Inspection on 10/11/05 for Amberley Lodge

This inspection was carried out on 10th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Amberley Lodge 27/11/08

Amberley Lodge 03/07/06

Amberley Lodge 09/12/04

Amberley Lodge 12/05/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Townley Road, 2-3

Orchard House Nursing Home

St Josephs Rest Home

Foxley Lane (121a)

Tudor Lodge

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

CARE HOMES FOR OLDER PEOPLE Amberley Lodge Amberley Lodge Nursing Home 86 -94 Downlands Road Purley Surrey CR8 4JF Lead Inspector Michael Williams Unannounced Inspection 10th November 2005 10:15 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 Amberley Lodge DS0000019020.V263519.R01.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. Amberley Lodge DS0000019020.V263519.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Amberley Lodge Address Amberley Lodge Nursing Home 86 -94 Downlands Road Purley Surrey CR8 4JF 020 8668 0999 020 8668 0378 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) Care UK Community Partnerships Limited Mr Osborne Acquaye Care Home 60 Category(ies) of Dementia - over 65 years of age (0), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (0), Old age, not falling within any other category (0) Amberley Lodge DS0000019020.V263519.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 23 residential service users A maximum of 10 service users aged between 55 and 65 years Date of last inspection 7th April 2005 Brief Description of the Service: Amberley Lodge is a large purpose built Care Home registered to provide care for up to 60 service users. On the ground and first floors it provides personal and nursing care for people over 60 years of age and who have dementia. The second (top) floor provides personal (“residential”) care, but not nursing care, for up to 23 people 60 years and above, and who have past or present mental disorder including PTSD (Post-Traumatic Stress Disorder) or who have dementia. The home has a single Manager with team leaders on each floor. Whilst the home is not registered to cater for service users with physical disabilities the home is adapted to meet the needs of service users who may have mobility problems; this includes assisted baths, ramps, grab rails and similar aids. Laundry and catering services are provided centrally with lounge and dining areas on each floor. The home’s Statement of Purpose states that the single bedrooms are at least 12 square metres and have ensuite toilets. The home itself is located in Purley to the South of the main A22/A23 Purley junction and is therefore close to shops and transport. Amberley Lodge DS0000019020.V263519.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second unannounced inspection of Amberley in the year 2005/2006 and on this occasion the inspection focused upon safety matters including the welfare of service users plus fire safety, health and safety and maintenance of the equipment and services. Many of the service users are very frail and do not have the mental capacity to give an accurate picture of life in the home so the inspector spent time chatting with them and observing how they were cared for and, as before, concluded that they appear well cared for and seem content with life in Amberley. Some service users were able to express an opinion and they advised the inspector that they are happy with the care and services provided in this home. In summary, the inspector remains impressed by the standards achieved in all areas inspected. All key standards were assessed in April and only those failing to meet standards in full were reevaluated on this occasion so the previous findings are restated here where appropriate. What the service does well: What has improved since the last inspection? 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. Amberley Lodge DS0000019020.V263519.R01.S.doc Version 5.0 Page 6 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 Amberley Lodge DS0000019020.V263519.R01.S.doc Version 5.0 Page 7 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): Detailed pre-admission assessments and clear plans of care assure prospective service users that their needs can be met when admitted to this home. EVIDENCE: Not inspected on this occasion but key standard 3 was assessed as met in the previous inspection and standard six does not apply in this home. Amberley Lodge DS0000019020.V263519.R01.S.doc Version 5.0 Page 8 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): 9 The home now has in place procedures for recording detailed information about medicines so as to protect service users. EVIDENCE: With the exception of standard 9, about medication, the other key standards in this section were not inspected on this occasion but were assessed as met in the previous inspection. During the previous inspection it was noted that not all medicines could be audited when they were not delivered in monthly dosette packs. The CSCI required that medication charts show the number of tablets held by the home at the beginning of each new (monthly) medicine chart and this is now the case. A sample of medication records were checked to confirm this good practice is now in place. Amberley Lodge DS0000019020.V263519.R01.S.doc Version 5.0 Page 9 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): The daily routines and choices available, including contact with family and friends which ensures that this care home meets service users’ expectations. The catering arrangements in this home ensure service users are receiving a wholesome and nutritious diet. EVIDENCE: Not inspected on this occasion but key standards were assessed as met in the previous inspection. Amberley Lodge DS0000019020.V263519.R01.S.doc Version 5.0 Page 10 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 The home has a clear and simple procedure for dealing with complaints so service users’ are confident their concerns will be dealt with promptly and effectively and that they are safeguarded from abuse. EVIDENCE: The record of complaints is in place. No new complaints are recorded since the previous inspection nor are any matters being dealt with dealt with under the procedures for dealing with the protection of vulnerable adults. No complaints were made by service users, or their relatives, during the course of this inspection. In contrast several compliments were paid to the home and the staff team by appreciative relatives. Staff confirmed that they have been told how they must conduct themselves, that is, with respect for service users and that they have received instructions about how to deal with allegations of abuse – by reporting it without delay. The home has a copy of the local authority’s procedures for dealing with allegations of abuse. Amberley Lodge DS0000019020.V263519.R01.S.doc Version 5.0 Page 11 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 26 The layout of the home and the manner in which it is being maintained is generally satisfactory ensuring the home is a clean, safe and comfortable environment for the service users. EVIDENCE: The inspector toured the premises observing matters such as fire doors, fire extinguishers, escape routes and general fire-safety matters; the use of cleaning materials and how they are stored, the quality of floor coverings, furnishings and fittings and the general décor of the home. The inspector also checked a number of bedrooms and communal areas such as the lounges and dining rooms plus facilities such as bathrooms and toilets to confirm they are in good decorative order and at a comfortable temperature and that they have suitable fixtures and fittings for the service users. The home is in a good state of repair and furniture and equipment is well maintained and the home was clean and tidy and free of offensive odours. Amberley Lodge DS0000019020.V263519.R01.S.doc Version 5.0 Page 12 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 28 29 30 The home has adequate numbers of staff and the staff recruitment procedures, induction, training, support and supervision regime in place so this will ensure they are competent in their jobs ensuring service users are in safe hands at all times. EVIDENCE: As an existing care home staffing levels are to be no less that proscribed by the previous registering authority. On the day of inspection it was noted that for 58 service users there were 4 Nurses and 10 care staff plus the manager, who is also a qualified Nurse; ancillary staff were also on duty including cleaners, cook laundry staff and maintenance staff. This is within the minimum staffing levels required. The staff files in the home are methodically laid out with a checklist of some of the police check processes. The manager asserts that all staff have had a CRB (police check) and a sample of CRB checks were examined to confirm this. Other recruitment processes are in place including application forms, references, health and qualification checks and interviews. The overall process appears sound and so it is clear service users are in safe hands and certainly service users say they feel safe and cared for, but a requirement is made to ensure that the application forms of prospective employers have a detailed work history in chronological order without unexplained gaps. In respect of equality issues, it is evident that an open and unbiased approach is taken when recruiting staff so that minority and other special needs groups are not disadvantaged by the recruitment process. The home employs a staff Amberley Lodge DS0000019020.V263519.R01.S.doc Version 5.0 Page 13 from a range of cultural and ethnic minority backgrounds and also employs a number of staff who reflect the culture and background of the service users. The staff files list the range of training taken up by staff and two new members of staff on duty at the time of the inspection confirmed that they are receiving induction training at the commencement of employment in the home. Amberley Lodge DS0000019020.V263519.R01.S.doc Version 5.0 Page 14 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): 38 The home is ensuring that, in so far as it is reasonably practical to do so, the health, safety and welfare of service users, and staff, is being promoted and protected however a number of matters of safety need to be addressed. EVIDENCE: Not all standards in this section were re-inspected on this occasion. In order to evaluate the management of health and safety and the promotion of the welfare of service users the inspector toured the premises, interviewed staff, discussed this area in some detail with the manager and checked safety certificates and records. The assistance of the maintenance person is acknowledged. The following matters require further attention; The guidance given by the Fire Authority must be complied with in full unless written evidence can be supplied to the CSCI to indicate that such guidance no longer applies to Amberley, self-closing bedroom doors for example. The manager is asked to provide confirm that the passenger lift, not in full working order, is repaired and made available for passenger use. The manager is also asked to confirm that the water regulation checks (due in November) Amberley Lodge DS0000019020.V263519.R01.S.doc Version 5.0 Page 15 have been completed. It is acknowledged that immediately after the inspection date the manager submitted confirmation of the Legionella testing (but not the full Water Regulation checks). The home must also provide the CSCI with confirmation that the electrical work has been corrected in accordance with the home’s five-yearly report of 2004. The stair well must be kept free of stored materials because it is a fire escape route. Whilst these are important safety issues they appear not to put service users and staff at immediate risk and so a reasonable timescale for works will be given. Amberley Lodge DS0000019020.V263519.R01.S.doc Version 5.0 Page 16 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X 1 Amberley Lodge DS0000019020.V263519.R01.S.doc Version 5.0 Page 17 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 OP29 Regulation 19(1)bi Requirement The registered person must ensure that the home has all the information listed in schedule 2 before employing staff; in particular a full employment history. Fire Safety: It is recommended that the home further consult the fire authority about whether or not self-closing devices are required for the bedroom doors applies to this existing home. Health & safety: the manager must provide CSCI with confirmation that safety certificates are in place for the following services; water, passenger lift and electrical safety tests. Timescale for action 30/12/05 3 OP38 23(4) 30/12/05 3 OP38 23(4) 30/12/05 Amberley Lodge DS0000019020.V263519.R01.S.doc Version 5.0 Page 18 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 Amberley Lodge DS0000019020.V263519.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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. 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