Inspection on 06/02/07 for Ancholme Lodge Care Home

This inspection was carried out on 6th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Ancholme Lodge Care Home 08/01/09

Ancholme Lodge Care Home 10/01/08

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

Similar services:

Abbey The

Snydale Care Home

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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 Mrs Kate Emmerson Key Unannounced Inspection 6th February 2007 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.V329865.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.V329865.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 Position Vacant 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.V329865.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. 27th February 2006 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 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 at the time of the inspection were £312 - £360.63. Additional charges included hairdressing £5.00 - £15.00 and chiropody £8.00. Ancholme Lodge Care Home DS0000002874.V329865.R01.S.doc Version 5.2 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 2007. 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 acting manager, staff on duty and people who lived in the home. Completed surveys were received from twelve service users, eleven staff and one health care professional. Paper work kept in the home was also seen make sure staff were safe to work in the home and that they had been trained to their job. Paperwork was examined to make sure that the home and the equipment used in it were safe and were checked often. The management had continued to work hard to improve systems in the home and the majority of requirements were met from the last inspection. 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 service users could sit and relax. The care service users needed was written down by the manager and checked often by the staff to make sure that there had been no changes. The service users who the inspector spoke to said they enjoyed living in the home and comments received included ‘ the staff are always there when you need them, they are very kind and look after me very well’, and ‘the staff are very nice’. The service users 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 service users who lived in the home said that the staff always came when they rang their bell. The staff had received training to make sure that they worked safely. The acting 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.V329865.R01.S.doc Version 5.2 Page 6 The service users received their medication as prescribed and medication records were clearly maintained. What has improved since the last inspection? What they could do better: They must use the monitoring forms provided to assess the health needs of the service users in more detail so they can recognise any problems as they arise. They must make sure that they have a written plan to show how they will minimise any risks as they are identified through risk assessment or accident monitoring records. All accidents must be recorded. They must replace carpets that are heavily stained or a trip hazard. The temperature of the hot water in the home must be adjusted to ensure that it is not too cold. The bathrooms must be improved and repairs completed as necessary. They must make sure that staff are safe to work in the home by obtaining all information such as references and criminal records checks. They must make sure that new staff have training to assist service users to move and transfer. They must make sure that staff receive regular supervision and are trained to care for those with dementia. The quality of the care in the home must be monitored and an action plan developed to improve any areas requiring improvement. Emergency lights must be regularly checked to ensure that they are working and electrical equipment in the home must be checked for safety every year. They must inform the Commission of any power cuts in the home. Ancholme Lodge Care Home DS0000002874.V329865.R01.S.doc Version 5.2 Page 7 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.V329865.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.V329865.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): 1 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provided sufficient information at the home for service users to make and informed choice. All the service users had their needs assessed and recorded prior to admission. EVIDENCE: Ancholme Lodge Care Home DS0000002874.V329865.R01.S.doc Version 5.2 Page 10 The general format and content of the statement of purpose and service users guide was found to be comprehensive and user- friendly and both documents had been reviewed just prior to the inspection. The statement of purpose had required some minor additions to include the actual measurements of all the rooms in the home and this had been completed. The service user guide requires more detail in regard to the range of needs that are catered for in the home specifically those relating to the registration for Dementia and it should also contain some of the service users views of the home. The documents were displayed in the hallway together with information leaflets that the manager had obtained from the Commission. All the service users, except one who was admitted in an emergency, stated in the surveys that they had received enough information about the home. There was evidence that all service users had had their needs and associated risks assessed prior to being admitted to the home and where a service user had been admitted to hospital the assessment had been updated prior to returning to the home. The home had obtained information and care plans for the Care Management teams where the Local Authority funded the service users placement. Ancholme Lodge Care Home DS0000002874.V329865.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): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The standard of care planning had been maintained and some improvements were evident. However to ensure health needs are met more effective evaluation of the information recorded is required. Care plans lacked specific detail to minimise risks identified in risk assessment. Service users were protected by the homes medication policies and procedures. None of the service users were self-administering medication. The service users felt they were treated with respect. EVIDENCE: Case tracking of four service users was completed. Care plans were generally well developed and described how the majority of care needs identified at assessment would be met. Care plans; updates and evaluations were now Ancholme Lodge Care Home DS0000002874.V329865.R01.S.doc Version 5.2 Page 12 dated and signed by staff and there was evidence that service users or their representative had agreed and signed their care plans. Daily diary recordings described in detail the care provided, health issues and recorded communication with other parties. Care plans had been evaluated monthly and there were documents in place to assist the care staff to monitor care requirements. However the evaluations did not link all the information recorded on the monitoring charts and in diary sheets. There was use of risk assessment tools for mobility, falls; tissue viability and nutrition although these did not always result in a care plan/risk management plan where needs were identified. For example where one service user was identified as having frequent falls from bed there was no care plan in place to minimise the risks. There were systems in place for risk assessment and monitoring of health needs but these were not always used effectively. Where a service user was identified as at high risk of pressure sore development the care plan lacked direction for staff re checking the service users skin and when to refer for medical input from the GP or District Nurse. Although bowel movements were being recorded this did not inform the care, it was noted that some service users had not had bowel movements recorded for long periods but there was no action taken regarding this. A care plan had not been developed where a service user was catheterised. Clear records were maintained for the receipt, administration and disposal of medication. Details regarding amendments to prescriptions were recorded and signed by staff. Controlled medication was checked; storage and recording was satisfactory. Accredited training in the safe handling of medication was provided to staff. Service users felt their privacy and dignity was respected. Observation of staff/service user interaction showed good relationships and staff were sensitive to service users needs. The service users had access to a pay phone and could use the office phone for private calls. The service users received their mail unopened. Ancholme Lodge Care Home DS0000002874.V329865.R01.S.doc Version 5.2 Page 13 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): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users were able to exercise choice in most areas of their life and they enjoyed living in the home. Routines were flexible and met service users needs. Visitors were welcomed into the home. Activities were available, as service users required them and activities should continue to be offered and reviewed. The service users received a varied and nutritious diet and although they had little input into the planning of menus the service users all enjoyed the meals. EVIDENCE: The service users stated that they enjoyed living in the home and that their needs were met. They felt that they had choices in their daily routines and there was evidence in care plans that independence was encouraged. There was no specific activities programme in the home and they did not employ a staff member specifically in this area. The manager stated that the Ancholme Lodge Care Home DS0000002874.V329865.R01.S.doc Version 5.2 Page 14 service user group accommodated at this time were not keen to participate in activities. There were varied comments from service users in surveys and on the day of the inspection regarding the availability of activities. One service user stated that it was ‘boring’ but was not able to identify any activity they would enjoy. The manager stated there were games and books available and staff were seen interacting on a one to one basis with the service users. There were records maintained of any activity undertaken and this included occasional outings to the nearby town or village shops and garden centre, and games such as bingo and dominoes. There were no religious services held in the home at the time of the inspection, the manager stated no one required this service although facilities were available if needed and the service users at this inspection raised no issues. One service user visited the local chapel on a weekly basis. The manager stated that there was open visiting to the home and the service users stated that their visitors were made to feel welcome into the home. Information about advocacy service was provided and displayed in the home. All the service users spoken with stated that they enjoyed the meals provided and said the food was ‘good’, ‘nice’ and ‘the meat is tender’. There were no set menus and little evidence that the service users had input into the meals served. The menus were planned approximately two weeks in advance around the meat order. From the records of food served there was a good variety of meals and diabetic diets and soft diets were catered for. Although there was only one choice of main meal at lunchtime and teatime an alternative would be provided if required. The meal on the day of the inspection was observed, the meal was well presented and there were good portion sizes. One service user liked to have their lunch meal later in the day and the staff catered for this. Where service users required assistance the staff gave this individually and in a sensitive manner. There was evidence of home baking and fresh fruit was available. Ancholme Lodge Care Home DS0000002874.V329865.R01.S.doc Version 5.2 Page 15 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): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home had good procedures for managing complaints which was made available to service users. Service users were satisfied with the service s provided at the home. Although there was improved practise in the protection of service users but more care needs to be taken in recruitment procedures to enure full protection. EVIDENCE: Ancholme Lodge Care Home DS0000002874.V329865.R01.S.doc Version 5.2 Page 16 The home had a comprehensive complaints procedure, which was contained in the service users guide and was also displayed in the foyer. Service users stated in surveys that they knew how to make a complaint and knew who to speak to if they were unhappy. The home had no recorded complaints since 2003 and the Commission had not received any complaints about the home. The service users expressed satisfaction with the service and care they received. 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. Leaflets 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 and records evidenced that since the last inspection all staff had received formal training in the protection of vulnerable adults, signs and symptoms of abuse and procedures to refer suspicion of abuse. There was evidence that the home had not obtained CRB/ POVA First (Criminal Records Bureau/ Protection of Vulnerable Adults) check for one new person recruited to the home prior to their employment. Although this was in place at the time of the inspection, this does not offer full protection to the service users. 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.V329865.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): 19, 21 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was clean and tidy and reasonably well maintained. Improvements were required to bathrooms and unoccupied bedrooms to enable the home to maximise their use. There were some areas causing a trip hazard. 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. Service users were encouraged to personalise their bedrooms and the three separate lounges were very homely. A programme of redecoration and refurbishment was ongoing and new carpets been fitted in the dining room, hallways and staircase since the last inspection. Six bedrooms had also been redecorated. The provider should ensure that Ancholme Lodge Care Home DS0000002874.V329865.R01.S.doc Version 5.2 Page 18 unoccupied bedrooms are maintained to a good standard and fully equipped to encourage occupancy. Records of maintenance work completed in the home were not completed but a person was employed to work in the home on a daily basis to complete maintenance tasks. The manager reported that the home had had frequent power cuts due to problems in the local area, she was able to describe the procedures they followed in this event. She had not informed the Commission of each power cut as required under Regulation 37. Lockable storage had been provided for some of the service users in the form of lockable drawers. The hot water temperature in the first floor bathroom was unacceptable at 32°C; the hot water temperature in the ground floor bathroom was 40°C. Temperatures must be maintained close to and not exceeding 43°C. The manager stated that only the ground floor bathroom was used usually. There had been little improvements to the bathrooms/shower room and generally these were not well presented, the shower room had some wall tiles missing and was used as a storage area. Carpet tiles were used in some of the bedrooms but in two bedrooms these had become loose and could be a potential trip hazard. One bedroom carpet was heavily stained. The home has systems in place for the control of infection in the home including dispensers for hand cleansers in the hallway and reception areas. The staff had received training in infection control. Ancholme Lodge Care Home DS0000002874.V329865.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): 27,28,29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staffing levels were appropriate for the current dependency of the service users accommodated. There was an active staff-training programme, but this did not include care for those with dementia. The recruitment practises in the home were generally robust but had not been adequately implemented in one case. EVIDENCE: The home had 16 service users at the time of inspection. The home was using the Residential Forum guidance to determine the minimum number of staff hours required per week to care for the service users accommodated. This was reviewed regularly. The manager and staff confirmed that the staffing levels in the home were consistently maintained and that there were always 3 care staff on duty in the day between 7.30am and 1.30pm and between 4.30pm and 7.30pm and two staff at other times Monday to Friday. At week ends there Ancholme Lodge Care Home DS0000002874.V329865.R01.S.doc Version 5.2 Page 20 were 3 staff on duty between 7.30am and 7.30 pm. duty at night. There were 2 staff on There was a very low turnover of staff fin the home. The service users confirmed that staff were ‘all very nice’ and that they ‘were gentle’. They confirmed that staff answered call bells promptly. The staff stated they were happy working at the home and there was a stable staff group. One of the staff members described the home as ‘one big happy family’ and they felt able to give good care. The staff files were well ordered and clear records were maintained. Two files of the most recent staff members recruited were checked and one showed that recruitment procedures had not been maintained, only one reference had been obtained and a CRB/POVA (Criminal Records Bureau/ Protection of Vulnerable Adults) check had not been returned prior to the staff member starting work in the home. The manager stated that the umbrella body that handles their CRB checks had confirmed that the POVA first check had been received prior to the staff member starting work but was unable to evidence this. This does not afford 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. The staff also attended an introduction to Skills for Care Standards at college that includes working through a computer based package on all the standards in one day. The staff also completed a health and safety workbook. The manager was advised to check the depth of the study provided in the day course to assure her that this was adequate. There was evidence that one of the new staff members had not received any moving and handling training as part of induction although she had been employed since October 2006. The manager had developed an overview of the training completed by the staff and training certificates were displayed in the home. Three paid training days per year and all training was funded by the home. Records showed staff had received training in mandatory areas such as moving and handling, fire safety, first aid, infection control and protection of vulnerable adults. Staff identified that they needed training in care of service users with Dementia and challenging behaviour. At the time of the inspection the manager had not developed a training plan for 2007 she was advised to complete this to ensure that mandatory training was kept up to date. All but two of the care staff had completed NVQ 2 and these two were registered to do so. Five staff had completed NVQ 3. Ancholme Lodge Care Home DS0000002874.V329865.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): 31, 33, 35, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has an experienced acting manager. Systems to monitor quality in the home is were not adequate to ensure the home is run in the best interests of the service users. Staff did not receive regular supervision. The service users financial interests were safeguarded. The manager was generally proactive in ensuring that the health and safety of service users and staff was promoted and protected. There was insufficient action recorded to minimise risks of falls. Ancholme Lodge Care Home DS0000002874.V329865.R01.S.doc Version 5.2 Page 22 EVIDENCE: The acting manager Mandy Sylvester has been in working in the home since July 2006 and has been acting manager since October 2006. She states she has been qualified as a registered General Nurse for six years and has worked in a senior position at a nursing home since 2004. She states she has almost completed the Registered Managers award. The previous registered manager of the home still works at the home in an administrative position and gives support as required. An application for Mandy Sylvester to be the Registered Manager had not been submitted to the Commission at the time of the inspection. This should be completed as soon as possible. There was a basic quality assurance programme. User-friendly surveys had been issued to service users and visitors in October 2006. All the surveys were positive. There was evidence that the manager had reviewed the policies and procedures and these had been updated as required. However the results had not been published and an action/ improvement-planning framework had not been developed. There was evidence that service users had little input into the running of the home for example meal provision. The management also needed to develop an annual development plan to support the programme and include local stakeholders in the survey programme. Staff supervision had been implemented in the home but there was little evidence that this had been completed on a regular basis. There was little evidence of regular staff or service user meetings and these are recommended to enable all parties to have input into the running of the home. The home assists some of the service users with their finances by providing safe storage in the office or bedrooms and making purchases on their behalf. Records of transactions were maintained and receipts were held. Ancholme Lodge Care Home DS0000002874.V329865.R01.S.doc Version 5.2 Page 23 There was evidence from records that staff had undergone moving and handling, fire safety, basic food hygiene, infection control and first aid training. The fire alarm was tested weekly but the last recorded emergency light test was in September 2005 and the last recorded periodic service of the emergency lights was in June 2005. Fire equipment and checks were all in place and up to date. Staff had accessed training in full evacuation and a simulated fire with the fire officer in the last six months. Random selections of service certificates for equipment in the home were examined. All seen were up to date except the portable electrical appliance testing (PAT), which was due just prior to the inspection in January 2007. 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. Although there was some evidence that there had not been sufficient action taken to minimise the risks of a service user falling from bed. Accident reports were maintained. Although where one service user had had frequent falls recorded in diary sheets these weren’t all recorded on the accident records. Individual logs of accidents where maintained in service users files so that the number of falls an individual was suffering could be monitored. However these were not always kept up to date and the management had no formal way to monitor the accidents in the home overall. The manager was advised that all accidents must be recorded on the accident record form however minor and that she should develop a formal method of auditing accidents in the home. Ancholme Lodge Care Home DS0000002874.V329865.R01.S.doc Version 5.2 Page 24 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 2 X X X X 3 STAFFING Standard No Score 27 3 28 4 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 2 Ancholme Lodge Care Home DS0000002874.V329865.R01.S.doc Version 5.2 Page 25 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 13(4) Requirement The registered person must ensure that care monitoring records and evaluations of care plans are more effective by including specific directions in their use in care plans including when further action is to be taken and ensuring that the monitoring forms are taken into account in monthly evaluations. (For example use of bowel monitoring charts) The registered person must ensure that an action plan/care plan is developed and implemented where a risk assessment has indicated a need for intervention to minimise that risk. (For example where the service user is at risk of pressure sore development or frequent falls). The registered person must ensure that carpets are replaced where they are causing a trip hazard and stained carpets are cleaned or replaced if staining cannot be removed. The registered person must DS0000002874.V329865.R01.S.doc Timescale for action 01/04/07 2. OP8 13(4) 01/04/07 3 OP19 23(2)(d) 13(4) 01/04/07 4. OP21 23(2) 01/04/07 Page 26 Ancholme Lodge Care Home Version 5.2 5. OP21 23(2) 6 OP26 37 7 OP29 19 8 OP30 18(1) 13(5) 24 9 OP33 10 OP36 18(2) 11 OP38 23(4) 12 OP38 23(2) ensure that the hot water is not too cold and temperatures are maintained close to and not exceeding 43°C. (Previous time scale of 01/04/06 not met) 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. The registered person must inform the commission of of any event, which affects the wellbeing of the service users such as power cuts. The registered person must ensure that the recruitment procedure is applied in all cases and all checks are obtained before staff start to work in the home. The registered person must ensure that staff are trained in moving and handling and care of those with dementia. 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 not met) The registered person must ensure that staff receive regular formal supervision, a supervision plan for 2007 must be developed and implemented. The registered person must ensure that the emergency lights in the home are tested at least monthly and serviced yearly. The registered person must ensure that PAT testing is DS0000002874.V329865.R01.S.doc 01/04/07 06/02/07 06/02/07 06/02/07 01/05/07 01/04/07 01/04/07 01/04/07 Page 27 Ancholme Lodge Care Home Version 5.2 13 OP38 17(2) completed and evidence of this is provided to the Commission. The registered person must 06/02/07 ensure that all accidents are recorded however minor. These must be audited and action plans implemented where risks are identified. 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 OP1 Good Practice Recommendations The registered person should include in the service users guide more detail in regard to the range of needs that are catered for in the home specifically those relating to the registration for Dementia and service users views of the home. The registered person should ensure that service users have input into the menu planning in the home. The registered person should ensure that unoccupied bedrooms are maintained to a good standard and fully equipped to encourage occupancy. The registered person should ensure that records of maintenance in the home are completed. The registered person should develop and implement a staff-training programme for 2007. The registered person should ensure that a manager’s application is submitted to the Commission by the acting manger. 2 3 4 5 6 OP15 OP19 OP19 OP30 OP31 Ancholme Lodge Care Home DS0000002874.V329865.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Hessle Area Office First Floor 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.V329865.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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