Inspection on 06/07/05 for Ashfield Lodge

This inspection was carried out on 6th July 2005.

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

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

Other inspections for this house

Ashfield Lodge 24/07/06

Ashfield Lodge 23/02/06

Ashfield Lodge 25/10/04

Ashfield Lodge 07/06/04

Similar services:

Trevayler Residential Care Home

Thornham Grove

Thistle Hill Hall

Conifer Lodge

Westwood Lodge

Egerton Lodge Care Home

Alfred Minto House Care Home

St Matthews Unit

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

CARE HOMES FOR OLDER PEOPLE Ashfield Lodge Ashfield Road Sleaford Lincolnshire NG34 7DZ Lead Inspector Toby Payne Unannounced 8:30am 6 July 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. Ashfield Lodge C53 C04 59242 Ashfield Lodge 236877 060705 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Ashfield Lodge Address Ashfield Drive Sleaford Lincolnshire NG34 7DZ 01529 307330 01529 414420 ashfield.lodge@craegmoor.co.uk Health & Care Services (UK) Limited 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) Vacant Care Home (CRH) with Nursing 20 Category(ies) of Dementia under 65 years of age (1) registration, with number Dementia - Over 65 years of age (14) of places -Mental Disorder under 65 years of age (1) Mental Disorder - Over 65 years of age (4) Ashfield Lodge C53 C04 59242 Ashfield Lodge 236877 060705 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: The Manager is to be determined. Date of last inspection 23rd October 2004 Brief Description of the Service: Ashfield Lodge changed its registration from an independent hospital to a care home on the 31/3/2004. The home now provides nursing care for up to 20 residents who have a dementia and or mental health problems. The home is a single storey purpose built facility close to the centre of the town of Sleaford. Accommodation is provided in single bedrooms each with en-suite facilities. There are also 2 lounge/dining rooms and an enclosed garden area with seating and plants which are accessible by residents. The home is within walking distance of local amenities, such as shops, newsagents, hairdressers etc. There are car parking facilitiesat the front of the home. The home provides transport for the residnets to enable them to use local facilities. Ashfield Lodge also provides day crae services within the home but in a separate unit. servcie provides transport, staff , meals and carer support. This service is however not registered by the CSCI and therefore not subject to inspection or regulation. Ashfield Lodge C53 C04 59242 Ashfield Lodge 236877 060705 stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and started at 8.30 a.m. It took place over 5 hours. The inspector spoke to 7 residents, one visitor, a visiting community pharmacist, 3 staff and the manager. The main method of inspection was called “case tracking”. This involved selecting 2 residents and tracking their care they received through the checking of records, discussion with them, the care staff and observation of care practice. Comment cards had been received prior to the inspection from one resident and 4 relatives/visitors. What the service does well: What has improved since the last inspection? One of the lounges has been redecorated following consultation with the residents. A bank handyperson has been employed which has enabled any required maintenance to be promptly attended to. The garden area at the back of the home has been fenced and now provides a more secure sitting area. Ashfield Lodge C53 C04 59242 Ashfield Lodge 236877 060705 stage 4.doc Version 1.40 Page 6 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. Ashfield Lodge C53 C04 59242 Ashfield Lodge 236877 060705 stage 4.doc Version 1.40 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 Ashfield Lodge C53 C04 59242 Ashfield Lodge 236877 060705 stage 4.doc Version 1.40 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 and 3 Although Ashfield House meets the needs of residents coming into the home there is not sufficient information available to allow them to understand the services provided by the home. People receive an assessment, which results in their assessed needs being met. EVIDENCE: Since the last inspection a statement of purpose has been produced but there was still no service user’s guide available. There is a comprehensive admission procedure, which identifies the needs of residents coming into the home. Before entering the home, each person is assessed by the manager. Ashfield Lodge C53 C04 59242 Ashfield Lodge 236877 060705 stage 4.doc Version 1.40 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, 9 and 10 There is a clear and detailed care planning system in this home. Arrangements were in place to meet the health and personal care of people living in the home. Medication is administered safely by competent staff. Staff respect the privacy and dignity of residents. EVIDENCE: All residents had detailed and up to date care records. These included assessment details, life history, risk and moving and handling assessments, dental, nutritional and daily living assessments as well as a comprehensive care plan and daily record. Care plans showed evidence of being reviewed monthly. Registered nurses are responsible for the administration of medication. A visiting community pharmacist was conducting an examination of the medication stock and records during the inspection. She was satisfied with the arrangements in the home. Comments were “there is a very professional approach and records were well maintained”. Ashfield Lodge C53 C04 59242 Ashfield Lodge 236877 060705 stage 4.doc Version 1.40 Page 10 Staff were seen to attend to residents many of whom were physically and mentally frail in a kind and sensitive manner. Talking to them, using their name and encouraging them to drink a cup of coffee as evidence of independence. Also using words such as please and thank you. A number of residents had keys to their bedroom doors which all had locks installed to promote privacy. Ashfield Lodge C53 C04 59242 Ashfield Lodge 236877 060705 stage 4.doc Version 1.40 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 and 15 A range of social activities is available to provide stimulation and interest for people living in this home. Meals provided are nutritious, balanced and offer a varied diet. Visitors are made to feel welcome and supported and can visit whenever they wish to do so. EVIDENCE: All care records outlined what the residents liked to do and their interests. Up to date information is placed on the notice board. Activities provided included cards, dominos, group discussions, board games, quizzes, word search, hand massage, bingo and sitting in the garden in fine weather. Some of the activities are shared with people using the day centre adjoining the home. The manager told the inspector that a trip was to be arranged the day after this inspection to Skegness. Residents said they enjoyed the food. Comments were, “the food is very enjoyable” and “ the menu is displayed on the wall”. Ashfield Lodge C53 C04 59242 Ashfield Lodge 236877 060705 stage 4.doc Version 1.40 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 Any complaints received are handled properly and residents and visitors know that any complaints they have to make will be addressed and taken seriously. Staff are recruited to ensure that residents are protected from abuse. EVIDENCE: Since the last inspection, one complaint has been received by the home. Records showed that the issue had been addressed to the satisfaction of the person who made a complaint. A comment card also stated “a complaint was appropriately dealt with and speedily rectified. This is a good nursing home with an excellent manager and nursing team”. Records also showed that a recently appointed member of staff had been recruited correctly with a Criminal Records check. A member of staff knew what abuse was and what their role was if abuse was suspected. All staff now receive abuse training during their induction. Ashfield Lodge C53 C04 59242 Ashfield Lodge 236877 060705 stage 4.doc Version 1.40 Page 13 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, 20 and 25 Residents live in clean, well decorated, well maintained and safe accommodation. The design allows residents with poor memory to find their way around. EVIDENCE: Residents who spoke to the inspector said how satisfied they were with the decoration and cleanliness of the home. Bedrooms were individual with pictures, ornaments, photographs and personal mementoes. Signs have been provided to resident’s bedrooms, toilets and bathrooms to help residents find their way around. One of the lounges has been redecorated and residents have access to safe garden areas. These have garden seats and plants. Ashfield Lodge C53 C04 59242 Ashfield Lodge 236877 060705 stage 4.doc Version 1.40 Page 14 The home has low surface temperature radiators and hot and cold water temperatures are monitored and recorded monthly. Records showed they were within safe temperatures. Ashfield Lodge C53 C04 59242 Ashfield Lodge 236877 060705 stage 4.doc Version 1.40 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30 There was a well trained and competent staff team. The number of staff was sufficient to meet the needs of the residents. Staff are correctly recruited. EVIDENCE: Examination of a staff file of a member of staff who had been recently recruited showed that they had been correctly recruited. None of the residents or staff expressed any worries about the level or availability of staff. During the inspection, staff were seen to attend to residents promptly. Staff commented, “we have enough time to care for the residents and work as a team”. There is an extensive training programme for staff, which includes National Vocational Qualifications, internal lectures and training from outside trainers. The home also has registered nurses who have specialist interests and pass information and their expert knowledge onto staff in the home in order to ensure that practice is up to date. The manager told the inspector that staff were to receive in the very near future dementia awareness training. Ashfield Lodge C53 C04 59242 Ashfield Lodge 236877 060705 stage 4.doc Version 1.40 Page 16 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 and 37 The home is well lead by a competent, experienced and committed acting manager whose application to be registered manager continues to be processed by the CSCI. There is a confident, supported and trained staff team. The home has comprehensive and up to date policies including clinical procedures. EVIDENCE: The acting manager who is a registered nurse has extensive care and management experience and since January 2005 has completed a recognised management qualification. Her application to be the registered manager is being processed by the CSCI. Comment cards stated “ we are delighted with the care my mother has received” and “staff are so kind and helpful and work hard”. Ashfield Lodge C53 C04 59242 Ashfield Lodge 236877 060705 stage 4.doc Version 1.40 Page 17 Staff felt safe working in the home and felt able to approach the manager if they had any concerns. One commented, “ the manager is approachable and knows what is going on in the home”. There were also regular staff meetings. The home had comprehensive policies and procedures. The company is to introduce in the near future a personal performance, review and supervision document for each member of staff to record supervision and development, which takes place. Ashfield Lodge C53 C04 59242 Ashfield Lodge 236877 060705 stage 4.doc Version 1.40 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 x x x x 3 x STAFFING Standard No Score 27 3 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 x x x x 3 x Ashfield Lodge C53 C04 59242 Ashfield Lodge 236877 060705 stage 4.doc Version 1.40 Page 19 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 1 Regulation 5 Requirement A service users guide must be provided in the home and a copy given to each resident and a copy sent to the CSCI. (The previous timescale of the 1/3/2005 not met) Timescale for action 6/9/2005 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 27 Good Practice Recommendations It is recommended that the manager obtain a copy of the Residential Forums Care Staffing in Care Homes for Older People. This gives guidance on staffing levels as recommended by the Department of Health. Ashfield Lodge C53 C04 59242 Ashfield Lodge 236877 060705 stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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 Ashfield Lodge C53 C04 59242 Ashfield Lodge 236877 060705 stage 4.doc Version 1.40 Page 21 - 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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