Inspection on 04/05/07 for Ashford Lodge Care Home

This inspection was carried out on 4th May 2007.

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 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

Ashford Lodge Care Home 01/04/08

Ashford Lodge Care Home 09/05/06

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

CARE HOMES FOR OLDER PEOPLE Ashford Lodge Care Home 1 Gregory Street Ilkeston Derby DE7 8AE Lead Inspector Steve Smith Key Unannounced Inspection 4th May 2007 09:30 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 Ashford Lodge Care Home DS0000066561.V335676.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ashford Lodge Care Home DS0000066561.V335676.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashford Lodge Care Home Address 1 Gregory Street Ilkeston Derby DE7 8AE 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) 0115 930 7650 0115 930 7650 andy@carnachan.plus.com Andrew David Carnachan Vacant Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Ashford Lodge Care Home DS0000066561.V335676.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Date of last inspection 9th May 2006 Brief Description of the Service: Ashford Lodge is a large detached property adapted to meet the needs of 20 older people, primarily with nursing needs. The Home has 2 floors with bedrooms on both floors; the first floor is accessible by a passenger lift. There is a large conservatory, lounge and dining area, along with a smaller quiet lounge area. The Home has an accessible garden area and parking for 2 - 3 cars. The Home provides nursing care and has a registered nurse on duty 24 hours a day. The charges made for a room at Ashford Lodge Care Home range from £340.10 a week for Residents with residential needs, to £498.20 a week, for those Residents with high level nursing needs. Ashford Lodge Care Home DS0000066561.V335676.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place in just over 9 hours. Discussion was held with two Residents, and the records of three Residents were ‘case tracked’. Discussion was also held with the Registered Provider and Acting Manager of the Home, and with one member of the care staff. A number of records were examined, and all of the Residents bedrooms and all public areas of the Home were examined. The Commission’s pre-inspection questionnaire, sent to the Acting Manager, was examined. The Commission’s Residents questionnaire was also sent to a selection of Residents, but none had been returned at the time of this inspection. What the service does well: What has improved since the last inspection? At the last inspection of the Home, in November 2006, only two Recommendations were left to be addressed. One of these required the Registered Provider to arrange for staff to attend training on Safeguarding Adults procedures, which was found to have been done. The second related to Ashford Lodge Care Home DS0000066561.V335676.R01.S.doc Version 5.2 Page 6 the Acting Manager applying to the Commission to be approved as Manager of the Home, but this had not been done at the time of this inspection. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ashford Lodge Care Home DS0000066561.V335676.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Ashford Lodge Care Home DS0000066561.V335676.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2, 3, & 6. The quality in this outcome area was Adequate. This judgement was made using available evidence including a visit to this service. The statement of purpose did not provided appropriate information to ensure that Residents were adequately informed about the Home prior to admission. EVIDENCE: The Registered Provider had provided a statement of purpose for the Home together with a Resident’s Guide, which was available in each Residents bedroom. Both documents clearly set out the ‘physical environment’ standards met by the Home. However, the Registered Provider had not updated the Residents Guide to address all of the issues listed in the Regulations that came into force in September 2006. The Residents Guide was well completed, although did not provide the opinions of Residents on what life was like in the Home. However, the Residents Guide did contained information on how contact could be made with the Commission, with the local Social Services Dept and with the local Health Authority. Ashford Lodge Care Home DS0000066561.V335676.R01.S.doc Version 5.2 Page 9 It became apparent, during an examination of three Residents files and from discussion with the Registered Provider, that the Registered Provider completed a contract for those Residents purchasing their care privately, but did not provided a statement of terms and conditions of residency for those Residents sponsored by Social Services Depts. When new Residents were admitted to the Home, the Acting Manager was provided with a summary of the needs of each person, completed by the Social Services Dept Care Manager supporting each Resident, copies of which were seen. If the Residents were self-funding from the outset, the Acting Manager completed her own summary of needs, although these summaries had not been completed in the three Residents files examined during the inspection. Standard 6 does not apply to this Home. Ashford Lodge Care Home DS0000066561.V335676.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9, 10 & 11. The quality in this outcome area was Adequate. This judgement was made using available evidence including a visit to this service. Residents’ personal care was not always appropriately recorded to ensure that Residents needs were being met. Medication was administered appropriately to meet Residents needs, although improvements were required. EVIDENCE: To help assess Standard 7, the Resident’s Plan of Care, the records of three Residents were examined, for the purpose of case tracking. All of the basic information, concerning each Resident, was found to be in the files examined. That was, their name, their date of birth, their preferred name, their next of kin, their GP, their Care Manager, their designated keyworker and their date of entry to the Home. Copies of the initial assessment completed by the Social Services Care Manager, where one was involved, were available, although the Acting Manager had not completed her own initial assessment of needs for each of the three Residents. Copies of the contract, where one was Ashford Lodge Care Home DS0000066561.V335676.R01.S.doc Version 5.2 Page 11 necessary, signed by each Resident, or their representative, on admission were available in the Home. The files did contain copies of the ongoing care plan for each Resident, although these records were extremely brief, and the files contained a risk assessment for each Resident. The Acting Manager had not provided information within the files to say what additional needs Residents suffering with dementia might have had. The records should have included details of each Resident’s possible limitations of choice, freedom and decision making. This information should be reviewed and updated at least at each formal six monthly review held in the Home. The records in the three files seen contained only very basic information. No record was seen of any review undertaken by the Social Services Dept or by the Acting Manager. All of the files were easy to read and entries had been made by the care staff. In one of the files it was recorded when the Resident chose to get up and go to bed. However, the files were poorly organised and none were found to contained a confidential section. The Registered Provider and Acting Manager were highly concerned by the evidence found within the records of the three files chosen at random. They presented alternative files which were well maintained, and contained the vast majority of the information missing from the files chosen at random. The quality of the recording within the Home, therefore, needed to be reviewed and made consistent across all files. During this visit to the Home time was taken to observe staff, and they were always heard to talk to Residents in a most polite and friendly style. Staff were appropriately maintaining the records of Residents health needs. All medication and the method of distributing it to Residents was examined. A good system was found to be in use, although the following issues required attention: The Medication Administration Record (MAR) sheets contained a number of handwritten entries completed by staff from the Home. However, these additional medications were not signed by two staff, to confirm the correct entry had been made, nor did they state the Doctor who authorised the medication, or the date on which the new medication was to start/had started. Ashford Lodge Care Home DS0000066561.V335676.R01.S.doc Version 5.2 Page 12 When the MAR sheet stated that a medication, such as Sudecream or Fortisips was to be provided, staff were found to have indicated that this had been done by ‘ticking’ the box on the MAR sheet and not using their recorded signatures. In the guidance given at the foot of the MAR sheet the letter ‘F’ was to be defined by staff. However, the letter ‘F’ had been used frequently without defining its meaning. When the blister packs and MAR sheets were compared, a number of medications were found to be still in the blister packs, but signed as having been given on the MAR sheets. A number of new blister packs had been supplied mid-month, by the Pharmacy used by the Home. The distribution of medication from these new blister packs had not been started in the same position as other blister packs already in use. To ensure the correct distribution of medication, all blister packs and MAR sheets should be in the same location for all medication. Two Residents were spoken to about life in the Home. They said that staff were very good at listening to their views on how they liked to be cared for and staff would carry out their wishes. They also said that their care needs were always met with dignity and respect – ‘Yes, they are very good at this’ ‘Yes, I think they do, I have had not trouble with them.’ As a result, they felt very safe in the Home, and appeared to have a strong sense and appearance of well being – ‘Staff make sure everything is done my way.’ ‘ Yes, staff check the way I want things done.’ A member of staff was also interviewed. It was her opinion that she and her colleagues always respected Residents wishes, which was well supported by Residents opinions. Staff were over heard talking to Residents, throughout the inspection, and this was seen to be done in a quiet and respectful manner. The staff member said that a telephone was always available for Residents use. She said they often used the Home’s telephone, which was a cordless telephone, even though the Residents telephone was available, but this was a static payphone. Both Residents and the staff member said that mail was delivered to the Residents unopened. The staff member said that all clothing was appropriately marked with each Resident’s name. She also said that the term of address requested by the Residents was always used, even were the Resident requested to be formally addressed as Mrs or Mr. She commented on the importance of the Home’s induction package for staff, that helped ensure that Residents were treated with respect at all times. When assisting Residents who were dying, the member of staff said that the Resident’s choice of treatment was always respected. She also describe the care provided following the death of a Resident, which was most appropriate. Ashford Lodge Care Home DS0000066561.V335676.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 & 15. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. Residents preferred lifestyles were respected by the Home, and Residents were given a wholesome and appealing diet in pleasant surroundings, that enhanced Residents well being. EVIDENCE: Two of the Residents were asked about the activities provided in the Home. One said the Home arranged ‘sing-a-longs’, and the second said that ‘…you had to entertain yourself, although all staff are very nice.’ The member of staff spoken to said that activities were provided, but as most Residents had dementia staff tended to sit and talk to Residents in the main. The member of staff also said that activities were posted on the notice board, and that families and friends could take Residents out if they so chose. The two Residents said that they decided when they got up and went to bed – ‘I can get up and go to bed whenever I like, I go to bed at about 9.30 pm and I get up when I am ready’ ‘I am happy to be assisted to get up at about 8.00 am. Staff come and ask (when I want to go to bed) and I say no until about 10.00 pm.’ One of the Residents also said that they had two baths a week, which they enjoyed. Ashford Lodge Care Home DS0000066561.V335676.R01.S.doc Version 5.2 Page 14 Relatives and friends of Residents were able to visit at any time, and could always be seen in private - ‘I mostly see my daughters in my bedroom’ ‘Yes, I can see them in my bedroom, if need be’ The staff member interviewed said that relatives could visit at anytime, and could see Residents in their bedrooms. She also said that Residents could refuse to see visitors if they so chose. She remembered one Resident refusing to see a visitor, and so the visitor had to leave. Both Residents also said that when staff came to the door of their bedrooms they knocked, paused and opened the door, they never waited to be invited in. The Residents also said that their mail was always delivered unopened. One relative was seen during this inspection. She was able to comment that the care provided was very good, and that the Resident (her mother) had put on weight since being in the Home, which she saw as a good sign of wellbeing. The Residents commented about the meals provided by the Home by saying ‘a choice is provided at breakfast and at teatime, but not at dinner time.’ However, the second Resident said that ‘…if you don’t like something they will give you another dish’. The member of staff interviewed said that a choice was always available at breakfast and teatime, the Resident would need to say that the midday meal was disliked to be offered an alternative. The member of staff also said that drinks and snacks were always provided between meals for Residents. She said that mealtimes were never rushed, and that usually if a Resident required assistance from a member of staff to eat their meal this was always done on a one to one basis. However, throughout the dinner time one Resident was seen to need assistance to complete her meal. Assistance was provided, but this was provided by three separate staff, who came and went, dependent on the other tasks that needed to be addressed for other Residents. Ashford Lodge Care Home DS0000066561.V335676.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 & 18. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. Complaints made to the Registered Provider or Acting Manager were addressed to meet Residents needs. The protection policies and procedures provided meant that Residents were well protected. EVIDENCE: One Resident was able to say that if he had a complaint to make ‘I would tell the Deputy Manager.’ The second Resident said that ‘I would tell (the Registered Provider), the top man.’ However, both said that they had never had to do this. The Commission had not received any notice of complaint since the last formal inspection of the Home in May 2006. Since that inspection, the Registered Provider and Acting Manager said that they had no record of a complaint or concern raised by any Resident. The record was examined, which confirmed this view. However, the Registered Provider said that the Home did not keep separate records of ‘concerns’ raised by either Residents or their relatives. These ‘concerns’ would be simply logged in the Residents files. However, the Registered Provider’s complaints procedure detailed that all complaints would be responded to by the Registered Provider or the Acting Manager within at least 28 days. Ashford Lodge Care Home DS0000066561.V335676.R01.S.doc Version 5.2 Page 16 The Registered Provider had a Safeguarding Adults procedure that included a ‘Whistle Blowing’ policy. However, copies of the Public Interest Disclosure Act of 1998 and of the Dept of Health’s policy called ‘No Secrets’ were not available in the Home. It was confirmed that all allegations and incidents of abuse would be promptly followed up and that all actions taken would be recorded. The policies and practices laid down by the Registered Provider ensured that all staff understood physical and verbal aggression by Residents. The Registered Provider also said that a policy was not available to staff stating that they could not benefit from Residents wills. However, the member of staff interviewed said that staff were not allowed to benefit from Residents wills. Ashford Lodge Care Home DS0000066561.V335676.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20, 21, 22, 23, 24, 25 & 26. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. The Home was well maintained throughout, providing all Residents with a safe, comfortable environment in which to live. EVIDENCE: A tour was made of the entire Home, which included all of the bedrooms of the Residents. The Home was attractively decorated throughout, and the lounges and dining room were pleasant to sit in, and were provided with the appropriate items for the Residents. However, the Registered Provider said that a re-decoration programme was underway in the Home. All of the bedrooms provided good space and provision for each Resident. The Registered Provider had provided appropriate furnishings in all locations, although two comfortable armchairs had not been provided in all bedrooms. Ashford Lodge Care Home DS0000066561.V335676.R01.S.doc Version 5.2 Page 18 Toilets were easily available to all Residents, were clearly marked, and were provided with handrails where necessary. A call system was available throughout the Home. All bedroom doors were provided with locks, which Residents could chose to use. However, the locks were not governed by a master key system, which the Registered Provider was encouraged to install. The system should allow a draw bolt to be used by Residents on the inside of the bedroom. All radiators were appropriately guarded, and could be controlled within each bedroom. The Home had appropriate sluicing facilities, and laundry was washed at appropriate temperatures. However, one of the bedrooms suffered with a poor odour, which needed to be addressed. Ashford Lodge Care Home DS0000066561.V335676.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 & 30. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. Care staffing was provided to meet the needs of Residents. However, the Manager needed to ensure that appropriate recruitment practices were always followed, when employing new members of staff, to safeguard Residents welfare. EVIDENCE: A good level of staffing was found to be provided in the Home to meet the needs of Residents. At the time of this inspection it was found that more than 50 of care staff had a qualification of at least NVQ level 2 in Care, and therefore surpassed the expectation of the Commission. The staff member interviewed said that she held an NVQ level 2 in Care. The records of two new staff employed during the past 7 months were examined to see whether the Acting Manager had obtained all relevant information about them. It was found that almost all information had been obtained, however, only one reference, rather than two references, had been obtained for both staff reviewed. All other information was found to be satisfactory. Ashford Lodge Care Home DS0000066561.V335676.R01.S.doc Version 5.2 Page 20 The Acting Manager said that new staff would be provided with induction and foundation training. She also said that all care staff were provided with at least three paid days training a year, and a member of the care staff provided corroboration. The records of some of this training was seen. All staff also had an individual training and development assessment and profile. Ashford Lodge Care Home DS0000066561.V335676.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36 & 38. The quality in this outcome area was Adequate. This judgement was made using available evidence including a visit to this service. Management arrangements at the Home were not sufficiently robust to ensure that residential care was maintained to a positive standard. EVIDENCE: The Acting Manager, a registered nurse, had been in post for a number of months prior to this inspection and held an NVQ level 4 qualification in Management, however, she had not applied to the Commission for her post to be assessed, and hopefully approved. The Registered Provider, while being in the Home on a daily basis, was not providing the written monthly ‘inspections’ of the Home, as required by Regulation 26. Ashford Lodge Care Home DS0000066561.V335676.R01.S.doc Version 5.2 Page 22 The Registered Provider and Acting Manager were aware of many of the issues required to address the Quality Assurance information needed in the Home, however, none had been completed at the time of this visit. The Acting Manager was able to show that the personal money of Residents was maintained satisfactorily. However, the savings of one Resident amounted to a significant sum, but this was not banked under the Resident’s name to allow the Resident to benefit from interest provided by the bank. The member of staff interviewed was asked whether she received regular supervision from the Acting Manager, and she said that this did not happen. This was later confirmed by the Acting Manager, although she was able to say that performance assessment of each member of staff did take place once or twice a year. The training required by the Regulations was examined. This showed that Moving and Handling training, First Aid training, Food Hygiene training and Infection Control training were all up to date. Fire Safety training had been provided for all staff, but a second amount of training had not been provided for staff required to work nights. In addition to the above required training, the Acting Manager said that training was also provided on Dementia Awareness, Health and Safety, Diabetes, Continence Awareness, Tissue Viability, POVA, Venepuncture and Blood Sugar Monitoring. The Registered Provider was able to show that the Home had complied with the majority of legislation applicable to its operation, although he said he did not have information on the Management of Health and Safety at Work Regulations 1999, the Workplace (Health, Safety and Welfare) Regulations of 1992 or the Provision and Use of Work Equipment Regulations of 1992. The Registered Provider was not able to show that he had provided risk assessments on all safe working practices of staff; that is for care staff, catering staff and domestic staff. Nor had he provided a written statement of the policy, organisation and arrangements for maintaining these safe working practices. The Acting Manager was able to show that all accidents, injuries and incidents of illness or communicable disease were recorded and reported to the relevant government bodies. With the assistance of the Fire Service, fire safety notices were also posted in relevant places around the Home. Ashford Lodge Care Home DS0000066561.V335676.R01.S.doc Version 5.2 Page 23 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 2 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 2 Ashford Lodge Care Home DS0000066561.V335676.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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 5 Requirement The Residents Guide must include the details listed within the legal amendment, relating to the Guide, introduced during September 2006. A new Guide must then be distributed to Residents staying in the Home. The Registered Provider must provide to all Residents sponsored by Social Services Depts details of the statement of terms and conditions of residency applicable to each Residents staying in the Home. A copy of the Acting Manager’s initial assessment of need must be available for all Residents who are self funding. Copies of the Social Services Dept initial assessment of need of each Resident must be available within each file. 4. OP7 15(1) & (2) The Acting Manager must complete a detailed Resident’s plan of care, for all Residents, DS0000066561.V335676.R01.S.doc Timescale for action 29/06/07 2. OP2 5 31/07/07 3. OP3 & OP7 14 29/06/07 29/06/07 Ashford Lodge Care Home Version 5.2 Page 25 laying out how the Resident’s needs in respect of their health and welfare are to be met. 17 & Sch 3 The Acting Manager needs to ensure that each Resident suffering with dementia, or their representative, has had the opportunity to discuss their rights of choice, freedom and decision-making while staying in the Home. The outcome needs to be recorded in each Resident’s records, at least on a 6 monthly basis. If an alteration or an additional medication is necessary on the Medication Administration Record (MAR) sheet, this must always be signed by two staff, dated and state the name of the Doctor authorising the change to the medication. When staff administer a prescribed medication, such as Fortisips or Sudecream the MAR sheet must by signed by the staff member administering the medication. When the letter ‘F’ is used on a MAR sheet it must always be defined. When medication is not given to Residents the code letter at the foot of the MAR sheet must be used, and not the signature of staff. The Acting Manager must ensure, when appointing new staff, that all the requirements listed in Regulation 19 and Schedule 2 of the Care Homes Regulations 2001, as amended during 2004, are obtained. That DS0000066561.V335676.R01.S.doc 5. OP9 13(2) 29/06/07 6. OP29 19(1)(b) (i) 29/06/07 Ashford Lodge Care Home Version 5.2 Page 26 is that 2 references must always be obtained when appointing new member of staff. 7. OP31 26(4) & (5) The Registered Provider must provide a written account of his formal ‘inspections’ of the Home, on a monthly basis, following the requirement laid down in Regulation 26. The Registered Provider and Acting Manager must address the Quality Assurance issues listed within Standard 33.1 to 33.7, and in Regulation 24, amended in 2006. All care staff must receive formal ‘supervision’ from the Acting Manager or another senior nurse. Fire Safety training must be provided for all night staff twice a year. 29/06/07 8. OP33 24 31/08/07 9. OP36 18(2) 29/06/07 10 OP38 23(4)(d) & (e) 31/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Refer to Standard OP1 OP3 No. 1. 2. Good Practice Recommendations The Residents Guide should include the views of Residents on what it is like to live in the Home. The Acting Manager should complete a summary of needs of all Residents initially moving to the Home whether they are sponsored by Social Services Dept or self-funding. The quality of the recording should be the same in all Residents files. 3. OP7 Ashford Lodge Care Home DS0000066561.V335676.R01.S.doc Version 5.2 Page 27 4. OP9 When the Pharmacy supplies new blister packs of medication to the Home mid-month, medication should be distributed from this blister pack from the same position as all other blister packs currently in use in the Home. A planned activities programme should be devised, possibly with the appointment of an Activities Coordinator. Staff should be informed which Residents should be encouraged to invite staff into their bedrooms when staff knock on their doors, and which Residents could no longer do this due to dementia or other conditions. 5. OP12 6. 7. OP15 OP16 When assisting a Resident to complete a meal, one member of staff should do this during the whole meal. A record of all concerns and complaints should be maintained, whether provided in writing or verbally, showing the nature of the complaint/concern and what the Acting Manager has done about the complaint/concern. Copies of the Public Interest Disclosure Act 1998 and of the Dept of Health guidance called ‘No Secrets’ should be obtained and be available in the Home at all times. A policy should be devised stating to staff that they are not permitted to benefit in any way from Residents wills. 8. OP18 9. OP24 A door lock system should be installed that will allow the use of a master key to unlock all doors. The system should also allow Residents to lock their door with a draw bolt on the inside of the bedroom. The odour in the bedroom identified during the inspection needed to be urgently removed. This might be done by much more frequent carpet cleaning or removing the carpeting and replacing with a cushion flooring. The Acting Manager should complete the application for registration as soon as possible. (This issue is outstanding from the inspection report dated 26 November 2006) Arrangements should be put in place to allow the savings of the Resident identified during the inspection to be banked to allow the Resident to benefit from interest payments made by the bank. DS0000066561.V335676.R01.S.doc Version 5.2 Page 28 10. OP26 11. OP31 12 OP35 Ashford Lodge Care Home 13 14 OP36 OP38 Care staffing should be supervised at least 6 times a year. The Registered Provider and Acting Manager should ensure the services provided by the Home comply with the Management of Health and Safety at Work Regulations 1999, Workplace (Health, Safety and Welfare) Regulations 1992 and the Provision and Use of Work Equipment Regulations 1992. The Registered Provider should provide risk assessments on all working practice topics in order to ensure that significant findings are recorded and acted upon. He should also provide a written statement of the policy, organisation and arrangements for maintaining safe working practices in the Home. Ashford Lodge Care Home DS0000066561.V335676.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ashford Lodge Care Home DS0000066561.V335676.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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