Care Home: Ashleigh House

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CARE HOME ADULTS 18-65 Ashleigh House 133 Bromley Road Catford London SE6 2NZ Lead Inspector Lynne Field Unannounced Inspection 4th December 2008 10:00 Ashleigh House DS0000066388.V373381.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 Ashleigh House DS0000066388.V373381.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. Ashleigh House DS0000066388.V373381.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashleigh House Address 133 Bromley Road Catford London SE6 2NZ 020 8698 4166 020 8698 4166 ashleighhouse@googlemail.com 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) Ashley Healthcare Limited T/A Ashleigh House Ms Zobeeda Hosany Care Home 9 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (9) of places Ashleigh House DS0000066388.V373381.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following categories of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Mental Disorder, excluding Learning Disability or Dementia - Code MD The maximum number of service users who can be accommodated is: 9 6th December 2007 Date of last inspection Brief Description of the Service: Ashleigh House is a registered care home for nine adults with mental health needs. The house is semi-detached and is situated on a busy road in a residential area. It is a short walk away from shops, railway services and other public transport links. The provider is in the process of developing the home and the service since taking over the ownership of the home. All but one of the current residents all have lived at the home for over nine years and some since it opened in 1992. Most of the residents hope to remain at the home on a long-term basis. The current group is all male and aged from early forties to late sixties. At the time of this inspection visit the home had no vacancies. The residents guide states that the home’s aim is to ‘provide a high standard of accommodation and care in a large family setting’. There is a lounge on the ground floor and this has been extended to incorporate a large comfortable dining area. It overlooks a large back garden. The staff office is next to this and the kitchen. The laundry facilities are in the garage next to the house and there is a large dry food store in a separate room next to the laundry. The bedroom accommodation has just been extended into the loft space. They have to add extra two bedrooms but at the present time only one extra bedroom has been passed as meeting registration regulations, making nine single bedrooms. Two bedrooms of the nine bedrooms are accessible to people with disabilities and are situated on the ground. The other seven are on the first and second Ashleigh House DS0000066388.V373381.R01.S.doc Version 5.2 Page 5 floors. Fees range from £450-£520-93 per week and includes accommodation, food and staffing. Personal expenditure such as clothing, toiletries and outings are not included. Residents Guide and Statement of Purpose are available in residents’ rooms. Ashleigh House DS0000066388.V373381.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is two stars, which means that people at the home receive a good service. This key unannounced inspection took place on 4th December 2008. The inspection involved speaking with the people using the service, the staff on duty, registered manager as well as the provider. The registered manager facilitated the inspection. The inspection also involved the case tracking of three people’s care, the assessment of a range of the home’s records, procedures and forms as well as observation and a tour of the premises. We spoke to the registered manager and provider about how the home was developing and systems that are in place to ensure the residents are given the service they want and need. During a tour of the home we met and spoke to all the residents, including the new resident and one member of staff. The inspection included a tour of the home, garden and the examination of records on care plans, medication records and the complaints book. The manager returned a standard form, the Annual Quality Assurance Assessment (AQAA), to CSCI. This was taken into consideration. What the service does well: What has improved since the last inspection? The home has strived to meet requirements made at the previous inspection. Ashleigh House DS0000066388.V373381.R01.S.doc Version 5.2 Page 7 There have been continued improvements to the physical standards of the home since the last inspection visit. The home is still in the process of being extended. Much of the home has been refurbished and has more communal space for the residents to use including a smoking room. This has made it more homely and spacious. Outside space has been improved and made more user friendly. Care plans and risk assessments are more detailed and being up dated on a more regular basis. The dispensing and administration has been risk assessed and residents are able to take their medication out with them safely. The registered provider has developed a quality assurance and quality monitoring systems to seek the views of residents, their representatives and community professionals and the results of surveys have been given to us. Residents are being more actively encouraged to develop personally as well as take a more active part in running the home. The storage of confidential records has improved. 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. Ashleigh House DS0000066388.V373381.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ashleigh House DS0000066388.V373381.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents’ needs and aspirations are assessed, so that a service tailored to their needs could be provided. EVIDENCE: We saw the statement of purpose and the resident’s guide, which includes the complaints procedure in the resident’s guide that has been reviewed and up dated to reflect the changes made in the home. There has been one admission to the home since the last inspection in December 2007. We were able to speak to the resident who said they were able to make a choice about coming to live at the home and had all the information about the home before coming there. The registered manager said the home followed the homes admissions procedure that it has revised to meet current standards. This includes a complete assessment based on personal history, a care management assessment and a full needs assessment to ensure the home could meet the prospective residents needs. If the prospective resident has any family members or friends, they would be invited to visit the home with the prospective resident and their care manager to help them Ashleigh House DS0000066388.V373381.R01.S.doc Version 5.2 Page 10 decide if the home could meet their needs. We were able to check their file and this contained the initial assessment and risk assessment on file. Ashleigh House DS0000066388.V373381.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents are involved in planning their care with their key worker, the manager, appropriate professionals and family members. Potential risks are identified and residents are supported to take risks within a risk management framework. EVIDENCE: We looked at three residents files one was of the new resident. Resident’s are involved in planning their care with their key worker, the manager, appropriate professionals and family members. We were shown copies of the residents key worker meetings that are held every month. The records showed mental health issues, personal hygiene, finance, medication and any other issues that have arisen are all discussed at these meetings and were signed by the resident and their key worker. Each resident has an activities planner that is reviewed during key worker sessions. Each resident has a daily book that records Ashleigh House DS0000066388.V373381.R01.S.doc Version 5.2 Page 12 activities, outings or appointments the resident has taken part in. The residents told we they were happy with their key worker and felt the benefit of having a key worker session. From looking at the residents files we could see residents had six monthly reviews or earlier if the need arises. Care plans reviews are kept on file. The new resident had a six weekly review on file as well as the normal six monthly reviews. We spoke to them during the inspection and they said they were happy with the support they received from the staff in the home. Resident’s annual reviews are conducted by the residents’ care manager and include the residents’ family members, key worker and any relevant professional involved in the residents’ development. Medication is reviewed at the same time. At times residents have refused to attend their annual reviews even though it was being held in the home and this was recorded in the review notes. There were detailed guidelines and risk assessments on file on how the residents behaviour could be managed and supported safely. Potential risks are identified and residents are supported to take risks within a risk management framework. We were told residents are involved in their risk assessments and managing the risks in their life. The homes management said they continue to try to encourage the residents to participate more actively in the decision making of the home, for instance, decoration of their room, choice of furniture and their own choice of paintings. They are always kept informed on activities and they participate actively in the choice of their outings and leisure activities. We noted some residents are very active and go out and about a lot but others are very reluctant to go out at all. Through out the inspection we noted residents came and went as they pleased, having made decisions about what they wanted to do for the day. Ashleigh House DS0000066388.V373381.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents engage in appropriate, enjoyable and fulfilling activities and mix with the general community. Residents are actively encouraged to keep in touch with friends and family and develop appropriate friendships. Residents’ rights and responsibilities are respected. The meals are enjoyable and nutritious. EVIDENCE: We noted the daily routines are flexible at the home. On the day of the inspection residents were seen to be freely coming and going from the house, moving around the home, and making drinks in the kitchen. We met all the Ashleigh House DS0000066388.V373381.R01.S.doc Version 5.2 Page 14 residents who lived in the home during the course of the inspection and spoke to one resident in depth. At previous inspections it was found that motivation is a problem for residents at the home and most prefer to spend time doing solitary activities such as reading, watching television, or listening to music. At a previous inspection in February 2007, we noted there was little evidence of any rehabilitation work or the involvement in daily life skills, which would equip them to become more independent. Since then the registered manager has referred a number of residents to the occupation therapist. We spoke to the occupation therapist at the last inspection and she said she had come to assess the residents’ needs and work with residents to help them to become more independent. This is slowly changing with staff encouraging and supporting residents to develop daily living skills they will need should they move on into a flat of their own. Each resident has an individual activity planner. This is flexible and can be changed they want to do something else that they feel is more important or enjoyable. We were shown copies of the resident’s activities and daily living skills. The staff said they continued to try to motivate the residents and it is an ongoing. One resident told we he “hoped to get a place of his own”. The senior support worker spoke to him about his development program and he said he was cooking some meals for himself with support from staff. We were able to meet and speak to all the residents who were in the home on the day of the inspection. The residents we spoke to all had very different interests that they followed and took part in. They said they felt free to come and go as they pleased and were supported to continue with their activities. Eight of the residents go out independently. One resident continues to go all over the place using their freedom pass. Another said he “goes shopping and does small chores for the home”. One resident is a keen photographer and does his own printing. We were shown photographs he had taken of the holiday which he had printed for the home to keep. The home consults with residents about the type of individual and group activities they would like to take part in at key worker sessions and residents meetings. We were shown copies of the minutes of residents meetings that are held on monthly basis. We saw during residents meetings they are asked if they would be interested in spending a week in a holiday resort paid by the home or having several different outings. Residents said they would prefer a week at a holiday resort. The main meal of the day is in the evening at the home. We were able to see the weekly menus that are displayed on a board in the hall. These showed that the meals offered are balanced and nutritious. The home has a flexible approach to menus and depending on resident’s wishes the meal offered is not always as stated on the menu. The registered manager said they try to ensure that whilst taking into account the preferences of residents, there is sufficient variation of meals offered. We spoke to residents who all said they were happy Ashleigh House DS0000066388.V373381.R01.S.doc Version 5.2 Page 15 with the meals. One resident said they went to a local café each morning because they liked the breakfast and the company there. We were as told the home encourages the residents to see their family as often as possible. Families are invited for meals from time to time and are encouraged to join in the Christmas meals, birthday parties and barbecues. On the day of the inspection one resident was visiting their family for the weekend. They do this on a regular basis as well as their family visiting them in the home. One resident had arranged to meet their mother on the day of the inspection and came to say they were going out and what time they hoped to be back. Ashleigh House DS0000066388.V373381.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive personal support, in the way they prefer and their physical and emotional needs are met. Residents are protected by the homes policies and procedures for dealing with medicines. Risk assessments are in place for residents who take their medication out with them and the box is labelled appropriately. Medication administration was found to be properly documented and is handled safely. EVIDENCE: We was told the staff help the residents maintain their self respect and dignity and they try to maximise their independence and control over their lives. The home works in partnership with residents to find the most effective way to Ashleigh House DS0000066388.V373381.R01.S.doc Version 5.2 Page 17 manage their health care. The residents who need support are helped to attend their appointments with the GPs or other health professionals. The care plans we checked contain information about how residents like to be supported in all aspects of their daily lives. Care plans detail how much support people need in various aspects of daily living. The home has a key worker system to ensure consistency for residents. One resident needs support to bath and we was told the home had employed a male carer to help him with this although he was happy to be support ed by a female carer. Residents spoken with confirmed that they get the support they need. As part of the care plan, each resident is encouraged to take part in the running of the home. The registered manager explained most of the residents who have been at the home for many years, do not want help around the house. They said it has been difficult to motivate the residents. We were told tasks are discussed with residents in key worker meetings. In the past the home asked the occupation therapist to come to the home to assess the residents’ needs and work with residents to help them to become more independent. When we met the occupational therapist at a previous inspection, they said some residents were reluctant to develop skills such as cooking. This continuing to change is slowly changing with staff encouraging and supporting residents to develop daily living skills they will need should they move on into supported living or a flat of their own. We saw copies of minitues of the residents meetings. These arre held on a monthly basis. It was noted that one resident always refused to attend these meetings. The resident’s medication is stored securely in a locked medication cabinet in the dinning room of the home. We inspected three of the resident’s medication with the senior support worker. The registered manager and staff said only care staff that have completed the medication training are allowed to dispense medication. Copies of training records where seen by we that confirmed this. The home uses a blister pack system and all medication stocks checked where in order. Homely remedies are signed as being able to be given by the GP. We were told the registered manager audits the medication weekly. Medication is dispensed into a residents pillbox to take out with him to the day centre and this has been risk assessed following the guidance sent to the home by the pharmacy inspector following the last inspection when it was highlighted as a risk. Staff induction includes medication training and medication administration records. All staff has been on the First Aid course to ensure there is always some one who is qualified to give First Aid on duty. We were shown copies of the certificates that confirmed this. There was a copy of all staff signatures that dispense medication and information about the medications in use. Ashleigh House DS0000066388.V373381.R01.S.doc Version 5.2 Page 18 Staff told we medication was discussed at individual residents reviews. The manager and staff have annual medication refresher training. The training records that were shown to we confirmed this. Two staff checks the medication before it is dispensed. The medication records viewed were on a printed form and were complete. Where the medication is hand written there are two signatures to conform the accuracy of the transcription. All the records viewed contained photographs of the residents. All records stated whether or not a resident had any allergies. Mar charts continue to be signed by the CPN when they administer an injection and this is witnessed and counter signed by the registered manager. The medication policy has been reviewed and all the staff had medication training at the Mulberry Centre. All staff has been on the First Aid course to ensure there is always someone who is qualified to give First Aid on duty. We were shown copies of the certificates that confirmed this. The registered manager told us the district nurse had come into the home to speak to the staff and the resident, who is diabetic, about his condition. She gave each member of staff an information pack and training about how diabetes can be controlled by diet and what signs and symptoms they need to be aware of that could endanger the residents’ health. There is a risk assessment is on file and how the risk could be minimised. They carry out in house blood tests on the resident who suffers from diabetes. We met the district nurse at the last inspection, when she came to check on the residents’ progress and confirmed staff have been trained to check the blood glucose levels of the resident. We noted that this was part of the residents’ care plan. We were told they had recently noticed that one resident was complaining of stiffness when he plays the guitar. This was reported to his GP and consultant. The consultant then discontinued one of his medication due to one of its side effects, which causes stiffness in the limbs. Ashleigh House DS0000066388.V373381.R01.S.doc Version 5.2 Page 19 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are safeguards in place to protect the resident from abuse, neglect and self-harm. EVIDENCE: There is a complaints policy and this is kept in a folder that is accessible to residents and their relatives. The registered manager said they hoped to display it on the wall in the home as this would make it more accessable. We were shown the complaints book. There were seven complaints since the last inspection. These were about such things as things that needed to be repaired or another resident playing their music too loud. The registered manager said she dealt with all complaints and treated them all with the same seriousness. These had been dealt with within the time scale of 28 days. We saw copies of the responses and outcomes. Residents are encouraged to speak up in the residents meetings about issues that concern them and this is helped them be more confident about speaking up for themselves. One resident who spoke to we said he would speak to the manager if he was unhappy with anything and felt he was able to do this. We was shown a copy of the home’s Adult Protection and Whistle Blowing policy, which has been developed in line with the Local Authority requirements and the governments “No Secrets” legislation. The organisation refers staff to Ashleigh House DS0000066388.V373381.R01.S.doc Version 5.2 Page 20 POVA as appropriate. None of the staff in the home have been referred for inclusion on the POVA list. The registered manager said they had all received POVA training and the training records seen by we confirmed this. The home has a policy regarding the protection of the resident’s finances. As part of the inspection the residents’ money and petty cash accounts were inspected and they were in order. A receipt must be obtained for all purchases and the amount spent recorded in the residents’ accounts book. The member of staff supporting the resident when the money is spent signs this. The registered manager does weekly financial checks and audit by the service manager every three months. These are monitored during the providers monthly registered persons visit. Ashleigh House DS0000066388.V373381.R01.S.doc Version 5.2 Page 21 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,27,28,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is safe and comfortable with adequate private and shared space, toilets and bathrooms. The home is well maintained and furnished. Resident’s bedrooms are comfortable and are decorated to reflect their personalities. The home is looking at ways to resolve the problem of the ninth bedroom. EVIDENCE: The home is a large semi-detached house located on a main bus route and about ten minutes walk from Catford and Catford Bridge railway stations, shops and facilities. The home is in keeping with the local community and not identifiable as a care home. Ashleigh House DS0000066388.V373381.R01.S.doc Version 5.2 Page 22 There is space for parking at the front of the property. The home is furnished in a comfortable, homely way and is clean and well maintained. There are new stylish radiator covers installed together with new seats for the lobby, which looks homely and welcoming. The dining room, stairs and downstairs bedroom carpets have recently been replaced, and bedrooms redecorated. The work on refurbishing program of the home has continued. The large lounge on the ground floor has been extended to incorporate a large comfortable dining area. It overlooks a large back garden that has been partly paved. New garden furniture has been purchased and this has made it an attractive sitting area with the garden well maintained. The old dining room is now the staff office and is large enough to be used as a meeting room. Next to this is the kitchen. The bedroom accommodation has just been extended into the loft space. They have added extra two bedrooms, one ensuit and separate toilet as well as a communal lounge. At the present time only one extra bedroom has been passed as meeting registration regulations, making nine single bedrooms. Two of the nine bedrooms are accessible to people with disabilities and are situated on the ground floor. The other seven are on the first and second floors. There is a small smoking room on the second floor that has a small fridge with a supply of snacks and a kettle. Residents said they could make themselves a hot drink and have a snack. The homes fire escape leads off this room. There is a shower room and toilet on the ground floor and a bathroom, toilet and shower room on the first floor. Liquid soap dispensers and paper towel dispensers have been put in place to promote hygiene and control of infection. The laundry facilities are in the garage next to the house and there is a large dry food store in a separate room next to the laundry. The whole of the concrete surface around the home has been pressure cleaned to make it more welcoming. We spoke to residents who were happy to show us their bedrooms. One said he helped to keep it clean and tidy. He said he was happy with his bedroom and it had just been made larger because of the refurbishment, so he had been able to rearrange it. There is a small smoking room on the second floor that has a small fridge with a supply of snacks and a kettle. Residents said they could make themselves a hot drink and have a snack. Ashleigh House DS0000066388.V373381.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35,36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Training needs for all staff has been identified and is formally planned, including NVQ training for all staff, to ensure that 50 of the homes staff achieved NVQ level 2 or 3. Appropriately supervised staff meets the residents’ individual needs. EVIDENCE: The homes recruitment procedure is based on equal opportunities. There has been one new member of staff employed since the previous inspection. The home operates a good recruitment process, following the organisations recruitment policy and procedures. This includes formal interview, taking up two references, CRB checks and POVA checks prior to appointment. The new member of staff is going through the Skills for Care workbook as part of their induction. We was told they make sure that during the induction programme, that new staff understand the principle of care and relates that to the experiences and in particular to the needs of the residents. Copies of signed contacts were on file. Staff records are kept in a locked cabinet in the staff Ashleigh House DS0000066388.V373381.R01.S.doc Version 5.2 Page 24 room and are only accessible by the management of the home so confidentiality is not breached. We looked at four staff files during the course of the inspection including the new member of staff. Copies of training records and supervision records were held on file. All the staff files had detailed records of recruitment with all the required checks having been made. All staff has a training and development profile. Staff training and development is reviewed at supervision and appraisal sessions. The registered manager had developed a training plan in conjunction with an external consultant from the learning skills council and this is ongoing. This offers a comprehensive plan of training for the next 12 months including an in house training programme for all staff based on the identified needs of residents and staff. This will take place once every month for the next 12 months. Staff are able to access training through Lewisham Development at the Ladywell Unit and Lewisham Adult Social Services. The registered manager said she tried to access as much staff training for the staff as possible. Staff has been provided with a range of training and copies of training records and supervision records were seen on file. Four staff have already gained NVQ level 2 or above and two more staff are starting their training towards NVQ level 3. We were told the NVQ assessor comes to the home to assess the staff. Staff meetings are held monthly and we was shown copies of the minutes of the meetings. Ashleigh House DS0000066388.V373381.R01.S.doc Version 5.2 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,42, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents know the home is well managed and planned. Working practices and associated records ensure that the health and safety of residents is promoted. EVIDENCE: The registered manager is an experienced registered mental nurse who has been a ward sister and unit manager in psychiatric hospitals. She has managed the home since 1996. She is currently completing the NVQ level 4 in Management. Ashleigh House DS0000066388.V373381.R01.S.doc Version 5.2 Page 26 The organisation completes the monthly monitoring required by the National Minimum Standards and keeps copies of file which we were able to view as part of the inspection. The home had a policy on health and safety and we viewed health & safety records held in the home. Certification was in place regarding the Landlord’s Record of Gas Safety, Portable Electrical Appliance testing, and Certificate of Electrical Installation. Records showed that regular checks of the fire alarm call points were made and that fire drills were conducted. The home has up dated the Fire risk assessment of the home to include the loft conversion of the home. All other health and safety checks were inspected and there is a range of certificates available to show these are being properly addressed in the home. A quality assurance system has been developed including anonymous surveys of residents in addition to seeking the views of relatives, other representatives and community professionals. All residents and residents’ relatives were asked to complete a quality monitoring form. The home had three replies from resident’s relatives, seven from the residents and three from professionals who support residents who live in the home. Comments from professional were “the home is very good”, “would recommend this home” and “staff are very professional and have good interpersonal skills”. All responses were viewed by we and found to be positive. All confidential records are kept locked up in a filing cabinet in the staff office and accessible only to the management of the home. Ashleigh House DS0000066388.V373381.R01.S.doc Version 5.2 Page 27 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 3 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 3 26 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 3 3 X X 3 x Ashleigh House DS0000066388.V373381.R01.S.doc Version 5.2 Page 28 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. 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. Refer to Standard Good Practice Recommendations Ashleigh House DS0000066388.V373381.R01.S.doc Version 5.2 Page 29 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. Extracts may not be used or reproduced without the express permission of CSCI Ashleigh House DS0000066388.V373381.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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