Inspection on 07/06/05 for Ashbury Lodge Residential Home

This inspection was carried out on 7th June 2005.

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

The inspector 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

Ashbury Lodge Residential Home 02/11/06

Ashbury Lodge Residential Home 17/11/05

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE Ashbury Lodge 261 Marlborough Road SWINDON Wiltshire SN3 1NW Lead Inspector John Hurley Unannounced 7 June 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ashbury Lodge D51 D01 S57248 Ashbury Lodge V221309 070605 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Ashbury Lodge Address 261 Marlborough Road SWINDON Wiltshire SN3 1NW 01793 496827 01793 525953 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Coate Water Care Company Limited Mrs Geralding Frances Smith Care Home 44 Category(ies) of DE(E) Dementia - over 65 - 25 registration, with number MD(E) Mental disorder - over 65 - 25 of places OP Old Age - 19 PD Physical disability - 18 years to 64 years - 1 Ashbury Lodge D51 D01 S57248 Ashbury Lodge V221309 070605 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: 1 The only service user in the age range 18-64 years with a physical disability who may be accommodated in the home is the named, male client referred to in the application dated 26 March 2004 Date of last inspection 14th October 2004 Brief Description of the Service: Ashbury Lodge is a private care home situated on the outskirts of Swindon. The owners also own another care home in the area. They operate the home as a family business. The home fulfils 3 distinct but complimentary services. On the ground floor care and accommodation is provided to older people who need less supervision and have more awareness of their environment. On the first floor care accommodation is provide to older people who need extra supervision. For reasons of safety the egress from this floor is electronically locked. Each floor to all intents and purposes operates as separate units. The home provides for older people who either have dementia type conditions or experience (or have experienced) mental illness and older people who need care only because of infirmity or reasons associated with getting old. All but 4 rooms provide single accommodation, some with on-suite facilities. Ashbury Lodge D51 D01 S57248 Ashbury Lodge V221309 070605 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over five hours. The inspector viewed all areas of the home and observed the service users go about their daily routines. The inspector spoke with the three care staff on duty, deputy manager and manager. The inspector did not have an opportunity to meet with any relatives on the day of the inspection but had been contacted by two relatives prior to the inspection. The inspector spoke with three service users, one at some length. A number of records were examined including three service users care plans, risk assessments, health and safety records and staff recruitment files. What the service does well: What has improved since the last inspection? What they could do better: The management needs to ensure that the review process is robust and analyses all information in order to generated short-term aims and objectives. The management further need to ensure that the receipt, administration, recording and return of any prescribed medication is robust enough to demonstrate safe practice. They further need to ensure that all staff follow the policies and procedure of the home with regards to medication administered on a “per required needs” (PRN) basis. Ashbury Lodge D51 D01 S57248 Ashbury Lodge V221309 070605 Stage 4.doc Version 1.20 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ashbury Lodge D51 D01 S57248 Ashbury Lodge V221309 070605 Stage 4.doc Version 1.20 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Ashbury Lodge D51 D01 S57248 Ashbury Lodge V221309 070605 Stage 4.doc Version 1.20 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,5,6 The information obtained by the home with regards to the service users needs is good. The management and staff take many efforts to ensure the new resident settles in well. EVIDENCE: The documentation relating to the last service user to take up residency contained good details relating to the individuals presenting issues as well as a good social history. Their assessed health and social needs are clearly recorded in the form of a community care assessment. The homes management also carry out their own assessment to ensure that they can meet the needs and aspirations of any prospective placement. A standard form of contract between the purchaser of care and the home is available or there is a statement of the terms and conditions of residency. The statement of purpose and service user guide support these documents. A selffunding service user who had placed themselves in the home confirmed that they had visited prior to taking up residency. They further confirmed that they had been given more than enough information and support in deciding if the home would suit their individual needs. Intermediate care is not a service which is offered at this home. Ashbury Lodge D51 D01 S57248 Ashbury Lodge V221309 070605 Stage 4.doc Version 1.20 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10 There has been progress in providing good quality care plans and documentation which if followed allows all staff to work in a consistent and agreed manner. More attention to the monthly review process would greatly enhance the over all validity of the documentation. Management need to pay greater attention to the administration and recording of medication to ensure there is little possibility for errors. EVIDENCE: A care plan is generated from the initial assessment documents that demonstrates how the home will met the assessed needs. The care plan contains good detail relating to health and social care needs, however they would benefit form having a recent photograph of the resident. The staff have started to carry out monthly reviews of the care plans. These reviews need to be more than checking the original plans is still valid. For example, the daily recording of an individual service user indicated that the staff had noted that the individual was having problems with a hearing aid. The review of the care plan had not picked this up and there was no short-term goal to address the problem. However in general terms the staff were able to inform the inspector of most of the aims and goals of the individual care plans. The service user files evidence health care workers visits such as doctors and district nurses along with other specialist inputs from the community health Ashbury Lodge D51 D01 S57248 Ashbury Lodge V221309 070605 Stage 4.doc Version 1.20 Page 10 team. The service user’s file also note when appointments need to be made and when regular check ups need to be attended. At the time of the inspection no service user was self-medicating. The reasons for this were clearly documented in their individual records. The records relating to the medication were found to be inaccurate with some preparations on the premises that could not easily be accounted for at the time of the inspection. The policy to double sign when administering controlled drugs had not been adhered too. This was also found to be the case with regards to the PRN policy where the reasons for administering medication via this route were not stated. The inspector observed some poor care practice. The deputy manager took action immediately to address this by talking with the member of care staff and pointing out exactly what was not acceptable and the reasons why. In general terms good care practices were observed. Most staff demonstrated a compassionate and thoughtful approach to their work. One service user commented that they were given just enough help when it was required. They further commented that they appreciated this as they wished to retain as much independence as was possible. Ashbury Lodge D51 D01 S57248 Ashbury Lodge V221309 070605 Stage 4.doc Version 1.20 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,15 Now that service users needs and wishes are formally recorded and acknowledged this has led to more targeted and needs led provision. The approach to the catering arrangements is flexible enough to meet the wishes of the service user group. EVIDENCE: Relatives confirmed that they can visit at any reasonable time and take out family members in to the wider community. A service user whose care plan acknowledges the need to ensure that the individual has opportunities to go out walking now has this need met when possible. Mental health issues to some degree limit a full range of choice. Where there are limitations these are made through a risk assessment framework and in consultation with the service users advocates. Service users records contain information on their dietary requirements. Specialist advice has been obtained from the dietician. Service users likes and dislikes are acknowledged and staff confirmed alternatives are offered if the service users refuse the meal provided. One service user explained that most of the time the food is good but felt that the size of the portions were too large. They confirmed that there was a good degree of variety. The chef confirmed that the budget is sufficient to provide Ashbury Lodge D51 D01 S57248 Ashbury Lodge V221309 070605 Stage 4.doc Version 1.20 Page 12 the meals that are planned and that they will provide specialist meals in accordance with any special dietary requirements. Staff were observed serving the lunch time meal in an unhurried manner engaging in conversation with the service users making meal times a social experience. A service user confirmed that they have choices with regards to where they eat their meals, this is either communally or in their own rooms. Ashbury Lodge D51 D01 S57248 Ashbury Lodge V221309 070605 Stage 4.doc Version 1.20 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 The home makes many efforts to listen to the service users and their sponsors views, continuing to learn from complaints that are made. The home has a proactive approach to vulnerable adults work. EVIDENCE: There has been one formal complaint relating to an accident made since the last inspection. This was made directly to the Commission and was investigated during this unannounced inspection. The documentation available in the service user file informs that the issue had been investigated at the time and the relatives had been informed of the findings of the homes own internal investigation into how this accident happened. The evidence available appears to support the homes view that this was a accident. A risk assessment has been carried out following the accident and a strategy employed to minimise the risk of this happening again. The complaints file demonstrates that the home takes any issues brought to them seriously. It further evidences what the homes management has learnt from each issue. The home has adopted the Adult Protection procedure (including Whistle Blowing), which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets. Through discussion with staff it is clear that they understand their duties and responsibilities should abuse be suspected. Ashbury Lodge D51 D01 S57248 Ashbury Lodge V221309 070605 Stage 4.doc Version 1.20 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,23,24 The accommodation provided is clean and comfortable. There are sufficient communal areas which are free from offensive odours. The home makes many efforts to provide a safe and secure environment EVIDENCE: The inspector viewed all areas of the home and found it was clean, comfortable and free from offensive odour. Discussion with service users confirmed they were satisfied with the standard of accommodation in their bedrooms. They confirmed they had a degree of choice of furniture and fittings provided. One service user commented they brought most of their personal furniture with them. The accommodation is over two levels, the upper floor having restricted access via electronically coded doors. This is to provide a safe and secure environment for those service users who need this level of security. Individuals placed on the first floor only take up a place there following consultation and agreements with the individual’s sponsors. There is a passenger lift between the two floors. Ashbury Lodge D51 D01 S57248 Ashbury Lodge V221309 070605 Stage 4.doc Version 1.20 Page 15 The standard of communal living accommodation is good with evidence of ongoing internal investment. Service users confirmed their laundry is washed and returned promptly. Policies and procedures for reducing the risk of infection were in place at the home. Ashbury Lodge D51 D01 S57248 Ashbury Lodge V221309 070605 Stage 4.doc Version 1.20 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 29,30 The home has a robust recruitment procedure which ensures that those who wish to work with vulnerable people are adequately vetted and supported to undertake the roles they are employed for. EVIDENCE: A sample of recent staff applications demonstrated how the home protects the service users in line with its corporate policy. There was sufficient evidence on file to illustrate that the home verifies identity and takes up references. The inspector spoke with two new members of staff who confirmed that they had attended an interview following submitting a formal application. They further confirmed that they had a formal induction and were having formal and informal supervision. The staff records set out their training needs. These range from industry standards such as health and safety and manual handling through to more targeted training such as dealing with aggressive behaviour. Ashbury Lodge D51 D01 S57248 Ashbury Lodge V221309 070605 Stage 4.doc Version 1.20 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,37,38 The home is being effectively and safely managed and there is good progress in moving from a task-orientated approach to a needs led approach. Safe working practices are being followed in the home EVIDENCE: The health and safety of service users and staff is generally addressed through a risk assessment process. The safety of the more vulnerable service users is partially protected through separating the home into two distinct floors. Examination of records and discussion with staff indicate safe working practices are being observed on the home. Records indicate fire safety drills are being held every three months and training is provided for staff. Periodic routine safety checks to lighting and fire alarms systems are being completed. Electrical and gas safety checks are being carried out at the required intervals Ashbury Lodge D51 D01 S57248 Ashbury Lodge V221309 070605 Stage 4.doc Version 1.20 Page 18 The home has implemented a quality assurance survey that has been completed by the relatives of service users. The outcome of the survey is collated and the findings circulated to service users their representatives and stakeholders. The service user documentation is now focused on individual needs and how these needs should be met. The management has demonstrated its ability to work well with the regulator and others to address vulnerable adult issues. Ashbury Lodge D51 D01 S57248 Ashbury Lodge V221309 070605 Stage 4.doc Version 1.20 Page 19 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. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x 3 x x x STAFFING Standard No Score 27 x 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 3 x x x 3 3 Ashbury Lodge D51 D01 S57248 Ashbury Lodge V221309 070605 Stage 4.doc Version 1.20 Page 20 no 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. 2. Standard 9 9 Regulation 13(2) 13(2) Requirement Timescale for action 11/07/05 3. 7 15(2)(b) The registered manager must ensure that all medicines can be accounted for. The registerd manager must 11/07/05 ensure that all medicines administered via the PRN route are done so in line with the homes policies and procedures The registered manager must 1/07/05 ensure that when reviewing care plans the review must acknowledge any change in circumstances 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. 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