Care Home: Ashleigh House

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What the care home does well People who use the service are happy at Ashleigh House and expressed their satisfaction. The manager does not admit anyone into the home unless their needs have been fully assessed. This means the manager can be confident that the home has the resources necessary to meet the needs of the individual. A plan of care is developed for all of the people using the service, they are reviewed and amended as changes occur. The people using the service and/or their families can be involved in this process, although not everyone knew this. Comments from relatives were positive regarding the quality of care provided in the home. Some of these comments are included in the main body of this report. The staff are committed and enthusiastic in providing good quality care to the people who use the service. This personable attitude and approach to care is appreciated and welcomed by the people who use the service and visitors alike. Health needs are closely monitored and access to other health professionals is arranged as required. Families and visitors are made welcome. What has improved since the last inspection? A number of requirements were made at the last inspection; action has been taken to address these and is as follows. During the last inspection we did not feel the call bell was responded to as required and we were unsure if staff knew how to handle the situation appropriately when a person fell. We are now satisfied that the people who use the service are supported appropriately and receive medical assistance in a timely manner when required. There were a number of requirements made about the administration of medication and although the manager has addressed these issues we still require the home to improve their medication management systems to further protect the people who use the service. We checked the homes records and found that all the staff have now received the necessary fire training. We are satisfied there are enough staff on duty to meet the needs of the people who use the service. CARE HOMES FOR OLDER PEOPLE Ashleigh House 2 Stonehouse Road Boldmere Sutton Coldfield West Midlands B73 6LR Lead Inspector Rachel Davis Key Unannounced Inspection 21st July 2008 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ashleigh House DS0000063255.V368184.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ashleigh House DS0000063255.V368184.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashleigh House Address 2 Stonehouse Road Boldmere Sutton Coldfield West Midlands B73 6LR 0121 354 1409 0121 308 8091 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) Senex Ltd Mrs Suzanne Hammond Care Home 13 Category(ies) of Old age, not falling within any other category registration, with number (13) of places Ashleigh House DS0000063255.V368184.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home is registered to provide personal care for 13 people for reasons of old age (13 OP) The home must provide a minimum of three members of staff on duty during peak hours when the home is at full occupancy (this may include the manager). This can be reduced pro-rata for reduced occupancy to no less than 2 members of staff, however, the staffing levels must be determined by the dependencies of the service users in the Home at that time. 2nd July 2007 Date of last inspection Brief Description of the Service: Ashleigh House, formerly a large family home has been extended to provide accommodation for thirteen older people on two floors. It is situated in a residential area of Sutton Coldfield, within easy walking distance of local amenities and public transport. The registered manager is Mrs Suzanne Hammond , she is also the proprietor. The homes category of registration is for older people, this excludes people in need of care for dementia related conditions, learning disabilities or other reasons. The home has adaptations including a stair lift to assist people to access the first floor however access to the first floor for wheelchair users is restricted. All bedrooms are single occupancy and each has an en suite toilet and a wash hand basin. Decoration in the home is to a good standard. There is a spacious lounge and dining room with doors and ramp access opening out onto a small patio area and garden. Information about the fees for this service were not available as needed, fees must be recorded in the Service User Guide but presently people will need to enquire directly to obtain this information. Ashleigh House DS0000063255.V368184.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 2 star. This means people who use this service experience good outcomes. This announced inspection (2 days notice given) took place over 8 hours; it was carried out by one inspector who used the National Minimum Standards for Older People as the basis for the inspection. This was a ‘Key’ inspection; during a ‘Key’ all the core standards are assessed. A quality rating is provided throughout the report based on each outcome area for the people who use the service. These ratings are described as excellent, good, adequate or poor based on findings of the inspection. Prior to visiting the home on this inspection, survey information was completed and returned to us by people who use the service and staff. During this ‘Key’ inspection we looked at the life people are able to lead and whether their health and personal care needs are being met. We also looked around the home to see the standard of the accommodation. We looked to see whether people who use the service are being protected and the arrangements the service has for listening to what people think about Ashleigh House. During the visit we met and spoke to a number of people living in the home, visitors, members of staff and a visiting professional. Observations were made of staff and resident interaction around non-personal care tasks, at lunchtime, and medication administration was seen. Our inspection reports can be obtained directly from the provider or are available on our website at www.csci.org.uk What the service does well: People who use the service are happy at Ashleigh House and expressed their satisfaction. The manager does not admit anyone into the home unless their needs have been fully assessed. This means the manager can be confident that the home has the resources necessary to meet the needs of the individual. Ashleigh House DS0000063255.V368184.R01.S.doc Version 5.2 Page 6 A plan of care is developed for all of the people using the service, they are reviewed and amended as changes occur. The people using the service and/or their families can be involved in this process, although not everyone knew this. Comments from relatives were positive regarding the quality of care provided in the home. Some of these comments are included in the main body of this report. The staff are committed and enthusiastic in providing good quality care to the people who use the service. This personable attitude and approach to care is appreciated and welcomed by the people who use the service and visitors alike. Health needs are closely monitored and access to other health professionals is arranged as required. Families and visitors are made welcome. What has improved since the last inspection? What they could do better: Medication systems require some attention to ensure that the people who use the service are fully safeguarded. The Service User Guide needs to give individuals an accurate account of the fees payable. The home may also wish to offer a more informative version, this will help to support the decision making process for people who may wish to use their service. Ashleigh House DS0000063255.V368184.R01.S.doc Version 5.2 Page 7 There needs to be better evidence to confirm the home is able to meet the diverse needs of the people who use or may use the service. Although the home is proactive in promoting equality and diversity it should continue to consider ways in evidencing this. The manager should improve upon the recording of complaints, however minor they may appear, including the outcome, this will further evidence the homes openness and transparency. 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 DS0000063255.V368184.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ashleigh House DS0000063255.V368184.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Ashleigh House carries out a needs assessment before people who use the service are admitted to the home. The home should offer more written information about their service so people can make a fully informed choice about the home. EVIDENCE: The service has a statement of purpose and service user guide, which set out the aims and objectives of the home, and include information about the service. However, the service user guide needs to be reviewed and offer information about the fees payable. There was little evidence to show if the service user guide was made available to people who use the service. The manager assured us it was, but realised evidence is needed. Ashleigh House DS0000063255.V368184.R01.S.doc Version 5.2 Page 10 Ashleigh House should consider developing their statement of purpose and service user’s guide specific to their resident group, where necessary information should be in a format suitable for them and their families’ needs, examples may include appropriate language, audio or large print. The home should be as open and transparent as possible and offer diverse information to prospective people about gender (including gender identity), age, sexual orientation, race, religion or belief, and disability. They should also be clear of what is or is not available, offering such information then enables prospective users the opportunity of making an informed choice as to whether they would be happy with these arrangements. When asked in questionnaires: Did you get enough information regarding home before moving in? Both responded ‘yes.’ We also had the opportunity to speak with a family member whose relative recently moved into Ashleigh House. They said they had been well informed and had a good understanding of the home prior to their relative moving in. They confirmed a trial period had been offered and their questions had been suitably answered. The care records for a number of people who use the service were checked and contained the needs assessment as required, pre admission documentation is sound and offers appropriate opportunities for the manager to assess whether Ashleigh House can meet the needs of the prospective user. Although the home meets the needs of the people who use the service they should consider ways in evidencing equality and diversity and how they support people in a ‘person centred’ way, that is in a way which is individualised and tailored to meet their specific needs. Ashleigh House should consider developing a key worker system, having a named worker will help individuals feel comfortable in their new surroundings and enables people who use the service to ask any questions about life in the home. It should also encourage and help the staff to develop a person centred approach to care. Standard 6 is not relevant to this home and therefore not assessed. Ashleigh House DS0000063255.V368184.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Each person has a plan of care and the practice of involving people who use the service in the development and review of the plan has commenced. Overall medication systems follow good practice but require some attention to ensure people who use the service are fully safeguarded. EVIDENCE: The plans of care within the home have been developed to include a variety of information to enable individuals’ needs to be easily identified and the support required by the staff team. We are aware that these new plans continue to be implemented but have not been completed for everyone using the service. These plans will become person centred and offer more information where a person who uses the service has complex needs; examples could include life plans and more evidence of service user and family involvement. Ashleigh House DS0000063255.V368184.R01.S.doc Version 5.2 Page 12 The manager has ensured evidence is available to confirm that people who use the service and /or their representatives are offered the opportunity to participate in the care plan and subsequent reviews. All people who use the service spoken with spoke well of the care provided and people who use the service stated they were treated with dignity and respect, and encouraged to be as independent as possible. The staff observed had a knowledgeable and positive attitude towards people who use the service and feedback from questionnaires was very encouraging about their relationships: “Very satisfied with care and support.” “ The care is excellent.” Two visiting relatives both confirmed: “They always phone me and let me know what is happening.” Staff were observed knocking on doors, offering people who use the service choice, and allowing them to complete tasks in their own time. Questionnaires returned to us offered satisfactory information regarding health support – we ask: do you receive the medical support you need? Everyone had recorded ‘always’ A visiting professional seen by us stated: “ The staff are good at identifying need and know their limitations. They refer appropriately and offer preventative rather than reactive care.” We observed a staff member administering medications at lunchtime and the process was well organised and well recorded. An example of good practice was that eye drops were not administered at the dining room table. The staff wait until the person has retired from their meal and then offer their assistance on a one to one basis in a quieter environment. We found that the recording the receipt of medicines into the home was occurring and the staff who administered medication to the people who use the service had received training on the safe handling of medicines. The home has developed an efficient medication policy, procedure and practice guidance. Staff all have access to this written information and understand their role and responsibilities. However, the audit sampling process showed that some people were not receiving their medication as prescribed by their doctor. Staff were seen Ashleigh House DS0000063255.V368184.R01.S.doc Version 5.2 Page 13 treating prescribed medication with ‘as and when required status.’ This means decisions and judgements are being made by staff members without receiving professional agreement from the General Practioner and where labelling by the pharmacist is considered ambiguous clarity must be sought. We found suitable recording of Controlled Drugs in the register, we saw the register was an accurate recording of the receipt, administration and disposal of Controlled Drugs. We consider the temperature of the treatment room may exceed the maximum temperature required to store medication. The home was asked to ascertain the correct temperature for this area and ensure medication was stored within the required range. The maximum and minimum temperatures of the fridge were recorded on a daily basis as required. We found that a prescribed cream for one person was opened and being stored and used by another person in their bedroom, this was discussed with the staff and manager during the inspection. Staff must ensure that any medication delivered to a person’s room is correctly named and stored appropriately. The degree of self medication can vary and we found some people who use the service administered their own inhalers and applied creams. Any process involving self medication must be subject to a robust risk assessment which is reviewed at regular intervals and when there is any change in the person’s circumstances. The care plan must reflect the person’s wishes and the specific arrangements for their medication. Any medicines ordered by the home must be properly receipted and a record made when they are handed over to the person who self medicates and a locked storage must be provided for each person. We feel the home could improve their practice in this area. Ashleigh House DS0000063255.V368184.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home does provide opportunities for interaction within the current staffing and resources but we feel they could be improved. Ashleigh House encourages and welcomes visitors. EVIDENCE: Our discussions with people and staff identified a relaxed atmosphere where the needs of people who use the service were respected. The home should consider introducing a key worker system, which will enable closer resident staff relationships where likes, dislikes and needs can be shared and should be recorded. Ashleigh House does not employ an activities coordinator. Presently there are no individuals in residence from ethnic minority groups, the manager advised us that the needs of people with specific religious needs were met. An example of this was a visiting priest. We were advised the people who use the service do receive varied and positive stimulation and activities are also offered on a one to one basis for some Ashleigh House DS0000063255.V368184.R01.S.doc Version 5.2 Page 15 individuals if this is more appropriate. However this information came from the manager and we did not evidence this during our inspection, therefore the homes evidence in this area should be improved upon. Both questionnaires from people who use the service recorded when asked: ‘Are there activities arranged in the home which you can take part in?’ both replied “Sometimes.” Visitors advised us that they didn’t regularly see activities but that may be due to the time of day, one said; “ one carer always likes to get them singing but I think there should be a little more stimulation.” The manager has recorded under this section on the Annual Quality Assurance Assessment (this is a legal document that must be completed by the home for the Commission for Social Care Inspection) that, “We encourage the residents to participate in activities but also encourage them to make their own decisions, so if they don’t want to take part we respect their decision and don’t force them.” We would like the manager to consider evidencing creative ways of providing activities such as adapted equipment for those with disabilities, life story work and seeking individual interests could enhance life at Ashleigh House. The manger advised us they are presently taking photographs and compiling a book with this information. This will confirm a consistent ‘person centred’ approach rather than a task centred approach. The manager reported that links with the community are forged and the home has an open door policy, people who use the service and their visitors verified this. We spoke to the cook and can confirm the kitchen is well maintained, it is clean and tidy, the crockery and cutlery are of a suitable standard. Food supplies were seen and consisted of a large number of ‘value’ products, we noticed that only UHT milk is used (no fresh milk) and saw no evidence of fruit juices, however fresh fruit and vegetables are available. We would recommend the manager to seek professional advice to ensure the amount of value products used, including meat, fish and tinned produce is suitable to meet the dietary needs of the people who use the service. The staff are recording the fridge temperatures as required but not always recording the temperature probes. The home has one dining area and lunch is relaxed and informal. Ashleigh House DS0000063255.V368184.R01.S.doc Version 5.2 Page 16 We discussed diversity with the cook who indicated awareness in meeting individual requirements, for example consideration for people who have diabetic needs. Individual preferences are recorded in plans of care and staff meet with and discuss these requirements with individuals. A ‘white board’ is updated daily to identify meals for the day. The choice of dining room, lounge or bedroom was at the discretion of the people who use the service. We observed that staff offered discreet assistance with meals to those who required it. People who use the service said: “I find the meals good.” “Today’s meal has been lovely, I love Yorkshire pudding.” “I can’t fault the food.” Ashleigh House DS0000063255.V368184.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home has a suitable complaints procedure and ensures the people who use the service are protected from abuse in accordance with written policies. EVIDENCE: We have not received and formal complaints about the home since the last inspection, nor has the manager. The complaints procedure is available in the service user guide and it is also sited in the hall. The home should reconsider their policy as it states the manager should be approached in the first instance. We discussed how a person who uses the service might feel about this if they wished to complain about the manager. It is important people who use the service know they have other options in making a complaint, including the commission, is they so choose. Relative’s questionnaires and feedback from relatives spoken to evidenced knowledge of the complaints procedure. We ask do you know how to complain? All questionnaires returned said ‘ yes.’ Everybody spoken to also said they would feel comfortable if they needed to make a complaint and felt the manager and staff were approachable. Ashleigh House DS0000063255.V368184.R01.S.doc Version 5.2 Page 18 Comments, compliments, grumbles or concerns could also be recorded, it is recommended the home should also site a comments book or suggestion box in the hall. The manager is happy to promote the recording of complaints in a transparent manner. From the records available on the day of inspection it was clear that the staff are trained to recognise the signs and symptoms of adult abuse, this training is mandatory. No vulnerable adult referral has been made since the last inspection. We consider people’s legal rights are protected by the systems in place in the home to safeguard them. These include their contract, the continual assessment and review in care planning, the policies in place, for example, the complaints procedure and Whistleblowing policy. Ashleigh House DS0000063255.V368184.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25 and 26. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home provides an environment that is appropriate to the specific needs of the people who live there. EVIDENCE: We looked around the premises, which we found to be clean and tidy with all communal rooms and bedrooms suitably maintained. Ashleigh House is fresh and comfortable and has a homely feel, people who use the service felt: Those people we spoke to expressed a sense of belonging and satisfaction in the quality and presentation of their living areas. The home is always nice and clean it always looks nice.” “It’s got a good atmosphere.” “I could not have chosen anywhere better.” Ashleigh House DS0000063255.V368184.R01.S.doc Version 5.2 Page 20 When asked: Is the home fresh and clean Everyone responded ‘always.’ The home has a designated laundry and this area is well organised, all clothing is individually returned to avoid misplacement. Laundry is being washed at the required temperature and dealt with correctly. We saw the home ensures infection control standards are met, examples include: paper towels, liquid soap and personal protective clothing. When we walked around the home we noticed a number of radiators are not guarded, risk assessments for radiators within the home must be robustly recorded to evidence the people who use the service are protected and radiators are maintained at a safe temperature. Some bedrooms were seen during this visit and were personalised to reflect people’s interests, families and lifestyle. Ashleigh House DS0000063255.V368184.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff at the home are suitably trained and sufficient in numbers to meet the needs of the people who use the service. Recruitment procedures are not as robust as required and therefore do not fully protect vulnerable people. EVIDENCE: The number of staff on duty was suitable to meet the needs of the people who use the service. It was evident that staffing levels weren’t compromised. The Annual Quality Assurance Assessment says: “The staff have been with us long term we do not have a big turn over of staff and we do not use agency.” During our inspection we were able to corroborate this statement. Two staff files were examined and both demonstrated that recruitment practices were not as thorough as required. The manager must undertake an audit of all the staff files to ensure all the required pre employment information is available. The service must take action to ensure all checks are completed. This will make sure people who use the service are fully protected. The home must ensure• A full employment history is recorded Ashleigh House DS0000063255.V368184.R01.S.doc Version 5.2 Page 22 • • • • • • Application forms cover any gaps in employment history A photograph is on file There is suitable identification on file to confirm the individual is as said. A health declaration is available to confirm the person is both physically and mentally fit for purpose. The prospective employee has the opportunity within the application form to advise the home of any convictions. This is normally a declaration under the Rehabilitation of Offenders act 1974. There is clear evidence of supervision between a Protection of Vulnerable Adults First check and the receipt of a Criminal Record Bureau disclosure. We also consider it good practice to remove the date of birth from the homes application form to meet with new legislation. All staff receive relevant training that is focussed on delivering improved outcomes for the people who use the service. The home understands the importance on training and staff report that they are supported to meet the individual needs of people who use the service. To further this, the manager should consider offering training to the staff on equality and diversity and the Mental Capacity Act and ensure all staff receive an induction and appraisal that meets with the standards. One questionnaire returned said: “The very best way to learn is by shadowing other staff and learn from them, as all people are different and it would be impossible to learn everything from paperwork or video and its useful to share ideas and experiences.” Two of the staff returned our questionnaires and other staff also reported during our visit that they are supported to meet the individual needs of people who use the service. “It is a very happy home, residents are all very happy here. They go to their rooms when they want to or sit in the garden after lunch.” “Mrs Hammond informs me if there are any changes that I need to know about.” The manager has completed the Registered Managers Award, this is a legal requirement for managers of a care service. National Vocational Qualification training is offered to the staff working at Ashleigh House, out of 13 staff (all female) 9 have a National Vocational Qualification 2 in care and 3 are presently doing their National Vocational Qualification level 2. Ashleigh House DS0000063255.V368184.R01.S.doc Version 5.2 Page 23 The people who use the service were happy with the staff they used words like “kind” “helpful” “friendly.” Other people who use the service said: “The staff are good, we see the same faces.” “They’re all very nice.” Ashleigh House DS0000063255.V368184.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home must continue to evidence that it is run in the best interests of the people who use the service. EVIDENCE: The manager and proprietor, Suzanne Hammond, has the required qualifications and the experience necessary to run the home. She has a clear understanding of the key principles and focus of the service, based on organisational values and priorities. The manager promotes equal opportunities, has good people skills and understands the importance of person centred care and effective outcomes for people who use the service. Ashleigh House DS0000063255.V368184.R01.S.doc Version 5.2 Page 25 There is a feeling of warmth and openness in the home and overall staff deliver good care. People who were spoken to were happy with the manager and staff team and felt they were approachable. The home has a statement of purpose that sets out the aims and objectives of the service. The manager knows she needs to improve and develop this and continue to evidence and monitor practice and compliance with the home. A quality assurance system is in place within the home, action plans are developed and reviewed as required. Records were seen to confirm staff receive formal supervision. Staff have also received fire training including regular fire drills. The annual quality assurance assessment (AQAA) is a legal document that all services have to complete on a yearly basis. All sections of the AQAA were completed and the information gave us a reasonable picture of the situation within the service. The evidence to support the comments made is satisfactory, although there are areas where more supporting evidence would have been useful to illustrate what the service has done or how it is planning to improve. The AQAA only gave us limited detail about the areas where they still need to improve and the ways that they were planning to achieve this are only briefly explained. Monies were checked and all records and receipts tallied, people who use the service can be confident their allowances are stored and managed suitably. Ashleigh House DS0000063255.V368184.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X X X X 2 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Ashleigh House DS0000063255.V368184.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No 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 OP9 Regulation 13(2) Requirement Appropriate information relating to medication must be kept in risk assessments and/or care plans guaranteeing the staff know how to use and monitor all medication including “when required” and “variable dosed” medication. This will ensure all medication is administered safely, correctly and as intended by the prescriber to meet individual health needs. Prescribed medications or creams must not be shared. Risk assessments for radiators within the home must be robustly recorded to evidence the people who use the service are protected. The manager must undertake an audit of all the staff files to ensure all the required pre employment information is available. The service must take action to ensure all checks are completed. This will make sure people who use the service are fully protected. Timescale for action 01/09/08 2 3 OP9 OP25 13(2) 13(4)(a) 25/08/08 25/08/08 4 OP29 19(1) (b)(i) Schedule 2 25/08/08 Ashleigh House DS0000063255.V368184.R01.S.doc Version 5.2 Page 28 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 OP1 Good Practice Recommendations It is recommended that information is made available to confirm that the Statement of Purpose and Service User Guide are available in a format appropriate to the people who use the service, individual capacity and language. The fees need to be included within the Service User Guide so people who use the service know the appropriate cost and what is and isn’t included. It is strongly recommended that a key worker system is introduced at Ashleigh House to encourage and develop a more person centred approach to care. Plans of care should be developed to evidence a person centred approach. Equality and diversity information about people’s preferences should be included on care plan documentation and this will ensure that people are treated as individuals and in the way they prefer. The home should confirm the medication is stored within the temperature range recommended by the manufacturer, this will ensure that medication does not loose potency or become contaminated. It is recommended that the manager seeks professional advise to ensure value foods meet the dietary needs of the people who use the service. The home could improve upon the recording of complaints, however minor they may appear, including the outcome, this will further evidence the homes openness and transparency. The home may wish to improve the content of their application form so it fully conforms to recent legislation. Training on the Mental Capacity Act should be offered to a cross section of the staff team. Training on equality and diversity should be offered to a cross section of the staff team. The manager should offer more written evidence to corroborate her verbal statements. 2 3 4 OP1 OP4 OP7 5 OP9 6 7 OP15 OP16 8 9 10 11 OP29 OP30 OP30 OP38 Ashleigh House DS0000063255.V368184.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection West Midlands Office West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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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