Inspection on 18/01/07 for Amphion Lodge

This inspection was carried out on 18th January 2007.

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

Amphion Lodge 21/01/06

Amphion Lodge 30/08/05

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

CARE HOMES FOR OLDER PEOPLE Amphion Lodge 2-4 Auckland Road Doncaster DN2 4AG Lead Inspector Stuart Hannay Key Unannounced Inspection 09:00 18th January 2007 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 Amphion Lodge DS0000063969.V312132.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. Amphion Lodge DS0000063969.V312132.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Amphion Lodge Address 2-4 Auckland Road Doncaster DN2 4AG 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) 01302 326050 NONE NONE Amphion Lodge Ltd Jacqueline Margaret Hackworth Care Home 30 Category(ies) of Dementia - over 65 years of age (30) registration, with number of places Amphion Lodge DS0000063969.V312132.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st January 2006 Brief Description of the Service: Amphion Lodge is registered as a care home for up to thirty elderly people who have a diagnosis of dementia who require residential care. Bedrooms are on ground, first and second floor, which are accessed by a shaft lift. The home benefits from well-tended gardens the rear garden is secure. The home is located in a residential area approximately one mile from Doncaster town centre. A regular bus service on Thorne Road is a short distance from the home. Amphion Lodge DS0000063969.V312132.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection lasted for 8 hours. Nine service users and two staff members were formally interviewed to obtain their views about the service. The inspector also spent time with some of the service users who were not able to be formally interviewed due to problems associated with dementia. One relative was interviewed by telephone three days after the inspection. Discussions were also held with the owner, the home’s general manager and the Principal Carer in charge of the shift. The home’s registered manager was on sick leave at the time of the inspection. A check was made of the environment and the following records were checked: staff training, fire safety, service users’ care plans and health and safety documents. A check was made of the storage and recording of medication. What the service does well: The service users spoke warmly of the staff and felt that they were well cared for at the home. There was a relaxed atmosphere in the communal lounges at the home. Some of the service users were unable to clearly express their feelings about the service due to problems with dementia; however, all the service users seen were well dressed in clean, age appropriate clothing. Staff had taken care to ensure that glasses, hearing aids and dentures were clean and well maintained. The service users had been assessed prior to them moving in to ensure that their needs could be met. The care plans were straightforward and identified service users’ needs and how staff should help them. Care was reviewed on a regular basis and all contact with other healthcare professionals. Medication was stored securely and generally well managed. Service users and staff said that there were generally activities everyday and that these were part of the home’s routines. Trips and visits outside were also provided as well as visiting entertainers. All the service users spoken with said that the food was good. There had been no complaints about the home and the home had adult protection procedures and policies in place. There were adequate staffing levels but the home needs to review these in light of the increasing numbers of service users and the dependency levels of the current service users. Staff had undertaken a range of statutory training and training related to the needs of people with dementia. Amphion Lodge DS0000063969.V312132.R01.S.doc Version 5.2 Page 6 The home was clean with no unpleasant odours noted on the day of the inspection. The lounges were bright and pleasantly decorated. Bedrooms seen were decorated to a good standard and had been personalised by the service users. Staff, service users and one relative spoken with felt that the general manager and the Principal Carer were very approachable. 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. Amphion Lodge DS0000063969.V312132.R01.S.doc Version 5.2 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 Amphion Lodge DS0000063969.V312132.R01.S.doc Version 5.2 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): 3&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Assessments of the service users had been made prior to them coming into the home, ensuring that the staff were able to meet their needs. The home does not provide intermediate care. EVIDENCE: Three service users’ care plans were checked. Their needs had been assessed prior to their admission and there was information provided by their social workers. The home also made their own assessments on admission. A representative of the home also visited the potential service users in hospital whenever possible. The home does not provide intermediate care. Amphion Lodge DS0000063969.V312132.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were plans in place to identify what help and support service users needed. They appeared well cared for and their care plans indicated that health and personal care needs are identified. Service users felt that the staff treated them in a friendly way and took care to maintain their dignity. The medication system was well generally managed but more information is needed to be recorded by staff on the medication records. EVIDENCE: Each of the service users had a care plan; three of these were checked in detail. They were written in a clear, straightforward style, they contained details of the service users’ needs and what action was needed by staff. Each area of the care plans had been reviewed and amended as necessary. Weight charts had been completed and there were risk assessments in each file – these had also been reviewed on a regular basis. Amphion Lodge DS0000063969.V312132.R01.S.doc Version 5.2 Page 10 Nine service users were spoken with. Most were able to say that they thought they were well cared for at the home and had contact with other healthcare professionals when necessary. The care plans contained details of contacts with chiropodists, GPs, district nurses and Community Psychiatric Nurses. Service users said that they saw dentists and opticians if they needed to; details of these contacts were also in the care plans. Medication at the home was generally well managed. Two of the service users spoken with said that the home looked after their medication for them and this was with their consent. The medication was securely stored in cupboards and lockable trolleys. In some cases, staff had to copy prescription information from printed labels onto the medication sheets. The information appeared to have been accurately copied but not all entries had been signed by the staff member. A second signature was also needed to show that another member of staff had checked that the information was accurate. The home’s pharmacist had done regular checks of the system. All the service users spoken with said that their views and opinions were taken into account by staff and they felt that they were treated with kindness and in a dignified way. One visitor interviewed felt that the staff were very friendly and treated her relative in a respectful way. Amphion Lodge DS0000063969.V312132.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users felt that there were enough suitable activities provided at the home to keep them stimulated. Visits from relatives and friends were encouraged ensuring that service users kept in touch with people who were important to them. Service users said that the food was good and they were offered a choice. EVIDENCE: Service users spoken with said that the home provided activities and events for them. These were part of the daily routines and included chair aerobics, softball, games and arts and crafts. Events were also held, for example, a Valentine’s Day dance was planned and there were visiting entertainers. A series of trips had been proposed for the forthcoming year. Staff interviewed said that on the majority of days there were sufficient staff on duty to ensure that activities could take place. All the service users who were able to clearly said that their visitors were made welcome at the home. They said that the visiting hours were very flexible. Amphion Lodge DS0000063969.V312132.R01.S.doc Version 5.2 Page 12 Service users said that they were able to choose what time to get up and go to bed, when they wished to have a shower or bath and that they could generally choose how to spend their day. The staff confirmed that the routines were flexible. All the service users spoken with said that the food was very good and there was a good choice. All the care plans contained detailed nutritional assessments and service users’ weights were regularly recorded. Daily notes contained information about what people had eaten. Amphion Lodge DS0000063969.V312132.R01.S.doc Version 5.2 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 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home had a complaints procedure to allow service users to raise any concerns. The staff had been trained in the recognition and reporting of abuse and checks were made on them prior to them starting work, which reduced the risk of harm to vulnerable service users. There was insufficient evidence to show that all staff had undertaken Criminal Records Bureau checks. EVIDENCE: The home had a complaints book. No complaints had been received at the home or by the CSCI. The home has adult protection policies and procedures linked to those of the local council. Staff were aware of their responsibility to report concerns and said that the manager and seniors were very receptive to any concerns raised about service users. Two adult protection issues had been referred to the Adult Protection team by the home. One had been resolved and the second was still under investigation at the time of the inspection. An audit revealed that some staff working at the home had not undertaken a CRB check – the general manager had applied for these but they were not completed at the time of the inspection. Amphion Lodge DS0000063969.V312132.R01.S.doc Version 5.2 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): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was clean, tidy and well maintained ensuring that the service users live in pleasant and comfortable surroundings. Some areas of the home were being upgraded. EVIDENCE: There were no unpleasant odours noted in the home on the day of the inspection and all the communal areas were clean, tidy and well decorated. The entrance hall was being redecorated at the time of the inspection. The staff were taking measures to adapt the home to help service users with dementia to orientate themselves in the building. Six bedrooms were checked (two on each floor of the home). These were clean, tidy, well furnished and well maintained. Amphion Lodge DS0000063969.V312132.R01.S.doc Version 5.2 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): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There were sufficient staff deployed to ensure that the service users’ physical, social and healthcare needs could be met, however the home needs to review staffing numbers as the number of service users increases and their dependency levels change. Staff had generally received training in understanding service users’ needs and how to provide a safe service – however there was no clear overview of what training people had had. An audit revealed that some staff working at the home had not undertaken a CRB check – the general manager had applied for these but they were not completed at the time of the inspection. EVIDENCE: The home is currently working with reduced occupancy and the staffing levels have been reduced in accordance with this. Staff and service users interviewed felt that most of the time these numbers were sufficient to provide the physical, social and personal care needs of the service users. There were 23 service users in the home at the time of the inspection. There were 3 care staff on each shift, 1 senior carer and 2 care assistants. Between Monday and Friday, the Principal Carer was deployed in addition to this, mostly on the morning shifts. Amphion Lodge DS0000063969.V312132.R01.S.doc Version 5.2 Page 16 There were 2 night staff deployed at the home, I senior carer and 1 care assistant. Staff spoken with felt that these numbers were generally sufficient but that it could be difficult as there were currently 2 service users being cared for in bed. They said that it was harder at weekends when the Principal Carer was not working, although she was available in an on-call role. The home needs to conduct a review of the staffing levels, taking into account the rising number of service users, their dependency levels and also, with particular regard to night staff, the layout of the building. The home’s general manager had recently completed an audit of the recruitment records and identified that, for seven staff, there was no record as to whether they had undertaken a Criminal Records Bureau check. He had informed the CSCI of this and applications had been made for all of these staff members. Staff had undertaken statutory training, such as moving and handling and fire safety, as well as training related to the needs of the service users. A new induction programme has been obtained by the general manager and all staff are to be taken through this. However, an overview is needed of the training that has taken place and when updated training is required. The majority of staff at the home had started working towards obtaining their NVQ Level II in care and some had already obtained this. The home did not yet have 50 of care staff with this qualification. Amphion Lodge DS0000063969.V312132.R01.S.doc Version 5.2 Page 17 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, 37 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service users, staff and relatives felt that the general manager was approachable and there was an open atmosphere beneficial to the care of the service users. The registered manager was absent at the time of the inspection. EVIDENCE: The home’s registered manager has been on sick leave since October 2006. The home is being managed at present by a general manager with the support of the Principal Carer. Staff and service users said that the manager and Principal Carer were very approachable and that they would have no hesitation in reporting any concerns to them. They said that senior staff were always responsive to any concerns or queries they had about service users. Amphion Lodge DS0000063969.V312132.R01.S.doc Version 5.2 Page 18 The owner has regular contact with the home but had not completed monthly audits for much of the previous year. The general manager had documented events at the home in more detail since last autumn, however more detailed monthly reports are still required. Some concerns within the management of the home, such as the service users’ monies and the CRB checks, might have been identified earlier if the audits had taken place. The general manager has designed a programme of formal staff supervision but this has not yet been implemented. It was not possible to make a check of the service users’ monies as some of the key documentation was missing. This matter had already been reported to the CSCI and to the police. The general manager and the owner were trying to obtain this documentation. This issue has been referred to the local Adult Protection Team and is currently under investigation. The fire records were checked. There was regular training and drills for staff. The alarm system had been checked on a weekly basis and any repairs had been carried out promptly. The alarm system had been serviced by an external company. As identified above in the ‘Staffing’ section, the home needs to provide a clearer overview of the training that has taken place. The home had an up-to-date gas safety certificate and the lifts had been serviced within the previous 12 months. Amphion Lodge DS0000063969.V312132.R01.S.doc Version 5.2 Page 19 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score N/A 3 2 X 1 2 2 3 Amphion Lodge DS0000063969.V312132.R01.S.doc Version 5.2 Page 20 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 OP9 Regulation 13 Requirement Handwritten entries on the MAR sheets must accurately reflect the prescription label. All entries must be signed by the person making the entry and by a witness to check the details are accurate. All staff must have Criminal Records Bureau and POVA checks. The general manager must undertake a review of the staffing levels to ensure they are sufficient to meet the needs of the service users. This must take into account the increasing numbers of service users, their level of dependency and the layout of the building. 50 of care staff must have a NVQ Level II qualification in care. Monthly monitoring visits must be undertaken and records kept. A copy of the report must be sent to the CSCI office. The home must have accurate records of all monies held on behalf of service users. These DS0000063969.V312132.R01.S.doc Timescale for action 01/03/07 2. 3. OP29 OP27 18 18 01/03/07 01/04/07 4. 5. OP30 OP33 18 Reg 26 01/06/07 01/03/07 6. OP35 17 (2) and Schedule 01/03/07 Amphion Lodge Version 5.2 Page 21 4 7. OP36 18 records must be available for inspection. The system of formal staff supervision must be implemented. 01/04/07 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 OP30 Good Practice Recommendations The general manager should provide an overview of what training staff have undertaken and what training needs updating. Amphion Lodge DS0000063969.V312132.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Amphion Lodge DS0000063969.V312132.R01.S.doc Version 5.2 Page 23 - 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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