Inspection on 09/01/06 for Ashley Lodge Nursing Home

This inspection was carried out on 9th January 2006.

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 11/08/05

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 Mrs Rekha Bhardwa Unannounced Inspection 9th January 2006 10:55 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 Ashley Lodge Nursing Home DS0000010938.V275299.R01.S.doc Version 5.1 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. Ashley Lodge Nursing Home DS0000010938.V275299.R01.S.doc Version 5.1 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 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) 020 8998 9071 020 8810 4398 Mr and Mrs Kassam (County Point Limited) Mrs Nabat Tajdin Kassam Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (0), Physical disability (0), Physical disability of places over 65 years of age (0) Ashley Lodge Nursing Home DS0000010938.V275299.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 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 accommodated, 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. 11th August 2005 Date of last inspection 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 DS0000010938.V275299.R01.S.doc Version 5.1 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. A total of 7 hours was spent on the inspection process. The Inspector carried out a brief tour of the home, and inspected service user plans, staff records, maintenance and servicing records. 6 service users, 3 staff and 1 visiting professional were spoken with as part of the inspection process. The purpose of this inspection was to follow up the one requirement from the last inspection, and to view some additional standards. The majority of key standards were viewed at the last inspection and it is recommended that this report be read in conjunction with the last report to gain full inspection information for the home. What the service does well: What has improved since the last inspection? What they could do better: Shortfalls were identified in relation to wound care documentation. The need to have a separate wound care plan for each wound was discussed. Moving and handling assessments must detail the equipment to be used and all service users must have a nutritional assessment. Annual surveys must be undertaken and the results collated published. Copies of the Regulation 26 Visit reports must be sent to the CSCI each month. Ashley Lodge Nursing Home DS0000010938.V275299.R01.S.doc Version 5.1 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 DS0000010938.V275299.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Ashley Lodge Nursing Home DS0000010938.V275299.R01.S.doc Version 5.1 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 the following standard(s): 2 The home does not provide intermediate care. Written agreements are available for service users, providing clear information about the services provided. EVIDENCE: The home has specific contracts for each service user. Contracts for privately funded and Social Services funded service users were viewed and these were clear and up to date, and had been signed on behalf of the service user and also on behalf of the home. Ashley Lodge Nursing Home DS0000010938.V275299.R01.S.doc Version 5.1 Page 9 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 the following standard(s): 7,8,9 & 11 Service users individual needs are identified and information was up to date. Shortfalls identified in relation to assessments require addressing. Shortfalls in wound care documentation potentially do not allow for continuity of care. Medications in the home are generally well managed. Service users needs in respect of death and dying are being met, thus ensuring that the service users final days are comfortable and appropriately managed. EVIDENCE: The Inspector viewed two service user plans. Overall these were up to date and gave a good picture of the service users needs. There was evidence of updates to reflect changes in a service users needs plus monthly reviews had been carried out. Wound care documentation for one service user was viewed for a service user with multiple wounds. It was not clear from the documentation viewed the details of the dressings being used, how frequently the dressings needed to be reviewed and the progress of the wound. Pressure relieving equipment had been identified. Ashley Lodge Nursing Home DS0000010938.V275299.R01.S.doc Version 5.1 Page 10 Assessments on moving and handling, pressure sore assessments, nutritional assessments, risk of falling and continence assessments were available for one service users file. For another service users all assessments with the exception of a nutritional assessment were available. Moving and handling assessments did not identify the type of equipment to be used in all instances. The CSCI Pharmacist Inspector carried out an inspection on 18/1/06 and a separate report is available. The requirements resulting from that inspection have been incorporated into this report. The changing needs of service users are met by the home. Where possible the service user’s wishes concerning death and dying are discussed and wishes carried out. The Registered Manager stated that some service users and their families find death and dying a very difficult subject to discuss. Where possible service users families/representatives can stay with their loved one at the home. Ashley Lodge Nursing Home DS0000010938.V275299.R01.S.doc Version 5.1 Page 11 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 the following standard(s): 15 The meal provision is good, offering choice and catering for special dietary needs. EVIDENCE: The lunchtime meal was observed, and service users were socialising and enjoying their meals. Staff were available to assist service users in a sensitive manner. Service users spoken with said that they enjoy the food provision at the home and that choices are available. The kitchen was not viewed at this inspection. Ashley Lodge Nursing Home DS0000010938.V275299.R01.S.doc Version 5.1 Page 12 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 the following standard(s): 17 Service users rights are protected and service users are able to exercise their legal rights directly. EVIDENCE: Standards 16 and 18 were viewed and met at the last inspection. The Registered Manager reported no complaints had been received since the last inspection and that there had been no adult protection issues. The Registered Manager stated that all service users are on the electoral roll and that they can vote in person if possible or via the postal voting system. Advocacy services would be obtained via Age Concern or through the service users Social Worker. Ashley Lodge Nursing Home DS0000010938.V275299.R01.S.doc Version 5.1 Page 13 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 the following standard(s): 19 & 23 The standard of the environment within the home is good, providing service users with a homely and comfortable place to live. EVIDENCE: A tour of the home was carried out and a sample of rooms viewed. Some areas along the corridors needed decorative attention where wheelchairs and the hoist had damaged them. The Registered Manager stated that she had made the maintenance person aware of this. A routine programme of redecoration and replacement and renewal of furnishings was in place. A full time maintenance person is employed. Where service users choose to have their bedroom doors kept open a dorgard mechanism has been fitted. Bedrooms viewed were well maintained and were personalised to meet the service users preferences. Ashley Lodge Nursing Home DS0000010938.V275299.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 & 30 The home was appropriately staffed to meet the current needs of the service users. The vetting and recruitment practices are robust, thus safeguarding service users. Foundation training is in place and provides staff with the skills and knowledge to care for service users. EVIDENCE: There were no changes to the staffing levels at the home from the previous inspection. The management of the home are aware of the need to keep staffing levels under review on an ongoing basis to ensure that the changing needs of service users are met. Ancillary staff are employed in appropriate numbers. The staff employment files viewed contained details of the applicants completed application forms, medical declaration, two references, copies of passports, work permits, photographs and POVA First checks had been carried out. The Registered Manager explained that there had been a delay in receiving the Enhanced Criminal Record Bureau checks and that this was being progressed by the homes umbrella body. The Registered Manager reported that since the last inspection Foundation training programmes to meet the Skills for Care (formerly TOPPS) were in place. Ashley Lodge Nursing Home DS0000010938.V275299.R01.S.doc Version 5.1 Page 15 Ashley Lodge Nursing Home DS0000010938.V275299.R01.S.doc Version 5.1 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33 & 38 Systems for quality assurance are in place; shortfalls in undertaking annual surveys potentially do not facilitate feedback from the service users and their representatives. Health and safety is well managed thus safeguarding service users. EVIDENCE: The last service user and representative survey was carried out in 2004. The need to have annual surveys was discussed with the Registered Manager. Ashley Lodge Nursing Home is registered to ISO 9001 standards, as part of the quality programme an annual audit by an external assessor is undertaken. The audit report was available for the Inspector to view. The results Regulation 26 Visits were being undertaken by the Registered Provider, however copies of the visit reports were not always being sent to the CSCI. Ashley Lodge Nursing Home DS0000010938.V275299.R01.S.doc Version 5.1 Page 17 The Registered Manager stated that service users and their representatives are encouraged to voice any concerns. Medication audits are undertaken by the Senior Nurse. Servicing records were viewed at random and those viewed were up to date. The fire records were up to date and there was evidence of weekly fire alarm tests and fire drill training. The fire risk assessment had been reviewed by an external health and safety Consultant. The Registered Provider reported that they were awaiting his report. The training matrix viewed indicated that staff were receiving mandatory training. Ashley Lodge Nursing Home DS0000010938.V275299.R01.S.doc Version 5.1 Page 18 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 X 2 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 3 18 x 3 X X X 3 X X X STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 2 x x x x 3 Ashley Lodge Nursing Home DS0000010938.V275299.R01.S.doc Version 5.1 Page 19 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 OP8 Regulation 12, 17 Requirement Wound care documentation must clearly identify each wound and the dressing regime required for each separate wound. Moving and handling assessments must detail the moving and handling equipment required. Nutritional assessments must be available for all service users and periodically reviewed. That the home has a procedure to facilitate self-medication as appropriate. The home should also have a procedure to manage those service users who refuse medication or develop swallowing difficulties. Only controlled drugs must be stored in the CD cupboard. Annual surveys must be undertaken as part of the quality assurance programme. The results of these surveys must be published and sent to the CSCI. Copies of Regulation 26 Visit reports must be sent to the CSCI. Timescale for action 06/02/06 2 OP8 13(5) 06/02/06 06/02/06 01/04/06 3 4 OP8 OP9 12, 17 13(2) 5 6 OP9 OP33 13(2) 24 01/02/06 01/03/06 7 OP33 26 06/02/06 Ashley Lodge Nursing Home DS0000010938.V275299.R01.S.doc Version 5.1 Page 20 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Ashley Lodge Nursing Home DS0000010938.V275299.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection West London Area Office 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 DS0000010938.V275299.R01.S.doc Version 5.1 Page 22 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!