Care Home: Ashburnham Grove (75)

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What the care home does well Adequate information was provided about the service. Care plans were person centred and resident`s care need kept under review. Staff worked with residents and relatives to ensure residents had a lifestyle that suited them and all residents. Staff worked with residents, relatives and life planners to ensure residents let fulfilled lives and to plan future goals. Residents were supported to access local facilities and to be part of the local community. Despite budget restraints staff ensured the home was nicely decorated for the residents by doing a lot of the painting themselves Staff spoken with were very knowledgeable about residents and their care and emotional needs. Systems were in place to ensure the health needs of the residents were met. The environment was well maintained and homely. Systems were in place to manage complaints and to ensure safeguarding people. All suspicions of abuse were referred to the learning disability team. Staff received training relevant to the work they did and received regular supervision. The service was well managed, adequate staffing levels were maintained and staff presented and said they worked well together as a supportive and enabling team. Many of the staff team had been in post for long periods, which provided continuity of care for residents. Policies and procedures were kept under review. Regular audits were undertaken on specific areas of the service. Attention was given to providing a safe environment for residents and others. What has improved since the last inspection? Staff were dating and signing documents. Foods with a shelf life were dated when opened. Medicine management had improved and medicine profiles were prepared for all residents. Improvements had been made to the environment through some areas having new flooring fitted, some areas were redecorated and new furniture and fittings were provided in some rooms. Requirements made at the last inspection in relation to the environment had been met. Improvements had been made to reviewing the quality of the service. What the care home could do better: Ensure staff countersign hand written entries they make of medicine administration charts and staff do not transfer medicines from the dispensed container to another container. Continue to develop the quality assurance system. CARE HOME ADULTS 18-65 Ashburnham Grove (75) 75 Ashburnham Grove Greenwich London SE10 8UJ Lead Inspector Ms Pauline Lambe Unannounced Inspection 12th January 2009 09:40 Ashburnham Grove (75) DS0000036887.V373794.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 Ashburnham Grove (75) DS0000036887.V373794.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. Ashburnham Grove (75) DS0000036887.V373794.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashburnham Grove (75) Address 75 Ashburnham Grove Greenwich London SE10 8UJ 020 8692 5032 020 8692 4301 Angela.Gibbons@greenwich.gov.uk 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) Greenwich Council Angela Margaret Gibbons Care Home 11 Category(ies) of Learning disability (11) registration, with number of places Ashburnham Grove (75) DS0000036887.V373794.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (CRH - PC) to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Learning disability - Code LD The maximum number of service users who can be accommodated is: 11 8th February 2008 Date of last inspection Brief Description of the Service: Ashburnham Grove is a registered care home for eleven younger adults with a learning disability, who are residents of the London Borough of Greenwich. The registered provider for the service is Greenwich Council. The home is situated in West Greenwich, within a conservation area known as the Ashburnham triangle. The home is close to the centre of Greenwich, the train station, Greenwich park and Maritime Museum. The service accommodates seven permanent residents within two flats, and four short-term or respite residents in a separate flat on the first floor. All the bedrooms are for single occupancy. The respite and long stay residents live on separate floors and each floor has a designated staff team. The property has a separate flat to the rear of the building, which residents use for leisure and activities. Greenwich Learning Disability pays the care fees with residents paying nominal fees for food, transport and rent. Residents pay privately for personal items such as toiletries, social outings and holidays. Ashburnham Grove (75) DS0000036887.V373794.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 star. This means the people who use this service experience excellent quality outcomes. The site visit for this unannounced inspection was completed over two visits. The first visit was on 12th January 20009 and the second visit was on 13th January 2009 with an expert by experience. The manager, staff and where possible residents, participated with the inspection. The home had seven long stay, one emergency and two respite residents at the time of this inspection. The last key inspection was on the 8th February 2008 and on 12th March 2008 a pharmacy inspector from the Commission completed a separate medicine inspection. The inspection included a review of information held on the service file, a tour of the premises and inspection of records, talking to residents and the staff team and reviewing compliance with previous requirements. The manager sent a completed Annual Quality Assurance Assessment (AQAA) to the Commission, which provided information on the service over the last year and plans for future development. Feedback surveys were sent to residents prior to the inspection but currently the Commission do not send surveys to relatives. Feedback was received from five people including telephone contact with two relatives. The expert by experience spent time with residents, staff and management and provided a report to the Commission on their findings. Feedback about the service and the quality of care provided was positive. The manager and staff worked well together to ensure the service was well run. Staff displayed a very good understanding of the residents and their needs and ways in which they acted as advocates for residents. One to one care was provided for residents when this was needed. Staff supported residents to have a lifestyle that suited them, to ensure residents had an annual holiday and staff worked well together to provide a caring and homely atmosphere for the people who live in the home. The expert by experience found many positive aspects about the service provided and did not report any negative aspects. What the service does well: Adequate information was provided about the service. Care plans were person centred and resident’s care need kept under review. Staff worked with residents and relatives to ensure residents had a lifestyle that suited them and all residents. Staff worked with residents, relatives and life planners to ensure residents let fulfilled lives and to plan future goals. Residents were supported to access local facilities and to be part of the local community. Ashburnham Grove (75) DS0000036887.V373794.R01.S.doc Version 5.2 Page 6 Despite budget restraints staff ensured the home was nicely decorated for the residents by doing a lot of the painting themselves Staff spoken with were very knowledgeable about residents and their care and emotional needs. Systems were in place to ensure the health needs of the residents were met. The environment was well maintained and homely. Systems were in place to manage complaints and to ensure safeguarding people. All suspicions of abuse were referred to the learning disability team. Staff received training relevant to the work they did and received regular supervision. The service was well managed, adequate staffing levels were maintained and staff presented and said they worked well together as a supportive and enabling team. Many of the staff team had been in post for long periods, which provided continuity of care for residents. Policies and procedures were kept under review. Regular audits were undertaken on specific areas of the service. Attention was given to providing a safe environment for residents and others. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ashburnham Grove (75) DS0000036887.V373794.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ashburnham Grove (75) DS0000036887.V373794.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were admitted to the home based on a full assessment of need and regular respite residents had their needs reviewed at each admission. EVIDENCE: No long stay residents were admitted to the home since the last inspection. Residents were admitted to the service based an assessment of need completed by the community Learning disability Team (CLDT) and an assessment completed by staff from the service. Where possible new residents were given the opportunity to visit the home, have an overnight stay and get to know staff and residents before taking up permanent residence. Regular respite residents had their care needs assessed prior to their first stay in the home and a review of needs at each admission. However respite people did not routinely have a pre-admission assessment completed prior to each admission. Ashburnham Grove (75) DS0000036887.V373794.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 9. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Care plans seen were person centred and reflected resident needs. Staff made efforts to ensure residents were involved in decisions about their care and lifestyle. Residents were supported to participate in all aspects of living based on risk assessment. EVIDENCE: Care records for two residents were viewed, one for a respite and one for a long stay resident. Care records were person centred, were written in the first person, reflected the person’s needs, showed how these were to be met and were kept under review. Records seen included needs assessments, risk assessments and care plans. The care plans were updated six monthly or when a person’s needs changed. Risk assessments had been completed on areas such as eating problems, money management, use of the kitchen, trips and falls, seizure management, going out of the home and mobility. The assessments seen provided adequate guidance for staff on how to manage risks. The care plans seen provided adequate guidance for staff on how to Ashburnham Grove (75) DS0000036887.V373794.R01.S.doc Version 5.2 Page 10 meet residents and included information on the person’s skills, independence and abilities. Feedback received from residents who could comment and from relatives indicated satisfaction with the care provided. Comments made included “I am very pleased with my relative’s care”, “I can do what I want” and “my relative is very happy to stay in the home”. CLDT and staff from the home assessed resident’s needs prior to their first admission for respite care. On subsequent admissions staff contacted carers’ or relatives to get an update on the resident’s state of health and well being. If this had not changed then care plans prepared previously were continued. If there had been changes to care needs then the person would be reassessed and care plans reviewed. The home accommodated residents for regular respite care, which meant staff became familiar with the resident, their care needs and their relatives. The findings of the expert by experience were that long stay and respite residents were relaxed and comfortable in the home and were happy with the care they received. Residents who spoke to the expert said that they liked the home and were happy there. One person said they had stayed at the home before in the respite section, but came back when they could not cope with living on their own. Residents said they felt safe in the home. Feedback from residents and relatives showed satisfaction with the care provided. Information provided in the AQAA said that staff had convened best interests meetings to arrive at the best possible decision for the residents and these involved a range of professionals and families. Most of the residents were unable to fully participate in decision-making. Staff worked with relatives to ensure resident’s needs were met and appropriate decisions were made on their behalf. Over time staff became familiar with the resident’s likes, dislikes, areas of interest and mood changes. This helped staff provide suitable activities, know when to use distraction methods and to provide care in a way that suited the person. Respite residents were often more able to make decisions and staff supported and encouraged this. For example supporting residents to go out alone and to remain independent. As mentioned risk assessments were in place where needed. Risk assessments seen included some in relation to safety, eating, participation in various activities, going out alone or assisted and use of kitchen facilities. Restrictions were only made to resident freedom if this was in their best interest and to ensure their safety. Staff worked with relatives to ensure residents had the opportunity for personal development and to enjoy socialising based on assessment. Ashburnham Grove (75) DS0000036887.V373794.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15, 16 and 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents were supported to take part in age appropriate activities both in the home and in the community. Contact with relatives and friends was encouraged. Menus seen showed a varied diet was provided. EVIDENCE: Most of the residents attended day centres during the week where they had opportunities for personal and social development and to engage in activities of choice. The day centre staff wrote reports on the person’s progress and involvement in various activities. The home and day centre staff worked together to ensure residents were involved in activities that suited their ability and interests. There were no plans in place for the current residents to seek paid employment or to live independent lives. A ‘life planner’ was involved with preparing life plans for and with residents, which reflected progress made and agreed goals for future development. The findings of the expert by experience were that residents were offered Ashburnham Grove (75) DS0000036887.V373794.R01.S.doc Version 5.2 Page 12 various activities in and out of the home. They had choices of what to do, like bowling, shopping, and cinema. A member of staff who spoke to the expert said residents were supported with cleaning and tidying their bedrooms, gardening and bed making. Feedback from residents and relatives showed satisfaction with the resident’s lifestyle. Information provided in the AQAA included that three of the residents in the home had chosen not to attend day centre services, two of those people now attended the older persons day centre twice a week, as this was a smaller group and more suited to their needs. Four of the residents also attended a sensory club once a week. Also included was that in the last year staff introduced coffee mornings for the respite unit, this was done to give family carers the opportunity to meet staff and discuss any issues. Residents were supported to take part in activities of choice and to access local facilities such as outings to the cinema, the pub, restaurants, hairdressing, local parks and to enjoy day trips and holidays. Staff worked with relatives to ensure they become familiar with residents choice and preferences and to include this in care planning. Risk assessments were completed where needed in relation to activities and outings. The findings of the expert by experience were that residents were supported to access community facilities. For example one person went to help out at a community farm and another person went out to the pub in the evenings and helped staff there. Residents were happy and excited when talking about these activities. Many relatives remained very involved with their resident’s life. Relative feedback showed that they were welcome to visit the home and where possible residents spent time at home with their family. Relatives said that staff kept them informed of issues regarding their resident and involved them in their care. One comment made included “staff are excellent at getting residents out into the community”. The findings of the expert by experience was that friends and family were allowed to visit the residents at the home. The findings of the expert by experience was that staff worked well with residents who had high communication needs. Staff provided picture reference tools. Residents spoken with said that they can have private moments if they wish. One person said “I can go and sit in my bedroom to have a quiet time if I need to”. Residents had their meals provided in the flats they occupied. The kitchens in flats 1 & 2 seen were clean and tidy. Adequate food supplies were seen and records were kept for the fridge, freezer and food temperatures. Where possible residents were involved with preparing menus and meals. Staff had compiled a file of meal pictures to help with resident involvement when planning menus. Menus seen showed a varied and nutritious diet was provided. The kitchen on the respite flat was clean and tidy and since the last inspection had new flooring and new worktops fitted. The findings of the Ashburnham Grove (75) DS0000036887.V373794.R01.S.doc Version 5.2 Page 13 expert by experience were that residents participated in the planning and preparation of meals. During the visit the expert observed one resident helping to prepare the evening meal and laying the table with staff support. A choice of meals was offered in case people did not want what is on the menu on the day. Ashburnham Grove (75) DS0000036887.V373794.R01.S.doc Version 5.2 Page 14 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): Standards 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems were in place to ensure the personal and healthcare needs of residents were met. Resident’s privacy and dignity was respected. Medicine management had improved. EVIDENCE: Care plans seen showed how personal care needs were to be met. All bedrooms were for single occupancy, which provided privacy for residents. Staff were observed knocking on bedroom doors before entering and interacting in a patient and supportive way with residents. Personal care was given in private. It was difficult to assess this standard from residents view due to communication difficulties. The findings of the expert by experience was that staff were friendly and treated the residents well. Feedback from residents and relatives did not indicate they had any concerns as to how staff met the care needs of the residents. All residents were registered with a GP and respite residents remained registered with their own GP when staying in the home. Arrangements were in Ashburnham Grove (75) DS0000036887.V373794.R01.S.doc Version 5.2 Page 15 place to ensure other health care needs such as dental, vision and chiropody services were made available to residents. A private chiropody service was available if residents and relatives preferred this. Staff provided foot care for residents following training and where appropriate. Staff supported residents to attend hospital and psychiatric appointments and clinical reviews. A medicine policy and procedure was provided and was updated in March 2008. Medicines were stored separately for each flat. Medicine management was viewed for all flats. For flat 1 the medicines were stored in the staff office. This room was quite hot during the warm weather. On the day of the inspection the temperature records seen showed that the room temperatures were satisfactory. Medicines were stored in a metal cabinet fixed to the wall. Boots supplied medicines in a monitored dose system together with pre-printed administration charts. Internal and external medicines were stored separately and the medicine fridge temperature was monitored daily. Medicine supplies and records were checked for two residents. For one person one dose of one medicine was not signed for at the time of administration, however the stock of medicines were correct which indicated the dose was given. The supply of one medicine for the second person were incorrect as there were more in stock than had been dispensed. This may have happened if staff transferred old stock to the new container. Staff had not countersigned all the handwritten entries they had made on administration charts. In flat 2 there was a lack of adequate storage space for the amount of medicines held. Otherwise storage arrangements were satisfactory including the storage for controlled drugs. Medicine supplies and records were checked for two people and were correct. However staff had not countersigned all hand written entries they had made on the administration charts. In the respite flat medicines were stored in the staff office. A metal storage cabinet was provided to store medicines and this was fixed to the wall. Medicine supplies and records were checked for two people and were found to be correct. However staff had not countersigned all hand written entries they had made on the administration charts. In all flats staff recorded receipt of medicines on the administration chart and kept a record of medicines returned to the pharmacy. The temperature of storage areas and the fridge were monitored daily. Staff had access to up to date information on medicines and since the last inspection all staff responsible for managing medicines had received training competency assessments completed. Medicine profiles were introduced for residents and a system put in place to complete an annual competency assessment for staff that managed medicines. Requirement 1 and recommendation 1. Ashburnham Grove (75) DS0000036887.V373794.R01.S.doc Version 5.2 Page 16 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): Standards 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Adequate procedures were in place to manage complaints and safeguard people. Relatives and residents indicated they knew how to make a complaint. EVIDENCE: A complaints policy and procedure was provided and residents were provided with a copy of the procedure in a format with widget icons. Feedback from residents and relatives indicated they knew how to make a complaint and who to talk to if they had concerns. No complaints had been recorded since the last inspection and none were made to the Commission. It was therefore not possible to fully assess complaint management however the manager was aware of the need to comply with this standard. The finding of the expert by experience was that residents were aware of the complaints procedure. When one person was asked what they would do if they were not happy about something, they said ‘I will tell the staff or the manager’. A copy of Greenwich safeguarding adult procedure was provided. Allegations or suspicions of abuse were referred to the community learning disability team for investigation. Since the last inspection the local authority were informed of a safeguarding issue involving two residents. Management and staff spoken with displayed an awareness of safeguarding adults and their responsibility should abuse be alleged or suspected. The training programme included sessions for staff on safeguarding people. One comment made to the expert by experience by a resident was “I feel safe in the home”. Ashburnham Grove (75) DS0000036887.V373794.R01.S.doc Version 5.2 Page 17 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): Standards 24, 25, 27, 28 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff and management had done a lot of work to improve the environment and to ensure it met the needs of the residents. Staff supported residents to participate in the decoration programme and with choosing furniture and fittings. The environment was well maintained. EVIDENCE: Flat one had two bedrooms, a bathroom, lounge and a kitchen diner. The lounge and hall area was nicely decorated, had laminate flooring and furniture and fittings were in good condition. The two bedrooms were viewed and were clean, tidy and personal. Both rooms had been redecorated and had laminate flooring fitted. The bathroom was clean and tidy and the flooring had been replaced since the last inspection. Flat two had five bedrooms, shower room and toilet, kitchen and lounge diner. The lounge had been redecorated and had laminate flooring fitted, furniture and fittings were in good condition. The four bedrooms seen were nicely personalised and decorated to a good standard. In two bedrooms the carpets Ashburnham Grove (75) DS0000036887.V373794.R01.S.doc Version 5.2 Page 18 were stained and the manager said that plans and agreements were in place to replace these. The bathroom and kitchen were clean and hot water checked was within safe limits. All areas seen were clean and tidy and no unpleasant odours were noted. The respite flat on the first floor had four bedrooms, a lounge/diner, kitchen and bathroom. The lounge was nicely decorated and furnished. The bathroom was clean and tidy. All bedrooms were viewed and were well maintained. Since the last inspection new flooring and worktops were fitted in the kitchen and plans were in place to redecorate the room. The corridor in this flat was repainted and had new flooring fitted. New carpet was fitted to the stairs. Overall the environment was well maintained and suited the needs of the residents. The finding of the expert by experience was that staff supported residents to choose the furniture and décor for their bedrooms. The completed AQAA sent to the Commission included all the improvements completed and those planned for the coming year. Ashburnham Grove (75) DS0000036887.V373794.R01.S.doc Version 5.2 Page 19 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): Standards 32, 34 and 35. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Staff were recruited in line with regulation, had access to appropriate training and regular supervision. EVIDENCE: The staff team comprised of a full time manager and deputy manager, support workers and one domestic assistant. Staffing levels were based on resident needs and occupancy of flats and the respite flat had a designated staff team. The night shift was covered with one waking person, one person sleeping in and on call back up cover. Staff rosters were kept and those seen showed adequate staffing levels were maintained. The manager said that currently very little agency staff were employed as the home had its full compliment of permanent staff. Nine of the sixteen support staff employed had NVQ2 qualification or above with two people currently working towards this qualification. Information in the AQAA said that the service had a consistent, diverse, competant staff team, many of whom had many years service within residential learning disability homes. Supervision records were seen for some staff and staff spoken with said they received regular supervision. One support worker employed since the last inspection said they were very pleased Ashburnham Grove (75) DS0000036887.V373794.R01.S.doc Version 5.2 Page 20 with their induction programme. Employee recruitment files were not kept in the home and the manager arranged to have these at the home for inspection on 13th January 2009. A recruitment policy and procedure was provided and the process managed by the organisation human resources department. The manager said that she was involved in the short listing and interview process. Three employee files were viewed and all included the information required by regulation including CRB checks. Staff spoken with confirmed the recruitment process was implemented. The manager said that when agency staff were employed she had arranged for the agency to provide the person’s details including training and dates of CRB checks. Staff had access to an annual training programme and individual training files were kept for staff. Records seen for four people showed that they had received 2 or 3 days training in the last year. Training attended included NVQ courses, infection control, mental capacity act, fire marshal, medicine management, equality and diversity and dementia care. Staff spoken with said they were satisfied with the training provided. Staff who spoke with the expert by experience said they received training and were keen to do more training as and when it was available in order to support the residents. Ashburnham Grove (75) DS0000036887.V373794.R01.S.doc Version 5.2 Page 21 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): Standards 37, 39 and 42. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The service was well managed and attention was given to ensuring a safe environment was provided for residents and others. Efforts were made to hold meetings with residents and involve them in making decisions about their lives and the service. Improvements had been made to the quality assurance review system. EVIDENCE: The manager was in post for about two years and was registered with the Commission. She had the skills and experience needed to fulfil her role and was supported by a full time deputy manager. Relatives contacted were satisfied with the way the service was managed. Most of the long stay residents were unable to voice their opinion on the service management but residents who could knew the manager by name and indicated they were satisfied with the way the service was managed. It was evident that residents Ashburnham Grove (75) DS0000036887.V373794.R01.S.doc Version 5.2 Page 22 with non-verbal communication also knew the manager and responded to her. Staff spoken with said that the manager was approachable, helpful and supportive. The manager and deputy manager got involved with resident care when needed. The expert by experience spent time talking to the manager and agreed the service was well managed. Residents meetings were held in each flat and staff supported resident involvement. Coffee mornings were introduced on the respite unit in 2008 and management liaised with neighbours to resolve any issues they had. Minutes of resident and staff meetings were seen. Regulation 26 visits were made to the service and the reports seen in the home. Staff meetings were held monthly where resident care and management issues were discussed. An annual satisfaction questionnaire was sent to relatives and other interested parties. Information included in the AQAA was that the responses from the past surveys were positive, with a positive response from other professsionals. Health and safety checks were up to date. The Safeguarding Adults Policy was implemented and given priority in supervision, team meetings and training. Quality assurance systems had improved and systems implemented to complet audits on areas such as medication, health & safety and general food audits. Some audits were seen at the time of the inspection. To ensure the quality assurance review was completed management should colate all the information into an annual report and improvement plan and make this available to residents, relatives, the commission and others. Recommendation 2. A health and safety policy was provided and last reviewed in September 2008. Safety records checked included fire safety equipment service, gas certificate, electricity certificate, hot water temperatures were checked monthly and the service had a satisfactory environmental health inspection in December 2008 and was awarded a ‘clean food certificate’. Fire drills were held at times to include day and night staff and a fire risk assessment was in place and reviewed six monthly. Accidents to residents and staff were recorded and reported appropriately. Notifications were sent to the Commission as required by regulation 37. From the records seen attention was given to ensuring the health and safety of residents and others. Staff who spoke to the expert by experience confirmed they attended regular fire drills. Ashburnham Grove (75) DS0000036887.V373794.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 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 3 23 3 ENVIRONMENT Standard No Score 24 3 25 4 26 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 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 4 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 2 X 4 X 3 X X 4 X Ashburnham Grove (75) DS0000036887.V373794.R01.S.doc Version 5.2 Page 24 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 YA20 Regulation 13 Requirement The registered person must ensure medicines are managed safely: Two staff signatures must support hand written entries they make on administration charts. Staff must not transfer medicines from one container to another. Timescale for action 24/03/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA39 Good Practice Recommendations To ensure the quality assurance review was completed management should colate all the information into an annual report and improvement plan and make this available to residents, relatives, the commission and others. Ashburnham Grove (75) DS0000036887.V373794.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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. 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