CARE HOMES FOR OLDER PEOPLE
Ancholme Lodge Scawby Road Broughton Brigg North Lincolnshire Lead Inspector
Kate Emmerson Unannounced 17 May 2005 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 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 J54 S2874 Ancholme 17 May 05 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Ancholme Lodge Address Scawby Road Broughton Brigg North Lincs 01652 657349 Telephone number Fax number Email 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 Balbir Singh Lally Mrs Alison Kitching Care Home 24 Category(ies) of OP (20) DE(E) (4) registration, with number of places Ancholme Lodge J54 S2874 Ancholme 17 May 05 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: Alison (the manager) must complete the registered managers award and attend mandatory updates within 6 monthsa of registration. Date of last inspection 28 October 2004 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 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 to a good standard. There are a variety of communal sitting areas and a large dining area. The home provides very pleasant accommodation, the atmosphere is warm and homely. The gardens are mainly paved and are accessible to service users. There is ample parking provided at the front of the building.
Ancholme Lodge J54 S2874 Ancholme 17 May 05 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over one day in May 2005. To find out how the home was run and if the people who lived there were pleased with the care they got the inspector spoke to the manager and the 4 staff working in the home at the time of the inspection. The inspector also spoke to 7 people who lived in the home and to 1 person who went to the home during the day to be cared for whilst their family were at work. Paper work kept in the home was also seen to make sure that the that checks to make sure staff are safe to work in the home were done before they started and that they had trained to do their job safely. Paperwork was looked at to make sure that the home and the things used in it were safe and were checked often. The manager of the home, Alison Kitching, had been in charge since December 2004 and had tried hard to make sure anything that had needed to be done from the last inspection had been done. What the service does well:
The home was very clean and tidy, had a very friendly feeling and had lots of space in the rooms where people sit and relax or eat. The staff were very friendly and knew about the care the people who lived there needed before they came in because the manager always visited people before they went into the home. The care people needed was written down by the manager with their help and checked often by the staff to make sure that there had been no changes. The people who the inspector spoke to said the staff were very good and did anything they could for them and made their family and friends feel welcome. They said the staff always knocked on their doors before going into their rooms or the toilets and if they needed help going to the toilet the staff made sure that this was kept private. The people who lived in the home really liked the meals and said that there was plenty of different things to eat and if they didn’t like something they would be given something else. They said that there was lots of home baked cakes at tea - time The home had enough staff in the home at any one time to make sure everyone could be cared for and the people who lived in the home said that the staff always came when they rang their bell.
Ancholme Lodge J54 S2874 Ancholme 17 May 05 Stage 4.doc Version 1.30 Page 6 The manger made sure the home was safe by often doing checks of the home and the things used to care for people. 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. Ancholme Lodge J54 S2874 Ancholme 17 May 05 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Ancholme Lodge J54 S2874 Ancholme 17 May 05 Stage 4.doc Version 1.30 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 standard(s) 1, 2 and 3 The service users were provided with information regarding the home and always met a senior member of staff prior to admission. Staff were empathetic to the needs of the service user on admission and were well informed of the care needs of the service users prior to admission, which assisted the service user to feel safe, secure and welcome in the home. EVIDENCE: The statement of purpose had been reviewed to include information on emergency admissions to the home and the contact details to reflect the NCSC organisation change to CSCI however the document still required some minor additions to include the actual measurements of all the rooms in the home. The general format and content of the statement of purpose was found to be comprehensive and user- friendly. The majority of the service users stated that they were not involved in the decision to come to the home and had left this to family or taken advice from social services staff but where they had been involved in the decision regarding
Ancholme Lodge J54 S2874 Ancholme 17 May 05 Stage 4.doc Version 1.30 Page 9 their placement they had received information regarding the home in the form of a service users guide. Some of the service users were from the local area and had previously accessed the home for day care or respite before choosing to become a permanent resident. Staff were aware of the service users guide and its contents and stated that this information was provided in each bedroom. The manager had provided all the service users with a contract/statement of terms and conditions, which included their bedroom no and the fees to be paid. The manager stated that she or the deputy manager assesses all service users prior to admission to the home and was able to provide evidence of completed assessments and care plans. The staff stated that prior to the admission of a service user the manager had always completed a care plan and provided this to staff. The staff described the process of admitting the service user that included assisting in unpacking and introduction to other service users and staff. Ancholme Lodge J54 S2874 Ancholme 17 May 05 Stage 4.doc Version 1.30 Page 10 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 standard(s) 7, 8, 9, and 10. Although care plans were not always adequately developed or evaluated which could leave the service user at risk of inadequate care and unidentified health problems there was sufficient evidence that health and care needs of the service users were met. The service users were involved in the development of the care plans and staff were knowledgeable about the care needs of the service users, carried out care tasks in a manner that respected the privacy and dignity of service users and communicated appropriately with relatives and care professionals. Deficiencies in the accuracy of transcribing medication on to administration records, although minor, could put service users at risk of being administered the incorrect dose of medication. EVIDENCE: The service users stated that their care needs were met and described how care was provided in a way that respected their privacy and dignity. They stated that they were aware that records were kept. The service users stated that the staff had explained and discussed their care plans with them and their
Ancholme Lodge J54 S2874 Ancholme 17 May 05 Stage 4.doc Version 1.30 Page 11 families. Staff were knowledgeable about the care requirements of the service users. Case tracking of 3 service users was completed. This included examination of care records and discussion with service users and staff. Care plans were generally well developed and described the care needs identified at assessment. The care plans had been evaluated on a monthly basis and there was some evidence that care plans had been updated. There was use of risk assessment tools for mobility, falls, tissue viability and nutrition. Daily diary recordings described in detail the care provided, health issues and recorded communication with other parties. There were some deficiencies in the care planning process. There was evidence that where risks had been identified plans to reduce the risks had not been developed, for example where a service user was identified at high risk of development of pressure sores a plan of care had not been recorded. There was also evidence that where a service user had deteriorated the care plan had not been updated adequately. However there was evidence that the appropriate care was being provided from the daily diary recordings, monitoring records and through discussions with the staff. Evaluation of the care plans had not always taken account of information recorded on monitoring charts such as weight gain/loss and bowel function charts which could leave the service user at risk of unidentified health problems. Care plans, updates and evaluations were not always dated and signed by staff so it could not always be assessed that the care plans had been updated in a timely manner. Medication records were checked. The manager completed computerised medication administration sheets; one transcribing deficiency was identified in the records examined where the administration sheet did not accurately reflect the dosage on the medication label. This is not acceptable due to the risks in administrating the incorrect dose of medication and processes must be put in place to reduce this risk. Controlled medication was checked; storage and recording was satisfactory. Ancholme Lodge J54 S2874 Ancholme 17 May 05 Stage 4.doc Version 1.30 Page 12 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 standard(s) 12, 13, 14 and 15 The service users daily routines and social activities were varied and flexible and enabled service users to exercise choice. The staff could be more proactive in the provision of activities. Staff were polite and pleasant and made visitors feel welcome. The meals provided in the home were of good quality offering choice and variety. EVIDENCE: Service users described a variety of activities that they participated in such as bingo, dominoes, crochet, knitting, crosswords, jigsaws and reading. TV’s were provided in the communal rooms and the home provided a library with large print book, games and entertainment such as singers. The 8 service users spoken with stated that although there were was little organised entertainment in the home they felt their needs were met. The service users stated that they did not know when entertainment would be provided prior to the event and although the manager stated that this would be advertised on the notice board in the hallway the service users stated they did not pass this part of the home to go from their bedrooms to communal areas and were not able to access this unaided.
Ancholme Lodge J54 S2874 Ancholme 17 May 05 Stage 4.doc Version 1.30 Page 13 The manager described the activities available and stated that in general the service users were not really interested however there was little evidence that management and staff were proactive in enabling service users to be involved in the activities available in the home. The service users stated that they were able to exercise choice in aspects of their life and daily routines and family and friends were made to feel welcome when visiting the home. There was open visiting, the inspector observed a number of visitors to the home during the inspection; there was positive interaction between staff and visitors; it was clear that the staff endeavoured to build positive relationships and communication was good. The service users all spoke positively about the meals provided and described the quality, choice and variety of the meals as good or very good. The service users stated that they did not know what was on the menu for that day but would ask the staff if they wished to know. The manager stated that the menu was displayed in the dinning room but this was not the case on the day of inspection. Staff were seen to assist the service users in an appropriate manner, which respected the privacy and dignity of the service users. Ancholme Lodge J54 S2874 Ancholme 17 May 05 Stage 4.doc Version 1.30 Page 14 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 standard(s) 16 The relationships between the manager, staff and the service users enabled the service users to feel confident in making a complaint if it was necessary. This was supported by the policy and procedures in place. EVIDENCE: A complaints procedure was displayed in the entrance hall. The procedure was clear; appropriate timescales for resolution and contact details were included. The manager stated that the home had not received any complaints since the last inspection. The service users were able to identify how they would make a complaint if necessary and stated they would feel confident to approach the manager or a member of staff, all stated that they had not had to make a complaint and were very satisfied with the care provided. Ancholme Lodge J54 S2874 Ancholme 17 May 05 Stage 4.doc Version 1.30 Page 15 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 standard(s) 19 and 26 The home was clean and tidy and the manager was proactive in meeting requirements and maintaining the home. EVIDENCE: The home was clean and tidy and free from offensive odours in the areas accessed by the inspector. The hallway required redecoration and the manager stated that quotes were being sought. All the requirements arising from the previous inspection, except 1 pertaining to the provision of lockable storage space, had been addressed. There had been few changes in the home since the last inspection. A bedroom (9) had been changed into a training room. Ancholme Lodge J54 S2874 Ancholme 17 May 05 Stage 4.doc Version 1.30 Page 16 The fire officer had visited the home in April and identified some requirements for the home to be completed within 3 months and the manager had commenced work to meet these requirements. Ancholme Lodge J54 S2874 Ancholme 17 May 05 Stage 4.doc Version 1.30 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30 The staffing levels were appropriate for the current dependency of the service users accommodated. Whilst there was some evidence to indicate an active staff training programme which included NVQ training the manager was not able to provide up to date evidence of training provided or planned. Staff completed a basic induction into their role but this area needs further development to meet the standard. There was no evidence that staff received service specific training and development in areas such as dementia and conditions common to the elderly. The recruitment practises in the home had not been adequately implemented in all cases to ensure sufficient protection for the service users. EVIDENCE: The staff confirmed that the home staffing levels in the home were consistently maintained and that there were always 4 staff members on duty in the day between 8am and 8pm. The service users confirmed that staff were ‘excellent’ and that they ‘couldn’t do enough for them’ They confirmed that staff answered call bells promptly. The staff interviewed were very experienced carers and had received a variety of training.
Ancholme Lodge J54 S2874 Ancholme 17 May 05 Stage 4.doc Version 1.30 Page 18 The staff files of the 2 most recent staff members recruited showed that the home had not received 2 written references prior to employment and the manager had accepted a CRB check from previous employment in one case this is not acceptable. Both staff members had previously worked at the home and the manager sited this as the reason for the deficiencies in recruitment practises. The manager was advised of the correct procedures, which must be followed in all cases to ensure adequate protection for the service users. Induction training was provided in the home, which included orientation to the home and the staff member working as an extra member of staff for 2-3 days. This does not meet TOPPS standards. The manager stated that a package to deliver induction training to these standards had been purchased but had not implemented this yet. The manager did not have an overview of the training completed by the staff or a staff-training plan. The manager stated that she was in the process of auditing all the staff files to bring them up to date and identify training needs. However the staff interviewed confirmed that there was an active training programme in place and stated that they were all currently receiving NVQ 2 or 3 training. . Ancholme Lodge J54 S2874 Ancholme 17 May 05 Stage 4.doc Version 1.30 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 The manager was proactive in ensuring that the health and safety of service users and staff was promoted and protected and requirements from previous inspections had been met. To ensure staff and service users are put at risk the manager will need to provide a training plan to ensure that mandatory training is maintained up to date. EVIDENCE: Ancholme Lodge J54 S2874 Ancholme 17 May 05 Stage 4.doc Version 1.30 Page 20 There was evidence from records and staff interviews that staff had undergone moving and handling, fire safety, basic food hygiene, COSHH, infection control and first aid training. However the manager stated that the records were not all up to date and there was no training plan in place to ensure that mandatory training requirements would continue to be met. At the previous inspection staff reported problems with the emergency call system in a small number of rooms the staff and service users stated that this had been addressed. The fire safety equipment and checks were all in place and up to date. Staff accessed regular drills. Records showed that whist regular fire drills were undertaken not all the staff had taken part in a fire drill or fire training since December 2004. Individual risk assessments covered falls, moving and handling and general issues were completed. Accident reports were maintained. Ancholme Lodge J54 S2874 Ancholme 17 May 05 Stage 4.doc Version 1.30 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 3 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3
COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x x x x x x x 2 Ancholme Lodge J54 S2874 Ancholme 17 May 05 Stage 4.doc Version 1.30 Page 22 yes Are there any outstanding requirements from the last inspection? 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 1 Regulation 4(1) Requirement The registered person must ensure that the Statement of Purpose contains all information to comply with Schedule - to include the actual measurements of all the rooms in the home. (Previous Timescale of 31 January 2005 not met) The registered person must ensure that the care plans reflect the needs of the service users and are updated as needs change. (Previous Timescale of 31 January 2005 not met) The registered person must ensure care plans, updates and evaluations are dated and signed by the staff. The registered person must ensure that the standard of medication recording with regard to transcribing is maintained in line with guidance from the Royal Pharmaceutical Society and CSCI. (Previous Timescale of with immediate effect not met) The registered person must provide a lockable space in all service users’ bedrooms Timescale for action 1 August 2005 2. 8 and 7 15 1 July 2005 3. 8 and 7 15 With immediate effect With immediate effect 4. 9 13(2) 5. 24 12(4) 1 August 2005 Ancholme Lodge J54 S2874 Ancholme 17 May 05 Stage 4.doc Version 1.30 Page 23 6. 30 18(1) 7. 30 and 38 18(1) 8. 29 19 (Previous Timescale of 31 March 2005 not met) The registered person must ensure that staff receive induction and foundation training within the first 6 months of employment which is compatible to NTO specification. (Previous Timescale of 31 January 2005 not met) The registerd person must develop and implement a staff training programme which ensures that mandatory training such as fire training and moving and handling is maintained up to date and provides service specfific training in areas such as Demetia and conditions of old age. The registered person must ensure that CRB checks, POVA list checks and two written references are obtained before employment. 1 July 2005 1 July 2004 With immediate effect 9. 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. 2. 3. Refer to Standard 12 Good Practice Recommendations The registered person should ensure that staf are more proactive in the provision of actiivties. Ancholme Lodge J54 S2874 Ancholme 17 May 05 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection Unit 3, Hesslewood Country Office Park Ferriby Road Hessle East Yorkshire HU13 0QF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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