Inspection on 10/04/06 for Ascot Lodge Nursing Home

This inspection was carried out on 10th April 2006.

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

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

Other inspections for this house

Ascot Lodge Nursing Home 11/03/08

Ascot Lodge Nursing Home 06/03/07

Ascot Lodge Nursing Home 01/11/05

Ascot Lodge Nursing Home 05/07/05

Ascot Lodge Nursing Home 08/09/04

Ascot Lodge Nursing Home 09/06/04

Ascot Lodge Nursing Home 18/02/04

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

CARE HOMES FOR OLDER PEOPLE Ascot Lodge Nursing Home 48a Newlands Road Intake Sheffield South Yorkshire S12 2FZ Lead Inspector Marina Warwicker Key Unannounced Inspection 10th April 2006 8:00 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 DS0000021765.V288232.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. DS0000021765.V288232.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Ascot Lodge Nursing Home Address 48a Newlands Road Intake Sheffield South Yorkshire S12 2FZ 0114 264 3887 0114 264 3969 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) Southern Cross Healthcare Services Limited ** Post Vacant *** Care Home 50 Category(ies) of Dementia - over 65 years of age (50) registration, with number of places DS0000021765.V288232.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Care Home with Nursing Dementia over 60 years Date of last inspection 1st November 2005 Brief Description of the Service: Ascot Lodge is a purpose built fifty-bedded home providing service for older people with dementia. The home is situated in the Intake area of Sheffield. It has good access to public services and amenities. The accommodation is on two floors and each floor is divided into two units. Most rooms at the home are single rooms with en-suite facilities. There is a car park. The weekly fees for the service users were between £418 and £552. The administrator explained that the fees were charged according to the dependency levels of the individuals and also according to source of funding. The service users buy their own toiletries and pay for hairdressing and chiropody with their pocket money. DS0000021765.V288232.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced inspection was carried out on the 10th April 2006 between 8.00 am and 9.30 pm. On the day of inspection eighteen residents, two relatives and eleven staff were spoken to. Time was spent observing and interacting with staff and the service users from the four units. The acting manager was present during the tour of the premises which included an inspection of service users bedrooms, feedback was given at the time. A sample of records were checked which included four staff recruitment and training records, four residents’ care plans and daily statements completed by care staff and the nurses. All staff on duty during the day and night shift were spoken to and of these eleven staff were formally interviewed. Staff and relatives survey responses were received following the site visit and they are included in this report. The acting manager was informed of the findings of the day and a meeting was held with the Operations Director on the following day due to some serious concerns about the home. An action plan was agreed by the Operations Director to address the concerns and rectify them within the timescales. A reflection on the findings of the care managers and the nurses when they had carried out reviews of service users at the home was undertaken. The inspector would like to thank all the staff, service users, relatives and other professionals who helped with the inspection process. The inspector is also appreciative of the acting manager and the Operations Director in their honesty and openness with regards to the issues at Ascot Lodge. What the service does well: The residents are treated with respect and the staff value their right to privacy. Staff interaction with service users was respectful and three service users said that the staff were “good” to them. The staff were committed to caring for the residents and this was commented on the relatives’ surveys. One relative said “the staff are very kind and caring and do their best”. The staff encourage trial visits especially trial periods for service users before moving in. The relative surveys and the staff interviews highlighted that this helps the families to decide on the suitability of the service. Relatives said that the nurses were very helpful when they came to view the home. One relative DS0000021765.V288232.R01.S.doc Version 5.1 Page 6 said “the staff attitude and openness is what swayed it for me. They said it like it is”. Three service users said that they were comfortable at the home. The relatives were made welcome by the staff at the home. What has improved since the last inspection? What they could do better: The organisation needs to appoint an experienced, knowledgeable manager to take over the day-to-day running of the home. The line management from Southern Cross need to make a commitment to supporting the acting manager and audit the staff training and care practises. There needs to be an audit of moving and handling equipment and aids required at the home based on the dependency levels of service users. Following on the outcome the management need to take action. All staff at the home need to receive specific training on caring for those with dementia. Following training the staff need to be deemed competent by the management and supervised. Monthly unannounced visits to Ascot Lodge by the responsible individual need to include: • Interviewing with consent and in private service users, their representatives and the staff working at the home. • Observation of care practices • Inspect the premises of the home including service users’ rooms/flats. • Check records of events, complaints and make assessments. • Monitor staff training including issues relating to diversity. The acting manager of the home must be informed of the findings and the responsible individual needs to take appropriate action which should include giving the staff praise when it is due. Following the visit a written report needs to be prepared and submitted to the CSCI and the homes manager. DS0000021765.V288232.R01.S.doc Version 5.1 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. DS0000021765.V288232.R01.S.doc Version 5.1 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 DS0000021765.V288232.R01.S.doc Version 5.1 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): 1, 2, 3, 4 and 5. Standard 6 not applicable. The overall quality in this outcome area is adequate. The above judgement is based on the information gathered from service users, relatives, staff and by checking the relevant documentation. Although there was information available regarding the service, it was not accessible for the residents, relatives and the staff. Therefore they were not able to compare the actual service to the service user guide. The service users’ needs assessments had been carried out by the placing authorities or for those self-funding by a senior staff at the home. This process is to assure the users of the service that the staff are able to deliver the care for the individuals identified needs. Trial periods are organised so that the service users, their families and friends are able to decide on the suitability of the service. DS0000021765.V288232.R01.S.doc Version 5.1 Page 10 EVIDENCE: All care staff on duty were consulted and four care plans were checked. The respective residents had copies of their needs assessments in their care plans. There were also copies of the home’s individual assessments of the residents prior to admission. This indicated how the identified needs were to be met. Some relatives were interested in finding out how the home received the assessments of needs since they had not been part of the process. Discussion took place explaining that the care managers were responsible for the assessments in the case of social services funded residents and that they need to be contacted regarding such issues. Due to severe dementia many of the service users were unable to hold a conversation but they mostly demonstrated wellbeing. There were comments received from the surveys sent out by the Commission for Social Care inspection (CSCI) that identified the staff at the home did not have the specialists skills in dealing with conditions such as dementia. This was again identified at the site visit. The staff and relatives had not seen the service user guide and therefore were unable to comment on it. The relatives and the staff said that due to the condition of the residents it was considered more appropriate to offer a trial period rather than trial visits and this was the home’s practice. The relatives said that contracts/ statements of purpose had been provided to service users. The administrator said that the company was in the process of issuing a revised contract to all service users. This will be checked at the next inspection. DS0000021765.V288232.R01.S.doc Version 5.1 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 and 11 The overall quality in this outcome area is poor. The above judgement has been made using the written evidence, discussion with relatives, staff, care managers and free nursing care auditors and the site visit. The residents care plans do not reflect the actual care given to the service users and so are unreliable. The lack of organisation within the staff team created an atmosphere of being hectic, therefore relatives and service users avoided asking for help. Although the staff treated the residents with respect and valued their right to privacy, the majority of the staff did not have the skills and knowledge to care for people with dementia. The present client group is unable to self medicate and rely on the nurses to administer their medication. However, due to the layout and the skill mix of staff, the carers need to have adequate knowledge of the service users’ medication and the side effects so that they are able to observe and report to the nurses. DS0000021765.V288232.R01.S.doc Version 5.1 Page 12 EVIDENCE: Four care plans were checked, the individual service users were observed during the inspection and the qualified nurses were consulted. The care plans had been devised by the qualified nurses. In a few instances the relatives have had some input. There was very little link between what the care staff had delivered and the nurses’ view of the care given to service users and this was not helped by the care staff and nurses keeping separate records. Furthermore there were several issues regarding the care staff documentation. The following are some examples. • The staff had checked the bath temperature prior to giving a service user bath and the temperature was recorded as 37oc. This is too cold for the bath water, there was no comment regarding the low temperature or whether the service user had in fact requested it. The Operations Director was informed of this. • One care plan highlighted that a service users was prone to falls. There was no explanation as to why he/she was prone to this and what action was to be taken to prevent these falls. • On a daily record there was a comment regarding a service user becoming agitated during the evening and through that night shouting on and off. There was no comment on what the staff intervention was and there were no comments on how the service user was during the following shift. • One service user who was known to be incontinent did not have an assessment and an action plan. • Relatives had complained about loss of underwear and socks. There was no follow up regarding this matter to say whether this had been resolved. The inspector interacted with the service users in the communal areas and also spoke to visiting relatives, staff and some service users. There was very little interaction between staff and the service users. The relatives said “the staff have got a lot to do, they never stop”. The inspector observed that mostly staff were carrying out daily tasks, getting on with the routines and only reacted to the service users’ behaviour. The staff were kind and comforting to those who were anxious however, but there was little or no time spent with the service users involving them in person centred activities. The relatives inquired why the staff were not allocated to the units and that service users did not get a chance to get to know the staff. The care staff too raised their preference about introducing the key worker system again. The acting manager was made aware of this. The following example confirms the need to have regular staff on each unit and the importance of good hand over between shifts. A relative questioned one of the care staff about finding a pair of new spectacles in the service user’s room. The staff on duty were not aware of the visit by the optician or delivery of new spectacles. During the visit the DS0000021765.V288232.R01.S.doc Version 5.1 Page 13 inspector found out at least three service users had been provided with new spectacles by the optician following his visit. Another service user was in the dining room and the inspector found a hearing aid at his/her side on the table. The staff were not sure who it belonged to. Four medication sheets were checked. The records were satisfactory. As stated in the judgement it is good practice to train the carers to observe drug effects and side effects since most people with dementia are unable to vocalise their feelings. DS0000021765.V288232.R01.S.doc Version 5.1 Page 14 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 and 15 The overall quality in this outcome area is poor. The above judgement has been made using the evidence available during the inspection process. The routines of daily living and activities are not flexible and varied to suit service users’ expectations, preferences and capacities. They are organised around the staff activities, therefore the service users do not receive person centred care. The daily routine does not lend itself for the meals to be taken at flexible times to suit the individual service users. Mostly meals served at the home are of a good quality and the residents are offered a choice. Visitors are encouraged and residents are able to maintain contact with family, friends and members of the local community. Thus the residents are able to maintain outside contacts. EVIDENCE: There was a list of activities posted at the home, however on questioning the staff and some service users it was ascertained that the service users had not had activities for sometime. The staff said that they were unable to carry out DS0000021765.V288232.R01.S.doc Version 5.1 Page 15 small group activities since they had other tasks to perform. The relatives and staff surveys also commented on the lack of staff interaction and activities due to pressures of work. One relative commented that due to the advancing condition the service user was unable to participate in any activities. The visitors to service users were welcomed and treated with respect by the staff. Mealtime was chaotic and there was a lack of staff to assist, help and feed service users. One service user was served the midday meal by a carer. She/he removed the meat and vegetables and placed them on the plate of the person sitting nearby. As she/he had a second mouthful of potatoes with gravy the plate was removed and pudding was served. The service user ate all the pudding and looked happy. Staff were too busy serving food to note how much each service user had eaten and treated the mealtime as a task to be completed on time. This was pointed out to the acting manager who agreed that corrective action needed to be taken to rectify this. Discussion took place with the Operations Director on the following day and assurance had been given to address this. Relatives and staff also commented that the evening meals were sandwiches and that a varied menu would encourage service users to enjoy the last meal of the day better. DS0000021765.V288232.R01.S.doc Version 5.1 Page 16 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, 17 and 18 The overall quality in this outcome area is poor. The above judgement has been made using the evidence available throughout the inspection process. The home has a complaints policy, which complies with the Care Home Regulations. There are policies and procedures in place to protect the service users’ legal rights and to protect the abuse of service users. However, the staff working at the home are not trained and familiar with the above policies and procedures, therefore placing the service users and themselves at risk. EVIDENCE: The home did not keep a record of all the complaints made and details of investigation and action taken to rectify and monitor matters arising from the complaints. During care plan checks the qualified staff had recorded relatives raising concerns/complaints and this had not been recorded in the complaint record. Staff said that they were aware of the complaints policy but have not had the opportunity to familiarise themselves with the procedure. Care staff unanimously said that if anyone complains they will tell the nurses in charge. On further questioning they said that if they could solve the problem immediately then they would do so and then inform the nurse. All staff knew that the service users had rights and those who lack in capacity could have advocacy service. However, the staff did not know how to contact or any DS0000021765.V288232.R01.S.doc Version 5.1 Page 17 names of service or whom they should ask for. Staff being aware of such information contributes to good practice. Not all staff have received formal training on adult abuse and protection of vulnerable people. But they said that the acting manager had discussed with them the policy on protecting the vulnerable adults and that they hope to go on training. Some issues surrounding protection of vulnerable adults had been identified at the home since the last inspection. Appropriate departments have been involved and action has been taken to resolve this. DS0000021765.V288232.R01.S.doc Version 5.1 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 the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26 The overall quality in this outcome area is adequate. The above judgement has been made using the evidence available at the time of the inspection. The layout and the location of Ascot Lodge are suitable for its stated purpose. The rooms are naturally ventilated. Although there are pleasant outdoor areas they are not safe for use and so not fit for their purpose. The residents use the lounges on the units day and night. This demonstrates that no restrictions have been imposed on the residents’ movement within the units. The laundry is sited away from the kitchen and food preparation areas, thus preventing infected and soiled clothing from being carried through these areas. DS0000021765.V288232.R01.S.doc Version 5.1 Page 19 EVIDENCE: During the tour of the premise the inspector the home was found to be clean, bright and welcoming. There were paved and lawned areas surrounding the home. However, the areas were not safe and accessible to the service users. There was inadequate lighting especially in the car park areas at night times. Some residents looked comfortable and relaxed whist others looked lonely in the communal areas. Care staff were seen interacting with the service users whilst delivering care. During the day of the site visit the inspector noted that the care staff required training on moving and handling. Lack of equipment was also having an impact on the way service users were handled, putting the staff at risk of harming themselves at work. Care managers and staff expressed their worry about the lack of training and availability of equipment within the home. On walking around the building with the operations director it was observed that a room with cleaning materials and electrical equipment was left unattended by the domestic staff, thus placing those service users who were independently mobilising in that unit at risk. The laundry assistant was alerted and immediate action was taken by locking the room. DS0000021765.V288232.R01.S.doc Version 5.1 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 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 and 30 Quality in this outcome area is poor. The above judgement has been made using the evidence from direct observation, consultation with staff and other professionals and also by checking available documentation. Staffing levels and skill mix does not reflect the assessed needs, the size and the purpose of the home. This contributes to the lack of supervision of care staff by nurses and inefficient use of work force. The recruitment procedure at the home is based on equal opportunities and it needs to be more rigorous in order to protect the service users and the staff working at the home. Due to lack of training and development the staff are may not be competent to carry out their jobs and therefore questionable whether the service users are in safe hands. EVIDENCE: The staff allocation did not reflect the needs of the service users on each unit. The care staff determined where they wanted to work and objected if asked to move. Such practice is not conducive to good team working. Staff said that they have not had any specific training on caring for people with dementia, but they had picked up skills on the job. The relative surveys highlighted the lack of staff knowledge and skill in the specific client group. Two relatives DS0000021765.V288232.R01.S.doc Version 5.1 Page 21 questioned whether the nurses had received formally recognised dementia care training since they are in charge of the units. Some staff have registered mental health training. However, none of the care staff have had formal training in dementia. The care staff said that they had commenced NVQ training and some others had completed level 2 and two staff showed interest in working towards NVQ level 3 specialising in dementia care. Four staff files were checked for training records (checked on the computer matrix) and recruitment information. The following gaps were noted. Staff training: • According to the training records none of the four staff had received mandatory training on moving and handling, health and safety, fire safety and infection control in the last year. The last records were 20th October 2004 – 20th April 2005.This information was verified at the staff interviews and the above was confirmed. • The staff had not received any service specific training such as tissue viability, adult protection, continence promotion and management, nutritional assessment, first aid, food hygiene, specialist knowledge and management of medication for people with dementia, death and palliative care in the last year. The observations made by the inspector during the day and comments made by other care managers and other professionals highlighted the lack of supervision, knowledge and competence of the staff working at the home. Staff recruitment files: • Employment histories had not been checked and the reasons for gaps had not been explored. • When staff had moved homes within the company the files had not followed them. Therefore the inspector was unable to check the information. • Not all references had been checked for the reason for leaving the last employment. • One member of staff had not fully completed the application form. The administrator was made aware of the gaps during the inspection. DS0000021765.V288232.R01.S.doc Version 5.1 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 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, 34, 35, 36, 37 and 38 Quality in this outcome area is poor. This judgement has been made as a result of available evidence including a visit to Ascot Lodge. Evidence were sought by using direct observation; staff, service users and relatives’ surveys; formal interviews and documentary evidence. Due to the lack of a registered manager and inadequate management support from Southern Cross Health Care Ltd. there is a lack of staff supervision, organisational commitment to the health, safety and welfare of the service users and staff, therefore people at Ascot Lodge care home could be at risk. DS0000021765.V288232.R01.S.doc Version 5.1 Page 23 EVIDENCE: The service has been without a registered manager since September 2005. The lack of manager and the organisational changes have contributed to the present situation where there are no clear lines of responsibility within the home. The surveys, observations and interviews with staff stated that the acting manager who was appointed in February 2006 had not had organisational support and therefore unable to fulfil his/her role. Staff and some relatives commented about the lack of understanding and commitment to equal opportunities within the staff group. The staff team should address diversity and ethnicity. The Operations Director was informed of this. The quality audits carried out by the management did not seek the views of service users, their next of kin, visiting professionals and the staff working at the home. The reports focused mainly on the fabric and decoration of the premise than the way the home was performing against the aims and objectives and the statement of purpose set by Southern Cross HC. The administrator maintained written records of all transactions and explained that the company auditor audited this regularly. The staff said that they had not had supervision and there were no records on recent supervision on the staff files checked. On the day of inspection a manager from another Southern Cross home was carrying out staff supervision at the home. There was serious concern about the security of the premise during the day. On the day of inspection the inspector entered the home and walked around the building at least twice looking for a staff. Since it was peak time all the staff were busy and the access to the home put the service users and the staff at risk. DS0000021765.V288232.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 2 2 2 3 2 3 3 2 3 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 3 3 1 X 2 DS0000021765.V288232.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4,5,6 Requirement The statement of purpose and the service user guide must be reviewed and where appropriate revised and copies of these must be made available for relatives service users and staff. The home must be able to demonstrate its capacity to meet the specialist needs (Dementia) of individuals admitted. In order to meet the individuals needs the care plans must be completed in full at the earliest possible opportunity. Previous timescale of 05/09/05 not met. The nurses and the care workers assigned to the service users must review the service user plans. The daily documentation must reflect the joint ownership of care by both care staff and the nurses. The staff on the units must be aware of those service users who use hearing aids and spectacles. They must ensure that the service users are encouraged to use the aids. DS0000021765.V288232.R01.S.doc Timescale for action 30/06/06 2. OP4 14 30/06/06 3. OP7 12 10/06/06 4. OP7 14 10/06/06 5. OP8 13,12 10/06/06 Version 5.1 Page 26 6. OP8 14,13 7. OP9 13 8. OP11 18 9. OP12 14,16 10. OP15 12 11. OP15 16 There must be clear instructions for identified needs. Records must be maintained to monitor the care progress (e.g. food charts, what types of pads to be used) made. Previous timescale of 15/12/05 not met. The staff must be trained to monitor the condition of the service users with regards to medication. Any concerns or changes in the condition that may have resulted from medication must be reported to the GP without delay. The staff must document the action taken and the outcome in the service users’ records. All staff must receive training on palliative care; pain management, bereavement counselling and dementia care at appropriate intervals. Previous timescale of 24/10/05 not met. The activities must be varied, flexible, suit residents’ expectations, preferences and capabilities. There must be records of activities and the involvement of residents. Previous timescale of 15/12/05 not met. The meal times must be unhurried and staff must be available to offer assistance when necessary. The staff must monitor when service users decline to eat or leave meals. The person responsible for providing meals must consult the service users, relatives and the staff and make available the preferred choice for the evening meals. DS0000021765.V288232.R01.S.doc 10/06/06 10/06/06 10/07/06 10/06/06 10/06/06 10/06/06 Version 5.1 Page 27 12. OP16 22,18 13. OP18 12,17 14. OP19 13,23 15. 16. OP20 OP22 13 16,23 17. OP25 12 18. OP27 18 19. OP28 18 The staff must be aware that the home is required to keep a statement containing a summary of the complaints made during the preceding twelve months and the action that was taken in response. Previous timescale of 05/10/05 not met. All staff must receive training and deemed competent on responding to suspicion or evidence of abuse or neglect. The training must include whistle blowing. Previous timescale of 15.12.05 not met. The management must ensure work is undertaken to repair and make safe the paved area surrounding the home for the use of service users, staff and visitors. Arrangements must be made to ensure sufficient lighting is provided outside of the home. The home must provide sufficient numbers of moving and handling equipment. Immediate requirement served on the day of inspection. Previous timescale of 01/11/05 not met. The security arrangements at Ascot Lodge during the day must be reviewed. Immediate requirement issued on the day of inspection. The management of the home must employ suitably qualified, competent and experienced staff in such numbers as are appropriate for the health and welfare of the service users Staff must be facilitated by Southern Cross to achieve the appropriate levels of training. DS0000021765.V288232.R01.S.doc 10/06/06 10/07/06 10/06/06 10/06/06 10/06/06 10/05/06 10/06/06 10/07/06 Version 5.1 Page 28 20. OP29 7,12,19, Schedule2 21. OP30 12,18 22. OP31 9,7 23. OP33 24,26 24. OP36 18 25. OP38 12,13,16, 23 The management must operate a thorough recruitment procedure complying with the Care Standards Regulation 2002 and the associated schedule. Previous timescale of 15/12/05 not met. The staff training must be revised to meet the aims of the home and the changing needs of the service users. Previous timescale of 05/01/06 not met. A qualified and competent manager must be appointed. Previous timescale of 15/12/05 not met. The quality monitoring must include feedback from staff of the performance of the home. Previous requirement not met. All staff supervision must include all aspects of practice, philosophy of care including the new care plans and their career development. Previous timescale of 05/12/05 not met. The management must ensure safe working practices are adhered and complied by the staff. The service users’ call system needs to be revised to achieve reliability. Previous timescale of 15/12/05 not met. 10/06/06 10/07/06 12/09/06 10/06/06 10/06/06 10/06/06 DS0000021765.V288232.R01.S.doc Version 5.1 Page 29 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 OP9 Good Practice Recommendations The care staff should be trained in the medication the residents are taking. The training should include effects and side effects of medication. Where service users lack capacity the staff at the home should know how to facilitate the service users or their relatives to access advocacy services. 2. OP17 DS0000021765.V288232.R01.S.doc Version 5.1 Page 30 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 DS0000021765.V288232.R01.S.doc Version 5.1 Page 31 - 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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