Inspection on 21/01/06 for Amphion Lodge

This inspection was carried out on 21st January 2006.

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 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

Amphion Lodge 18/01/07

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 Ms Rosemary Reid Unannounced Inspection 08:00 21 January 2006 st 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.V266244.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. Amphion Lodge DS0000063969.V266244.R01.S.doc Version 5.0 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 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.V266244.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th August 2005 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.V266244.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 31st January from 8:00 – 12:50pm and the 22nd February 2:00 – 3:30. Mrs. Jacqueline Hackworth is the registered manager and she was available throughout both visits. The inspection focused on the requirements from the previous inspection, four residents files were case tracked along with medication, staffing rota and Adult Protection, Health & Safety and the temperature of the home’s environment All care plans have been changed to the home’s new care plan format. Four staff members, one relative were spoken with along with observation of service users and staff. The interaction between staff and residents was good humoured and staff were seen to be kind to residents. There were no complaints received during the inspection and the one relative who was visiting the home said that they were satisfied with the delivery of service provided at Amphion Lodge Care Home. They had positive comments about the staff members and the care their relative received. On a tour of the building it was evident that there was a problem with the low temperature/heating on the second floor in the home. The owner was contacted to discuss the issues and temperature were taken and recorded. The owner took immediate action to contact the gas provider and resolved the problems. The representative of the parent company can be contacted at any time and visits the home on a regular basis. Management meetings along with undertaking monitoring visits have taken place. However, there were no records of these monitoring meetings taking place from March 2005. Feedback was given at to the provider on the first day of inspection and the to the manager on both days of inspection. What the service does well: Activities take place in and out of the home for example entertainment in the home on a monthly basis. A coordinator works each Wednesday to undertaken activities for the benefit of the residents. Amphion Lodge DS0000063969.V266244.R01.S.doc Version 5.0 Page 6 Out of a total of 17 staff group, 12 care staff have NVQ level 2 in Care with a further 5 staff working toward the qualification 1 staff is working towards level NVQ level 3 and other training has been undertaken. The home is on target to have six staff supervisions and annual appraisal in a year. 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.V266244.R01.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 Amphion Lodge DS0000063969.V266244.R01.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): These standards were not assessed. EVIDENCE: Amphion Lodge DS0000063969.V266244.R01.S.doc Version 5.0 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 - 10 The manager has changed the format of the care plan system and risk assessments to ensure that residents’ needs identified were fully met. Staff are not working to the policies for the administration of medication, which promotes the wellbeing of residents. EVIDENCE: The manager recognised that the care plans in their present form did not meet resident’ changing needs and has taken action to alter the format of residents’ files, risk assessment and care plan system. Four care files were examined and there was evidence that the care plans were being reviewed monthly. No residents had pressure sores. If there is a need the Community Nurse are involved and a referral to the Tissue Viability nurse who will provide pressurerelieving equipment. Medication policies and procedures are in place, which promotes safe handling and administration of medication. Eleven staff that administer medications have undertaken a course on the administration of medication. The six other Amphion Lodge DS0000063969.V266244.R01.S.doc Version 5.0 Page 10 staff do not deal with medications. However, there were members of staff who when administering medications did not follow the medication policies by failing to record the administrations of drugs. Amphion Lodge DS0000063969.V266244.R01.S.doc Version 5.0 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 - 15 The home’s manager and her team have worked hard to encourage visitors to the home. Residents were able to maintain contact with family, friends and the local community. The home provides a varied diet for the well being of the residents’ heath and wellbeing. EVIDENCE: Visitors confirmed that they were able to visit the home at any reasonable time. The home has an activities coordinator who visits on a Wednesday. Residents were observed to be looking/reading newspapers, watching television or looking at magazines. Each month there is an entertainer at the home. There was a pantomime in the home at Christmas and another is booked for the summer. The manager said that a future development was looking at the possibility to take some residents for short holidays. The religious and cultural needs of all service users are considered at assessment and action taken within their individual care plan. Records show that meals are varied and families said that they thought that food was good and there was variety in the menu. Mealtimes were unhurried. Service users who require specialised diets are available. Amphion Lodge DS0000063969.V266244.R01.S.doc Version 5.0 Page 12 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 policies and procedures to protect service users from abuse. In discussions with relatives they stated they knew how to complain and who to complain to. The home has a clear complaints system, which service users and relatives said they would use to register their grievances and/or concerns EVIDENCE: Complaints are recorded and the manager and the company have taken action to resolve complaints and issues. No verbal or written complaints were given to the inspector by relatives and residents. There was no record of complaint since the previous inspection. All staff has received training on Adult Protection matters and this is on going to ensure all new staff have the same training. There have not been any Adult Protection issues at the home since the previous inspection. Amphion Lodge DS0000063969.V266244.R01.S.doc Version 5.0 Page 13 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 Amphion Lodge was clean, bright, tidy and bedrooms were personalised. Service users lived in a safe well-maintained environment, which was clean pleasant and hygienic. When there was a problem, which affected the health and welfare of the resident, the company resolve it immediately EVIDENCE: The inspector toured the building with the home’s manager. The domestic staff members were observed to work hard to maintain a clean and homely environment. The home did not have offensive odours in any part of the building. There are three lounges along with a dinning room on the ground floor and a lounge on the second floor. Bedrooms were personalised and some residents enjoy sitting in their bedrooms relaxing, watching television or receiving their visitors. The ground and first floor of the building was at a comfortable temperature for residents and staff. However, the temperature on the second floor was very Amphion Lodge DS0000063969.V266244.R01.S.doc Version 5.0 Page 14 low as a result of the problem with the heating system. Temperatures were recorded in this part of the home. When this problem was highlighted, the company representative took immediate action to resolve the problem. Amphion Lodge DS0000063969.V266244.R01.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): 27 - 30 Staff were employed in sufficient numbers to meet the needs of service users in accordance with agreed staffing levels. A training and development programme was in place, which met the changing needs of service users. EVIDENCE: Rotas were examined which showed that there was sufficient staff on duty. All care staff have acquired NVQ level 2 course or in the final stages of completion of the qualification. There is one member of staff who has NVQ level 3 award, 12 staff members that have NVQ level 2 with a further five who working to achieve the award, which promote staff development and competence. There has been no new staff employed in the home. Staff has had induction, training in Abuse, Adult Protection, Moving & Handling, First Aid, Health & Safety and Dementia. Amphion Lodge DS0000063969.V266244.R01.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 Generally the health, safety and welfare of service users and staff are promoted and protected. The manager ensured that staff worked as a team and they receive regular staff supervision sessions EVIDENCE: The manager was registered in November 2004. Staff said that they felt supported and valued by her and has worked hard to develop a culture of continuous improvement amongst the staff group. Staff said they received support and guidance on a daily basis. Formal staff supervision sessions have been started and were on target to have six staff supervision session in a year, which was confirmed by records. Staff training records show that the following course have been undertaken First Aid, Moving & Handling, Health & Safety. Abuse, Adult Protection, Dementia. Fire prevention training has been undertaken. Records show that fire alarm test is undertaken weekly and the fire system had been serviced on the 30th January 2006. Amphion Lodge DS0000063969.V266244.R01.S.doc Version 5.0 Page 17 Monthly monitoring visits by a representative of the company have not taken place. Amphion Lodge DS0000063969.V266244.R01.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 X X X 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 3 18 3 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 3 3 3 3 3 Amphion Lodge DS0000063969.V266244.R01.S.doc Version 5.0 Page 19 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 OP9 Regulation Reg 13 (2) Sch 3 (i) Requirement The registered person must ensure that medication records must be completed at the time of administration as per medication policies and procedures to comply with The Medicines Act 1963, the Royal Pharmaceutical Society requirements of The Misuse of Drugs Act 1974. Monthly monitoring visits must be undertaken and records kept. A copy of the visit must be sent to the CSCI office. Timescale for action 31/01/06 2 OP33 Reg 26 31/03/06 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 Amphion Lodge DS0000063969.V266244.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Doncaster Area Office 1st Floor, Barclay Court Heavens Walk Doncaster Carr Doncaster DN4 5HZ 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.V266244.R01.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. 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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