Inspection on 04/12/07 for Ascot Lodge

This inspection was carried out on 4th December 2007.

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 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

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Ascot Lodge 38 Chambres Road Southport Merseyside PR8 6JQ Lead Inspector Mrs Claire Lee Key Unannounced Inspection 4th December 2007 9:00 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 Ascot Lodge DS0000069981.V352368.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. Ascot Lodge DS0000069981.V352368.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ascot Lodge Address 38 Chambres Road Southport Merseyside PR8 6JQ 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) 01704 538470 Veatreey Development Ltd Mrs Christine Hunt Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Ascot Lodge DS0000069981.V352368.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only. Care home with nursing - code N, to people of the following gender:Either. Whose primary care needs on admission to the home are within the following categories: Old age not falling within any other category - Code OP The maximum number of people who can be accommodated is: 18 Date of last inspection Not applicable - new service Brief Description of the Service: Ascot Lodge is a Care Home providing nursing care and accommodation for eighteen older residents. Veatreey Developments purchased the home this year and a new Certificate of Registration was issued on 21st September 2007. Mr Apputhurai Sakathevan is the Registered Individual for the service and the registered manager is Mrs Christine Hunt. The home comprises of a large house and it is situated in a residential area of Southport. It is close to local amenities and public transport. Residents reside in very comfortable clean accommodation. There are two lounges, one of which can be used as a dining room. There are twelve single bedrooms and eight of these rooms have ensuite facilities. There are two double bedrooms and one is ensuite. Two bathrooms are domestic in style and one bathroom is fitted with a bath hoist to assist residents who are less independent. Residents have a call system with an alarm and a ramp provides wheelchair access to the front door. There is a small enclosed garden and patio at the rear of the premises and car parking space to the front. The weekly fee rate for accommodation ranges from £476.00 to £683.02. Ascot Lodge DS0000069981.V352368.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A site visit took place as part of the unannounced inspection. It was conducted over one day for a duration of approximately eight hours. Eighteen residents were accommodated at this time. A partial tour of the premises took place and a number of care, staff and health and safety records were viewed. Discussion took place with five residents, one relative, four staff and the manager. During the inspection two residents were case tracked (their care files were examined and their views of the service were obtained). This was not undertaken to the detriment of other residents who also took part in the inspection process. All the key and other standards were inspected during the site visit. Satisfaction survey forms “Have Your Say About …” were distributed to a number of residents, relatives, staff and health care professionals prior to the inspection. A number of comments in the report are taken from interviews conducted and surveys received. An AQAA (annual quality assurance assessment) was completed by the manager prior to the site visit. The AQAA comprises of two self questionnaires that focus on the outcomes for people. The self assessment provides information as to how the manager and staff are meeting the needs of the current residents and a data set that gives basic facts and figures about the service, including staff numbers and training. What the service does well: Residents were seen to receive a good standard of care by enthusiastic staff. There was a warm, friendly atmosphere and preparations were underway for the festive period. Residents appeared relaxed and comfortable with the staff and a relative reported that the atmosphere was always made pleasant by the staff. During the day residents were helped with various aspects of care and the staff carried this out in a professional and caring manner. Emphasis was placed on helping residents to maintain their independence but staff were around to assist as needed. Ascot Lodge DS0000069981.V352368.R01.S.doc Version 5.2 Page 6 Residents take up residency when the manager has assessed their needs to ensure staff can provide the necessary care and support required. Health and social care needs are then identified in a plan of care based upon individual need. Care plans are reviewed regularly to report any changes in the care. Family members are encouraged to be involved with this process to help them feel part of the care and to keep them informed of their relative’s welfare. This helps promote good communication between all parties and ensures good outcomes for people. Resident and relative comments regarding the care included: “Very good indeed” (resident) “The staff know what I can do and help me when I want” (resident) “I like to be independent and the staff understand this” (resident) “An excellent place with good care” (relative) ”I can’t praise the staff at Ascot Lodge too highly. The care is second to none”. (relative) Activities were being raised for Christmas including a party and carol singing. Residents’ social wishes and interests had been recorded in their plan of care to ensure they could continue to enjoy their hobbies where possible. Family involvement is encouraged and visitors can visit when they want. The accommodation is maintained to a very good standard. The bedrooms are individually decorated with matching drapes and bed linen. Residents can bring in items from home to make their rooms feel special to them and ‘homely’. The lounges have comfortable armchairs and the hall and landings also have seating if a resident would like to have some quiet time. Residents and relatives are approached to give their views of the service. Surveys are sent out regularly and the manager is quick to act on any suggestions or sort out any concerns if raised. Those surveys seen reported favourably regarding the care provision. Feedback from residents and relatives was very positive regarding the caring professional attitude of the staff. Health care professionals commented on the service being well managed. What has improved since the last inspection? Not assessed – new service. Ascot Lodge DS0000069981.V352368.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Ascot Lodge DS0000069981.V352368.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 Ascot Lodge DS0000069981.V352368.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): Standard 1 and 3. Standard 6 was not assessed, as intermediate care is not provided. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and relatives are provided with information regarding the service. Residents are admitted following an assessment so that the staff are able to ensure that care needs can be met. EVIDENCE: The Service User Guide (a brochure regarding the service) was displayed in the main hall. This document provides good information regarding the service but should also include the relevant qualifications and experience of the owner/Registered Individual. This will help ensure residents have the correct information to help them make a choice regarding whether they wish to live at the home. A relative commented that they had received sufficient information regarding Ascot Lodge when looking round. Ascot Lodge DS0000069981.V352368.R01.S.doc Version 5.2 Page 10 Two care files were seen and these evidenced a full assessment of need. The assessments are carried out prior to admission and on occasions at the time of admission if a resident requires an emergency placement. The assessments had identified key areas including, nutrition, mobility, personal hygiene, medical history, continence, risk of falls, social/family background, communication and mental state. There was evidence of supporting documentation from other professionals to help with the assessment process. A dependency assessment is subject to regular review and the information is used to help form the basis for the plan of care. Residents had been asked about their sight, hearing, chiropody and dental needs, which are so important to the care of the older person. A relative said that her next of kin had settled in very well and that the staff had been very supportive with the changes faced when a family member comes in to a care home. Ascot Lodge DS0000069981.V352368.R01.S.doc Version 5.2 Page 11 Ascot Lodge DS0000069981.V352368.R01.S.doc Version 5.2 Page 12 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): Standards 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ health care needs were identified in a plan of care and medicines were administered safely to them. Residents were observed to be treated in a respectful manner. EVIDENCE: Residents had an individual care file, the contents of which were accessible, kept in good and easy to read. As part of the case tracking process two resident care files were viewed. Care plans identified a number of health and social care needs, for example, mobility, nutrition, continence, skin care and relevant medical conditions. The information had been reviewed regularly however reviews are brief and record ‘no change’. It is recommended that the evaluations be in more depth, as they should be a statement set against the main aim of the plan. Staff are provided with good details on the nursing intervention needed to ensure good outcomes for people. Resident and/or their relative’s agreement had been sought to the plan of care and relatives provided with a summary of their family member’s care needs. This helps Ascot Lodge DS0000069981.V352368.R01.S.doc Version 5.2 Page 13 families to be involved where possible. A number of risk assessments had been completed as part of the care planning process and these identified any potential risk that may affect a resident’s well being. These included areas such as, nutrition, moving and handling and care of the skin. Management of risks addresses safety issues whilst aiming for a better quality of life for the residents. Not all care records seen had been dated and signed and this should be rectified to ensure their accuracy. GP appointments are arranged at the home for residents who are unable to attend the surgery and there was evidence of these visits and other contacts with health professionals. Pressure relieving equipment, for example, special mattresses were in place for residents who have to spend long period of time in bed. This helps with the prevention of pressure sores. Residents are moved to a ground floor room if they are at risk of falling and crash (protective) mats are available to place around a bed if needed. It was evident though discussion with the manager and by reviewing care documents that the health care needs of the residents were being met effectively. Residents and relatives were very pleased with the standard of care and comments included: “Very good indeed, you could not want for better” (resident) “They (staff) know what they are doing which is reassuring” (resident) “Excellent record of caring” (relative) There were no residents who require wound care management however the manager has the relevant documents. These would be completed to ensure wound care is well managed with input from a tissue viability nurse (skin specialist nurse) if this required. Staff interviewed gave examples of how independence for the residents is encouraged and how important it is for residents to make their own choice and decisions. This was evidenced in relation to meals and residents preferring to stay in their own room and attend the lounge when they want to. A resident said, “I like to be independent and have my own routine”. Medications were well managed and residents can keep their own medicines following a completion of a risk assessment to ensure they are capable of undertaking this practice safely. Risk assessments for self administration should be subject to regular review to support this and should include a list of medicines to be self administered. A resident interviewed stated that it was good to be in charge of their own tablets. The manager completes a safety check for each resident who administers their own medicines to ensure the prescribed medicines are being taken at the right time and in accordance with the prescription. Ascot Lodge DS0000069981.V352368.R01.S.doc Version 5.2 Page 14 MARS (Medicine administration records) viewed evidenced that medicines are administered as prescribed. It is good practice to evidence two staff signatures for hand written entries to help protect the residents. Staff receive medicine awareness training to update their skills and knowledge in this field. A competency assessment is recommended for all staff who administer medicines to ensure they have the skills and knowledge to undertake this practice. Medicines are administered from a medicine trolley and a small portable contained which is carried round the home. The temperature of the medicine fridge was being monitored daily to ensure medicines were stored at the correct temperature. Residents were observed to be treated with respect. Staff knocked on bedroom doors before entering and were polite when addressing residents. A relative said, “The staff are always polite and helpful”. Assistance was given with meals in an unhurried and sensitive manner. Staff were observed to explain different procedures in a reassuring manner when assisting residents to the bathroom. Ascot Lodge DS0000069981.V352368.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 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. Residents are able to exercise choice and control over their lives. Residents were pleased with the food however concerns raised over the lowering of the food budget may affect the choice of foods offered to them. EVIDENCE: Residents interviewed said the atmosphere was very pleasant. The routine appeared relaxed and staff were seen spending time talking with residents on a one to one basis on in a group. A number of the residents have lived at the home for many years and the staff have a good understanding and appreciation of their individual needs. Staff interviewed state that the routine was based around the wishes of the individual and there was recognition that residents have different needs and preferences. This was discussed in relation to choice of foods, time of residents getting up in the morning or retiring at night. A resident said that the staff do not mind if they stay in their room, as they prefer to be quiet. Ascot Lodge DS0000069981.V352368.R01.S.doc Version 5.2 Page 16 Residents can practice their religion if they wish and Holy Communion is offered by visiting Clergy. There are policies and procedures available covering cultural, sexuality and spiritual needs to ensure the diverse needs of the residents can be met. A relative who was visiting said that the staff were welcoming, cheerful and that there were no restrictions on visiting times. They also stated that the home, “Has a great family feel”. Visitors and staff are asked to sign in to provide an accurate record of the people on the premises for fire regulations. Residents were pleased with the meals and said that the cooks were always willing to prepare what they wanted. A resident said, “The meals are served on time and nicely presented on the plate”. Likewise a relative reported, “The menus are reviewed, food is fresh and ‘home made’ and caters for all tastes”. A menu of the day was on display in the hall however there were no menus in the lounges for residents to decide what they would like to eat. These should be provided in the communal areas and bedrooms, as the majority of residents cannot walk to the hall. An alternative meal is offered at lunchtime and teatime and details of this should also be on the menu. Staff raised concerns at the time of the site visit regarding cut backs on the food budget and the freezer stock was low. Staff reported on occasions they have brought in basic foods to make cakes on the weekends. The staff made comments that on occasions they have run out of certain foods and that shopping each week at a supermarket is proving difficult. Although the residents raised no issues regarding the standard of food served a review should take place of existing catering arrangements and cut backs not made to the food budget. This will help ensure residents continue to receive good wholesome meals. Fridge and freezers should be well stocked at all times. The full time cook is leaving this week and two members of the care staff are taking on this role. Both have the required certificates in food hygiene. The owner stated that arrangements would remain the same in the kitchen with no cutbacks on the cooks’ hours. This is essential as resident dependences are high at present and care staff need to remain on the ‘floor’ caring for the residents. There is also a risk of cross infection if care staff are involved with food preparation along side their care duties. Ascot Lodge DS0000069981.V352368.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are confident their complaints will be listened to. Policies and procedures are in place to safeguard and protect vulnerable people from abuse. EVIDENCE: The complaint procedure is displayed for residents to view and a copy is kept in the resident’s care file. The National Care Standards Commission is stated in the policy and this should be changed to Commission for Social Care Inspection to ensure the document is accurate. The complaint procedure encourages residents and their visitors to raise any matters of concern so that perceived problems can be dealt with as soon as possible. The AQAA stated that no complaints have been received and the manager confirmed this. A complaint log would be completed should a concern arise. Staff interviewed said they would report any worry or concern raised by a resident and/or family member. Staff have access to an abuse policy and staff received adult protection training to ensure they are aware or what constitutes abuse. Sefton and Liverpool’s Adult Protection Procedure was available as this is the protocol that must be adhered to for reporting an alleged abuse incident. A staff member was unsure of this document and this was brought to the manager’s attention. Ascot Lodge DS0000069981.V352368.R01.S.doc Version 5.2 Page 18 Abuse training should continue and staff should be advised of Sefton and Liverpool’s Adult Protection Procedure and referral to the local authority. This forms part of the safeguarding procedures for reporting an alleged incident. Staff interviewed were aware how residents’ rights should be protected. This was discussed in relation to respecting privacy and dignity, choice of meals, activities and receiving visitors. Ascot Lodge DS0000069981.V352368.R01.S.doc Version 5.2 Page 19 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): Standards 19,20,21,22,23,24,25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The temperature of the hot water to the ground floor bathroom is not currently regulated to a safe temperature and may place residents at risk. EVIDENCE: Residents live in pleasant clean accommodation. A relative described the bathrooms as being spotless. The overall décor is of a very good standard especially in the bedrooms. The bedrooms have excellent furnishings and fittings and are decorated in an individual style. Residents can bring in items from home to make their room feel special and ‘homely’. The lounges have comfortable armchairs and coffee tables and there is also seating in the main hall and the landing areas. There is a dining room table but due to the frailty of a number of the residents they prefer to have their meals on their own small coffee table. Different areas in the home were clean and bright and bedrooms Ascot Lodge DS0000069981.V352368.R01.S.doc Version 5.2 Page 20 well aired. A maintenance person is responsible for the completion of every day jobs and the basement is currently being decorated. There are three bathrooms however the bathroom on the ground floor can only be used as this is fitted with a bath hoist, which is required by all the residents. Access to the bathroom on the first floor is restricted and there is only a bath chair in the bathroom on the top floor. There is no separate shower facility to offer residents a choice of bathing facilities. Consideration should be given to providing this as at present eighteen residents are using one bathroom. The ground floor bathroom was clean and tidy however the shower hose was broken and had been taped up to stop it leaking. Staff had recorded the temperature of the hot water prior to bathing residents however when tested during the site visit the hot water tap was in excess of 50 degree centigrade. This poses a health and safety risk to residents and staff. There is a mixer tap to this bath however a risk assessment must be completed to highlight the current high temperature. The owner was advised of the temperature reading and contact is to be made with an engineer to rectify this with urgency. A raised toilet seat in the ground floor bathroom should be replaced as it is old and the finish chipped. Emergency lighting is provided throughout the premises and record seen evidenced regular checks ‘in house’ and by an external contractor. This ensures it is working effectively. Infection control procedures were adhered to by the staff thus promoting the health and safety of the residents. Glove and aprons were being worn at the appropriate time. A relative was complimentary regarding the standard of the laundry service. The staff on completion of their care duties attend to the laundry. The external paintwork at the rear of premises is flaking due to age. The painting or replacement of these windows should be considered to ensure the general upkeep of the home. Ascot Lodge DS0000069981.V352368.R01.S.doc Version 5.2 Page 21 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): Standards 27,28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient numbers of trained staff provide care to the residents. They are recruited through robust procedures to ensure their ongoing protection. EVIDENCE: The staffing rota evidenced the staff on duty and the manager is supported by a full compliment of staff. A registered nurse or the manager is on duty in the mornings with three to four care staff, a cook and maintenance person. The dependencies of the residents is currently high with ten residents requiring two members of staff to assist them with their mobility and other personal tasks. Staff raised concerns that staffing levels may be dropped in the afternoons and are worried that this would have a detrimental affect on the care. Staffing numbers must be according to the assessed needs of the residents. Three care staff on duty in the afternoons will ensure a good standard of care. Residents interviewed reported that the staff were caring in their approach and that the staff made the home lovely. A relative said, “Staff are very friendly and caring, ready to help with any request”. Likewise a resident reported, “The staff are wonderful people”. Ascot Lodge DS0000069981.V352368.R01.S.doc Version 5.2 Page 22 Staff are assigned a key worker role where they are given extra responsibilities for a number of residents. Staff are also responsible for the completion of daily reports regarding the care provision and they are encouraged to become involved with the development of the care documents. Two staff files were examined for most recently appointed staff. Staff had completed application forms and the files evidenced the necessary police checks and two written references. References should be dated for accuracy. Robust recruitment procedures help ensure the delivery of a good quality service and protect the individual. The AQAA provided details of NVQ (National Vocational Qualification) at Level 2 and above. 75 staff have achieved a qualification in care. The member of staff who is now employed as the new cook is undertaking an NVQ course in Cookery. This will assist with the development of this role. A resident made reference to the new cook as being excellent. New staff receive an induction in accordance with the Skills for Care Induction Standards, which provide them with basic skills and knowledge to undertake their work ‘safely’. Staff interviewed confirmed that they had received an induction which, included fire safety procedures. Staff are also able to attend an external induction training day in line with care standards. A recruitment and equal opportunities policy ensures staff are recruited without any discriminatory practices. Staff are trained in safe working practices to provide them with the skills and knowledge to care for the residents. Courses include moving and handling, health and safety, infection control, fire prevention, abuse, medicine awareness and food hygiene. Staff stated that the training programme was good and personal development plans identified courses undertaken. Ascot Lodge DS0000069981.V352368.R01.S.doc Version 5.2 Page 23 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): Standards 31,32,33,35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is competent and adept at ensuring the health and welfare of the residents and making the residents and relatives feel part of the home. EVIDENCE: Mrs Hunt is a registered nurse and was appointed by the Commission as the registered manager in September 2005. Mrs Hunt has completed NVQ Level 4 in Management and the mentorship course for the placement of student nurses at the home. Mrs Hunt completes mandatory training in safe working practice areas and has undertaken a course in Medicine Management and Clinical Update 2 to enhance her knowledge and to evidence best practice. Mrs Hunt is currently studying infection control. Ascot Lodge DS0000069981.V352368.R01.S.doc Version 5.2 Page 24 Staff, residents and relatives were complimentary regarding Mrs Hunt’s commitment to the service and her caring manner. Mrs Hunt works closely with all staff to monitor standards. There is an external quality award and surveys are sent to residents and relatives to gain their views regarding different aspects of the service. Surveys seen from November 2007 reported favourably in all areas. No issues were identified from the surveys returned to the Commission. A relative reported, “I cannot praise the staff at Ascot Lodge too highly, the care is second to none”. Resident meetings are not held however being a small home communication is very good and residents spoken with confirmed they could speak to Chris (manager at any time). Staff meetings are held and minutes kept. The registered individual is attending the home each week to meet with the manager but there is no formal report of a monthly visit in line with Regulation 26 of the Care Standards. A report should be compiled as to the conduct of the home and interviews conducted with staff, residents and relatives. A number of staff, residents and a relative stated that they have had no formal meetings with the new owner and that they would like more contact with him. Communication is important and the new owner should arrange meetings with residents, staff and relatives to alleviate any worries they may have and to answer questions regarding the new ownership. The manager is not responsible for residents’ monies. The resident and/or their family deal with this. The manager is currently reviewing policies and procedures to ensure they are relevant and in line with current legislation. Staff are given copies of a number of policy documents during their induction and these include, fire prevention, health and safety at work and confidentiality. Training for staff has not been provided regarding equality and diversity however the care needs of the residents are identified through the assessment and care planning process. This helps to provide good outcomes for the residents. Accepting changes in circumstances for a resident is identified in a care plan as staff appreciate the difficulties residents face when deciding to live in a care home. The AQAA provided details of general maintenance and services of the premises. A spot check was undertaken of the maintenance contracts for gas, electric and moving and handling equipment. These were in date. The fire logbook evidenced that fire alarms are tested weekly and fire prevention equipment serviced annually. There is fire risk assessment of the building however this has not been reviewed in respect of changes to the fire regulations. The home is a no smoking building. Staff receive fire prevention training to enable them to know how to respond in the event of a fire and this training is now being carried out every six months. Ascot Lodge DS0000069981.V352368.R01.S.doc Version 5.2 Page 25 A health and safety issue regarding the hot water to the ground floor bathroom was raised as a requirement under the standards relating to the environment. Accidents or incident affecting the welfare of a resident are recorded in accordance with Data Protection guidelines. Ascot Lodge DS0000069981.V352368.R01.S.doc Version 5.2 Page 26 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 X X 3 Ascot Lodge DS0000069981.V352368.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Not applicable 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 OP25 Regulation 13 (4) (a) (b) (c) Requirement The registered provider must the home free from any unnecessary risks. The hot water to the bath on the ground floor must be regulated to ensure hot water is delivered at a safe temperature to protect the residents and staff from harm. A risk assessment must be completed to highlight this risk. Contact is to be made with an engineer to rectify this with urgency. The shower hose must be mended to make it fit for use. Timescale for action 27/12/07 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. 2. Refer to Standard OP1 OP7 Good Practice Recommendations The Service User Guide should include the owner’s relevant qualifications and experience. The care evaluations should be in more depth, as they should be a statement set against the main aim of the DS0000069981.V352368.R01.S.doc Version 5.2 Page 28 Ascot Lodge 3. OP9 4. OP15 5. 6. 7. 8. 9. 10. OP19 OP21 OP22 OP25 OP29 OP33 11. OP38 plan. All care documents should be dated and signed by the staff to ensure their accuracy. Risk assessments for self medication should be reviewed regularly to support the residents with this practice. The risk assessment should include details of the medicines being administered by the resident. A competency assessment is recommended for all staff who administer medicines to ensure they have the skills and knowledge to undertake this practice. It is good practice to evidence two staff signatures for hand written entries on the MARS. The menu should be displayed in the main communal areas and bedrooms for resident to view. The menu should include details of an alternative at each mealtime. A review should take place of existing catering arrangements and cut backs not made to the food budget. This will help ensure residents continue to receiving good wholesome meals. The paintwork to the windows at the rear of the premises is flaked due to age. These should be painted to ensure the upkeep of the premises. Consideration should be given to providing an alternative bathing facility as at present eighteen residents are using one bathroom. A raised toilet seat should be replaced as it is chipped. A service report of the work carried out to the hot water supply is to be forwarded to the Commission. Staff references should be dated to ensure their accuracy. The owner should conduct meetings with staff, residents and relatives to ensure effective communication. The owner should conduct Regulation 26 visits and write a report of his findings. The fire risk assessment of the premises should be reviewed in light of changes to the fire regulations. Ascot Lodge DS0000069981.V352368.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Merseyside Area Office 2nd Floor South Wing Burlington House Crosby Road North Liverpool L22 0LG 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 Ascot Lodge DS0000069981.V352368.R01.S.doc Version 5.2 Page 30 - 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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