Inspection on 10/01/08 for Ancholme Lodge Care Home

This inspection was carried out on 10th January 2008.

CSCI found this care home to be providing an Adequate service.

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

Ancholme Lodge Care Home 08/01/09

Ancholme Lodge Care Home 06/02/07

Ancholme Lodge Care Home 27/02/06

Ancholme Lodge Care Home 17/05/05

Ancholme Lodge Care Home 28/10/04

Ancholme Lodge Care Home 10/06/04

Ancholme Lodge Care Home 03/03/04

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

CARE HOMES FOR OLDER PEOPLE Ancholme Lodge Care Home Scawby Road Broughton Brigg North Lincolnshire DN20 0AF Lead Inspector Theresa Bryson Key Unannounced Inspection 10th January 2008 09:00 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 Ancholme Lodge Care Home DS0000002874.V357693.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. Ancholme Lodge Care Home DS0000002874.V357693.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ancholme Lodge Care Home Address Scawby Road Broughton Brigg North Lincolnshire DN20 0AF 01652 657349 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) Mr Blabir Singh Lally Mrs Alison Jane Kitching Care Home 24 Category(ies) of Dementia - over 65 years of age (13), Old age, registration, with number not falling within any other category (24) of places Ancholme Lodge Care Home DS0000002874.V357693.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Alison must complete the registered managers award and attend mandatory training updates within 6 months of registration. Regulation 10. 6th February 2007 Date of last inspection Brief Description of the Service: Ancholme Lodge is registered for the care of 24 service users with residential care needs; four of these places are for service users with needs associated with dementia. The home is set on the outskirts of the village of Broughton, near the main town of Scunthorpe. It is a large older style Victorian building that has maintained a number of existing features. The accommodation is provided on two floors accessed by a passenger lift, stairs and a platform lift. All bedrooms are for single occupancy and the majority have en-suite facilities; all the rooms are individually furnished. There are a variety of communal sitting areas and a large dining area. The gardens are mainly paved and are accessible to service users. There is ample parking provided at the front of the building. The fees for the home range between £312 - £360.63, which are reviewed annually. Additional charges include hairdressing and chiropody. The Service Users Guide and Statement of Purpose are on display in the main reception area and given to each prospective person seeking accommodation. Ancholme Lodge Care Home DS0000002874.V357693.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 1 star. This means that the people who use this service experience adequate quality outcomes. This inspection site visit took place over one day in January 2008. Prior to the visit the home submitted an AQAA document and other information about the home. Surveys were sent to relatives, health professionals and staff, to which there was an adequate response. The service history kept by us was checked prior to the visit. The site visit comprised of a tour of the building and checking of a number of documents and records. 6 staff members were spoken to, 7 people who were living in the home and 2 visiting health professionals. The registered manager accompanied us through out the site visit. What the service does well: Staff in the home are very friendly and welcoming. There is a calm and happy atmosphere and all staff are most cooperative to us, visiting professionals and other visitors. Many positive comments were made by people using the service about how they are cared for and that staff come when requested and al their needs were being met. The home produces comprehensive documentation to enable people to make informed choices about the home and what it can provide. Adequate assessments take place prior to admission to ensure the home can meet that person’s needs. Suitable social activities and events are provided to enable people to develop hobbies, develop friendships in peer groups and satisfy their social, religious and cultural expectations. The wider community is welcomed in to the home and people also make frequent visits to outside events. Meals are provided in a clean and safe environment. People have choices at each mealtime and the catering staff can also provide for special diets. Fresh produce such, as vegetables; fruit and homemade cakes are available throughout the week. Staff take care to assist people who need it at meal times to ensure they have a balanced diet to help their well being. Ancholme Lodge Care Home DS0000002874.V357693.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Although the home has developed well the current care planning system in the home, this should still be checked by the management team to ensure staff are following the needs of people living their. This must be coupled with more robust supervision of staff with formal discussion and observational supervision to ensure each person can fulfil their job description and not be putting people at risk. Care must also be taken that all staff administering medication are safe to do so and that accurate records and storage is maintained. This will prevent people from being harmed. The records must also show peoples wishes as their lives draw to a close and that the appropriate guidelines are followed when resuscitation is not deemed to be required for an individual and all permissions are in place. The management team need to ensure that there are always suffiecnt staff, in the correct roles to meet the needs of people at all times. This includes mealtimes, domestic tasks and activities. People must not be put at risk because insufficient staff have been recruited to relevant roles. There must also be suitably qualified first aiders on duty through a 24-hour period to meet emergency needs of people as they arise. Failure to do so could result in people being put at risk. Ancholme Lodge Care Home DS0000002874.V357693.R01.S.doc Version 5.2 Page 7 Any volunteers must have some supervision and training through out the year to ensure they are not putting people at risk. The general upkeep of the home was good but some attention to detail is still required to ensure it is a safe and comfortable environment in which to live. This includes better monitoring of water temperatures, to ensure people are not exposed to too cool water; the shower room to be decorated and made useable so people have this option to bath and that all untoward incidents like the replacement boiler being put in - are notified to us, so we can monitor the safety of the people. The home still has to develop a quality assurance programme to ensure all aspects of the home are looked at and audited, the needs and expectations of people living there are being met and that a development plan is in place to ensure the home is running for the peoples benefit. This will ensure people are consulted and outside agencies and the home team can plan developments. 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. The summary of this inspection report can be made available in other formats on request. Ancholme Lodge Care Home DS0000002874.V357693.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 Ancholme Lodge Care Home DS0000002874.V357693.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Standards 1,3,4 and 6 were checked. Adequate documentation is provided to ensure people can make informed choices about entering the home. EVIDENCE: A condition remains on this Registration, which has now been fulfilled and will be removed by the CSCI Registration team. The Manager was able to detail the training undertaken since the last inspection and the status of the Registered Manager’s Award. In the care plans tracked written evidence was provided to show that prior to admission each person is assessed using a holistic record tool. This is comprehensive and helps staff to prepare for a person’s admission. Both Ancholme Lodge Care Home DS0000002874.V357693.R01.S.doc Version 5.2 Page 10 managers, sometimes accompanied by a senior carer completes each assessment to ensure the home can meet that person’s needs prior to offering accommodation. The staff records showed that some training in service specific topics had taken place over the last year to enable staff to have the knowledge basis to look after each person’s specific needs. Comments from people using the service included, “the carers seem to know what they are doing” and “when I want help with a problem they appear to know the answers”. The home does not provide intermediate care and Standard 6 is not applicable. Ancholme Lodge Care Home DS0000002874.V357693.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Standards 7,8,9,10 and 11 were checked. The home provides comprehensive documentation to ensure current needs of people are recorded, but a safer system of drug administration recording must be in place to ensure people are not put at risk. EVIDENCE: Prior to the site visit a number of surveys were sent to relatives, staff and health professionals visiting the home, there was a reasonable response from each group. Many positive comments were made about the delivery of care and kind attitude of the staff.2 health professionals and 7 people using the service were spoken to during the site visit. The care documentation has improved since the last inspection and staff have taken more care in ensuring that each person’s care plan is evaluated regularly and meets their current needs. The supplementary information such as opticians’ visits is thoroughly recorded in the correct sections of the care plan, Ancholme Lodge Care Home DS0000002874.V357693.R01.S.doc Version 5.2 Page 12 to ensure the reader can follow the progress of each person. Risk assessments were seen to be in place for some of the 4 care plans tracked, such as tissue viability needs and management of aggressive behaviour and advice recorded, when sought from other health professionals. Professionals who returned surveys and those spoken to stated that staff complete documentation well and promptly when asked and were able to follow instructions. One stated, “staff are willing” and another “staff will contact me immediately a new need arises”. People using the service made such comments as “they are patient with me” and “girls will do anything for me” and “nothing is too much trouble”. The management team are helping staff to put together comprehensive care plans and will now need to move on to the next stage and ensure their work is monitored regaurly to ensure consistence, accurace and clarity when reviewing each care plans. It had been stated that auditing would take a three way process of observation of delivery of care, care plans and testing of knowledge base. There was no documented evidence yet to support this method, but we were assured this would soon begin to take shape. Included in this must also be some checks as to when daily reports are written to ensure they remain an accurate record of what happened during each shift change of staff, this will ensure correct information is recorded and passed on. During the tracking of the care plans some written evidence was seen concerning the possible wishes of persons should they be near the end of their life. This had not been sufficiently well recorded and the policy for the care of the dying person did not reflect what was stated by staff. Accurate information must be available for staff to follow to ensure they can then inform people using the home and/or their next of kin. This will ensure that all needs are maintained until the person’s life ends. The medication for people is kept in a large, clean and safe environment with temperature checks made regularly to ensure medication is stored correctly. The controlled drugs were checked and found to show accurate maintenance of the register. There was no medication stored in the fridge and no homely remedies in use. There were some gaps in the recording of medication when regular dosages were transcribed that should have been given. Although a code system is in place on some occasions this had not been used and no adequate explanation could be given to ensure us that the correct medication had been given and if not why. Also some items were shown as having been stopped but with no indication of why this had occurred and who had given this instruction. Staff can only change and/or stop medication on the advice of a medical practioner, nurse practioner or designated other health professional trained to give advice. This will ensure people are free from harm. Ancholme Lodge Care Home DS0000002874.V357693.R01.S.doc Version 5.2 Page 13 On inspecting the drug trolley, which was clean and tidy, some medication appeared to have been dispensed many months before hand with little used. One bottle was taken out of the system by us as it looked as though it had changed colour. The management team must ensure that a drug audit is completed regularly to ensure staff are administering medication correctly and that dates are also checked on all medication to ensure they are safe to use. This will ensure people are not put at risk from ill stored medication and that safe practises are in use. Staff were observed through out the day assisting people with personal care, meals and activities. This is they did with patience and preserving each person’s dignity. Each person was spoken to with respect and people using the service commented on how “kind” staff were to them. Ancholme Lodge Care Home DS0000002874.V357693.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Standards 12,13,14 and 15 were checked. Sufficient social events are provided to ensure peoples expectations can be met. EVIDENCE: Although no separate social needs activities co-ordinator is employed people stated there are various events, which take place, which meet their needs. There was ample evidence in the care plans, with posters and on talking to people using the service that a good selection of social events take place in the home. Some people stated, “I like the bingo” and another “I never thought I’d do exercises but I am here, with music”. The records showed that each person has a social needs assessment, which is evaluated regularly and some had a life history. There was some inconstancy in the documents used, but the management team were currently reviewing this to ensure staff can use the same documentation. Ancholme Lodge Care Home DS0000002874.V357693.R01.S.doc Version 5.2 Page 15 The trolley shop was in operation during the course of the site visit and people using this appeared to enjoy this weekly visit and be able to make their own choices of for example toiletries and birthday card for family and friends. There was ample evidence in the bedrooms seen that people had been able to personalize them. One person stated how this had helped them settle into the home. The manager accompanied us on a tour of the kitchen, which was very clean and tidy. Records were seen to show that regular temperature checks are completed to ensure equipment is safe and deliveries of food are safe. The last environmental health kitchen audit had been in August 2007 and any outstanding requirements actioned. There had been no requirements on the health and safety audit by environmental health officers in November 2007. This ensures all food is prepared in a safe and clean environment. The home operates a 2-week cycle of menus and although no choices are actually listed, people spoken to stated they could have alternatives if they wish. Every one stated the portion sizes were plentiful and sufficient to meet their needs. There was ample fresh fruit, vegetables and homemade cakes to ensure people have fresh produce each day. The dining area was light and airy and care had been taken to ensure there was clean linen and the placement settings laid for each meal. Staff were seen to assist people at meal times with dignity and respect and encouraged those who needed help maintaining a balanced diet to assist their well being. Ancholme Lodge Care Home DS0000002874.V357693.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Standards 16 and 18 were checked. A robust system is in place to ensure people are protected from abuse and can be confident concerns will be dealt with promptly. EVIDENCE: Since the last inspection the home had referred concerns to the local safe guarding adults team because of the behaviour of a person in the home. They referred and recorded all actions correctly and had been very cooperative to the local team. The policy manual was up to date and staff had received training to ensure they can recognise abuse and know how to refer. This ensures people are free from harm and risk. We had received no complaints since the last inspection and none by the home. The complaints log was seen and the policy was on display. People spoken to stated they felt happy to approach any member of staff if they had a concern and knew this would be dealt with in confidence and promptly. Ancholme Lodge Care Home DS0000002874.V357693.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Standards 19,21 and 26 were checked. Some attention to detail is required in some areas of the home to ensure people are living in a safe and well maintained environment. EVIDENCE: The laundry assistant accompanied us on a tour of the laundry. All equipment was in working order and the area clean and tidy. A safe system is in place to handle soiled linen and staff were able to adequately state how this works to prevent cross infection in the home. Ancholme Lodge Care Home DS0000002874.V357693.R01.S.doc Version 5.2 Page 18 Some linen was not in a good state of repair and an audit needs to be completed to ensure that the people are comfortable and there is no risk to people due to damaged linen which could cause pressure sores. The manager accompanied us on a tour of the home, which was clean and tidy. Some areas still need attention to ensure the home is safe, secure and comfortable to live in. The shower room identified as needing attention on the last visit still has not been maintained and appeared to be being used as a temporary storage area. Although it was stated this area is not used by staff at the moment it is still included in the allocation of bathroom/shower rooms for the numbers of people registered to use the home and needs to be made a priority on the maintenance plan. The water temperature records were checked and some appeared to be consistently running at low temperature. Failure to maintain adequate temperature control could put people at risk from bring exposed to too cool a temperature to ensure safe bathing and washing. During the course of the site visit the boiler was being replaced and it was stated that the provision of adequate water supplies was being compromised for a short period. We had not been notified of this and the home was asked to supply a retrospective Regulation 37 notice. Failure to notify us of any untoward incident is an offence as we require the home to keep us up to date with all events in the home so we can judge whether the safety of the people living there is being put at risk. The garden area was tidy and appeared to be free from hazards, although a full tour of the outside area could not take place as the weather on the day was so bad it prevented us from completing a full tour.There was ample space for people to sit outside and the car park was safe and very large. Ancholme Lodge Care Home DS0000002874.V357693.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Standards 27,28,29 and 30 were checked. A robust system is in place to employ staff and adequate checks are made to ensure they are safe to work with people in the home, most training was up to date. EVIDENCE: At the time of the site visit there were no outstanding vacancies for staff recruitment except for an activities co-ordinator. The rota system for all staff was seen and the manager stated the assessment had been completed that there were sufficient staff on duty at all times to meet people’s needs. Although people living in the home stated all their needs were being met and made such comments as “if you want any thing at night I press the buzzer and they come” and “nothing is too much trouble”. The manager was asked to review this as the matrix is for dedicated care hours and not other tasks. There was written evidence seen that night staff are asked to complete certain tasks and the afternoon staff complete tasks in the kitchen and care staff through out the day try to fit in some social activities Ancholme Lodge Care Home DS0000002874.V357693.R01.S.doc Version 5.2 Page 20 with people and escort on outside visits and medical appointments. This could put people at risk from needs not being able to be met, especially during staff holidays and periods of sickness. 5 staff personal files were tracked and found to have sufficient evidence to support that adequate checks had been made to ensure they were safe to work with people prior to the commencement of employment. This included health screening and an interview checklist where a robust number of questions were asked and time given for questions from the interviewee. The files also contained the training records of staff and most mandatory and service specific training had now been completed. This has included topics such as challenging behaviour, dementia and infection control. The training for adequate numbers of staff to have completed first aid training needs to be completed, to ensure there are suffivent staff on duty throughout a 24hour period to respond to emergency aid. This will prevent people from being in harmful situations when staff know how to respond quickly. Staff stated how training undertaken in the last year has enhanced the care they give to people and given them a better understanding of peoples needs. Comments were made such as “we have loads of training” and “it’s inspired me to go on my NVQ training”. The home uses volunteers working in the home. The home has made sure safety checks have been completed through the Criminal Investigation Bureau, but must keep a file to ensure they have adequate supervision and training throughout the year to ensure they are safe to work with people living there. Ancholme Lodge Care Home DS0000002874.V357693.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Standards 31,33,35,36 and 38 were checked. Records showed that the home was reasonably safe to live in but staff should be supervised more and more evidence produced that quality checks about the service are made to ensure people are happy with the service provided. EVIDENCE: The home still could not produce enough evidence to support that adequate quality auditing checks are made about the service. Although people spoken to appeared happy with the service making such comments as “haven’t known better” and “cant think what any one would complain about”. There was no Ancholme Lodge Care Home DS0000002874.V357693.R01.S.doc Version 5.2 Page 22 supporting written evidence to show other stakeholders and a broader range of people living in the home and their loved ones had been asked about all aspects of running the home. The staff have stated this is a weakness on their part and are actively seeking to rectify the situation in the next few months. This must include an annual development plan for the home to ensure us that all aspects of running the business have been looked at and areas for development identified and prioritised. The management structure has changed slightly since the last inspection and this was detailed in the Statement of Purpose and Service Users Guide. People living in the home were aware of the changes and stated they had every confidence that the team would deal with any concerns in a professional way. The owner still has total control of the financial aspects in the home, but the contingence plan in case of illness and holiday was explained. There was no written evidence to support this process and the home was advised to develop a policy so all members of the team are aware of what happens in an emergency and the running of the home is not compromised financial and can still run safely to prevent people from being at risk. The management team have commenced the supervision records of staff and this has much improved since the last inspection. There still needs to be more evidence on file to ensure us that all staff are being monitored adequately in their job roles and are safe to work with the people in the home. This must also include observational supervision and cover all aspects of as laid out in the National Minimum Standards for Older People. A sample of other records were seen such as fire checks, certificates for lifting equipment, accident records and maintenance repair records to satisfy that the home was being monitored for the safety of people living there, visitors and staff. The home had an open and friendly feel and staff were very cooperative to us during the site visit. People living there appeared happy and cared for and there was a lot of friendly banter in the sitting room areas. Ancholme Lodge Care Home DS0000002874.V357693.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 X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 2 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 3 3 X 2 X X X X 2 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X 2 2 2 3 Ancholme Lodge Care Home DS0000002874.V357693.R01.S.doc Version 5.2 Page 24 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 OP7 Regulation 15.2.b. Requirement The management team must ensure that adequate checks are made to ensure staff are accurately recording the care given to individuals to ensure current needs are being met. The staff must ensure that there is accurate recording of medication given and any changes recorded accurately with the fullest details as possible. To ensure people are not harmed by incorrect medication being given. The staff must ensure that all medication when opened is fit for use and any that is not disposed properly. This will prevent people from being harmed. The staff must ensure that all records accurately record the wishes of each person for their death and last offices and all permissions have been obtained when resuscitation is not required to take place. The registered person must ensure that the hot water is not too cold and temperatures are DS0000002874.V357693.R01.S.doc Timescale for action 30/04/08 2 OP9 13.2. 28/02/08 3 OP9 13.2. 28/02/08 4 OP11 15.2.b. 30/04/08 5 OP21 23.2. 28/02/08 Ancholme Lodge Care Home Version 5.2 Page 25 maintained close to and not exceeding 43°C. (Previous time scale of 01/04/06 and 01/04/07 not met) 6 OP21 23.2. The registered person must ensure that missing wall tiles in the shower room are replaced and this area is cleared and made ready for use. (Previous timescale of 01/04/07 not met). The staff must ensure that linen provided for people using the service is in a good standard of repair and an audit completed to see where shortfalls in provision may be. This will ensure they are not exposed to pressure damage and are living in a comfortable environment. The owner must ensure that there are sufficient staff on duty to meet the needs of individuals at all times and review the job roles to ensure adequate numbers of staff also cover kitchen, domestic and activities duties as well as care hours. This will ensure people are not put at risk from insufficient staff on duty to meet their needs. The home must ensure that any volunteers have written evidence in a file to ensure supervision and training has taken place throughout the year to ensure they are safe to work with the people at the home. There must be adequately trained staff on duty, who have completed a first aid course, 24hours a day, some of which must have completed a 4-day course. To ensure there are sufficient staff to respond on any DS0000002874.V357693.R01.S.doc 30/05/08 7 OP26 16.2.e. 30/04/08 8 OP27 18.1.a. 28/02/08 9 OP29 18.2. 30/04/08 10 OP30 18.1.c.i. 30/04/08 Ancholme Lodge Care Home Version 5.2 Page 26 11 OP33 24 emergency. The registered person must ensure that the quality monitoring systems are further developed, results from surveys are published, and an annual development plan to support the programme is developed and include local stakeholders in the survey programme. (Previous timescale 01/07/06 and 01/05/07 not met) The owner must ensure there is a written policy of who can access finances in their absence to ensure the smooth running of the home. The registered person must ensure that staff receive regular formal supervision, a supervision plan for 2007 must be developed and implemented. (Previous timescale of 01/04/07 not met). The management team must ensure that CSCI is notified immediately any event occurs which could adversely affect the well-being of the people in the home. 30/04/08 12 OP35 25.2.c. 28/02/08 13 OP36 18(2) 28/02/08 14 OP37 37.1.e. 28/02/08 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 OP19 Good Practice Recommendations The registered person should ensure that unoccupied bedrooms are maintained to a good standard and fully equipped to encourage occupancy. DS0000002874.V357693.R01.S.doc Version 5.2 Page 27 Ancholme Lodge Care Home Ancholme Lodge Care Home DS0000002874.V357693.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Ancholme Lodge Care Home DS0000002874.V357693.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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