Inspection on 12/07/06 for Annesley Lodge Care Home

This inspection was carried out on 12th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Annesley Lodge Care Home 27/09/05

Annesley Lodge Care Home 17/01/05

Annesley Lodge Care Home 20/09/04

Annesley Lodge Care Home 15/03/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Annesley Lodge Care Home Annesley Road Hucknall Nottingham NG15 8AY Lead Inspector Mary O`Loughlin Unannounced Inspection 12th July 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Annesley Lodge Care Home DS0000050038.V298957.R03.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. Annesley Lodge Care Home DS0000050038.V298957.R03.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Annesley Lodge Care Home Address Annesley Road Hucknall Nottingham NG15 8AY 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) 0115 9555522 0115 9555522 sharon.blackwell@anchor.org Anchor Trust Mrs Karen Anne Hutson Care Home 51 Category(ies) of Old age, not falling within any other category registration, with number (51) of places Annesley Lodge Care Home DS0000050038.V298957.R03.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service Users shall be within category OP (51) The Manager completes the Registered Managers Award. Date of last inspection 27th September 2005 Brief Description of the Service: Located in a residential area and within a mile of Hucknall town centre, Annesley Lodge provides personal care for up to 51 older persons. All rooms offer en-suite accommodation, 45 single rooms and three double rooms. There are a number of comfortable, homely communal areas and facilities include the provision of all personal care, meals, laundry and hairdressing. The home is purpose built and owned by Anchor Trust. The range of fees are; £325.00 to £375.00 Annesley Lodge Care Home DS0000050038.V298957.R03.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was undertaken unannounced over 4 hours. A range of information was used to inform the report. All key standards were assessed. The main method of inspection used was case tracking four residents, this means their records were viewed and the arrangements around their care observed. The residents were then spoken with and their rooms were examined. The manager, deputy manager and two care staff were spoken with. Three relatives were spoken with. Responses to the Commission for Social Care Inspection pre-inspection surveys were also received and the information used to inform the inspection and the report. All those spoken with were happy with the service the home provided and found the staff sensitive, helpful and caring. What the service does well: The home has substantial strengths and a sustained track record of compliance with meeting the National Minimum Standards for the care of Older People. As areas of improvement emerge the service recognises and manages these well. The staff receive an excellent training provision, which ensures they know how to do their job and deliver up to date care for the residents. There is significant time and effort made by all staff to ensure that residents feel valued and that their wishes about how they are cared for are upheld. Annesley Lodge Care Home DS0000050038.V298957.R03.S.doc Version 5.2 Page 6 This is a well-managed service. What has improved since the last inspection? What they could do better: There were two recommendations made at this inspection. The Registered Provider Anchor Trust is presently trialling a new system of care planning that will hopefully be implemented at the home in the near future. However before this takes place the manager needs to ensure that care plans/lifestyle plans contain up to date information following each review. The plan should set out in detail actions to be taken by staff to meet the needs of the resident as conditions change. The medicine policies should be adhered to in regard to ensuring that any alteration to a drug administration sheet is signed and witnessed to provide appropriate safeguards until the pharmacist provides the type written record. Annesley Lodge Care Home DS0000050038.V298957.R03.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. Annesley Lodge Care Home DS0000050038.V298957.R03.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 Annesley Lodge Care Home DS0000050038.V298957.R03.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3-6 Quality in this outcome area is excellent. This Judgement is made using available evidence including a visit to this service. Prospective residents and their representatives have the information they need to choose a home that can meet their needs. Residents can be assured that their needs will be met following an assessment by a suitably qualified person, before admission. Intermediate care is not provided. EVIDENCE: Records of recently admitted residents for both long term and respite care show that significant time and effort is spent ensuring that the persons needs are considered and planned for before agreeing admission. Annesley Lodge Care Home DS0000050038.V298957.R03.S.doc Version 5.2 Page 10 There is a range of written information provided to prospective residents and their families that provide a guide to the service the home provides and the facilities offerred. The service also ensures they obtain a care management assessment from the responsible social worker. Staff are skilled in the needs of the residents admitted and any specialist training that may be required is arranged and ensures that care staff deliver appropriate care. Annesley Lodge Care Home DS0000050038.V298957.R03.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7-8-9-10 Quality in this outcome area is good. This Judgement is made using available evidence including a visit to this service. The health and personal care which residents receive is based on their individual needs. The principles of respect, privacy and dignity are put into practice. EVIDENCE: The records of four residents were examined which demonstrated that each person had been consulted on how they wished to receive their care at the home. The record system is based on individual lifestyle plans with regular risk assessment that is in place to ensure that any risk to the resident is as far as possible identified and eliminated. Annesley Lodge Care Home DS0000050038.V298957.R03.S.doc Version 5.2 Page 12 There were some very good lifestyle plans in place which clearly set out the wishes of the individual. However, the reviews of these lifestyle plans although undertaken monthly, did not inform changes to the original plans.The plans could not be used as an up to date working tool which could be used by people not familiar with the resident. Daily records are held and clear records of how staff promote the residents access to health and remedial services. Through discussion with the manager, staff and confirmation from the residents spoken with it is clear that the attitude and approach to maintaining residents privacy and respecting their wishes is of paramount importance. There is significant effort made to consult with residents through care planning and meetings to ensure that the policies and practices at the home reflect the views of the residents. Staff demonstrated a sensitivity and awareness of the individual rights of the residents. Medicines are generally well managed, supported by policies and practice guidance. Staff are trained to administer medicines safely. The supplying pharmacists audit the service and the most recent audit had good outcomes with minor reccommendations made. The medicine records examined did show that more adherance to the policies on hand written medicines needs tightening up to reduce any unecessay risks. Annesley Lodge Care Home DS0000050038.V298957.R03.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12-13-14-15 Quality in this outcome area is excellent. This Judgement is made using available evidence including a visit to this service. Residents are able to choose their lifestyle and social activities. Contact with family and friends is encouraged. A varied and healthy diet is available according to the assessed needs of the residents. EVIDENCE: The home has a sustained record of compliance with these standards. The last inspection recommended that activity plans should be completed to ensure that the usual interests of the residents were considered and activities arranged to suit. These are now in place. Residents are supported to enjoy a full and stimulating lifestyle that suits their abilities. Residents discussed the events around the home that encouraged contact and involvement of their families. Annesley Lodge Care Home DS0000050038.V298957.R03.S.doc Version 5.2 Page 14 There are activities within the home and events organised during fine weather in the private gardens. Food is considered highly important and meal times are considered a social occasion. The dining areas are exceptionally well presented and the manager is now offering table service during meals that encourages residents to choose from a menu at the table. The menu is varied and nutritious offering healthy options. All residents spoken with were very happy with the meals provided and discussed how they communicate directly with the cook and kitchen staff. Annesley Lodge Care Home DS0000050038.V298957.R03.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16-18 Quality in this outcome area is excellent. This Judgement is made using available evidence including a visit to this service. Residents have access to a robust, effective complaints procedure, and are protected from abuse from a well informed staff team. EVIDENCE: The service has a sustained track record of meeting these standards. The service has a well developed complaints procedure that highlights the importance of complaining or making suggestions for improvement. There are leaflets available within the home which enable everyone associated with the service to complain or make suggestions. The records of concerns and complaints demonstrate that the manager deals with them effectively and sensitively. The service then make improvements as a result of complaints and suggestions to ensure they do not recur. The policies and procedures regarding adult protection are reflective of locally recognised guidance. Staff are trained in issues relating to adult abuse and how to protect the vulnerable residents at the home. Annesley Lodge Care Home DS0000050038.V298957.R03.S.doc Version 5.2 Page 16 Annesley Lodge Care Home DS0000050038.V298957.R03.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19-26 Quality in this outcome area is excellent. This Judgement is made using available evidence including a visit to this service. The physical design and layout of the home enables residents to live in a safe, well maintained environment that encourages their independence. EVIDENCE: A well maintained, safe, comfortable, attractive home which has all the specialist equipment and adaptations to meet the needs of the residents. Staff are trained to use equipment such as hoists and confirmed that any concerns they have about their competancy with this type of equipment is swiftly dealt with through extra training. There are robust policies on infection control, staff are provided with training and equipment to ensure they protect residents from cross infection. Annesley Lodge Care Home DS0000050038.V298957.R03.S.doc Version 5.2 Page 18 Separate laundry facilities have the appropriate equipment to wash linen at safe temperatures to control infection. Annesley Lodge Care Home DS0000050038.V298957.R03.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27-28-29-30 Quality in this outcome area is excellent. This Judgement is made using available evidence including a visit to this service. Staff at the home are trained, skilled and sufficient in numbers to fill the aims of the home and meet the changing needs of the residents. EVIDENCE: The home has a highly developed recruitment procedure and 2 staff files examined showed that appropriate safeguards are in place to protect residents from people who may be unsuitable to work with vulnerable adults. All new staff receive a comprehensive induction training package and this leads to further foundation training in the needs of the residents accommodated. The service also ensures that over 50 of the care staff are trained to level 2 NVQ in care, three assesors are on site to continuously provide the training and development towards this qualification. The numbers of staff at the previous inspection were considered insufficient. This inspection found there was above the minimum requirement for staff numbers based on the current occupancy level. Annesley Lodge Care Home DS0000050038.V298957.R03.S.doc Version 5.2 Page 20 Residents spoken with felt safe and well cared for, and always found the staff responsive to any support they required. Staff felt they could access training when they wished and considered that the training resource was excellent. Annesley Lodge Care Home DS0000050038.V298957.R03.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31-33-35-38 Quality in this outcome area is excellent. This Judgement is made using available evidence including a visit to this service. The management and administration of the home is based on openess and respect, has an effective quality assurance system in place. The manager is qualified and competent. EVIDENCE: The registered manager has the required qualification and experience, is highly competent to run the home and meet its stated aims and objectives. The manager has good people skills, encourages an open and inclusive atmosphere in which staff stated they felt supported and valued. Annesley Lodge Care Home DS0000050038.V298957.R03.S.doc Version 5.2 Page 22 The manager works hard to ensure that staff are aware and follow the policies and procedures at the home. Staff receive regular supervision of their practice. The home does not manage the personal monies of residents but can hold small amounts of cash within an account for those wishing to keep their money safely for use at certain times. Appropriate records of financial transactions are held which safeguard residents small cash floats. There was clear evidence that the manager is committed to ensuring the health, welfare and safety of the residents and staff through appropriate maintenance and servicing of all health and safety issues. There is a qualified first aid worker on duty at all times. The home has a sustained track record in meeting health and safety requirements. The management of fire precautions was checked at this inspection and found to be compliant with the required safeguards for training staff, servicing the alarm systems and emergency lighting systems, fire drills, tests and extinguisher checks. Excellent quality assurance systems are in place with continuous self monitoring and the involvement of the residents. The home has Investors in People Award. Annesley Lodge Care Home DS0000050038.V298957.R03.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 4 4 X X X X X X 4 STAFFING Standard No Score 27 4 28 4 29 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 3 X X 3 Annesley Lodge Care Home DS0000050038.V298957.R03.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO 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. Standard Regulation Requirement Timescale for action 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 OP7 Good Practice Recommendations The registered person should ensure that care plans/lifestyle plans contain information on how to meet the needs of the person if after a review their needs are identified as different from the original plan. The registered person should ensure that all hand written prescriptions are signed and witnessed. 2 OP9 Annesley Lodge Care Home DS0000050038.V298957.R03.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 Annesley Lodge Care Home DS0000050038.V298957.R03.S.doc Version 5.2 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. 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