Inspection on 03/06/09 for Angel Lodge

This is the latest available inspection report for this service, carried out on 3rd June 2009.

CQC has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CQC judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Angel Lodge 17/08/06

Angel Lodge 11/11/05

Angel Lodge 12/04/05

Angel Lodge 13/01/05

Angel Lodge 12/07/04

Angel Lodge 02/03/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

Extracts from inspection reports are licensed from CQC, this page was updated on 12/10/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Angel Lodge 15-17 Eastwood Road Goodmayes Ilford Essex IG3 8UW Lead Inspector Harina Morzeria Unannounced Inspection 9:30 3 & 16th June 2009 rd DS0000025883.V375558.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Angel Lodge DS0000025883.V375558.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Angel Lodge DS0000025883.V375558.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Angel Lodge Address 15-17 Eastwood Road Goodmayes Ilford Essex IG3 8UW 020 8597 4399 020 8597 4399 angel.lodge@btconnect.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) Chana Bros Limited Mr. Amrik Singh Chana, Mr. Bhupinder Singh Chana Pauline Ann Baker Care Home 20 Category(ies) of Dementia (20), Old age, not falling within any registration, with number other category (20) of places Angel Lodge DS0000025883.V375558.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 - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP 2. Dementia - Code DE The maximum number of service users who can be accommodated is: 20 27th July 2007 Date of last inspection Brief Description of the Service: Angel Lodge provides accommodation and support for twenty older people and is also registered to provide care for people with dementia. This is a privately owned care home and operated as a family business. The premises are situated in a residential area of Goodmayes, close to the busy Ilford High Road with access to shops and other community facilities. All bedrooms are single. There is a lift between the ground and first floors. There are sufficient numbers of bathrooms and toilets. The lounges, corridors and the bedrooms have been refurbished with new flooring and curtains. There is an ongoing refurbishment programme. There is a large well kept garden at the rear of the house with a summer house for the residents enjoyment during in fine weather. The home employs sufficient numbers of experienced and skilled staff to meet the needs of the residents. Personal care is provided on a 24-hour basis, with health needs being met by visiting professionals or by staff accompanying residents to hospital appointments and other healthcare specialists as required. A variety of activities and entertainment are enjoyed by the residents provided by the staff as well as in-house entertainment. A Statement of Purpose is available upon request and a Service Users Guide is given to each prospective resident, which details the service the home can provide. The home displays a copy of the key inspection report in the foyer and make it available at the request of the resident or their relative/representative. The fees for the home are £475 - £530 per week. Angel Lodge DS0000025883.V375558.R01.S.doc Version 5.2 Page 5 Angel Lodge DS0000025883.V375558.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 2 Star. This means that people who use the service experience good quality outcomes. This inspection was unannounced and took place over two days on 3rd and 16th June 2009. The manager, Ms. Pauline Baker was present at the first visit and a senior carer at the second visit, both of whom assisted with the inspection. The inspector looked around the home, spoke to the residents, staff and relatives at the home. Care staff were asked about the care that residents receive and were also observed carrying out their duties. Staff, care and other records were checked. Additional information relevant to this inspection has been gained from the Annual Quality Assurance Assessment and Regulation 37 notifications. The inspector spoke to the quality monitoring officers for the London Borough of Redbridge, Barking and Dagenham as well as a district nurse who visits the home regularly, to get feedback about the quality of the service provided at the home. All professionals stated that they are satisfied with the quality of care provided to the residents and do not have any issues of concern to report. The inspector had a discussion with the manager on the broad spectrum of equality & diversity issues and she was able to demonstrate an understanding of the varied needs of the service users around religion, sexuality, culture, disability and gender. What the service does well: The home is fully staffed and there is a stable staff team that residents say are kind and caring. More than half of the staff team have got NVQ qualifications, dementia care and safeguarding adults training as well as other relevant qualifications, so that they are able to meet the needs of the residents living at Angel lodge. There is a relaxed atmosphere in the home and relatives are welcomed. What has improved since the last inspection? All the requirements made at the previous inspection have been addressed and are now met. Care plans are specific with regard to the recording of religious, cultural and social care needs of residents and how these are to be met. Lounges, corridors and bedrooms have been redecorated. Activities continue to improve, and the manager is exploring opportunities for residents to go out on day trips. Angel Lodge DS0000025883.V375558.R01.S.doc Version 5.2 Page 7 Staff receive ongoing training and are knowledgeable and able to meet the needs of the residents. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Angel Lodge DS0000025883.V375558.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 Angel Lodge DS0000025883.V375558.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service can be assured that their needs will be properly identified and that the service that the home provides is acceptable to them. Information is available in different formats upon request and residents are provided with a written contract or statement of terms and conditions. The home does not provide intermediate care. EVIDENCE: The files of three residents were viewed and all showed evidence of a preadmission assessment and a statement of terms and conditions. There is a Statement of Purpose & Service Users guide. These are reviewed and updated annually and can be made available in different formats and Angel Lodge DS0000025883.V375558.R01.S.doc Version 5.2 Page 10 languages upon request. The service user guide informs prospective residents that information is available in different formats upon request. Each resident has a contract or terms/ conditions with the provider and a copy of these were seen in residents’ files. Prospective residents have an individual needs assessment and are given the opportunity to visit the home prior to making a decision to live there. Referrals are made by Social Services department and they provide initial assessment information. This may be from information that they have gathered or from assessments made by hospital staff. Assessments are then carried out by the manager before an individual moves into the home. At this time the prospective resident and/or their relatives are provided with information about the home and encouraged to visit. The assessments cover all of the required areas and include health, mobility, nutrition, religious, cultural and spiritual needs. Examples of this were seen on residents’ files. From this assessment information, an initial basic care plan is drawn up to enable staff to provide appropriate care for an individual when they move into the home. Evidence was seen on new residents’ files that they can visit the home and enter the home for a trial period of stay before deciding to move in permanently. The home does not provide intermediate care. Angel Lodge DS0000025883.V375558.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents receive personal care that meets their individual needs and preferences. The healthcare needs of all of the residents are met and clearly recorded in each person’s care plan which is drawn up with the involvement of the resident and/or relatives. Personal support is responsive to the varied and individual needs and preferences of the residents. The medication policies and procedures, and staff training, ensure that all residents are protected through the safe administration of medicines. The staff team are able to meet the needs of residents and support them in a way that they prefer, through gathering detailed information and good care planning arrangements. Angel Lodge DS0000025883.V375558.R01.S.doc Version 5.2 Page 12 EVIDENCE: The files of three residents were viewed and all had a person centred care plan. The manager is aware that residents and/or their family should be involved in drawing up the care plans. Reviews take place on a monthly basis, or more frequently if necessary. There was some evidence of life histories and this needs to be developed further. Obviously, the successful development of life stories will need the involvement of relatives because some residents who are living with dementia may not be able to remember some significant events in their lives. All of the residents have care plans, which give details of their needs and how to maintain their independence as far as possible. Individual plans clearly record people’s personal and healthcare needs and detail how they will be delivered. The care plans identify residents’ strengths and capabilities and how their needs should be met. They also contain information about residents’ likes and preferences. Care plans are split in to morning, afternoon and night time care. For example “assistance required during mealtimes ”, “likes to rise late in the morning”, give reassurance and make a cup of tea if unsettled at night. Each resident has a nominated key worker. The care plans are used as working tools and are reviewed and updated when a person’s needs change. They therefore contained up to date information to enable staff to meet residents’ current needs. Residents are registered with local GPs. The optician and dentist make regular checks. The district nurse visits as and when required to provide nursing support. The inspector spoke to a district nurse visiting the home on a regular basis who stated that the staff are always very helpful and friendly and act upon any issues raised. The residents always seem to be doing an activity. Residents’ weight is monitored and dietary needs are addressed if required. Manual handling assessments are in place and reviewed monthly. Aids and equipment are provided to encourage maximum independence for people using services, these are regularly reviewed and are replaced to accommodate changing needs. Specialist advice is sought by the home to ensure the effective use of equipment. Medical information is recorded and the outcome of visits to the doctor or hospital and any follow up action is recorded. Residents are supported by staff to attend doctors and hospital appointments. The manager arranges training on health care topics that are related to the health care needs of the residents to make sure that staff are trained and competent in health care matters relevant to the needs of the people who use the service. The home is registered as a service for people with dementia and staff assist residents appropriately as they have all received dementia care training. None of the residents can self medicate and medication is administered by staff that have received medication administration training. There are policies and procedures for the handling and recording of medication. The home now use the nomad system for medication administration. A random sample of Medication Administration Record (MAR) charts were examined and these were Angel Lodge DS0000025883.V375558.R01.S.doc Version 5.2 Page 13 appropriately completed. The medication records include a photograph of the resident, a medical history and details of any allergies. Medication is appropriately and safely stored in locked cabinets and liquid medicines have the opening dates recorded on them. There are regular times for administering medication. Medication is safely and appropriately administered in a way that meets residents’ individual needs and preferences. The manager should draw up a detailed policy, procedure and practice guidance to help staff when caring for residents with degenerative conditions, terminal care and death. All staff should receive training in End of Life care and practical advice and have support and opportunities to discuss any areas of anxiety and concern. The manager is in the process of drawing up end of life care plans for each individual. See recommendation. Angel Lodge DS0000025883.V375558.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents have the opportunity to join in a range of activities and outings. Visiting times are flexible and visitors are welcomed in the home and residents can keep in contact with friends and relatives. Residents’ views and opinions are important and are used in planning and developing the service. The meals in the home are good and residents have a choice of what to eat. Angel Lodge DS0000025883.V375558.R01.S.doc Version 5.2 Page 15 EVIDENCE: A variety of activities are provided each day. An activities room is available where staff carry out activities. These include art & craft, bingo, musical entertainment, knitting and reminiscence, news paper reading and light exercise. The care plans seen include information about preferred activities that residents may like to participate in including spiritual and cultural activities. Residents spoken to said that they enjoy the activities. Staff take some of the residents out to the local shops or other activities subject to a risk assessment. The manager has been advised to develop a programme of activities outside of the home for residents enjoyment after consultation with them and display photographs of the various activities and outings the residents have enjoyed over the year. A hairdresser visits once a fortnight and ensures that the ladies have their hair done and the gentlemen have their haircuts. The Roman Catholic priest comes to the home every month to give Holy Communion and hold prayers, and residents participate if they wish. Some residents visit the local church if they wish. Visitors are welcome at any reasonable time. A relative said “ we visit regularly and you can come when you want to.” The AQAA states that residents meetings are held and the residents talk about what they like, any complaints and where they would like to go for outings as well as menus. They put forward ideas and staff see what the can do. Residents’ opinions are sought and acted upon. Residents are encouraged to be as independent as possible and to be involved in choices about the home and about their lives. Appropriate activities and stimulation are provided for people with dementia such as board games, reminiscense, photograph albums and music. However, more could be done to develop further relevant activities for people with dementia. Residents are offered a choice of meals which are pictorial and the cook takes pride in preparing and presenting nutritious meals. Special diets are catered for. Meals are served in the dining area and drinks and snacks are available. The night staff make a cup of tea or a drink for any residents who have difficulty sleeping during the night. The residents all they enjoy their food. Assistance and encouragement are given to residents who need help. Angel Lodge DS0000025883.V375558.R01.S.doc Version 5.2 Page 16 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is a user-friendly complaints procedure that is followed in the event of any complaints being made so that people who use the service are able to express their concerns and dissatisfactions. People who use the service are protected by staff who have received safeguarding adults training to ensure that they are clear about what constitutes abuse and what to do if abuse is seen or suspected. EVIDENCE: There is a complaints procedure and this is displayed in the home. Complaints are recorded and dealt with by the manager and the staff team. Residents and relatives are encouraged to voice any problems so that they can be sorted out as soon as possible. The manager and staff must be reminded to record any complaints so that evidence can be seen that they are appropriately dealt with and to ensure that any trends are identified and rectified. Feedback from relatives states that any concerns raised are dealt with immediately by the manager or the staff team. The manager has reviewed the home’s safeguarding policy and procedure which clearly tells staff the actions to take in the event of abuse/suspected Angel Lodge DS0000025883.V375558.R01.S.doc Version 5.2 Page 17 abuse being discovered. All staff working within the home are now fully trained in safeguarding adults and know how to respond in the event of an incident being reported. Staff spoken to were aware of the issues surrounding safeguarding adults and aware of their responsibility to residents. Staff, residents and relatives feel able to raise any concerns that they might have. There is a clear system for staff to report concerns about colleagues and managers which ensures that concerns are investigated in line with local policies and procedures. One safeguarding issue was reported to the CSCI inspector since the last inspection which was appropriately dealt with by the manager. There were no issues or concerns raised by staff, residents or relatives at this inspection. The manager stated that they do not handle any finances on the residents’ behalf. All staff understand what restraint is and alternatives to its use in any form are always looked for. Equipment which may be used to restrain individuals such as bedrails, keypads, recliner chairs and wheelchair belts are only used when absolutely necessary with the home promoting independence and choice as much as possible. Angel Lodge DS0000025883.V375558.R01.S.doc Version 5.2 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The residents live in a clean and comfortable home that has suitable aids and adaptations for their needs. The staff team continue to work to improve the environment and to make it as homely as possible. EVIDENCE: Angel Lodge DS0000025883.V375558.R01.S.doc Version 5.2 Page 19 The home is in Goodmayes on a main bus route. The home is accessible to wheelchair users. On the ground floor there are two lounges and a dining area which has been redecorated since the last inspection and a side unit has been purchased to store crockery and cutlery. New furnishings have been purchased for these areas which gives the home a fresh and updated look. There is a lift to the first floor. Adapted bathing and toilet facilities are available to meet the residents’ needs. Hoists, slings, grab rails support frames and walking frames are available for residents that need these. Therefore, the equipment needed to meet the residents’ specialist needs is available in the home. The home is appropriately decorated and furnished throughout. Residents are encouraged to bring some of their own furniture and personal possessions with them if they wish. The AQAA form returned states that bedrooms and both lounges have been re- carpeted and decorated, all bedrooms have been recarpeted. Appropriate signage is used in the home, for example, pictorial signage on toilets and bathrooms. The manager has been advised that photographs of individuals on the doors can also be used to help residents identify their own room. There is also use of sensory and coloured paper around the corridors to assist residents to find their way around the home, and is especially helpful for one person who is partially sighted. There is a medium sized garden at the rear of the home as well as a summer house for the residents enjoyment during fine weather. The garden is spacious and accessible. At the time of the inspection, the home was clean and free from offensive odours. There is an infection control policy and advice is sought from external specialists if the need arises. All staff have received infection control training and the manager aims to raise staff awareness of this issue further in the coming year. Angel Lodge DS0000025883.V375558.R01.S.doc Version 5.2 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are supported and protected by the homes recruitment practice. Staffing levels are appropriate to support the needs of people who use the service. Staff receive the necessary training, supervision and support in order to meet residents’ current needs and provide a good service for them. Residents are supported by a staff team that know them well and who are committed to providing a good quality service. EVIDENCE: At the time of the visit there were fifteen residents living at the home, with five vacancies. There are three shifts for staffing the home and the usual staffing is three carers on the day shifts. At night there are two waking night carers. Domestics and kitchen staff support the care staff. There is a stable staff team and any additional shifts are usually covered by the staff team reducing the need for agency staff. Angel Lodge DS0000025883.V375558.R01.S.doc Version 5.2 Page 21 Therefore, residents receive a consistent service from a staff group that are aware of their needs and how to meet them and residents get continuity in their care. The staffing arrangements are sufficient and flexible to meet the changing needs of residents. The views of residents who contributed to the inspection was that the staff were always available to attend to them and meet their needs. One resident said “staff are always around if you need them”. From observation the staff showed a caring and helpful attitude towards the residents. A relative’s feedback says, “the staff do a wonderful job.” In addition to short courses the staff team have also shown a commitment to achieving their National Vocational Qualifications. More than fifty percent of staff have obtained NVQ Level 2 & 3 qualifications. The home has internal developmental training as well as formal training for staff as part of an ongoing training plan. The training records checked of three members of staff confirmed that they have received training in manual handling, dementia care, medication administration, fire safety, infection control, safeguarding adults, oral care, medication and first aid. Hence, staff are receiving the necessary training to provide an appropriate and safe service to meet the needs of the residents and future training needs have been identified. The manager has completed Mental Capacity Act training and a recommendation is made that all staff should also be aware of this and receive training. Staff records seen and feedback from staff confirms that they receive the right support from the manager to meet the different needs of the people who use the service. At the time of the first visit to the home the manager stated that although she does staff supervision this is not always recorded. Staff confirmed that they do receive regular supervision and good support from the manager. At the time of the second visit, records were available to show that staff had received supervision. The manager should ensure that records are available to show staff receive regular supervision from the registered manager and an annual supervision plan is in place. Staff have job descriptions and are clear as to their individual role in the home. Staff files checked evidence that the home has a thorough and appropriate recruitment procedure. There are application forms, interviews and the appropriate references and Criminal Records Bureau checks are made. A random sample of staff records were checked during the inspection and were found to contain the required information. Angel Lodge DS0000025883.V375558.R01.S.doc Version 5.2 Page 22 Angel Lodge DS0000025883.V375558.R01.S.doc Version 5.2 Page 23 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36,37,38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well managed and provides a safe environment for the residents. The manager and the staff team work well together and receive appropriate support to make sure that residents are safe and secure whilst living at Angel Lodge Care Home. The manager sets an example of good practice to her team and is keen to continue to develop the service at the home for the benefit of the people who use the service. EVIDENCE: Angel Lodge DS0000025883.V375558.R01.S.doc Version 5.2 Page 24 The registered manager has the required qualification and experience to run the home. The manager undertakes regular training and understands and values opportunities for continuing professional development. Therefore, the registered manager is competent to run the home and meet its stated aims and objectives. The atmosphere in the home is relaxed and friendly and there is a stable staff team. The manager communicates a clear sense of direction, is able to evidence a sound understanding and application of best practice operational systems particularly in relation to continuous improvement, customer satisfaction and quality assurance. Equality and diversity, human rights and person centred thinking are given priority by the manager aiming to continuously improve the service in order to meet the residents’ individual needs. The owner carries out monthly monitoring visits to assess how effectively the home is operating to meet its stated aims and objectives, and reports are available in the home. Residents are asked for their feedback about the service and improvements are made where gaps are identified. The manager does not handle residents’ finances and any expenses incurred by the residents are invoiced directly to their families or appointees. People are supported to manage their own money where possible. Record keeping is of a good standard. Records are kept securely and staff are aware of the requirements of the Data Protection Act. Residents know they can access their records at any time. The AQAA contains clear, relevant information that is supported by appropriate evidence. The manager recognises the areas that they still need to improve and has detailed ways in which they are planning to do this. The inspector will make contact with the manager on a regular basis to check on progress made regarding the requirements as well as discussion around any other matters. The home has a range of policies and procedures to promote and protect residents’ and employees’ health and safety. The manager is proactive with regards to health and safety to ensure that any potential risks are minimised as far as possible. Health and safety awareness issues are cascaded to staff to raise their awareness. Regular health and safety checks are carried out by appropriate professionals. The manager is aware that it is her responsibility to carry out all of the necessary health and safety checks and provide a safe environment for the residents and staff at all times. Two residents smoke in the home and the manager is aware that a separate, safe and well ventilated facility must be provided for them in order to fulfil the requirements of the Smoking Legislation. Staff meetings have been taking place regularly, providing staff with the opportunity to discuss problems and to be involved in the development of the service. Staff meetings have an agenda and minutes are available. Staff spoken to said that there is very good communication and teamwork in the home. Training and development needs are identified as part of supervision. Angel Lodge DS0000025883.V375558.R01.S.doc Version 5.2 Page 25 There are clear lines of accountability in the home. Appropriate insurance cover is in place. Angel Lodge DS0000025883.V375558.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 3 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 2 Angel Lodge DS0000025883.V375558.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? yes 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 OP16 Regulation 22 Requirement The registered person to ensure that all complaints are logged in the complaints log. This will ensure that any trends are identified and acted upon. The registered person to make available proper provision for residents who smoke which comply with the smoke free Legislation, in order to ensure that the health and safety of residents and staff are maintained at all times. Timescale for action 30/09/09 2 OP38 12/13 30/09/09 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 OP11 Good Practice Recommendations The manager should draw up a detailed policy, procedure and practice guidance to help staff when caring for residents with degenerative conditions, terminal care and death. All staff should receive training in End of Life care and these should be in place for all residents. DS0000025883.V375558.R01.S.doc Version 5.2 Page 28 Angel Lodge 2 OP12 The manager has been advised to develop a programme of activities outside of the home for residents enjoyment after consultation with them and display photographs of the various activities and outings the residents have enjoyed over the year. All staff to receive training re Mental Capacity Act training. 3 OP30 Angel Lodge DS0000025883.V375558.R01.S.doc Version 5.2 Page 29 Care Quality Commission London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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