Inspection on 09/08/05 for Apthorp Lodge

This inspection was carried out on 9th August 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 but made no statutory requirements on the home.

Other inspections for this house

Apthorp Lodge 09/03/10

Apthorp Lodge 21/01/10

Apthorp Lodge 03/11/09

Apthorp Lodge 17/08/09

Apthorp Lodge 19/06/09

Apthorp Lodge 11/06/08

Apthorp Lodge 04/12/07

Apthorp Lodge 22/05/07

Apthorp Lodge 14/08/06

Apthorp Lodge 12/12/05

Apthorp Lodge 13/01/05

Apthorp Lodge 22/07/04

Similar services:

Ashlong House

Norbury Crescent (30)

Henry Nihill House

Birchwood

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

The Infirmary

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

CARE HOMES FOR OLDER PEOPLE Apthorp Lodge Nurserymans Road off Brunswick Park Road London N11 1EQ Lead Inspector Anthony Lewis Unannounced 9 August 2005 at 09.10 am th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Apthorp Lodge G59 S51441 Apthorp Lodge V240515 09.08.05 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Apthorp Lodge Address Nurserymans Road, off Brunswick Park Road, London N11 1EQ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01296 393 055 Carole Sawyers for The Fremantle Trust Irene Rondell PC Care Home only 108 beds Category(ies) of DE(E) Dementia over 65 (37 beds) registration, with number OP Old Age (65 beds) of places LD(E) Learning Disability (6 beds) Apthorp Lodge G59 S51441 Apthorp Lodge V240515 09.08.05 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Consideration must be made in respect of the demography of the building. 2. Staffing levels must meet the needs of the service users at all times of the day and night. Date of last inspection 13 January 2005 Brief Description of the Service: Apthorp Lodge is a care home, which was first registered in August 2003 to provide personal care for 54 people, some of whom may have dementia and a learning disability. Following the closure of two other homes, which were also managed by Fremantle Trust, a further 54 places were commissioned in October 2004, bringing the total capacity of the home to 108 residents. The home is a large detached three-storey building. It is purpose built and organised on three levels, with lift access to all floors. It is divided into ten units or flats. Each unit has its own staff team, with a unit leader in charge. There is a kitchen, lounge and dining room in each unit. All bedrooms are single with en-suite facilities. There is also an additional assisted bathroom in each unit. Three units are dedicated to residents who have dementia and one unit to service users who have learning disabilities. The remaining six units are for mainstream services for older people. There is a registered manager in overall charge of the service, supported by two assistant managers, one of whom is responsible for specialist services on the ground floor. The home also has a small licensed bar available for residents. There is a car park to the side of the building and gardens to the side and rear, which are partly paved and accessible to the residents. The home is situated off Brunswick Park Road. It is well served with community services and facilities located along Russell Lane and East Barnet Road. The home has a day centre, which provides services to twenty-six service users specifically from the outside community. Apthorp Lodge G59 S51441 Apthorp Lodge V240515 09.08.05 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place on Tuesday 9th August 2005 at 9:10am and was completed at 8:35pm. The registered manager and deputy manager were available throughout the inspection process and were very helpful, accommodating and understanding. The Commission’s pharmacist inspector, Marilyn MacKenzie also conducted an unannounced inspection of the home’s medication policies and procedures from 10am to 3:15pm. To gather evidence for this inspection, an extensive tour of the home was conducted with the registered manager. Seven staff’s files and twelve resident’s files, four from each floor, were viewed. Evidence was also gathered from the pre-inspection questionnaire, staff list, twenty-two service users comment cards, seven relatives/visitors comment cards, two care managers/placement officer comment cards, two health and social care professionals in contact with the care home comment cards and four General Practitioners comment cards. Various certificates and records were also viewed. Eleven residents were spoken to throughout the day, five of whom were spoken to informally and six formally. Four relatives were spoken to in the presence of their relative and seven staff were individually spoken to in private. What the service does well: The overwhelming feedback from residents, relatives and from the comment cards received from health care professionals was that the staff are very welcoming, committed, caring and competent. The staff have done well, taking into account the sheer size of the home, to ensure that all areas of the home are kept clean, tidy and free from any offensive odours. The activities co-ordinator is very proactive and ensures that a variety of activities occur throughout the home on a weekly basis taking into account residents hobbies/interests and likes and dislikes. The home provides good specialist care to residents and a competent staff team cares for residents on the dementia unit. The kitchen staff ensures that the kitchen is kept clean and tidy with appropriate kitchen facilities provided. The home has good policies and procedures in place for the safe and secure handling of medication on behalf of service users. Apthorp Lodge G59 S51441 Apthorp Lodge V240515 09.08.05 Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: To ensure that prospective residents and existing residents in the home have up to date information regarding the home, the statement of purpose and service users guide must be updated to include the present situation. In order to ensure the safety of residents, staff and visitors to the home in the event of a fire occurring, all equipment must be working correctly. The bathroom lino must be repaired or replaced to ensure the safety of residents, staff and visitors. To ensure that the home is following the correct procedure when recruiting staff and to ensure residents safety, staff’s Criminal Records Bureau (CRB) checks must be retained in the home for inspection. All staff must receive training appropriate to the work that they perform to ensure that residents care needs are met by a competent staff team. The recording on the medication charts of the administration of medicines, or the annotation as to why the medication was not administered, needs to be improved to ensure that all the medication given can be accounted for. In order that all medication is available to service users, the registered manager must ensure that it is ordered, received and checked into the home with sufficient time for any omission to be corrected before it is required. Staff must receive regular supervision to ensure that they are being supported and that their personal development is being monitored. Apthorp Lodge G59 S51441 Apthorp Lodge V240515 09.08.05 Stage 4.doc Version 1.40 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. Apthorp Lodge G59 S51441 Apthorp Lodge V240515 09.08.05 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Apthorp Lodge G59 S51441 Apthorp Lodge V240515 09.08.05 Stage 4.doc Version 1.40 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 standard(s) 1, 2, 3, 4, 5 and 6. Prospective residents to the home are confident that the home will be able to meet all of their needs by a competent and well trained staff team, although some of the information that prospective and current residents receive may be misleading in that they may not reflect the current situation in the home. EVIDENCE: Fremantle and Apthorp Lodge have together produced a comprehensively constructed statement of purpose and service users guide to the home, which contains all of the information set out in Schedule 1 of the Care Homes Regulations. However, both the statement of purpose and service users guide refer to the Commission by its previous name of National Commission for Social Care (NCSC) rather than the present name of Commission for Social Care Inspection (CSCI). The service users guide also states an incorrect amount for resident’s personal spending allowance. A requirement is made that the registered persons ensure that the statement of purpose and service users guide are reviewed and updated to contain current information. Apthorp Lodge G59 S51441 Apthorp Lodge V240515 09.08.05 Stage 4.doc Version 1.40 Page 10 At the previous inspection, it was a requirement that contracts must include the fees charged and documents are signed by all stakeholders. The registered manager stated that the majority of residents are “block-contracted by the local authorities. She went on to say that in light of this the fees are not included in resident’s contracts due to the differing fees. Six residents files were viewed and all were signed by the stakeholders. The registered manager stated that assessments of each resident are carried out by one of the unit managers. Resident’s files contained information of the assessment, which covers all areas of the resident’s health and needs. The home has a dedicated dementia unit. Files for the staff on the dementia unit and the home’s training log showed that staff have undertaken dementia training on 7th April 2004 and 20th April 2005 and a course in the protection and dignity of people with dementia on 11th May 2004. At lunch in the dementia unit, staff were observed supporting residents in a caring, courteous and dignified manner. Staff spoken to in the unit had a good understanding of their roles and responsibilities and of the residents needs. The registered manager was able to explain in detail the process for prospective residents to the home. The home also has an admissions policy and procedure file. The home does not provide intermediate care. Apthorp Lodge G59 S51441 Apthorp Lodge V240515 09.08.05 Stage 4.doc Version 1.40 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 standard(s) 7, 8, 9, 10 and 11. Residents are confident that the information gathered about them will be used to ensure that their needs are met and the staff team will respect their wishes. The safe and secure handling and administration of medication by the home on behalf of service users is generally satisfactory but the records for the administration of medication need to be improved. EVIDENCE: The registered manager stated that care plans are compiled prior to admissions and within four weeks after admission. Care plans for twelve residents were viewed, each contained detailed information of the care that residents are receiving. They were seen to be reviewed monthly and were signed by the resident, their key-worker and supervisor. A requirement at the previous inspection that the residents who may be vulnerable to assault by other residents have a risk assessment included in their care plan has been met. The registered manager stated that the residents who are most vulnerable are on the dementia unit. All care plans and risk assessments seen on the dementia unit, contained information on residents who may be vulnerable and action to be taken by staff. Apthorp Lodge G59 S51441 Apthorp Lodge V240515 09.08.05 Stage 4.doc Version 1.40 Page 12 The home uses the Waterlow Scale for assessing the risk of pressure sores. At the previous inspection, there were two residents with pressure sores. The registered manager stated that one resident’s pressure sores have healed. The home also has a tissue viability policy developed by Fremantle to prevent the development of pressure sores and to ensure that residents are cared for effectively. The resident with pressure sores, was spoken to briefly. Although not able to fully communicate verbally, he was able to smile and make gestures to questions asked and seemed well cared for and happy. The District Nurses, who visits the home at least twice a week, more if required, treat his pressure sores. A form that they fill in after each visit was viewed and contained information on their visit and the treatment of the resident. Standard (9) was assessed by the Commission for Social Care Inspection’s pharmacist who carried out an unannounced inspection on the same day. The policies and procedures for the safe and secure handling of medication on behalf of service users are in place. One service user is taking responsibility for their own medication and the agreement form has been completed. Verbal agreement has been reached by all parties for four service users to have their medication disguised and the appropriate documentation is in place but for three of the service users the GP has not signed the agreement form. The specialist care manager stated that the relevant GPs will be asked during their next visit. There are some gaps in the administration charts where the administration of medication has not been signed for or non administration coded as to the reason for the non administration. The gaps were found for administration at all times of the day. [Repeated requirement was made]. The medication profiles were not completely up to date but had improved since the last visit. [Requirement was made]. The coding on the administration charts showed that at the beginning of the new medication monthly cycle a few items of medication were unavailable to service users; the unavailable items of medication were obtained within twenty four hours. [Requirement was made]. The temperature of the areas where the medication trolleys are stored remains at 25oC or below except on very hot days. [Requirement was made]. The temperature of the medication refrigerators was not always being recorded daily. The thermometers in two of the trolleys were found to be broken. Apthorp Lodge G59 S51441 Apthorp Lodge V240515 09.08.05 Stage 4.doc Version 1.40 Page 13 The Controlled Drugs are being stored and recorded in accordance with the standard. Medication training is provided by the company and the local pharmacist. Requirements made to comply with Regulation 13. The registered manager must ensure that the administration of all medicines is signed for on the MAR chart and any non administration coded as to the reason why the medication was not administered. [Twice repeat requirement]. The home managers must monitor the administration charts daily and bring any omissions in the completion of the administration charts to the relevant member of staff’s attention immediately. More training of staff must take place to ensure they realise the importance of this task. The registered manager must ensure that all medication is ordered and checked into the home with sufficient time to be able to remedy any omissions and mistakes before the medication is required by service users. The pharmacist should be given five working days to dispense the medication into the monitored dosage system and the staff must receive the medication at least two working days to check in the medication and rectify any errors with the service users’ GPs and the pharmacist. To achieve this the ordering and release of the prescription by the doctor may have to be brought forward. The registered manager must ensure that all areas where medication is stored, including the trolleys must be maintained at 25oC or below. The registered manager must ensure that the medication profiles are kept up to date to ensure a clear audit trail. Staff were indirectly observed interacting with residents in a respectful and professional manner throughout the inspection process. Residents seemed happy and comfortable with the staff. Residents and staff spoken to said that they are very happy with the care that the home provides. One resident’s husband was spoken to at length. He said that his wife is well cared for and the home provides a good level of service to his wife. All communal bathrooms and en-suites had locks for resident’s privacy and dignity. On viewing the laundry room, all resident’s clothes had their names either sewed or written in a discrete area. The laundry staff have a good system of sorting and laundering the clothes. The home has a dignity in dying policy and guidance folder. It ensures that the staff team work closely with resident’s family, friends and other staff to ensure that residents can die in the home if they so wish, with as much dignity, respect and comfort as possible. A letter sent by a relative thanking the staff Apthorp Lodge G59 S51441 Apthorp Lodge V240515 09.08.05 Stage 4.doc Version 1.40 Page 14 team for the care that they provided to her mother who died recently, was seen. Part of the letter read, “Thank you for providing a home for mum where she was happy and well cared for. Apthorp Lodge G59 S51441 Apthorp Lodge V240515 09.08.05 Stage 4.doc Version 1.40 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 15. Residents are confident that their expectations and wishes will be supported by the home. They have a great amount of autonomy and the care staff are flexible and encourage regular contact with family and friends. EVIDENCE: When spoken to, two residents said that they are able to go to bed and get up when they wish. Lunch was unrushed and residents were observed eating at their own pace, some with staff support when required. Three resident’s files were viewed and found to contain information regarding their hobbies, interests and likes and dislikes. The home has an activities co-ordinator, who was spoken to at length about his roles and responsibilities. He came across as very keen and proactive with a good understanding of the needs of the residents within the home. He has produced a monthly leisure and recreation programme for each month. The programme for August was viewed. The activities co-ordinator has ensured that there are programmes each day, which are split into two sessions, 10.30am – 12.30pm and 2.45pm – 4.15pm. There is also a separate programme for the residents in the dementia unit again, split into morning and afternoon sessions. One relative was very complementary about the activities that the activities co-ordinator provides for the residents. He was very impressed with the keep fit to music sessions. Of the twenty-one service users comment cards, seventeen residents indicated that the home provides suitable activities. Apthorp Lodge G59 S51441 Apthorp Lodge V240515 09.08.05 Stage 4.doc Version 1.40 Page 16 Throughout the day, resident’s relatives were seen to come and go freely. A husband and wife were spoken to at length about their mother and father-inlaw. They said that they were able to visit any day and at any reasonable time and that the staff team are very welcoming and supportive. Resident’s were indirectly observed receiving visitors in their bedroom. The home has a lounge on the ground floor, which has recently been refurbished and is available for residents to receive visitors in private if they so wished. One resident spoken to said that her mother was able to bring her own furniture when she moved into the home and that her mother and her chose the wallpaper and curtains. On the wall was information for residents regarding advocates acting for residents. The home’s menu was viewed and found to contain a variety of dishes. Residents are offered different choices for breakfast, lunch and tea. The home’s chef was not available, however the assistant chef was spoken to. She had a good understanding of the dietary needs of the residents. There is a list of residents who are on specific diets for diabetes or those who are vegetarians. At lunchtime, some residents were observed eating independently or being supported to eat their meal, some of which were liquidised. The lunch was cooked well and looked appealing and was tasty. Relatives spoken to stated that the meals provided by the home is good. One relative remarked that the meals are excellent. Apthorp Lodge G59 S51441 Apthorp Lodge V240515 09.08.05 Stage 4.doc Version 1.40 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18. The home’s policies and procedures ensure that any complaints made by residents will be taken seriously and acted upon promptly and a well trained staff team ensures that residents are protected from all forms of abuse. EVIDENCE: The home has a Fremantle policy and procedure for making a complaint. The complaints file was viewed and complaints were seen to be recorded correctly and appropriate action taken and the outcome recorded. Relatives spoken to said that they were aware of whom to make a complaint. The service users guide contains the Commissions address for making a complaint to. Of the seven relatives/visitors comment cards five indicated that they knew of the complaints procedure. The home’s “protection from abuse” policy and guidelines file was seen. The home also has a whistle blowing policy and guidelines. Five staff were spoken to and all stated that they have attended a Protection of vulnerable Adults (POVA) training. Three staff files were seen to contain certificates of adult protection training. Apthorp Lodge G59 S51441 Apthorp Lodge V240515 09.08.05 Stage 4.doc Version 1.40 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 21, 22, 24, 25 and 26. Residents live in a cosy and homely environment with a dedicated care, catering and domestic team ensuring that all of their needs to ensure their comfort are met. However, progress has been slow in ensuring that maintenance issues, which are potential risks to residents, staff and visitors are eliminated. EVIDENCE: An extensive tour of the building was conducted with the registered manager. All areas were clean, tidy and comfortable. The home has been decorated and furnished in warm pleasant colours, which exudes a cosy and welcoming ambience. The home is square in shape with a centre piece well kept secluded court yard style garden with a stone water fountain almost in the centre and with garden furniture. At the previous inspection, a requirement was restated that a rope on a landing near flat 9, dangling from a trap door into the loft be replaced by a more safer means of accessing the trap door. On touring the building the rope was still dangling from the trap door. The registered manager stated when the Apthorp Lodge G59 S51441 Apthorp Lodge V240515 09.08.05 Stage 4.doc Version 1.40 Page 19 trap door is opened, it will not close again and that the building design department was in the process of designing a mechanism to ensure that the trap door can be closed mechanically. This requirement is restated. All residents have been provided with en-suite facilities in their bedroom, which are wheelchair accessible. In addition, there are specially assisted bathrooms and toilets located on each floor. In one bathroom, it was noticed that the lino was sticking up in various places making the floor pervious and unsafe. A requirement is made that the registered persons ensure that the bathroom lino is repaired or replaced. The home has been purpose built for older residents. All areas are wheelchair accessible and there is a wheelchair accessible lift to all floors. Grab rails are provided in bathrooms, toilets and resident’s en-suite facilities. Bathrooms are also equipped with assisted baths and walk in showers. One residents was spoken to at length in the lounge about the service that he receives from the staff in the home. He was very enthusiastic and complimentary towards the staff team. He explained that he is a gifted poet and has had much of his work published and insisted that I see his bedroom. On viewing his bedroom, there were pictures of his family and friends on the walls and dressing table. Also on the walls were various certificates. One showed that he is a “Distinguished Member of the International Society of Poets”. Another showed that he has been “Elected to the International Poets Hall of Fame”. The home is heated by under-floor heating. All window in resident’s bedrooms and throughout the home have window restrictors and are large enough to allow adequate natural light in. The registered manager said that the home’s lighting, water, heating and air intake are all controlled from a plant room. While touring the home, it was found to be clean, tidy and free from any offensive odours. The domestic staff are to be commended for the way in which they keep such a large home, especially communal areas, so clean and tidy. The home has a health and safety manual, which was revised in February 2004 and will be next revised in 2006. There is also an infection control policy and procedure guideline. Each floor in the home has sluicing facilities and there is a large dedicated laundry room to the ground floor, with three washing machines, all with sluicing programmes. Apthorp Lodge G59 S51441 Apthorp Lodge V240515 09.08.05 Stage 4.doc Version 1.40 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30. Although residents are confident that there are enough staff on duty each shift to meet their individual and collective needs, residents are not confident that the home is ensuring that all residents are protected by the homes recruitment and training policies and procedures. EVIDENCE: The rota along with the staff list with staff’s personal and employment details were viewed. The rota showed that there is, on average, two care staff on the early and late shift in each of the ten units. Two residents spoken to said that they felt that there are enough staff to meet their needs. Each resident’s bedroom, the bathrooms, toilets and lounges, has an emergency call system. While touring the building, the system was tested on two separate occasions. On both occasions, care staff and the unit leader responded within a minute. The pre-inspection questionnaire indicates that of the seventy-six care staff, 39 have completed their National Vocational Qualification (NVQ) 2 or above, which amounts to forty-eight percent of the staff team. The registered manager stated that some staff are in the process of completing their NVQ. The registered manager stated that she has recently been to Eastern Europe to recruit staff and successfully recruited five new staff who commenced working in the home on 16th May 2005. Staff files viewed, including the five new staff, contained information which indicates that the registered persons are ensuring Apthorp Lodge G59 S51441 Apthorp Lodge V240515 09.08.05 Stage 4.doc Version 1.40 Page 21 that a thorough recruitment process is taking place. However, the registered manager stated that the home does not keep the original or a copy of staff’s Criminal Records Bureau (CRB), including their Protection of Vulnerable People (POVA) check, which are, she stated, kept at Fremantle’s headquarters. She produced detailed evidence, which is sent from headquarters, which confirms that all staff have received their CRB/POVA check. The information included the staff’s personal details and the date of their CRB and the CRB number. Although the home has ensured that all staff, including the new staff, have received a current CRB. It is a requirement that all staff’s CRB checks are retained in the home for inspection. All staff files viewed contained the induction file. Each member of staff has their own personal development file, which contained information of various training that they have received in their training log. The staff’s training matrix was also viewed and although staff have undertaken various training courses, there were gaps which indicated that some staff may not have undertaken some training or that they have not received a refresher. It is a requirement that the registered persons must ensure that all staff receive training appropriate to the work that they perform. Apthorp Lodge G59 S51441 Apthorp Lodge V240515 09.08.05 Stage 4.doc Version 1.40 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 36, 37 and 38 Residents are confident that the home is being competently managed and staff team who ensure that residents safety and general well being is of paramount importance. EVIDENCE: The registered manager stated that she has a diploma in counselling, Registered managers Award (RMA) and has been in care work for the past twenty-five years, nine of which has been at Apthorp Lodge as the registered manager. Throughout the inspection process, the registered manger demonstrated a clear understanding of the issues regarding the residents living in the home and the issues involved in caring for them. Her management style is transparent, honest and shows her professionalism as a manager. Apthorp Lodge G59 S51441 Apthorp Lodge V240515 09.08.05 Stage 4.doc Version 1.40 Page 23 Fremantle has produced an in-depth Business plan for the 2004 – 2005. It sets out clearly Fremantle’s commitment and investments to the various services. The registered manager produced a letter, which states that the director of care will be giving a presentation at Apthorp lodge on 18th November 2005 to present the new development plan, which, according to the registered manager, as many staff as possible will attend. The home has a policy and guidelines on confidentiality and access to records, which states that individuals have access to records to ensure that information stored is accurate. Residents records were kept securely locked in cupboards in their unit, with access limited to the unit leader. Other records are kept securely in the registered manager’s office. Six staff’s supervision minutes were viewed. Three staff were receiving regular supervision. However, three staff’s supervision was very irregular, with gaps of five months and one of seven months between supervisions. A requirement is made that the registered persons ensure that all staff receives regular supervisions, at least six times a year and the details recorded. Documents and certificates for the safety and welfare of residents, staff and visitors were viewed and were up to date. The environmental health authority inspected the kitchen on 2nd February 2005 and made a requirement that a new cleaning schedule be implemented. This was seen to have been done, with a new cleaning schedule now in place. The home has a fire procedure manual and various fire tests, which are up to date, with tests carried out regularly. The London fire and Emergency Planning Authority inspected the home on 22nd September 2004 and made no requirements. Apthorp Lodge G59 S51441 Apthorp Lodge V240515 09.08.05 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 1 x 2 3 x 3 3 x STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 3 x x 2 3 3 Apthorp Lodge G59 S51441 Apthorp Lodge V240515 09.08.05 Stage 4.doc Version 1.40 Page 25 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 OP1 Regulation 4 (2) Requirement The registered persons must ensure that the statement of purpose and service users guide are updated to include the Commissions correct name and the service users guide to also include the corrcet personal spending allowance and forward a copy of both to the Commission. The registered persons must ensure that the administration of all medicines is signed for on the MAR chart and any non administration coded as to the reason why the medication was not administered. [ Twice repeat requirement]. The home managers must monitor the administration charts daily and bring any omissions in the completion of the administration charts to the relevant member of staff’s attention immediately. More training of staff must take place to ensure they realise the importance of this task. The registered persons must ensure that all medication is ordered and checked into the home with sufficient time to be Timescale for action 02/09/05 2. OP9.3 13 (2) 11/08/05 3. OP9.4 13 (2) 11/08/05 Apthorp Lodge G59 S51441 Apthorp Lodge V240515 09.08.05 Stage 4.doc Version 1.40 Page 26 4. OP9.4 13 (2) 5. OP9.4 13 (2) 6. OP19 13 (4) (a) (c) 7. OP21 23 (2) (b) 8. OP29 9. OP30 19 (1) (b) (i) and Schedule 2 18 (1) (c) (i) 18 (2) 10. OP36 able to remedy any omissions and mistakes before the medication is required by service users. The pharmacist should be given five working days to dispense the medication into the monitored dosage system and the staff must receive the medication at least two working days to check in the medication and rectify any errors with the service users’ GPs and the pharmacist. To achieve this the ordering and release of the prescription by the doctor may have to be brought forward. The registered persons must ensure that all areas where medication is stored, including the trolleys must be maintained at 25oC or below. The registered persons must ensure that the medication profiles are kept up to date to ensure a clear audit trail. The registered persons must ensure that there is a safer means of accessing the trap door near flat 9. (Timescale of 31/03/05 not met). This requirement is restated. The registered persons must ensure that the identified bathroom lino is repaired or replaced. The registered persons must ensure that all staffs CRB chceks are retained in the home for inspection. The registered persons must ensure that all staff receive appropriate training for the work that they perform. The registered persons must ensure that all staff receieve regular supervisions at least six times a year and a record kept. 11/08/05 11/08/05 28/10/05 11/08/05 28/10/05 28/10/05 28/10/05 Apthorp Lodge G59 S51441 Apthorp Lodge V240515 09.08.05 Stage 4.doc Version 1.40 Page 27 11. 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 Good Practice Recommendations Apthorp Lodge G59 S51441 Apthorp Lodge V240515 09.08.05 Stage 4.doc Version 1.40 Page 28 Commission for Social Care Inspection Solar House 1st Floor, 282 Chase Road Southgate London N14 6HA 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. 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