Inspection on 16/04/09 for Ambleside

This inspection was carried out on 16th April 2009.

CQC found this care home to be providing an Poor service.

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

Ambleside 15/09/09

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Ambleside 60 Hart Hill Drive Luton LU2 0AY Lead Inspector Mrs Louise Trainor Unannounced Inspection 16th April 2009 07:30 DS0000072769.V374818.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Ambleside DS0000072769.V374818.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Ambleside DS0000072769.V374818.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ambleside Address 60 Hart Hill Drive Luton LU2 0AY 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) 01582 454402 Alka Patel Gerardine McCrossan Care Home 17 Category(ies) of Dementia (17), Old age, not falling within any registration, with number other category (17), Physical disability (17) of places Ambleside DS0000072769.V374818.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP Dementia - Code DE Physical Disability - Code PD The maximum number of service users who can be accommodated is 17 New service 2. Date of last inspection Brief Description of the Service: Ambleside was located in a pleasant residential suburb of Luton. The amenities of the town, which include links to national bus and rail routes, were a short car ride away. The building had been sympathetically converted from its previous use as a hotel. The accommodation was decorated and furnished to provide a comfortable environment. The home was registered to provide care for seventeen older people who may also have dementia and/or physical disabilities. Single room accommodation was provided. Eight of the rooms had en-suite toilet and washbasin facilities. Washbasins were fitted in the remaining bedrooms. A bathing facility was located on each of the three floors. Six toilets were provided at accessible locations in addition to the en-suite provisions. Ambleside DS0000072769.V374818.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. This inspection was carried out in accordance with the Care Quality Commission (CQC) policy and methodologies, which require review of the key standards for the provision of a care home for older people that takes account of service users’ views and information received about the service since the last inspection. Evidence used and judgements made within the main body of the report include information from this visit. This was the first Key Inspection for this service, since New Providers took over the business in October 2008. Regulatory Inspector Mrs Louise Trainor carried out this visit on The 16th of April 2009, between the hours of 07:30 and 15:00 hours. The homes manager arrived on duty at 08:00 hours, and was then present and assisted throughout the day. The Responsible Individual for this home was also present for the latter part of the inspection which included a thorough feedback of the inspection and its’ findings. During this inspection we looked at the file of four people who live in this home, tracking the care of two of them in detail. This involved reading their records and comparing what was documented, to the care that was being provided. Documentation and records relating to: staff recruitment, training and supervision, medication administration, complaints, quality assurance and health and safety in the home were also examined. We also spent some time in the communal areas of the home, talking to staff and residents and observing the care practices that were carried out during this seven and a half hour inspection. A full tour of the premises also took place. We would like to thank everyone involved for their support and assistance during this visit to the home. Ambleside DS0000072769.V374818.R01.S.doc Version 5.2 Page 6 What the service does well: People receiving care in this home are happy with the way staff deliver care and respect their dignity. People who use this service are encouraged to maintain and develop relationships that are important to them. Staff practices promote individual rights and personal choices. This home provides a clean, comfortable and safe environment for the people who presently live here. Records that we looked at indicated that fire call points are being tested weekly, water temperatures and emergency lighting are being tested monthly, and fire evacuation addressed in training. What has improved since the last inspection? What they could do better: People receiving care in this home are happy with the way staff deliver care and respect their dignity, however due to some gaps in the review process, there may be an inconsistency in the delivery of care. Medication records are generally in order, contain the required entries and are signed appropriately by staff. Internal auditing could be improved. People who use this home are provided with sufficient information about the service however there is no evidence of a formal pre admission assessment and contracts do not contain information relating to individual’s fees. Entries in some records identified that relatives had indicated that their loved ones should not be resuscitated. Although we appreciate the reasons for this, other documentation is required for this type of decision, such as Mental Capacity assessments and/or medical opinion, which should be reviewed regularly. Although the files included some risk assessments relating to falls, mobility, mental health status and some for individual pursuits, such as going out in the car. There was no evidence that any assessment is carried out routinely on Ambleside DS0000072769.V374818.R01.S.doc Version 5.2 Page 7 admissions relating to pressure area care or nutrition. The manager told us that she would address this immediately. This service recognises the importance of training and is in the process of delivering a programme that meets the National Minimum Standards. However there are some gaps in the recruitment process so that residents and staff may not always be protected. We reviewed the regulation 37 reporting processes in this home, and the manager was unaware that any events other than ‘deaths’ should be reported to the CQC. Records relating to residents ‘personal expenditure’ were insufficient in detail, calculations were inaccurate in places and there were transactions that had not yet been added to the record. This was not acceptable. Some of the core processes involved in the running of this home, particularly those involving the budget, have been taken out of the manager’s control by the new provider. This has resulted in a drop in standards. There are not records of complaints kept at the home, and the training programme has been interrupted resulting in limited awareness of safeguarding processes for staff. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Ambleside DS0000072769.V374818.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 Ambleside DS0000072769.V374818.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5, 6, People using the service experience adequate quality outcomes in this area. People who use this home are provided with sufficient information about the service, however there is no evidence of a formal pre admission assessment and contracts do not contain information relating to individual’s fees. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: This service has a Service User Guide and Statement of Purpose. A review of these documents is necessary to ensure that the details of the Care Quality Commission (CQC) are correct. Each resident has a file in their room that contains a copy of these documents. The file also contains details of the complaints procedure and each resident’s Ambleside DS0000072769.V374818.R01.S.doc Version 5.2 Page 10 personal contract, however we noted that individual fees were not identified in the contracts that we looked at. During the inspection we looked at the files of three residents, however we were unable to locate any pre admission documents. The manager advised us that although they do go and assess potential residents, and residents and their representatives are encouraged to visit the home prior to admission, there is no specific documentation / assessment form that they complete. Despite this, the files that we looked at and the residents / relatives that we spoke to, and spent time with, indicated that the home is presently meeting the needs of the residents who live at Ambleside. This home does not provide a service for intermediate care. Ambleside DS0000072769.V374818.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11 People using the service experience adequate quality outcomes in this area. People receiving care in this home are happy with the way staff deliver care and respect their dignity, however due to some gaps in the review process, there may be an inconsistency in the delivery of care. Medication records are generally in order, contain the required entries and are signed appropriately by staff. Internal auditing could be improved. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: During this inspection we looked at the care files of three residents. Each file contained numerous care plans and risk assessments. Ambleside DS0000072769.V374818.R01.S.doc Version 5.2 Page 12 The care plans were well written and contained specific details relating to individual’s choices and preferences. For example one care plan identified that the individual preferred a soft tooth brush, that their face and legs should be moisturised daily, they enjoy listening to music, but did not like one particular named channel, and that medication was required in liquid form. This detail was specific and promoted continuity of care. Our concern was that these care plans had not been reviewed since the 27/01/09, and this particular person had high needs, including pressure area care. There was no specific care plan for pressure area care and no evidence of turn charts. However this resident’s skin was intact. We reminded the manager of the importance of this documentation to support the care being given. There were ‘Advanced Planning’ documents completed for residents. These identified the resident’s wishes if they become seriously ill, or in the event of death. We did however notice that entries in some records identified that relatives had indicated that their loved ones should not be resuscitated. Although we appreciate the reasons for this, other documentation is required for this type of decision, such as Mental Capacity assessments and/or medical opinion, which should be reviewed regularly. Although the files included some risk assessments relating to falls, mobility, mental health status and some for individual pursuits, such as going out in the car. There was no evidence that any assessment is carried out routinely on admissions relating to pressure area care or nutrition. The manager told us that she would address this immediately. Observations of care and staff / resident interactions throughout this visit were very positive. Residents were relaxed and happy, and the staff were treating residents in a respectful way. One resident told us that she had only come into the home for a respite period, but has decided to stay permanently. She said. “I love it here, I’m very happy and the staff are all wonderful, they can’t do enough for you”. We examined the Medication Administration Records (MAR) sheets for seven of the residents living in this home. Generally these sheets were completed correctly with signatures and omission codes where appropriate, however it was difficult to reconcile stocks of medication such as paracetamol and co dydramol, which had been prescribed as, 1 or 2 tablets when required (PRN). Staff had not recorded what dosage had been given and therefore it was impossible to calculate what should be remaining. Although the manager audits the MAR sheets, this had not been identified as a problem previously. The home presently has two residents on Controlled Drugs (CD)s. Neither the storage nor the recording documentation for these drugs was in line with legislation. We suggested the manager seek advice from the pharmacist. Ambleside DS0000072769.V374818.R01.S.doc Version 5.2 Page 13 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 People using the service experience good quality outcomes in this area. People who use this service are encouraged to maintain and develop relationships that are important to them. Staff practices promote individual rights and personal choices. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: There were several visitors in the home at different times during the day, and the concept of residents’ maintaining relationships and involving families in their loved ones daily lives is an integral part of this home’s philosophy. Those that we spoke to indicated that they were very satisfied with the care provided in the home. Throughout this visit residents were busy doing activities of their own choice. Some were reading, some doing puzzles and some just having a good gossip Ambleside DS0000072769.V374818.R01.S.doc Version 5.2 Page 14 and a giggle as they waited for their turn with the hairdresser. In the afternoon staff were giving residents manicures and pampering sessions which was very well received. There are some scheduled activities, which include quizzes, music and exercise groups, visiting entertainers, 1 to 1 trips out to the town, or small groups to local restaurants. Some of the residents were telling us about their visit to a local Beefeater the evening before the inspection. It was clearly enjoyed by all. One resident told us how before she came into the home, she used to attend various clubs. She said that she has discussed this with the manager and hopes she will be able to pursue these again when she feels ready. A Local church group had been in over the Easter weekend, and residents talked about what a lovely time they had had. A basket of little Easter eggs and other favours was the centrepiece of the table, where residents could help themselves. The home has recently appointed a cook who is enthusiastic in his role. We visited the kitchen and were told that the stocks and the quality of the food is quite good, however we were also told that the manager receives regular calls to pick up basics from the shops on the way to work. On the day of the inspection she had been asked to buy some flour, as there was meat pie on the menu, and no flour in stock. She was also asked to purchase cleaning materials. This is not acceptable, and the home’s stock of these products should be monitored and replenished regularly to avoid this happening. Food temperatures were being recorded daily, and a cleaning schedule was in place. Menus are in place, which offer a variety of nutritious meals, including fresh fruit and vegetables daily. Residents that we spoke to told us that the food was ‘alright’. The manager told us that potential changes in menus are discussed with residents at meetings, which are held every 8 weeks. The CQC had received complaints about the standard of food in this home in January 2008; it was therefore pleasing to see an improvement. Ambleside DS0000072769.V374818.R01.S.doc Version 5.2 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 People using the service experience poor quality outcomes in this area. There are not records of complaints kept at the home, and the training programme has been interrupted resulting in limited awareness of safeguarding processes for staff. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: During this inspection we looked at the complaints file. There was no evidence of any complaints being received since the last inspection, despite the fact that CQC had formally requested the investigation of two complaints in January this year. We were aware that these had been addressed, as was the manager, however the Responsible Individual had all the related documentation at home. This is not acceptable, as evidence of all complaints and the investigatory processes used should remain filed in the home for inspection purposes. At present the complaints file is combined with the compliments file and is on display in the entrance of the home for visitors and relatives to view. Although we appreciate the importance of this openness, many complainants would not wish their concerns to be so public, and the content of some complaints may Ambleside DS0000072769.V374818.R01.S.doc Version 5.2 Page 16 compromise individual residents confidentiality. We suggested that the complaints file should be kept in the manager’s office for this reason. We had not been made aware of any safeguarding referrals being made by this home, however documentation that we saw, relating to one resident, identifying repetitive falls, and the homes inability to meet the individual’s needs due to a deterioration in condition, had not been reported. When the home was taken over in October 2008, restraints on the budgets affected the training programme, which has resulted in some staff not attending mandatory safeguarding training in a timely manner. This is now being addressed and training has been booked. It is essential that the manager and all her staff fully understand the processes and local protocols relating to Safeguarding. The Responsible Individual also told us that at present she has no understanding of ‘safeguarding.’ Ambleside DS0000072769.V374818.R01.S.doc Version 5.2 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26 People using the service experience good quality outcomes in this area. This home provides a clean, comfortable and safe environment for the people who presently live here. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: This home is situated over four floors. It was generally very clean, and there was a homely atmosphere throughout. The lounge area was comfortable and bright, and there is also a dining room, a small library and a conservatory on Ambleside DS0000072769.V374818.R01.S.doc Version 5.2 Page 18 the first floor, providing ample room for residents to go with their visitors if they wish to have some privacy. Bedrooms were clean and tidy, decorated and furnished to personal taste, often reflecting the individuals’ life history. We visited one resident in her bedroom, where she spends most of her time. She had family photographs around her, Easter decorations in place and her own menu on display in her room. The bedroom furniture was appropriate to meet her needs and included moving and handling equipment that had been serviced recently. There are toilets /shower / bathing facilities on each floor of this home, although we did notice one bathroom was not in use, and was being used to store a fan, a ‘hoover’ and a ‘clothes airer.’ The home was generally well maintained, however we were concerned that one room was in need of a restrictor on the window, and this particular room also smelt very strongly of urine, which we felt was coming from the carpet. Another concern was a bedroom on the first floor, which had an adjoining door to another bedroom. This room is presently vacant, however we understand that to use this room would either breach fire regulations if the door was locked, or compromise the privacy and dignity of the residents if it was left open. This issue needs to be resolved before anyone is admitted into this room. Ambleside DS0000072769.V374818.R01.S.doc Version 5.2 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 People using the service experience poor quality outcomes in this area. This service recognises the importance of training and is in the process of delivering a programme that meets the National Minimum Standards. However there are some gaps in the recruitment and training processes so that residents and staff may not always be protected. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: During this inspection we looked at the files of three members of staff that had been recruited since the recent take over of the home. All files contained fully completed application forms, which included an employment history, and references had been sourced and verified appropriately. Documentation relating to interviews and induction was present, and Criminal Record Bureau (CRB) checks had been carried out prior to employment start dates. We did however note that one member of staff from overseas, who was working on a student visa, was working up to five nights a week. This far exceeds hours permitted on this type of visa. Ambleside DS0000072769.V374818.R01.S.doc Version 5.2 Page 20 We also found that the file of another member of staff from overseas did not contain the appropriate documentation from the home office. The manager contacted this member of staff, who stated that she had lost the letter relating to her present working status. We advised the manager that this person should not be working without this documentation, and we consequently left an immediate requirement reflecting this. The staff involved, was contacted and will not return to work until the matter is resolved and evidence received by the home. This home has a committed team of staff, many of who have been in post for several years. The staffing numbers presently stand at three staff plus the manager during the day, however at night there is only one ‘waking staff’ on duty. They are supported by a ‘sleep in carer’. There are presently fifteen residents, residing over four floors in this home, which includes, several residents with dementia and one resident on the top floor who requires four hourly turns by two staff. Discussion with staff and the manager indicated that the staff feel vulnerable, the risk to residents are increased and their needs may not always be fully met with these limited resources. We discussed this matter with the Responsible Individual and consequently issued an immediate requirement relating to this matter. The Responsible Individual agreed to provide a second ‘waking’ carer for night duty to replace the ‘sleep in.’ We were also concerned to discover that ‘sleep in staff’ do not have appropriate facilities. They sleep on a fold up camp bed in the residents’ library. The manager told us that since the home changed hands last year, there had been issues relating to the budget for training, which had resulted in an interruption in the training programme which has consequently left some staff over due with some basic/ mandatory training. This problem, we understand from the Responsible Individual, has now been resolved, and there is a full programme in place to ensure that all staff have the opportunity to fulfil their training obligations. We will monitor the progress of this at the next inspection. The care practices and staff/ resident interactions that we observed during this inspection were very positive. Staff were confident and competent in their roles and addressed the residents in a respectful way, and care and support was offered in a dignified and unhurried way. Ambleside DS0000072769.V374818.R01.S.doc Version 5.2 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36, 37, 38 People using the service experience poor quality outcomes in this area. Constraints placed on the manager, relating to budgets, and information systems in the home, has resulted in some of the core areas of the homes’ management being compromised. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The manager at this home has worked in this home for seven years, however only took on the role as manager when the home changed hands in October Ambleside DS0000072769.V374818.R01.S.doc Version 5.2 Page 22 2008. She has worked hard to maintain a level of stability for both staff and residents. However some of the core processes involved in the running of this home, particularly those involving the budget, have been taken out of her control by the new provider. This has resulted in a drop in standards. She has completed her NVQ level 4, and told us she is keen to embark on the Registered Managers Award, or equivalent, as soon as possible, to ensure her management skills and knowledge are in line with present best practices. Her management style involves being visible and accessible to both staff and residents. We reviewed the regulation 37 reporting processes in this home, and the manager was unaware that any events other than ‘deaths’ should be reported to the CQC. There was evidence of accidents / injuries that had required medical attention, including a fracture that we had not been informed of. We advised the manager to go onto the CQC website to access more information and the relevant forms relating to these processes. She told us that at present she does not have access to the computer system or the Internet, unless the Responsible Individual is present, this seriously hinders her ability to access information relating to procedures she should be following. We looked at supervision records. These indicated that all staff have received at least one supervision with the manager since October 2008, however it is not possible at present to ascertain if she is on schedule to meet this standard for the year. There is a safe in the manager’s office where residents can keep small amounts of spending money. We looked at the records for six of the resident’s accounts. Of these we could only balance one correctly. Records were insufficient in detail, calculations were inaccurate in places and there were transactions that had not yet been added to the record. This was not acceptable. Records that we looked at indicated that fire call points are being tested weekly, water temperatures and emergency lighting are being tested monthly, and fire evacuation addressed in training. The home manager is in the process of addressing quality assurance through questionnaires to residents, visitors and other professionals that work with the home. We look forward to seeing the concluding report. Ambleside DS0000072769.V374818.R01.S.doc Version 5.2 Page 23 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 3 2 1 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 1 2 3 2 3 3 2 2 3 STAFFING Standard No Score 27 1 28 2 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 1 2 1 1 Ambleside DS0000072769.V374818.R01.S.doc Version 5.2 Page 24 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 OP3 Regulation 14 Requirement The registered person must not admit residents to the home until a full assessment of needs has been carried out and documented by a suitably qualified person. People who live in this home must have care plans that are reviewed regularly to reflect how their changing needs should be met. People who live in this home must be protected by accurate record keeping processes. Any complaint relating to this home should be clearly documented. This must include copies of any investigatory actions, and letters of correspondence relating to the complaint. People who live in this home must be cared for by staff that have a clear understanding of safeguarding procedures. All areas of the home must be properly maintained to promote the safety of the residents. The registered person must DS0000072769.V374818.R01.S.doc Timescale for action 30/04/09 2. OP7 15(2) 30/04/09 3. 4. OP9 OP16 13(2) 22 30/04/09 31/05/09 5. OP18 13(6) 31/05/09 6. 7. OP19 OP27 23(2)(b) 18(1) 30/04/09 30/04/09 Page 25 Ambleside Version 5.2 ensure that there are sufficient staffs on duty at all times to safely meet the needs of the residents. 8. OP29 19(1) Immediate Requirement issued. People who live in this home must be cared for by staff that have been appropriately recruited. This must include all the information specified in paragraphs 1 to 7 of schedule 2, on every person employed in the home. Immediate Requirement issued. People who live in this home must be cared for by staff that have been appropriately trained to carry out their duties. A report must be submitted to CSCI that reflects how the quality of care for people living in this home is being reviewed and addressed. Accurate records of personal expenditure must protect people who live in this home. People who live in this home must be cared for by staff that are appropriately supervised. The records of people who live in this home must be maintained and kept up to date. People who live in this home must be protected by the regulation 37 reporting process. 30/04/09 9. OP30 18(1) 31/05/09 10. OP33 24 30/06/09 11. 12. 13. 14. OP35 OP36 OP37 OP38 16(2)(l) 18(2) 17 37 30/04/09 31/10/09 31/05/09 30/04/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Ambleside Refer to Good Practice Recommendations DS0000072769.V374818.R01.S.doc Version 5.2 Page 26 Standard Ambleside DS0000072769.V374818.R01.S.doc Version 5.2 Page 27 Care Quality Commission Eastern Region Care Quality Commission Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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