Inspection on 08/11/05 for Amber Lodge

This inspection was carried out on 8th November 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 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 19/04/07

Amber Lodge 07/06/06

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 Carol Haj-Najafi Unannounced Inspection 8th November 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Amber Lodge DS0000001412.V255694.R02.S.doc Version 5.0 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.V255694.R02.S.doc Version 5.0 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 (10), Old age, not falling within any other category (40) Amber Lodge DS0000001412.V255694.R02.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The 10 places for MD(E) or DE(E) are specifically for the service users named in the variation application dated 24 February 2004 8th November 2005 Date of last inspection Brief Description of the Service: Amber Lodge is a two-storey purpose built home situated in Wortley, near Armley. It has a large private garden to the rear of the building. A large car parking area is located at the front of the building. Local shops and bus routes are within easy access.The home is registered to provide personal care for up to 40 older people. Accommodation is provided on two floors. There are 38 single bedrooms and one double bedroom. All bedrooms have en-suite facilities. Lounge and dining areas are located on both floors. There are three bathrooms, two of which have hoisting facilities, and two shower rooms. All laundering is undertaken on the premises. The gardens are enclosed; a large lawn and patio area is at the rear of the building. Service users can access the garden from the dining room. Service users and staff prefer the term residents, therefore this term has been used throughout this report. Amber Lodge DS0000001412.V255694.R02.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this unannounced inspection between 09.30am and 3.30pm. The purpose of the inspection was to ensure the home was operating and being managed to a satisfactory standard. The inspector spoke to eight residents, two visitors, four staff and the registered manager. The inspector also looked around some parts of the home. Records were inspected including care plans, assessments, staff recruitment and training records, accident reports, financial records and health and safety records. Feedback was given to the registered manager at the end of the inspection. What the service does well: What has improved since the last inspection? The manager has worked hard to improve management systems and the general organisation of the home. The recruitment practice has greatly improved. Interviews with candidates are recorded, and all documentation is obtained before new staff start work. Financial records have also improved. Each resident now has a book that clearly identifies how all monies are spent. Care plans contain more information and are more personal to each resident. This gives clearer guidance on how each person should be cared for. An activity organiser has recently been employed to work two days a week. Residents and staff talked about the different activities provided. The manager and all staff spoken to at the inspection said the activities programme was a good improvement. Amber Lodge DS0000001412.V255694.R02.S.doc Version 5.0 Page 6 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. Amber Lodge DS0000001412.V255694.R02.S.doc Version 5.0 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 Amber Lodge DS0000001412.V255694.R02.S.doc Version 5.0 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): 4 The home does not have the specialism to provide care for people with a mental disorder, and staff must receive appropriate training to ensure they have the knowledge and skills to meet the needs of people with a dementia. EVIDENCE: The home is registered to provide care for up to ten people with a dementia and up to ten people with a mental disorder. At three inspections the manager has confirmed that the home is not equipped to provide specialist care for people with a mental disorder. In August a ½ day training course on mental health and dementia was provided to eight staff, although this only covered the very basics . Six staff are completing a distance learning course (level 2) in demantia care. Staff spoken to the inspection said their knowledge in relation to mental health was very limited. Although they had knowledge of individual residents, some staff were unable to confirm which residents had a dementia or a mental health need. The home’s action plan stated that the commission would receive written information regarding the categories of registration by the end of Septemeber. Amber Lodge DS0000001412.V255694.R02.S.doc Version 5.0 Page 9 This has not been received.A meeting has been arranged with the registered manager and area manager from Meridian Healthcare Ltd to resolve this long standing issue. Amber Lodge DS0000001412.V255694.R02.S.doc Version 5.0 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 the following standard(s): 7, 9 & 10 Care plans and risk assessments have improved and these are now more personalised. Good medication systems are in place. Privacy and dignity are promoted in the home. EVIDENCE: The last inspection identified that some more information should be included in care plans and some risks to residents had not been properly assessed. A senior carer is responsible for monitoring care plans and risk assessments. Since the inspection additional information has been added to care plans. The information is more specific and personal to each resident. Risk assessments have also been developed. Care records for three residents were looked at. One resident’s needs had changed significantly. The care plan identified the changes and how these should be managed. A long term plan was also documented. This was well recorded. Amber Lodge DS0000001412.V255694.R02.S.doc Version 5.0 Page 11 The inspector observed medication being administered at lunchtime. Medication administration records had been filled in correctly. Administration of medication was carried out efficiently, and medicines were handled properly. All staff complete medication training before they can administer medication. Residents confirmed staff knock on doors before entering their room. One resident said staff cover them up as much as possible during personal care tasks. Staff gave good examples of how they promote privacy and dignity. Residents see health care professionals in their own room. A private room is provided for hair and chiropody appointments. Amber Lodge DS0000001412.V255694.R02.S.doc Version 5.0 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 the following standard(s): 12 & 15 The programme of activities has improved since the last inspection, residents have opportunities to engage in individual and group activities. The food is good and residents enjoy the type of meals served. EVIDENCE: The last inspection identified that activities must improve. The home has recently employed an activities organiser two days a week. One day is spent on each unit. The manager and staff confirmed this had increased and improved activities within the home. Residents spoke about playing board games, dominoes and bingo. The inspector spoke to eight residents, all of whom confirmed the food was good. Staff also confirmed the food was good. Each morning, carers ask people individually what they would like at teatime and suppertime. The menu rotates every four weeks, the meals are varied and nutritionally balanced. Currently any variations to the menu are not recorded, for example on the day of the inspection the main course was changed from mince to goulash. A record of changes to the menu must be maintained to make sure meal provision can be monitored. Amber Lodge DS0000001412.V255694.R02.S.doc Version 5.0 Page 13 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): 16 & 18 Residents are comfortable in discussing and reporting concerns. An appropriate complaint’s procedure is in place. Service users are safeguarded from abuse. EVIDENCE: Residents were asked ‘what they would do if they were unhappy about something in the home’. They said they would discuss it with the manager or staff. The registered manager said no complaints have been received during the past twelve months. The complaints procedure is displayed in the home. The registered manager and staff have attended adult protection training. The manager is aware of the procedure for reporting any allegations of abuse. Amber Lodge DS0000001412.V255694.R02.S.doc Version 5.0 Page 14 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): None of the standards were assessed during the inspection. EVIDENCE: Amber Lodge DS0000001412.V255694.R02.S.doc Version 5.0 Page 15 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): 29 The recruitment process has significantly improved. The manager has worked hard to ensure staff records that must be held at the home are available. EVIDENCE: Shortfalls with the recruitment process have been highlighted at previous inspections. Since the last inspection, the manager has gone through all staff files to ensure the correct documentation has been obtained. The inspector looked at files for two staff that have recently been recruited. All documentation had been obtained. Interview assessments for each candidate had been completed. One employment reference did not correspond with the employment address. The manager agreed to obtain another reference to confirm authenticity. The last inspection identified that tippex must not be used on the rota when changes are made. All changes are now written in ink and can be tracked. Amber Lodge DS0000001412.V255694.R02.S.doc Version 5.0 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): 31, 32, 33, 35, 36 & 38 The manager has introduced some positive changes to management systems, the home is now more organised. Financial systems are much better, and all transactions are clearly recorded. A good quality assurance system is in place. The health and safety of service users and staff are protected. EVIDENCE: The manager has been in post since July 2001. She has completed NVQ level 4 in care and has a further 4 units to complete to achieve the registered manager’s award. Since the last inspection the manager has spent time organising files and management systems. This was evident at the inspection as the manager was very organised and much more familiar with the location of all documentation. Improvements have been made to a range of records held at the home. Amber Lodge DS0000001412.V255694.R02.S.doc Version 5.0 Page 17 Staff confirmed that they are comfortable in approaching the manager and deputy, and will often seek advice and guidance. One staff described the home as ‘well organised and well managed’. Staff receive regular supervision. The manager has introduced a new system for recording finances. Each resident has a book. An individual record of incomings, expenditure and balance are maintained. Money held in the home on behalf of residents was counted. Some minor discrepancies were found, although these were due to change from residents being put in the wrong purses. More regular checking of balances would highlight errors sooner. A resident and relative survey was carried out in March. A survey summary report has been published and a residents and relatives meeting is being held at the end of November to discuss the outcome and recommendations for improvement. Several service and health and safety records were looked at. These were all up to date. Staff have attended a range of health and safety training courses. Amber Lodge DS0000001412.V255694.R02.S.doc Version 5.0 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 X X 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X 2 3 X 3 Amber Lodge DS0000001412.V255694.R02.S.doc Version 5.0 Page 19 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 2 Standard OP4 OP4 Regulation 12 18 Requirement The registered provider must confirm in writing the proposals for categories of registration. The registered provider must ensure that staff have the skills and experience to meet the needs of residents. The registered manager must make sure any changes to the menu are recorded The registered manager must make sure they have established on reasonable grounds as to the authenticity of references obtained. Timescale for action 31/12/05 31/12/05 3 4 OP15 OP29 17 18 31/12/05 31/12/05 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 OP35 Good Practice Recommendations The registered manager should carry out more regular checks on monies held on behalf of residents. Amber Lodge DS0000001412.V255694.R02.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Amber Lodge DS0000001412.V255694.R02.S.doc Version 5.0 Page 21 - 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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