Inspection on 16/12/05 for Ann Charlton Lodge

This inspection was carried out on 16th December 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ann Charlton Lodge 26/04/07

Ann Charlton Lodge 20/06/05

Ann Charlton Lodge 25/11/04

Ann Charlton Lodge 18/06/04

Similar services:

The Highlands

Blenheim House

1 Lanark Close

Beaconsfield Court Care Home

The Gardens Care Home

Westmoor View Nursing Home

Ashlea Mews Residential Home

St Aiden`s Cottage

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

CARE HOME ADULTS 18-65 Ann Charlton Lodge Eden Hall Grove Redcar TS10 4PR Lead Inspector Katherine Acheson Unannounced Inspection 16th December 2005 10:20 Ann Charlton Lodge DS0000000074.V258812.R01.S.doc Version 5.1 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 Ann Charlton Lodge DS0000000074.V258812.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 Adults 18-65. 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. Ann Charlton Lodge DS0000000074.V258812.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Ann Charlton Lodge Address Eden Hall Grove Redcar TS10 4PR 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) 01642 480660 01642 480660 Trustees of East Cleveland M S Homes Mrs Maureen Ireland Care Home 25 Category(ies) of Physical disability (25) registration, with number of places Ann Charlton Lodge DS0000000074.V258812.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Five named people who are over the age of 65 are able to be cared for at the home. 20th June 2005 Date of last inspection Brief Description of the Service: Ann Charlton Lodge is a detached, single storey, modern purpose built facility, which is situated in a residential area of Redcar. The building is set back from the road and occupies its own grounds. The home is near to bus routes and within reasonable distance of community facilities. The home is registered to provide personal and nursing care to a maximum number of twenty-five adults with a physical disability. Internally the home is well maintained and offers accommodation to residents in the form of twenty-five single rooms. All bedrooms offer ensuite facilities, toilet and hand washbasin. All bedrooms meet the size requirements of national minimum standards. There is a central spacious lounge/dining room. A hatch serves the dining area from the commercial kitchen and portable screens provide some privacy and separation from the main communal area. There is a second smaller lounge and a conservatory, which, is used by those residents who wish to smoke. There is another conservatory overlooking the rear gardens. The home also has a hairdressing room and physiotherapy room. Ann Charlton Lodge DS0000000074.V258812.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection started at 10.20am and lasted for almost six hours. Three residents were spoken to individually at length, and two other residents were spoken to briefly. Staff were spoken to informally and a lengthy discussion took place with the Manager. Records examined during the inspection included, medication, complaints, staff training/recruitment and a number of policies and procedures. The Manager accompanied the Inspector on a tour of the home. Requirements highlighted at the last inspection in June 2005 were re-visited. What the service does well: It is evident from the inspection and following discussion with the Manager that she takes great pride in the home and the care that the residents receive. The home continues to provide a high standard of care to its residents. Residents spoken to during the inspection complimented the Manager and staff team. One resident said, “The staff are excellent and so is the care”, another said, “I’m really happy here”. The Manager and staff ensure that residents are involved in decision making and the running of the home. Ann Charlton Lodge DS0000000074.V258812.R01.S.doc Version 5.1 Page 6 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. Ann Charlton Lodge DS0000000074.V258812.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ann Charlton Lodge DS0000000074.V258812.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The above standards were not inspected. EVIDENCE: Ann Charlton Lodge DS0000000074.V258812.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The above standards were not inspected. EVIDENCE: Ann Charlton Lodge DS0000000074.V258812.R01.S.doc Version 5.1 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 17 The home provides a wholesome, varied and appetizing menu that ensures dietary needs of residents are met. EVIDENCE: The home offers a two-week menu with an alternative choice available at each mealtime. Menus examined were wholesome and showed variety. Records were available to confirm that appropriate temperature checks are carried out on fridge, freezers and food. Records of food provided were available for inspection. One resident spoken to during the inspection said, “The food is excellent we are having turkey and beef for Christmas dinner and pork and duck for New Years Day dinner”. Residents spoke of direct involvement in menu planning, of well prepared and appetizing food. Resident’s families are able to spend time at the home and have a meal. The Manager spoke of a number of relatives who are having Christmas dinner at the home. Ann Charlton Lodge DS0000000074.V258812.R01.S.doc Version 5.1 Page 11 A satisfactory report of an Environmental Health/Food Safety visit carried out in November 2005 was available for inspection Mealtime was observed to be pleasant and relaxed. Ann Charlton Lodge DS0000000074.V258812.R01.S.doc Version 5.1 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 The home’s medication policy/procedure ensures that there are safe practices in place for dealing with medication. EVIDENCE: The home’s system for storing, administering and recording medication was seen to be effective, storage is safe and complies with the relevant regulations and records of medication received at the home and given to residents were seen to be accurate. An appropriate system for disposal of medication is in operation. A record of controlled drugs is maintained. The Manager said that those residents who are able are encouraged to self medicate, a risk assessment is carried out on the resident to determine ability and safety, and lockable storage for medication is provided. Ann Charlton Lodge DS0000000074.V258812.R01.S.doc Version 5.1 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 The home has an effective complaints procedure, which enables residents to make any complaints they feel necessary. The home’s adult protection policy and staff knowledge helps protect residents from abuse. EVIDENCE: The home has a clear complaints procedure, details of which are also available in the statement of purpose and service user guide. Residents spoken to during the inspection said that the Manager and staff at the home are approachable and if they felt the need to complain then they would do so. One resident spoken to during the inspection said, “I feel able to speak my mind”. The home has an adult protection policy/procedure in place that includes action that staff must follow if abuse is suspected. The Manager said that all staff receive adult protection training on induction, and that she is now in the process of working through an adult protection workbook with all staff. Records were available to confirm that this is the case. Ann Charlton Lodge DS0000000074.V258812.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: The above standards were not inspected, however a requirement highlighted at the last inspection in June 2005 was re-visited. The water in the shower room was identified as being too hot. The Manager at the time of the last inspection informed the Inspector that the shower room was rarely used and that residents would benefit from a specialist bath. The bath has now been installed into this area. Ann Charlton Lodge DS0000000074.V258812.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 The homes recruitment and selection process is robust and as such ensures that residents are protected. Staff receive appropriate training to ensure that care needs of residents are met. EVIDENCE: 60 of care staff at Ann Charlton Lodge are trained to NVQ level 2 and above (or equivalent). Duty rotas examined during the inspection confirmed that the home is working with the appropriate number of staff on duty. The Manager said that staffing levels fluctuate depending on dependency and resident numbers. Two staff files were examined at random during this inspection. Files examined contained a photograph, two references, one being from the last employer, proof of identity and appropriate POVA/Criminal Record Bureau checks. Both files examined confirmed that a thorough recruitment procedure had been followed. Ann Charlton Lodge DS0000000074.V258812.R01.S.doc Version 5.1 Page 16 Both files examined were those of staff who had been recently appointed and contained evidence to confirm that induction training had been undertaken. A discussion took place with the Manager regarding the new induction standards that are to come into force in September of next year. Records were also available to confirm that a rolling programme of training is provided for staff working at the home. The Manager keeps a record, which lists all mandatory and other relevant training to the job that staff do. The record highlights each staff member working at the home, training received and training that is due. Ann Charlton Lodge DS0000000074.V258812.R01.S.doc Version 5.1 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 The Manager works extremely hard to ensure that Ann Charlton Lodge is managed efficiently and effectively. Appropriate quality assurance monitoring is in place to ensure that the home is run in the best interests of the residents Not all portable appliances are checked on a yearly basis and as such does not ensure a safe environment for all. EVIDENCE: The Manager, Maureen Ireland is a State Enrolled Nurse who has also completed an NVQ level 4 in Management. The Manager has a wealth of knowledge and experience having worked with younger adults with a physical disability for many years. Residents spoken to during the inspection spoke highly of the Manager and of an effective staff team. One resident said, “ The staff are very approachable and kind”. Ann Charlton Lodge DS0000000074.V258812.R01.S.doc Version 5.1 Page 18 Appropriate quality assurance monitoring is in place to ensure that the home is run in the best interests of the residents. Standard 42 was not inspected in full, however a requirement highlighted at the last inspection was re-visited. Since last inspection the home has worked with the Fire Authority and carried out a number of fire practice evacuations. Following discussion with the Manager it became evident that the home has a system in place in which electrical items in the home are tested on a yearly basis, however, portable electrical equipment brought into the home by those residents receiving short term/respite care is not. The Manager said that she would take immediate action to address the situation. Ann Charlton Lodge DS0000000074.V258812.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 3 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 3 3 4 X 3 X X 2 X Ann Charlton Lodge DS0000000074.V258812.R01.S.doc Version 5.1 Page 20 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 YA42 Regulation 13 Requirement Portable appliance equipment brought into the home by those residents receiving respite/short stay must be checked on admission and then on a yearly basis. Timescale for action 16/12/05 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 Ann Charlton Lodge DS0000000074.V258812.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX 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 Ann Charlton Lodge DS0000000074.V258812.R01.S.doc Version 5.1 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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