DS0000053308.V277250.R01.S.doc Version 5.1 Page 23 - 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. 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