Inspection on 13/03/06 for Ash Lodge Residential Home

This inspection was carried out on 13th March 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 no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ash Lodge Residential Home 05/10/06

Similar services:

Whiteley House

Tyndale Avenue

2-10 Norfolk Road

Bennfield House Nursing Home

Eastfield Residential Home

Sign Health

Springwood

Fairburn Mews

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

CARE HOME MIXED CATEGORY MAJORITY ADULTS 18-65 Ash Lodge Residential Home 262 - 264 Beverley Road Kingston upon Hull East Yorkshire HU5 1AN Lead Inspector Eileen Engelmann Unannounced Inspection 11:00 13 March 2006 th Ash Lodge Residential Home DS0000065410.V263501.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ash Lodge Residential Home DS0000065410.V263501.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 and Care Homes for Adults 18 – 65*. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ash Lodge Residential Home DS0000065410.V263501.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Ash Lodge Residential Home Address 262 - 264 Beverley Road Kingston upon Hull East Yorkshire HU5 1AN 01482 440359 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) Michael Joseph Healand Ms Amanda Jayne Bennett Care Home 20 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (20) of places Ash Lodge Residential Home DS0000065410.V263501.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Residents already living at the home who reach the age of sixty-five main remain there, if the home can continue to meet their needs. Date of last inspection 24th February 2005 Brief Description of the Service: Ash Lodge is situated on Beverley Road, which is a busy main road into the centre of Hull. It is approximately two miles from the city centre. There are a variety of local amenities close by including shops, pubs, library, swimming baths and a park. The home is owned by a single provider and offers support to 20 service users who have mental health needs, and the age range is between 18 and 65. Currently there are four residents over the age of 65 who have lived at the home for some years, and their needs continue to be met by the service. The home has 18 single rooms, two with en-suite and one double without an en-suite. There are two lounges one of which is the designated smoking area; in addition there is a dining room. Outside to the rear of the building is a patio and parking area. Ash Lodge Residential Home DS0000065410.V263501.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out with the manager, staff and residents of Ash Lodge. The inspection took 4.15 hours and included a tour of the premises, examination of staff and resident files and records relating to the service. Three members of staff and five residents were spoken to in an informal manner; their comments and viewpoints are included within this report. The home registered a change in Provider in 2005 and this is the first inspection since Re-registration. All key standards have been assessed on this visit and the outcomes are within this report. What the service does well: What has improved since the last inspection? New and existing staff are given basic training when they start at the home, and then move onto more in-depth work based learning. This ensures residents are cared for by staff who understand their care needs. Ash Lodge Residential Home DS0000065410.V263501.R01.S.doc Version 5.1 Page 6 The homes policies and procedures have been up dated and reviewed, and offer the staff guidance around practice, resulting in a safer environment for the residents. Bedrooms are being decorated and supplied with new carpets and bed linen in line with a planned programme of maintenance, providing residents with comfortable personal space. 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. Ash Lodge Residential Home DS0000065410.V263501.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) Ash Lodge Residential Home DS0000065410.V263501.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 (adults 18-65) and 3 (older people). The systems for pre-admission and assessment of resident needs are satisfactory and provide individuals with sufficient information to make an informed decision about their care. EVIDENCE: Each resident has their own individual file and all those looked at included a needs assessment completed by the funding authority and also one from the home. Discussion with the manager indicated that she will go out into the community to see any prospective resident, to discuss the home with them and assess the individuals needs. The information from the assessment process is used to formulate the individuals care plan. Respite residents coming into the home are assessed using the same criteria as permanent individuals, however the staff are not using this information to produce a care plan. One respite file looked at consisted of the assessment of Ash Lodge Residential Home DS0000065410.V263501.R01.S.doc Version 5.1 Page 9 need and daily care notes written by the staff, this is not acceptable practice. Discussion with the manager indicate that she would ensure this practice was altered and that everyone coming into the home in the future would have a care plan produced from the assessment process. Three residents spoken to were able to give detailed information about their care needs and the input they required from the staff, service and outside professionals, and this was found to be accurately documented within their care plans. Ash Lodge Residential Home DS0000065410.V263501.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14, and 33 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 (adults 18-65) and 7, 14 (older people). The health, personal and social care needs of the residents are clearly documented and are being met by the service and staff. Residents are encouraged to be independent within their daily lives using a risk assessment approach to care. EVIDENCE: Individual care plans are in place for all residents and clearly set out the health, personal and social care needs identified for each person. Risk assessments are completed where needed and management plans were seen in some personal records, which contain information/advice from the Community Psychiatric Nurses. Ash Lodge Residential Home DS0000065410.V263501.R01.S.doc Version 5.1 Page 11 Evaluation of the care plan is conducted monthly, key workers have written input into the plans and daily notes are completed. Any changes to the care being given is documented and implemented by the staff. The residents sign their own care plan and those individuals spoken to were aware of the plan content and had input to the way it was written. The wishes of the residents have been recorded in the care plans, regarding the choices and decisions they make around activities of daily living. Three residents talked about attending reviews of their care and demonstrated a good understanding of their health care needs. They said they had good access to their local GP and other community professionals including the diabetic nurse, community psychiatric nurse and district nurse. The residents at Ash Lodge are mainly independent and they are able to go out into the community alone (following a risk assessment) or with a member of staff, and enjoy visiting the local amenities, pubs and social clubs. Discussion with the residents clearly showed that they make a number of decisions and choices regarding their care, and staff respect these and are supportive towards helping individuals achieve independence wherever possible. One resident commented that ‘staff listen to you, they are there for you when you need them and are very approachable’. Policies and procedures are available for the residents and families to read at all times and residents have access to advocacy services in the community. Information on this is available on the notice board within the home and the inspector recommended that Advocacy information and contacts are put into the Service Users Guide. The care plans contain clear guidance from professional individuals inputting to the residents’ care, which shows where decisions have been made and why around the care of the individual person. Staff record within the care plan the choices made by the residents and any decisions made on their behalf by the home. Management strategies, within the care plans, show that residents are encouraged to manage their own finances wherever possible. Risk management plans are in place where any limitations on facilities, choice or human rights to prevent self-harm or self-neglect, abuse or harm to others are made in the residents’ best interest, consistent with the purpose of the service and the homes duties and responsibilities under law. Staff enable residents to take responsible risks in their every day lives and information within the care plans includes a number of risk assessments covering activities of daily living and individual ones linked to residents choices and wishes regarding their care. Talking to the residents indicated that they found it important to have the freedom to come and go from the home and each individual had their own interests and hobbies they pursued. Smoking is restricted within the home to the allocated lounge for this pastime and risk assessments are in place for individuals using cigarettes and lighters. Use of kettles in rooms is also a personal choice, but some individuals liked being able to make their own drinks. Ash Lodge Residential Home DS0000065410.V263501.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. 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. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. 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. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. 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. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the 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, 15, 16 and 17 (adults 18-65) and 10, 12, 13 and 15 (older people). Residents are provided with choice and diversity in the meals and activities provided by the home. Relatives and visitors are made welcome at the home and good links to the community enrich the residents social and leisure opportunities. Ash Lodge Residential Home DS0000065410.V263501.R01.S.doc Version 5.1 Page 13 EVIDENCE: Some of the residents attend the Waterloo day centre or local college where they can learn practical life and social skills, with the opportunity of improving their social and emotional behaviours as they mix with others outside of the home. Residents also attend art classes, cookery classes, the women’s centre and MIND group on a regular basis. One individual said she enjoyed going to her club on a Wednesday as she met lots of different people and it was a very social event. One resident attends church and the manager said that anyone else expressing a religious need or interest would be able to attend the local church services. Three individuals living at the home commented that they enjoy going into the local community and visit the local pubs, cinema, shops and Bowling hall. They expressed interest in the local news and events and were able to visit friends and relatives in the area. One female resident said she liked to go to the hairdresser in town for her hair doing and also used the local dentist and optician. Other activities that residents said they enjoyed were football, rugby, watching films and music. Contact arrangements between residents and friends/family are clearly documented in the individual care plans and have been made using a risk assessment process that looks at vulnerability and risk of harm. The residents, and the people they wish to visit, make decisions around the contact process with some input from the home or other healthcare professionals were needed. Some individuals see their families on a regular basis, whilst others choose to visit less often or not at all. The manager said that the home enables residents to see their families by arranging public transport tickets or taxis. These trips are arranged weekly, fortnightly or monthly depending on the wishes of the individual resident. Three residents spoken to said that they all have their own keys to their bedrooms and staff respected their privacy at all times. Residents at Ash Lodge are mainly independent care wise, but those who need prompting and some support to meet their hygiene needs say the staff are helpful and caring. Mail is given to them unopened and there is a phone for their private use. Staff and residents have a good relationship and there was plenty of conversation and joking going on during the visit. All residents spoken to were full of praise for the quality and quantity of the meals provided at the home. One individual described the food as ‘excellent ‘, whilst other comments from the residents included ‘good choice, tasty and delicious’. Ash Lodge Residential Home DS0000065410.V263501.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) Service users retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicines. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 (Adults 18-65) and 8, 9 and 10 (Older people). The health, personal and social care needs of the residents are clearly documented and are being met by the service and staff. The medication system within the home needs some improvements to protect the health and safety of the residents. EVIDENCE: Information within the care plans clearly record the wishes and preferences of each resident regarding their personal care, and staff displayed a good understanding of the needs and support required for each individual. All residents spoken to are very happy with the care given and feel that staff help and encourage them to do as much for themselves as possible. One individual said ‘ the care is excellent, the staff recognise when you need to have time alone, but are there when you need someone to assist you’. Ash Lodge Residential Home DS0000065410.V263501.R01.S.doc Version 5.1 Page 15 Discussion with two residents indicated that they have insight into their illnesses and care needs. They talked about their problems and how input from outside professionals such as the Community Psychiatric Nurses and Psychiatrist were helping. Good access to local GP’s, dentists, chiropody, opticians and hospital services was evident, with records kept in the care plans of appointments attended and/or booked. Discussion with the manager revealed that individuals needing the diabetic nurse attended a clinic across the road from the home, and dietician advice was available on request from the GP. The home has a policy and procedure for the receipt, administration, return or destruction of medication. The manager said that the home is developing a self-medication policy and procedure, which reflects the practice at the home. Inspection of the medication system showed that records of the medication received, administered and leaving the home are mainly up to date and correct, but there were two areas that could be improved on ∗Transcribed medication (handwritten by staff onto the medication charts) did not have the quantities received written down or two signatures from the staff to indicate that they had both checked the information recorded initially was correct. ∗There was no positive identification of the resident (photograph) for the person administering medication to check against. The above practices could lead to medication errors being made and must be addressed by the manager as soon as possible. Discussion with the manager indicated that medication is administered by the senior staff, and staff have undergone accredited medication training. Ash Lodge Residential Home DS0000065410.V263501.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16-18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 22-23 (Adults 18-65) and Standards 16-18 and 35 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 (Adults 18-65) and 16, 18 (Older people). The home has a satisfactory complaints system with some evidence that residents feel that their views are listened to and acted upon. EVIDENCE: The home has a clear and simple complaints procedure that residents and staff are aware of and are confident of using if needed. Two residents showed a clear understanding about how to make their views and opinions heard and said ‘the manager comes round to see us regularly and talks to us about any niggles we may have. She tries to solve them immediately and will get back to us if she needs to take time to resolve them’. The home has policies and procedures to cover adult protection and prevention of abuse, whistle blowing, aggression, physical intervention and restraint and management of resident’s money and financial affairs. Information in the staff files indicated that they had received training around abuse and vulnerable adults. The home has a copy of the ‘No Secrets’ documentation and the manager displayed a good understanding of the process for reporting any concerns to the Protection of Vulnerable Adult (POVA) team. Ash Lodge Residential Home DS0000065410.V263501.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26 and 30 (Adults 18-65) and 19, 24, and 26 (Older People). The standard of decoration within the home is improving gradually with evidence of maintenance and future planning taking place. Residents are provided with a safe, warm and comfortable environment that is homely and welcoming. EVIDENCE: There is an ongoing programme of routine maintenance and renewal within the home providing residents with living accommodation that is warm, comfortable and safe. Observation of the premises showed that the walk-in shower room Ash Lodge Residential Home DS0000065410.V263501.R01.S.doc Version 5.1 Page 18 has been redecorated since the last inspection and residents said that they like using this facility. The bathroom near room 4 (262) has some stains on the floor covering and this should be replaced. Residents’ bedrooms are individually decorated and they have brought in their personal possessions to make them more homely. One individual commented that she shares a room with another resident and this is okay, as she likes their company. Discussion with the manager indicated that bedrooms have been up graded since the last inspection to make sure they have sufficient electrical points and power sockets. The rooms have also been supplied with lockable storage areas. A number of rooms have been painted and had new carpets fitted during 2005 and others are due for refurbishment, this is planned for completion over the next year. The home is clean, bright and comfortable and no malodours were present. Two residents said that they were satisfied with the laundry system at the home and that there was a quick turn around on the clothes sent for cleaning. Ash Lodge Residential Home DS0000065410.V263501.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 (Adults 18-65) and 27, 28, 29, 30 and 36 (Older People). The standards of recruitment, induction and training of staff are good with appropriate checks being carried out and staff demonstrating a clear understanding of their roles, ensuring that residents are protected from risk and looked after by motivated and knowledgeable people. EVIDENCE: The staff-training programme offers staff access to mandatory training and some specialist subjects linked to the needs of the residents. There is an induction and foundation course that meets National Training Organisation (NTO) specification for new members of staff, and 13 of the care staff have achieved an NVQ 2 or 3, with the rest of the staff due to complete the training in September 2006. Ash Lodge Residential Home DS0000065410.V263501.R01.S.doc Version 5.1 Page 20 The home has a recruitment policy and procedure that the manager understands and uses when taking on new members of staff. Checks of staff files showed that police/CRB checks, written references, health checks and past work history are all obtained and satisfactory before the person starts work. Information in the staffing rotas shows that there are 2 carers on duty throughout the am, pm and nightshift. The manager is usually in addition to these hours, as is the deputy manager, administration assistant, housekeeper and domestic. Since the last inspection the home has a vacancy for a cook and currently the care assistants are all helping to fill this post until someone is appointed. Residents spoken to are very happy with the amount of staff on duty and said ‘they are always helpful and available to see to anything you need doing and nothing is too much bother’. Discussion with two members of staff indicated that they are motivated and enthusiastic about their work, and have a relaxed and confident approach to their care of the residents. Staff comments were positive about their access to training and the support they receive from the manager. Individuals receive regular supervision, both formal and informal and feel that this aspect of support is useful and offers them an opportunity to discuss their views and get feedback on their performance. Ash Lodge Residential Home DS0000065410.V263501.R01.S.doc Version 5.1 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. 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. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 (Adults 18-65) and 31, 33, 35 and 38 (Older People) The manager has a clear development plan and vision for the home, which she effectively communicates to the residents, staff and relatives. EVIDENCE: Ash Lodge Residential Home DS0000065410.V263501.R01.S.doc Version 5.1 Page 22 The manager for the home is registered with the Commission and is working towards achieving her Registered Managers Award by the end of December 2006. The manager has been employed at the home for eleven years, commencing work as a carer, and achieving the position of assistant manager until 6 years ago when she was appointed as the manager. Two residents said that they like to attend the meetings held by the home. These are held every three months and individuals are able to voice opinions and viewpoints, which are listened to and action is taken by the staff where needed. Individuals spoken to felt that they could make changes to the services offered at the home through attendance at the meetings or during one to one talks with their key worker. The home continuously achieves the Local Council’s Quality Assurance Award (QDS Parts 1 and 2) and regularly audits and reviews its service. Satisfaction Questionnaires are sent out to the relatives, residents and other professionals involved in the residents’ care and their feedback is analysed and used to create the Annual Development Plan for the home. Policies and procedures are up dated and reviewed as an ongoing practice and action is being taken to ensure the requirements of the inspection reports are met. Discussion with the manager indicated that staff and residents are able to discuss the home’s policies and procedures through attending meetings, and as part of the supervision process for staff. Discussion with one resident indicated that she has access to her personal finances and that she prefers that the home keeps her money safe in the office. This individual receives her personal allowance on a Tuesday and said that she likes to save some for clothes shopping and trips out with her mum. Records are hand written and each person has their own account sheet, which is updated each week by the manager/administrator. Maintenance certificates are in place and up to date for the utilities and equipment within the building. Accident books are filled in appropriately, and regulation 37 reports sent to the Commission as appropriate. Training records show that staff have attended safe working practice courses and regular up dates. The fire officer has been contacted and has visited the home to talk to residents about not smoking in their rooms and the dangers this unauthorised smoking can hold. The home does have a clear smoking policy and reiterates to the individuals that this is a fire risk. A fire risk assessment is in place and training is carried out every 6 months. Fire tests and drills are carried out on a regular basis. The manager was asked at the last inspection to complete comprehensive generic and safe working practice risk assessments for the home. These have not been done and must be developed as soon as possible,with any significant findings recorded and reviewed on a regular basis. Ash Lodge Residential Home DS0000065410.V263501.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 2 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT Standard No Score 37 2 38 X 39 3 40 X 41 X 42 2 43 X 3 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Ash Lodge Residential Home Score 3 3 2 X DS0000065410.V263501.R01.S.doc Version 5.1 Page 24 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 YA2 Regulation 15 Requirement The home must develop a care plan for respite individuals, based on the Care Management assessment or the homes own assessment of need. The registered person must develop a self-medication policy and procedure that reflects the practice at the home. Accurate records must be kept of all medication received, administered, leaving the home or disposed of, to ensure there is no mishandling. The registered manager must ensure that risk assessments are carried out for all safe working practice topics. Timescale for action 08/06/06 2 YA20 13 08/06/06 3 YA20 13 08/06/06 4 YA42 13 08/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Ash Lodge Residential Home DS0000065410.V263501.R01.S.doc Version 5.1 Page 25 No. 1 2 3 4 5 Refer to Standard YA7 YA20 YA24 YA32 YA37 Good Practice Recommendations The manager should collect the advocacy/self-advocacy information for local services and put it within the service user guide. A photograph of each resident should be put into the medication system to aid positive identification of an individual. The bathroom near room 4 (262) has some stains on the floor covering and this should be replaced. 50 of care staff should have achieved an NVQ 2 by the end of September 2006. The registered manager should have achieved an NVQ 4 in management and care (or equivalent qualification) by the end of December 2006. Ash Lodge Residential Home DS0000065410.V263501.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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. Ash Lodge Residential Home DS0000065410.V263501.R01.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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