Inspection on 11/08/05 for Ashley Lodge Nursing Home

This inspection was carried out on 11th August 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Ashley Lodge Nursing Home 26/02/07

Ashley Lodge Nursing Home 09/01/06

Ashley Lodge Nursing Home 28/02/05

Ashley Lodge Nursing Home 13/09/04

Ashley Lodge Nursing Home 09/06/03

Similar services:

Ashlong House

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

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

CARE HOMES FOR OLDER PEOPLE Ashley Lodge Nursing Home 12/13 Carlton Road Ealing London W5 2AW Lead Inspector Rekha Bhardwa 11 and 15 th th Unannounced August 2005 at 15.00hrs 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 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. Ashley Lodge Nursing Home G61-G10 s10938 Una-Ashley Lodge v214420 110805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Ashley Lodge Nursing Home Address 12/13 Carlton Road Ealing London W5 2AW Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0208 998 9071 0208 810 4398 Mr & Mrs Kassam (County Point Limited) Mrs Nabat Tajdin Kassam Care Home 36 0, PD (E) Category(ies) of PD Physical Disability 0, OP Old age registration, with number Physical Disability - over 65 0 of places Ashley Lodge Nursing Home G61-G10 s10938 Una-Ashley Lodge v214420 110805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Physical disabilty (PD). Old age, not falling within any other category(OP), Physical disability over 65 years of age(PD(E). Elderly medically sick of either sex over the age of 60. Service Users to include OP,PD & PD(E), not to exceed 36. One named service user with Dementia can be accommdated, as agreed by the Commission for Social Care Inspection, on 20th December 2004, for as long as there is no deterioration which effects the well being of other service users. The home must advise the CSCI when the service user no longer resides in the home. Date of last inspection 28/2/05 Brief Description of the Service: Ashley Lodge is a Care Home providing nursing care for thirty-six service users. The home is a converted detached house situated in a residential area. There are 28 single rooms and 4 double rooms on two floors. The floors are connected by a stairway and a lift. The living/dining area, which is narrow and small, does not allow for service users to eat meals at a dining table. Instead, small over-chair tables are placed in front of each service user at meal times. This living/dining area is subdivided into three smaller areas. There is a quiet room with a garden outlook that allows seating for three to four service users. Service users and others access the first floor by one of several stairways or via the lift. Ashley Lodge Nursing Home G61-G10 s10938 Una-Ashley Lodge v214420 110805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the regulatory process. Rekha Bhardwa Lead Inspector undertook the inspection. A total of 6.55hours was spent on the inspection process. The Inspector carried out a tour of each floor of the home, and inspected service user plans, staff files and maintenance records. 8 service users, 3 visitors and 8 staff were spoken as part of the inspection process. At the time of the inspection there were 36 service users. The pre-inspection documentation completed by the home was also examined to inform the inspection. What the service does well: What has improved since the last inspection? What they could do better: The Registered Manager must ensure that all care staff undertake foundation training within the first six months of employment. Ashley Lodge Nursing Home G61-G10 s10938 Una-Ashley Lodge v214420 110805 Stage 4.doc Version 1.40 Page 6 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. Ashley Lodge Nursing Home G61-G10 s10938 Una-Ashley Lodge v214420 110805 Stage 4.doc Version 1.40 Page 7 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 Standards Statutory Requirements Identified During the Inspection Ashley Lodge Nursing Home G61-G10 s10938 Una-Ashley Lodge v214420 110805 Stage 4.doc Version 1.40 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,3,4 and 5. The home does not provide intermediate care. The service users in the home are provided with information about the home and the services provided, so as to be clear about the services the home provides to meet their needs. Service users are assessed prior to admission to ensure that the home can meet their needs. Prospective service users and/ or their representatives are encouraged to visit the home in order to allow them to make an informed choice. EVIDENCE: Service users, their relatives and representatives are provided with information regarding the home. A service user guide and statement of purpose were available. Both documents were informative and available to each service user. Ashley Lodge Nursing Home G61-G10 s10938 Una-Ashley Lodge v214420 110805 Stage 4.doc Version 1.40 Page 9 The pre-admission documentation is comprehensive, and some completed documents were viewed. All pre-admission assessments are undertaken by the Registered Manager or a Senior Nurse. Where service users have been referred by the PCT or Social Services a Needs Led Assessment is obtained beforehand. The documents viewed provided a clear picture of the service users needs. Staff had received training in topics relevant to the care of the elderly. One senior carer commented that undertaking the NVQ in Care had allowed her to gain a better understanding of the needs of older people. All staff are kept up to date in the needs of the service users, to include any changes. This is undertaken via the handover and with the deputy manager working on the floor with the staff. The Registered Manager said that whenever possible, prospective service users are encouraged to visit the home, and meet other service users and staff. If the service user were unable to visit the home, then their relative or representative would visit on their behalf. Ashley Lodge Nursing Home G61-G10 s10938 Una-Ashley Lodge v214420 110805 Stage 4.doc Version 1.40 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,and 10. The health and personal needs of service users had been identified and were being met. The systems for the administration of medication are good with clear arrangements in place to ensure that service users medication needs are met. Service users are treated with respect and courtesy, and the changing needs of service users were being identified and met. EVIDENCE: Individual service user plans were available and samples were viewed. Overall these were comprehensive, well written and contained a wealth of information on how the service users’ identified health, personal and social/religious/cultural care needs would be met. Service users plans were up to date and had been reviewed monthly and whenever there was a change in the service users needs. Ashley Lodge Nursing Home G61-G10 s10938 Una-Ashley Lodge v214420 110805 Stage 4.doc Version 1.40 Page 11 A standard format is used for service users and/or representatives to agree and sign the service user plan. Both service user plans viewed had been agreed and signed by the service user to whom the plan related. Daily records were available and detailed the care provided. Service users health needs were identified and detailed in the service user plan. Specialist input from health care professionals are accessed via referrals from the GP, this includes the Tissue Viability Nurse, Community Dietician, Chiropodist, Optician and other healthcare professionals. Assessments for moving and handling, risk of falling, pressure sore, nutritional screening and continence management were in place, with appropriate care plans and risk management plans in place to meet the identified needs. Risk assessments and signed consents for the use of bedrails had been completed for one service user. A sample of medication administration records were viewed, these were satisfactorily completed. The medication fridge temperatures were within the required range. The Controlled Drugs Register was viewed and found to be well recorded. The Registered Manager was in the process of updating the medication procedure to reflect the changes in relation to the disposal of medication. Staff were seen to address service users in a courteous manner. Service users and visitors spoken with were satisfied with the standard of care provided and the attitude of the staff. Training on customer care had been undertaken by some members of staff. Some service users choose to spend time in their bedrooms rather than the lounge. Where service users like their bedroom doors to be kept open a dorgard mechanism has been fitted. Ashley Lodge Nursing Home G61-G10 s10938 Una-Ashley Lodge v214420 110805 Stage 4.doc Version 1.40 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14 and 15 Social activities are in place in accordance with service users wishes. Visiting is encouraged for service users to maintain contact with family and friends. Service users choices in their care and routines are respected. Dietary needs of service users are well catered for with food choices provided and food available that meets service users preferences. EVIDENCE: A full time activities person is employed by the home. Individual and one to one activities take place. Activities for the day are displayed on the notice board. Photographs of outings were displayed throughout the home. The activity provision has improved since the last inspection. Several service users were seen reading newspapers and their books. Some were available in large print. The activities organiser arranges involvement from local community groups and outside entertainers. Day trips are also arranged to local parks. Relatives and friends were seen visiting service users on both days of the inspection. Service users can see their visitors in their bedrooms, in the lounge or as observed on the first day of the inspection in the garden. Some service users also visit their family and friends outside. Ashley Lodge Nursing Home G61-G10 s10938 Una-Ashley Lodge v214420 110805 Stage 4.doc Version 1.40 Page 13 Choices are offered in each aspect of the care provision and routine of the home. This includes where service users choose to spend their time and what activities they participate in. The lunch- time meal was sampled on the second day of the inspection and were well presented and tasty. A menu with choices is available. The cook also keeps a record of when service users have had something other than what is on the menu prepared for them. Where service users request specific items of food these are provided. Service users were seen on both days being offered hot and cold drinks. A mid afternoon snack is offered and fresh fruit is available. The kitchen was inspected by the Environmental Health Officer on the 8th August 2005. Adapted cutlery, plate guards, non-slip mats and beakers were available for service users. Where service users required assistance with their meal, the Inspector observed the staff sitting down with the service user and offering assistance sensitively and in an unhurried manner. Ashley Lodge Nursing Home G61-G10 s10938 Una-Ashley Lodge v214420 110805 Stage 4.doc Version 1.40 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 The home has a clear complaints procedure in place to address any concerns raised by service users and their representatives. Systems are in place for the Protection of Vulnerable Adults, so as to protect them from possible risk of harm or abuse. EVIDENCE: The home has a complaints procedure, which is displayed in the home. The Registered Manager stated that there had been no complaints since the last inspection. No complaints have been received by the CSCI since the last inspection. Relatives and service users who spoke with the Inspector confirmed that they knew the procedure for making a complaint. Staff had received training in POVA. The pre-inspection documentation indicated that a policy and procedure on the Protection of Vulnerable Adults was available. There have been no POVA issues since the last inspection. Ashley Lodge Nursing Home G61-G10 s10938 Una-Ashley Lodge v214420 110805 Stage 4.doc Version 1.40 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,24,25 and 26 The home was clean and tidy and the environment is safe for service users. This provides service users with a comfortable and safe environment for those living in the home and visiting. The premises were well maintained, odour free and a pleasant living environment. Policies and procedures and staff training for infection control are in place to safeguard service users from infection. EVIDENCE: A tour of each floor was carried out and a sample of rooms viewed. The rooms viewed were well maintained and there was in place a programme for the decoration and renewal of furniture and fittings. The home has a large garden to the rear, with seating for service users. The grounds were well maintained and safe for service users. The communal areas were well maintained, bright and had a homely atmosphere. Ashley Lodge Nursing Home G61-G10 s10938 Una-Ashley Lodge v214420 110805 Stage 4.doc Version 1.40 Page 16 Toilets and bathrooms are located close to the lounge, dining area and service users bedrooms. Soap, paper towels and gloves were available in the bathrooms and toilets viewed. The home has a passenger lift and there are rails in the corridors and in the toilet facilities. The home has a range of moving and handling equipment. Records viewed indicated that pressure relieving equipment was available. The home has a call bell system. The Inspector noted that the response to the call bell was prompt. Emergency lighting is available and regular internal and external checks are undertaken on this. Generally the lighting was satisfactory in the areas viewed. Water temperatures are carried out for designated areas every quarter. Where temperatures are found to be outside the designated safe range, corrective action can be taken. The bedrooms viewed were well maintained and contained service users personal items. Policies were available on Infection control. Staff had also received training in infection control. The laundry was viewed and found to be well ordered, with gloves, paper towels and aprons available. Information on the management of MRSA was also available. The home was clean, tidy and odour free with the exception of one isolated area on the ground floor. The Registered Manager was aware of this, and had systems in place to deal with this. Alternative flooring for this area was discussed with the Registered Manager. Ashley Lodge Nursing Home G61-G10 s10938 Una-Ashley Lodge v214420 110805 Stage 4.doc Version 1.40 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 and 30 Overall the systems for the recruitment of staff were robust so as to safeguard service users. The provision of in house training is good and ensures that the identified training needs of individual staff are addressed and that staff have the necessary skills to meet service users needs. The home is aware of the need for ongoing NVQ training for care staff. EVIDENCE: The staffing levels were adequate to meet the needs of the service users. On the second day of the inspection an extra carer had been rostered to undertake activities whilst the activities organiser was on annual leave. The home has a stable staff team with little turnover of staff. Ancillary, domestic and catering staff are employed in sufficient numbers. There are 14 care staff qualified to at least NVQ Level 2. The home does not use volunteers. The staff employment files viewed contained details of the applicants completed application forms, recent photographs, medical declaration, 2 references, copies of passports, plus terms and conditions of contract. POVA first checks had been carried out. A training matrix was in place, which showed when staff had attended training and updates in mandatory training. Staff training records were available and staff who spoke with the Inspector confirmed that they received training. Ashley Lodge Nursing Home G61-G10 s10938 Una-Ashley Lodge v214420 110805 Stage 4.doc Version 1.40 Page 18 Induction training to recognised standards was in place. Care staff had not undertaken foundation training. Ashley Lodge Nursing Home G61-G10 s10938 Una-Ashley Lodge v214420 110805 Stage 4.doc Version 1.40 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,34,35,36,37 and 38 The home is well managed and the Registered Manager has an open style of management. Meeting the service users needs is a priority with all staff who are well supported by the Registered Providers and Registered Manager. Staff work together to meet the needs of the service users. Health and Safety systems were in place to safeguard service users. EVIDENCE: The Registered Manager has been running the home for over thirteen years. She is a First Level Nurse and has several years experience of working with older people. The Registered Manager informed the Inspector that she was due to retire and that several recruitment campaigns for a Manager had been unsuccessful. Advertisements were due to be placed in the local newspapers and Nursing magazines. Ashley Lodge Nursing Home G61-G10 s10938 Una-Ashley Lodge v214420 110805 Stage 4.doc Version 1.40 Page 20 The Deputy Manager has a clinical overview and is also involved in the care and review of service users. Visitors who spoke with the Inspector were complimentary about the attitude and approach of the management and staff. A business and financial plan were available. The Inspector was also shown details of the audited accounts. The Registered Manager informed the Inspector that the home is not involved in managing service users finances. This is undertaken by the service user themselves, there representatives or an advocate. A system of formal supervision is in place. Supervision records were available and viewed. All staff are supervised on a day to day basis as part of the management of the home. The records viewed at this inspection were well maintained up to date and stored securely. Servicing records were viewed at random and those viewed were up to date. There was evidence that day and night staff received regular fire drills. A fire risk assessment was available. Generic and specific risk assessments were available. Ashley Lodge Nursing Home G61-G10 s10938 Una-Ashley Lodge v214420 110805 Stage 4.doc Version 1.40 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 N/A 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 N/A DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 N/A 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 N/A 3 3 N/A N/A 3 3 3 3 3 Ashley Lodge Nursing Home G61-G10 s10938 Una-Ashley Lodge v214420 110805 Stage 4.doc Version 1.40 Page 22 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 30 Regulation Requirement All care staff must undertake Foundation training within 6 months of employment. Timescale for action 5/9/05 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 Good Practice Recommendations Ashley Lodge Nursing Home G61-G10 s10938 Una-Ashley Lodge v214420 110805 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection Ground Floor 58 Uxbridge Road Ealing London W5 2ST National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ashley Lodge Nursing Home G61-G10 s10938 Una-Ashley Lodge v214420 110805 Stage 4.doc Version 1.40 Page 24 - 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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