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Inspection on 27/02/06 for Ancholme Lodge Care Home

Also see our care home review for Ancholme Lodge Care Home for more information

This inspection was carried out on 27th February 2006.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home was very clean and tidy, had a very friendly feeling and had lots of space in the rooms where people could sit and relax. 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 `looked after them well` and they felt safe and happy in the home. The people who lived in the home really liked the meals and said that there were plenty of different things to eat and if they didn`t like something they would be given something else. 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. The manger was keen to ensure that the home continued to improve and made sure the home was safe by often doing safety checks of the home and the things used to care for people.

What has improved since the last inspection?

The home had met most of the things that the inspector had asked them to do at the last inspection. The staff always write down how care must be given to make sure that people living in the home are kept, healthy, safe and comfortable. This is important to make sure that all the staff understand the care that everyone needs. The medication records were clearly maintained. The manager had checked all the staff files and training records so that she could plan training for the rest of year to make sure all the training is up to date. She had prioritised the training needed and had booked training sessions to address shortfalls in training staff must have to work safely.

CARE HOMES FOR OLDER PEOPLE Ancholme Lodge Care Home Scawby Road Broughton Brigg North Lincolnshire DN20 0AF Lead Inspector Mrs Kate Emmerson Unannounced Inspection 27 February 2006 09:30 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.V279284.R01.S.doc Version 5.1 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.V279284.R01.S.doc Version 5.1 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 (4), Old age, registration, with number not falling within any other category (20) of places Ancholme Lodge Care Home DS0000002874.V279284.R01.S.doc Version 5.1 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. 17th May 2005 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 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 home has benefited from a major refurbishment programme, which is ongoing. The gardens are mainly paved and are accessible to service users. There is ample parking provided at the front of the building. Ancholme Lodge Care Home DS0000002874.V279284.R01.S.doc Version 5.1 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 February 2006. 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 2 people who lived in the home comment cards were also received from 6 service users. Paper work kept in the home was also seen make sure staff were safe to work in the home and that they had trained to 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 Kitchen 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. The care of the service users was generally good. There was a programme of redecoration and refurbishment, which will improve the internal appearance of the home. 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 could sit and relax. 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 ‘looked after them well’ and they felt safe and happy in the home. The people who lived in the home really liked the meals and said that there were plenty of different things to eat and if they didn’t like something they would be given something else. 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. The manger was keen to ensure that the home continued to improve and made sure the home was safe by often doing safety checks of the home and the things used to care for people. Ancholme Lodge Care Home DS0000002874.V279284.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: The staff must make sure that they sign and date care plans when they update them so that it can be checked they were updated a the appropriate time. They must show any corrections to care records clearly and record why they have been altered. They must monitor the health needs of the service users in more detail so they can recognise if a person’s health is deteriorating or improving and seek professional medical advice where deterioration is seen. The staff must have training to ensure that they are able to recognise the signs and symptoms of abuse and be able to refer their suspicions to the appropriate agencies. The temperature of the hot water in the home must be adjusted to ensure that it is adequate. The bathrooms must be improved and repairs completed as necessary. New members of staff must be provided with training in the work they are to complete so that they can do this safely. The quality of the care in the home must be monitored and an action plan developed to improve any areas requiring improvement. Please contact the provider for advice of actions taken in response to this Ancholme Lodge Care Home DS0000002874.V279284.R01.S.doc Version 5.1 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ancholme Lodge Care Home DS0000002874.V279284.R01.S.doc Version 5.1 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.V279284.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 The service users were provided with information regarding the home EVIDENCE: At the last inspection the general format and content of the statement of purpose and service users guide was found to be comprehensive and userfriendly but the statement of purpose still required some minor additions to include the actual measurements of all the rooms in the home. The manager stated that this had been completed but was unable to provide any evidence for this. . Ancholme Lodge Care Home DS0000002874.V279284.R01.S.doc Version 5.1 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 the following standard(s): 7, 8 and 9 The standard of care planning had improved but to ensure health needs continue to be met more effective evaluation of the information recorded is required. Service users were protected by the homes medication policies and procedures. None of the service users were self-administering medication. EVIDENCE: Case tracking of 3 service users was completed. 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. The general recording in the care plans had improved and the manager stated she was checking the care plans regularly although there was not record of this. Ancholme Lodge Care Home DS0000002874.V279284.R01.S.doc Version 5.1 Page 11 Care plans; updates and evaluations were not always dated and signed by staff so it could not always be assessed if the care plans had been updated in a timely manner. There was evidence that staff had used correction fluid or had scored out entries made in care records with no explanation. The manager was advised that this is not appropriate. Generally the records to support the care service users required to meet health needs had improved. However although weights were recorded monthly and nutritional risk assessments had been completed this information was not used to identify any potential problems and there was no evidence that medical advice had been sought where a service user had been consistently losing weight. Records where staff were monitoring intake were not adequately detailed. Clear records were maintained for the receipt, administration and disposal of medication. Controlled medication was checked; storage and recording was satisfactory. Accredited training in the safe handling of medication was provided to staff. Ancholme Lodge Care Home DS0000002874.V279284.R01.S.doc Version 5.1 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 the following standard(s): These standards were not assessed at this inspection. EVIDENCE: Ancholme Lodge Care Home DS0000002874.V279284.R01.S.doc Version 5.1 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): 18 The service users were not fully protected from abuse due to the lack of staff training. EVIDENCE: The home had an adult protection policy in place that linked with the North Lincolnshire protection of vulnerable adults policy. There were also policies on whistle blowing, abuse, violence towards staff and staff members not benefiting from wills. Leaflet containing the procedure and how to recognise abuse were displayed in the home, as were contact numbers for referring any suspicion of abuse. The manager stated that staff had not received any formal training in the protection of vulnerable adults, signs and symptoms of abuse or procedures to refer suspicion of abuse. There was evidence that the home obtained CRB/ POVA First checks on all persons recruited to the home prior to their employment. The homes policies and practices regarding the management of service users finances were comprehensive and would safeguard against financial abuse. Ancholme Lodge Care Home DS0000002874.V279284.R01.S.doc Version 5.1 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 21 The home was clean and tidy and reasonably well maintained. Issues regarding water temperatures, carpets and storage of cleaning products may put service users welfare and health and safety at risk. EVIDENCE: A partial tour of the building was completed and a random selection of bedrooms was seen. The home was generally clean and tidy and free from malodours. A programme of redecoration and refurbishment was ongoing and new carpets were being fitted in hallways at the time of the inspection. A new stair carpet was also to be fitted. A new call bell system had been fitted. Lockable storage had still not been provided for the service users as note in previous inspections. Ancholme Lodge Care Home DS0000002874.V279284.R01.S.doc Version 5.1 Page 15 The hot water temperature in the ground floor bathroom was unacceptable at 32°C, the hot water temperatures must be maintained close to and not exceeding 43°C. The bathrooms generally were not well presented some being untidy and not well maintained and one had some wall tiles missing. Cleaning products had not been stored safely in line with COSHH Regulations (1999) having been left in the bathroom, which could have been hazardous to the service users. There was a piece of carpet missing in the corner of the dining room, which must be replaced as this is a trip hazard could put service users at risk of falls. Ancholme Lodge Care Home DS0000002874.V279284.R01.S.doc Version 5.1 Page 16 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 The staffing levels were appropriate for the current dependency of the service users accommodated. There was evidence to indicate an active staff-training programme, which included NVQ training. Staff completed a basic induction into their role but this area needs further development to ensure they are instructed in safe working practises. The recruitment practises in the home had improved and been adequately implemented in all cases to ensure sufficient protection for the service users. EVIDENCE: The home had 17 service users at the time of inspection. The manager confirmed that the staffing levels in the home were consistently maintained and that there were always 4 care staff on duty in the day between 7.30am and 3pm and 3 or 4 staff between 3pm and 7.30pm. There were 2 staff on duty at night. The service users confirmed that staff were ‘all lovely’ and that they ‘were looked after well’. They confirmed that staff answered call bells promptly. The manager had audited all the staff files and these were now well ordered and clear records were maintained. Three files of the most recent staff members recruited were checked and showed improved recruitment Ancholme Lodge Care Home DS0000002874.V279284.R01.S.doc Version 5.1 Page 17 procedures and that all the appropriate checks had been completed prior to staff being employed. 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 and does not provide adequate instruction in safe working practises. The manager stated that a package to deliver induction training to these standards had been purchased and stated that this had been implemented however she was unable to evidence this. The manager had developed an overview of the training completed by the staff and a staff-training plan since the last inspection. This had enabled the manager to identify that some staff were overdue for training such as moving and handling and fire safety but the manager had booked training to address the shortfalls. The records showed that the staff had access to a wide variety of training and NVQ training. Of the 21 staff employed 3 staff had achieved NVQ 2 and 7 were completing the training and 5 staff were doing NVQ 3. Ancholme Lodge Care Home DS0000002874.V279284.R01.S.doc Version 5.1 Page 18 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, 33, 35 and 38 The home has a Registered Manager. Further development of systems to monitor quality in the home is required to ensure the home is run in the best interests of the service users. The service users financial interests were safeguarded. The manager was proactive in ensuring that the health and safety of service users and staff was promoted and protected. 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 Care Home DS0000002874.V279284.R01.S.doc Version 5.1 Page 19 Mrs Alison Kitchen was the Registered Manager for the home. She had worked in the home for 10 years and had been the manager for 16 months. She stated she was half way through the Registered Managers Award and had kept up to date by accessing other training relevant to her role. There was a basic quality assurance programme. User-friendly surveys had been issued to service users in February. All the surveys were positive. There was evidence that the manager had reviewed the policies and procedures and she had also audited staff employment and training records. However the results had not been published and an action/ improvement-planning framework had not been developed. The management also needed to develop an annual development plan to support the programme and include local stakeholders in the survey programme. The home assists some of the service users with their finances by providing safe storage in the office and making purchases on their behalf. Records of transactions were maintained and receipts were held. The records balanced with the cash held on a random sample that was checked. There was evidence from records that staff had undergone moving and handling, fire safety, basic food hygiene, COSHH, infection control and first aid training. The manager had audited training records and provided and over view of the training provided from this she had identified some shortfalls in the provision of mandatory training and had booked training sessions to address these. Service users health and safety was put at risk due to cleaning products having left in bathrooms ant not being safely stored. The fire safety equipment and checks were all in place and up to date. Staff accessed regular drills. Random selections of service certificates for equipment in the home were examined. All seen were up to date except the gas appliances, which had been due in October 2005. The manager was requested to provide a certificate to evidence that this had been completed. Individual risk assessments covered falls, moving and handling and general issues were completed. Accident reports were maintained. Ancholme Lodge Care Home DS0000002874.V279284.R01.S.doc Version 5.1 Page 20 Ancholme Lodge Care Home DS0000002874.V279284.R01.S.doc Version 5.1 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 2 X 2 X X X X X STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Ancholme Lodge Care Home DS0000002874.V279284.R01.S.doc Version 5.1 Page 22 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 OP1 Regulation 4 Requirement The registered person must ensure that the Statement of Purpose complies with Schedule 4 - to include the actual measurements of all the rooms in the home. (Previous Timescale of 31 January 2005 and 1 August 2005 not met) The registered person must ensure care plans, updates and evaluations are dated and signed by the staff. (Previous Timescale – with immediate effect - not met) The registered person must ensure that corrections to care records are clear and that correction fluid is not used. The registered person must ensure that the health needs of the service users are monitored and professional advice is sought as requred. The registered person must provide training in the protection of vulnerable adults, signs and symptoms of abuse and procedures to refer suspicion of DS0000002874.V279284.R01.S.doc Timescale for action 01/05/06 2 OP7 17 27/02/06 3 OP7 17 27/02/06 4 OP8 13(1)` and (4) 27/02/06 5 OP18 13 (6) 01/05/06 Ancholme Lodge Care Home Version 5.1 Page 23 6 OP19 13(4) 23(2) 23(2) 7 OP21 8 9 OP21 OP21OP38 23(2) 13(4) 10 OP24 12(4) 11 OP30OP38 18(1) 12 OP33 24 13 OP38 13(4) 23(2) abuse. The registered person must ensure that the carpet in the dining room is repaired or replaced. The registered person must ensure that the hot water temperatures are maintained close to and not exceeding 43°C. The registerd person must ensure that missing wall tiles in the bathroom are replaced. The registered person must ensure that all cleaning products are safely stored in line with COSHH Regulations (1999) The registered person must provide a lockable space in all service users’ bedrooms (Previous Timescale of 31 March 2005 and 1 August 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 and 1 July 2005 not met) The registered person must ensure that the quality monitoring systems are further developed, results from surveys are published, an annual development plan to support the programme is developed and include local stakeholders in the survey programme. The registered person must provide evidence that gas appliances have been serviced. 01/05/06 01/04/06 01/05/06 27/02/06 01/05/06 01/05/06 01/07/06 01/04/06 Ancholme Lodge Care Home DS0000002874.V279284.R01.S.doc Version 5.1 Page 24 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 Ancholme Lodge Care Home DS0000002874.V279284.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Hessle Area Office First Floor 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Ancholme Lodge Care Home DS0000002874.V279284.R01.S.doc Version 5.1 Page 26 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!