Inspection on 19/04/07 for Amber Lodge

This inspection was carried out on 19th April 2007.

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

Other inspections for this house

Amber Lodge 15/04/08

Amber Lodge 07/06/06

Amber Lodge 08/11/05

Amber Lodge 19/07/05

Amber Lodge 22/10/04

Amber Lodge 12/05/04

Similar services:

Abbey The

Snydale Care Home

Whiteley House

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

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

CARE HOMES FOR OLDER PEOPLE Amber Lodge 21 Thornhill Road Armley Leeds West Yorkshire LS12 4LL Lead Inspector Valerie Francis Key Unannounced Inspection 19th April 2007 11:00 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 Amber Lodge DS0000001412.V332056.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Amber Lodge DS0000001412.V332056.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Amber Lodge Address 21 Thornhill Road Armley Leeds West Yorkshire LS12 4LL 0113 2633231 0113 2038556 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) Meridian Healthcare Ltd Mrs Lynne Dawson Care Home 40 Category(ies) of Dementia - over 65 years of age (10), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (6), Old age, not falling within any other category (40) Amber Lodge DS0000001412.V332056.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The places for MD(E) are specifically for named service users Date of last inspection 7th June 2006 Brief Description of the Service: Amber Lodge is owned and managed by Meridian Healthcare Ltd. The home is a care home without nursing, registered to provide personal care for up to 40 older people. The building is a two-storey purpose built home situated in Wortley, near Armley. It has a garden to the rear of the building. A large car parking area is located at the front of the building therefore access is easy for those with mobility problems. Local shops and bus routes are also within easy access. For the people who use the service, their accommodation is provided on both floors. There are 38 single bedrooms and one double bedroom. All bedrooms have en-suite facilities. Lounge and dining areas are located on the two levels. There are three bathrooms, two of which have hoisting facilities, and two shower rooms. All laundering is undertaken on the premises. The people who use the service can access the garden through the dining room patio doors. The current scale of fees is £390 weekly. Additional charges are made for chiropody, hairdressing, newspapers and personal items. Amber Lodge DS0000001412.V332056.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way care services are inspected. They are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example, Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate”, and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes are available on our website – www.csci.org.uk Information about the home is gathered from a variety of sources, one being a site visit. Additional site visits may be made that will concentrate on specific areas such as health care or nutrition. These are called random inspections. This inspection visit was unannounced carried out by one inspector over two days on the on 19th and the 23rd April 2007. The Mrs Lynne Dawson the registered manager was available during the inspection process. The purpose of this inspection was to assess all the key standards (the key standards are identified in the main body of the report) and to assess how the needs of people who use the service at the home are being met. The methods used at the inspection included looking at care records, talking to the people who use the service and visitors, observing care practices, talking to staff and management, looking at the environment and looking at written documents including staff records. The home provided some information to the CSCI in advance of the inspection in the PIQ (Pre-inspection questionnaire). Survey cards were sent to the home for residents and their relatives. Five were returned to the CSCI area office. Generally, all gave a positive view of the service provided. Amber Lodge DS0000001412.V332056.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Efforts have been to ensure that care staff carry out the community nurses instructions. And the manager must respond more robustly to issues with health centres about prescribed medication. Risk assessments are reviewed for those who smoke and in need of staff supervision. Complaint records including any investigation and action required were available for inspection. Work had started to fit light shades in en-suite facilities. Staff have had further training and discussion with senior management relating to adult protection and abuse, to make sure that they have full understanding of the procedure and what to do if an allegation of abuse occurred. During the discussion it was clear that they were aware of the whistle blowing policy procedure and would have no problem using it. Staff have had a two day training on non-violent crisis intervention within three months of employment, which is reviewed annually, this was supported by the organisation policy and procedure on intervention. Relatives responding to the survey indicated that they would have no hesitation in making a complaint. However, not all knew the procedure to follow if they had a complaint, but they would approach the manager in the first instance. Relevant references were seen for the people whose files were inspected. Amber Lodge DS0000001412.V332056.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Amber Lodge DS0000001412.V332056.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 Amber Lodge DS0000001412.V332056.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3. People who use the service experience adequate quality outcomes in this area. We made this judgment using a range of evidence, including a visit to the service. The admission processes do not always provide evidence that the needs of the person can be (or will be) met at the home. EVIDENCE: Three people recently moved into the home and pre admission assessment information was looked at. Although they had “ Easy Care” information (multiagency assessment information), these in most cases, did not have information that was up to date and related to the persons current care needs. Although the home has a format to record information on the care needs of people, the format did not prompt people to assess the persons mental ability and their mental health needs, especially people who has a diagnosis of dementia. Amber Lodge DS0000001412.V332056.R01.S.doc Version 5.2 Page 10 Despite this, generally the assessment information seen for these people was adequate. Staff must be provided with good information on the needs of the people who use the service in enough detail to give them good insight into the needs of the person they would be caring for. This should be aimed for in all assessments to make sure that the home is equipped to meet the overall needs of people. The manager is advised to request better quality information from other referral agencies before carrying out her own assessment. Amber Lodge DS0000001412.V332056.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience adequate quality outcomes in this area. We made this judgment using a range of evidence, including a visit to the service. The care plans were not detailed enough to give a picture of what the home was doing to meet peoples’ needs, this provides the opportunity for care needs to be overlooked. Overall medication practices are safe and the home always follows safe guidelines and return unused medication to the pharmacy. EVIDENCE: The care records of three people who use the service were looked at as part of case tracking. The records contained basic assessment information, personal details, health care needs, risk assessments and care plans. However, they did not provide clear detail of what intervention was needed in order to meet all the care needs. Although a full risk assessment was seen for one person who was at high risk of falling, there was no care plan to address this risk. One person had been Amber Lodge DS0000001412.V332056.R01.S.doc Version 5.2 Page 12 assessed as been at risk of being abused but no plan was in place to avoid this risk. There was no evidence of the changing needs of people and any discharge from hospital was not reflected in the records. Monthly nutritional risk assessments were seen, however, although two people were identified as at risk, there were no plans in place of what should be done to minimise and manage the risk. The manager said people have their weight checked monthly but some needed this done weekly; however, there were no evidence in any of the care files seen that monthly or weekly checks should be carried out, with the reasons why this should be done. None of the written information provided clear instructions for staff to meet the psychological needs of people with dementia in person centred plan. This is particularly important when caring for people with dementia, so that the plan provides staff with information as to how the person should be cared for and not just their diagnosis. On the whole staff were observed treating residents with respect and maintaining privacy. People were free to use their bedrooms as and when they wish and lockable facilities are provided. People using the service and their relatives said that staff looked after people in a way that maintained their dignity when carrying out their personal care tasks. There were no social care plans in place even though there was some general information seen in files, the manager was advised that the home should work with the people who use the service, families and friends to get their life history. This would provide staff with good information about the person they are caring for and would form the basis of a person centred approach to the individual care. The lunchtime medication round was observed. The member of staff administering the medication was knowledgeable and competent. The medication systems were correctly followed. She said some staff had received training from a distance-learning course provided by a local college. The manager said that none of the present group of people living at the home manages their own medication. Medication records were sampled and found to be in order. The home makes sure that any unused medication that has been prescribed for a person is returned to the pharmacy and is not kept at the home. Although the staff involved in giving medication have received training, not all had received the comprehensive distance learning training, which provides them with good knowledge on safe handling of medicine. There are policies and procedures to support the staff. The inspector advised that some consideration should be given to include the catering staff in the safe handling Amber Lodge DS0000001412.V332056.R01.S.doc Version 5.2 Page 13 of medication course, to make them aware of possible side effects of food served and any medication prescribed. The manager agreed to pursue this. The dedicated fridge provided for drugs storage needed defrosting, it is not lockable but is kept in a locked room. The manager must make sure that the temperature is checked occasionally to ensure that it is efficient. Their GP prescribes all medications given to people. The manager said the home do not administer any homely remedies. Amber Lodge DS0000001412.V332056.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience adequate quality outcomes in this area. We made this judgment using a range of evidence, including a visit to the service. Social activities for people using the service are very limited and lack variety; thus creating opportunity for apathy and boredom. Residents are able to make decisions about their lifestyle and maintain good contact with family, relatives and friends. More could be done to improve the opportunity for conversation, choice and independence at mealtimes. EVIDENCE: There was no real plan for recreational activities; the “motivation” person visited the home on the second day of the inspection to engage people in chair exercise and quizzes. Only the people on the ground floor who wanted to take part in the activity did so. The manager said people on the top floor also had the opportunity to take part but choose not to come down. It was recommended that the activities held on each floor alternately so that people have the opportunity to take part in activity provided. Amber Lodge DS0000001412.V332056.R01.S.doc Version 5.2 Page 15 There is no activity organiser this has left people who use the service without access to a member of staff whose role is to plan and engage them in meaningful recreational activities. People entertain themselves, two people go out independently, one goes to the city centre or the nearby shopping centre and the other goes for short walks in the grounds or the nearby street. Some people were seen reading books or magazines, people who stayed in their rooms passed the time by watching television or reading. For some people there was nothing really going on for them. They looked bored, when questioned people said they just sit. The inspector observed one person after lunch sitting at the table but when given a magazine which she clearly liked looking at, the manager said this person liked to move the vase and liked cleaning a recommendation was made for the person to assist staff with simple household tasks such as laying the table and wiping them after meals. The programme of activities should aim to provide interest and diversion for the whole group. This could be improved by drawing on peoples’ past life experiences and skills, to adopt a more focussed approach for individuals and those people with dementia. Several service users were in their bedrooms, some using the locking device for privacy. It was clear that those people who were able to express their views could make choices and have their wishes respected. One person said she prefers to stay in her room where she can entertain visitors and described herself as ‘very contented’. Another person said she was satisfied with the home. She said she spends time in her room, as she was unable to find anyone in the home with whom she could talk to. Another person spoken to said she was here for a short time so she was not to bothered by not having anything to do. People are encouraged to keep in contact with their relatives. From discussion with relatives and the manager it was evident that relatives are informed about any changes in people’s care needs. People are encouraged to bring to the home their personal effect. People using the service and their relatives are made aware of their right to see the information held on them. There is a written policy on the front of all care files reminding staff of people’s right to see their records. There are set meal times, which the manager said is flexible, the main meal is one standard meal with no real choice, the manager said if people did not like what was offer they could have something else. However, discussion with people who use the service indicated they were not quite sure what to do and would just leave it if they did not like the food served. The meal times do not allow people the opportunity for independence and choice by them servicing themselves. Amber Lodge DS0000001412.V332056.R01.S.doc Version 5.2 Page 16 Food was being plated and served from the kitchen hatch. This could make choices difficult for people with dementia who are unable to concentrate on the matter in hand. It was apparent from conversation with staff that they knew people’s like and dislikes. On tables there was little conversation during the meal between the staff serving the meal and the people who use the service, staff gave assistance and encouragement for people who were sitting looking at their plates but not eating. Mealtime observed was not hurried and people were given the time to eat their meal. One person was given time to complete her meal even though others had finished and left the table. People were asked during the day what they would like for supper, people should be given this choice much nearer the time, so that they can make a true choice of what they would like. The people spoken with said the food was good. Discussion was held with the manager about soft and pureed meals, the indication was that it was not served in its separate portions to allow the person eating the meal to distinguish between and enjoy different flavours to encourage nourishment. Amber Lodge DS0000001412.V332056.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience good quality outcomes in this area. We made this judgment using a range of evidence, including a visit to the service. People using the service and their relatives are confident that any concerns will be listened to and acted upon. The level of staff understanding gives assurance that complaints will be taken seriously and people who use the service will be protected from abuse. EVIDENCE: A log is kept of complaints and this was inspected. Copies of the written complaints and any letters to the complainants, which also include outcome letters, are also sent to the CSCI. A copy of the complaints procedure is available to people in their bedrooms and a copy displayed on the notice board in the entrance to the home. During discussion with people who use the service some said they would speak to staff but others was unaware because of their condition. From discussion with visitors and information from the relative survey questionnaires they knew how to complain and would be listened to and that any concerns or complaints would be dealt with promptly. All staff have been given training on adult protection and were aware of the issues of abuse and what to do if an allegation was brought to their attention. Each member of staff has been given a telephone number for whistle blowing. Staff said they have access to policy procedures on adult protection. Amber Lodge DS0000001412.V332056.R01.S.doc Version 5.2 Page 18 Amber Lodge DS0000001412.V332056.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience adequate quality outcomes in this area. We made this judgment using a range of evidence, including a visit to the service. The residents live in a reasonably safe and well-maintained environment with refurbishment and redecoration being addressed. EVIDENCE: A tour of the premises was undertaken during this inspection. Not all bedrooms were seen. Those that were seen in most cases had been well personalised. All had en suite access to toilet and wash hand basin. Ensuite facilities seen had shades to light fitments but all bathrooms and showers did not. This was brought to the attention of the manager. On the second day of the inspection new light fitments were fitted to the shower room with plans in place for all bathrooms to have the same. Amber Lodge DS0000001412.V332056.R01.S.doc Version 5.2 Page 20 The shower room and the hairdressing room were found to be dirty and cluttered. By the second day of the inspection these were cleaned and clutter removed. The towels in hairdressing room are now stored in the cupboards provided. The laundry room consists of a sluice cycle washing machine, a dryer and a hand basin. There was no sink so that staff can hand wash any delicate clothing belonging to the people who use the service. The housekeeper said these are done on a wool wash, the room was found to be reasonably tidy. Personal clothing is labelled to make sure that people wear their own clothes and they do not get lost or taken to other people rooms. However, there have been complaints that this still occurs. Discussion was had with the staff about handling of dirty/foul Laundry; the inspector was told they are hand sluiced first before putting into the washing machine on a sluice cycle wash. So that infection control is not compromised this practice should cease and the appropriate wash bags should be used for this purpose. The area designated as smoking, the staff room and toilet needs repainting and floor covering replaced. The electrical ventilation in the smoke room does not have the capacity to deal with the amount of smoke, therefore the smell of smoke is evident when entering the nearby sitting area, this has been noted and a free standing fan had been put in place and the window kept open. The manager was advised that this was not appropriate and some consideration should be given to fit appropriate ventilation to this area. The medicine room needed repainting, some tiles to the wash hand basin was missing, the ceiling panel in one area had a water mark from a previous flood in the room above. No unpleasant odour was noted in the areas seen on this inspection. All doors leading to the upstairs are fitted with a keypad, people have access via the lift. People were seen moving around the area freely and entering their private room whenever they wish. There are patio doors leading to the grounds which at the time was wire fenced separating the home from the building work that is taking place. This area must be risk assessed to make sure people are safe when they access the grounds without staff. Staff must be available to People with dementia when they are in the garden to make sure they are safe at all times. Amber Lodge DS0000001412.V332056.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30. People who use the service experience Adequate quality outcomes in this area. We made this judgment using a range of evidence, including a visit to the service. Overall the numbers of staff on duty are adequate for the needs of the residents. Staff are well trained and knowledgeable about the needs of the residents. The homes current recruitment practices need to be reviewed to make sure that new staff are thoroughly vetted to protect residents. EVIDENCE: There is a stable and constant staff group at the home providing continuity and consistency for residents. The manager said she continues to keep staffing levels under review to make sure that there are sufficient staff to care for the people in their care. Since the last inspection and following a complaint regarding night staffing levels this has increased from two to three staff. Amber Lodge DS0000001412.V332056.R01.S.doc Version 5.2 Page 22 There has also been an increase to the staffing level during the day. The rota showed on most day that there are five to six care staff up to 2pm and from then up to 8pm there are 4 care staff with one of the management staff in charge. Night staff do not have access to written confirmation which of the management staff for the home was on call. The recruitment files of three recently appointed care staff were looked at. Although there was evidence of two references, terms and condition of employment and a completed and signed application form by each applicant, there was no evidence of interview notes, letters inviting people to interview and an offer letter of employment, which would be good recruitment and selection practice. There was evidence that all three people had full Criminal Records Bureau checks. However, two people’s file showed when cross referenced with their application form and CRB form had disclosures and they had not declared them, the organisation application form stated that all matters must be declared regardless how old. This omission was discussed with the Manager who said she was unaware of the findings on the CRB forms. The Manager was reminded that care must be taken to make sure that full job histories are explored with applicants and any disclosers discussed. The home is sent a copy of the training plan each month from head office, which provides information on training to be undertaken by staff to meet the needs of people who are cared for in the organisations’ home. The manager said the district nurses and the deputy manager also carry out some training. Local colleges are also used for distant learning courses. At the time of the inspection staff were undertaking a course on dementia. A programme of training including the use of manuals for in house training showed that 68 of the care staff had completed a National Vocational Qualification (NVQ) award and two are just starting. A newer member of staff spoken with said she had received adult protection, health and safety, COSHH, food hygiene and fire safety training since she started. The staff were relaxed and pleasant but could have been more imaginative in the way they provided prompts to support service users with failing cognitive skills. The manager said she and other staff have undertaken several dementia awareness courses. Advice was given that the knowledge learned at these courses be put in practice to make sure that people who live at home with dementia has care that is person centred to meet their individual needs. The manager holds staff team meetings three times a year and monthly seniors meeting to give staff the opportunity to share information and express Amber Lodge DS0000001412.V332056.R01.S.doc Version 5.2 Page 23 their views. However, the notes of the last staff meeting were not available for inspection. Amber Lodge DS0000001412.V332056.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35, & 38. People who use the service experience adequate quality outcomes in this area. We made this judgment using a range of evidence, including a visit to the service. The management of the home is reasonably well organised, staff have the opportunity to contribute to the decision making process. The interests of the people who use the service are seen as very important to the manager and her staff and are safeguarded at all times. EVIDENCE: The manager has the relevant required qualification and experience in the care of older people. She had ongoing training to update her skills. The deputy manger has undertaken NVQ 2 and other training relating to the care of the Amber Lodge DS0000001412.V332056.R01.S.doc Version 5.2 Page 25 people who use the service and was in the process of starting a course for team leaders run by the organisation. Within the organisation there are formal systems in place for monitoring the quality of the service at the home. Questionnaires are sent/ available to people who use the service, visitors, staff and professionals who have contact with the home. The questionnaires are sent back to the head office for analysing and a report sent to the home looking at what could be done better. A report is made available to people taking part in the survey and a copy displayed in the home. The manager meets with the people who use the service daily and see the relatives. Monthly seniors meeting and full staff meetings are held at least three times a year. From discussion with staff they indicated that if they had any concern they could discuss it with the manager or the deputy, who they find helpful. The manager oversees three people personal allowance. A record was seen, all transaction with the signed initial of two staff one of who was the manager. Some people who use the service let their relatives and their solicitors handle their finances. Each person has a record that is kept in an exercise book. All transactions made by or on behalf of people is recorded with the initial of the two staff carrying out the transaction. However in the main it is the manager and the deputy who carry out this task so it was recommended that this be audited by a third person. The records are checked weekly, however there was no date or signatures of people carrying out the check. The matter relating to key holding was discussed with the manager and recommendation made, to make sure people are not restricted in having access to their money, the practice of staff using their own money for purchase for people who use the service then been reimbursed is poor practice, people should have access to their money at all times. Recommendation made that at handover safety checks system should be in place. The risk assessment carried out for the premises were mainly related to the gas and electrical equipments. It is acknowledged that each bedroom has been risk assessed as part of the individual care. However during the course of the inspection several health and safety hazards were identified. These was brought to the attention of the manage a free standing fan was in place, the manager was reminded that these must be risk assessed but in the main these should not be used as they could be a potential trip hazard to the people who use the service. There were burns to the carpet in the smoke area. This area is a potential fire hazard. The entrance door from the porch has a small step into the main hallway. This is a potential trip hazard. Regular health and safety checks on appliances and equipment used in the home have been carried out with documented records. Gas and electric checks Amber Lodge DS0000001412.V332056.R01.S.doc Version 5.2 Page 26 had been carried out in the required timescales. All moving and handling equipment is checked. Staff have access to good health and safety policy procedures. Records also showed PAT testing for electrical equipments throughout the home. Amber Lodge DS0000001412.V332056.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 4 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 X X 2 Amber Lodge DS0000001412.V332056.R01.S.doc Version 5.2 Page 28 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 OP3 Regulation 14 Requirement The manager must makes sure that all people admitted to home have a full assessment that provide good details of all their care need. Information must be clear of people’s psychological needs. Staff must have access to a care plan that identifies the needs of people with the action to be taken to address these needs, with a plan that is person centred, and evidence that people and/or relatives are involved in care planning process. Timescale given at the last inspection31/08/06. The manager must ensure that a care plan follows on if a risk has been identified. Timescale given at the last inspection31/08/06. The manager must make sure that there is a plan in place for people’s social care needs, with the action to be taken to meet those needs. DS0000001412.V332056.R01.S.doc Timescale for action 05/06/07 2. OP7 15 05/06/07 3. OP7 15 05/06/07 4. OP12 16 (m) 05/06/07 Amber Lodge Version 5.2 Page 29 5. OP12 16 (m) 6. OP15 16 7. OP15 14 The manager must make sure that people are involved in meaningful social and recreational activities to meet their needs. The manager must make sure that people have the opportunity to have a choice of food at mealtime. People who are have been identified of been at risk, following a nutritional risk assessment. Must have with input from the dietician, and a plan with the action to be taken to minimise and manage the risk. The registered provider must make good all the areas identified in relation to the premises. The manager must make sure that the people who use the service is safe and staff are suitable to work with vulnerable adults. The providers must review the present procedures for recording fees and the pooling of residents savings. Timescale given at the last inspection31/08/06. The providers must submit evidence that there is a fire risk assessment of the building. Check with the local fire officer about the timing of the testing of emergency lights. Timescale given at the last inspection31/08/06. The registered provider must sure all potential hazards in relations to the building and any equipment used is risk assessed. And all areas identified in the body of the report as a potential DS0000001412.V332056.R01.S.doc 05/06/07 05/06/07 05/06/07 8. OP19 23 05/08/07 9. OP18 OP29 19 05/06/07 10. OP35 17, 20 05/06/07 11. OP38 16, 23 05/06/07 12. OP38 23 05/06/07 Amber Lodge Version 5.2 Page 30 hazard must be assess with an action plan how the risk would be minimised / managed. 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 OP7 Good Practice Recommendations A review of care documentation should be carried out to stop repetition of records. A review of the current nutritional tool in use should be carried out to ensure that it is effective. The manager and cook should work closely to make sure that any meal served to people looks like the food intended. Some consideration should be given to people to serve themselves thus enable them to be independent at meal times. The registered provider should give some consideration to installing a sink in the laundry for the purpose of hand washing people’s clothes and other items. 2. OP15 3. OP19 Amber Lodge DS0000001412.V332056.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Amber Lodge DS0000001412.V332056.R01.S.doc Version 5.2 Page 32 - 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. 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