CARE HOMES FOR OLDER PEOPLE
Ashlea Lodge Residential Home Hylton Road Millfield Sunderland SR4 7AB Lead Inspector
Sam Doku Unannounced Inspection 29 November & 9 December 2005 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ashlea Lodge Residential Home DS0000034296.V253986.R01.S.doc Version 5.0 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. Ashlea Lodge Residential Home DS0000034296.V253986.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Ashlea Lodge Residential Home Address Hylton Road Millfield Sunderland SR4 7AB 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) 0191 510 9405 0191 510 9406 Winnie Care Limited Darren Kennedy Care Home 40 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (7), Mental Disorder, excluding learning of places disability or dementia - over 65 years of age (4), Old age, not falling within any other category (40), Physical disability over 65 years of age (8), Sensory Impairment over 65 years of age (5) Ashlea Lodge Residential Home DS0000034296.V253986.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The DE service user category relates to one current service user only. Date of last inspection 3rd June 2005 Brief Description of the Service: Ashlea Lodge is a two-storey building, which has been specifically designed to provide personal care for older people who may have a variety of needs. The layout of the building allows for the home to be divided into three separate units and each contains a lounge, dining room, kitchen, bathroom, toilets and en suite bedrooms. A garden, which is accessible to people who use a wheelchair is at the rear of the building and there is a car park at the front. The home is located close to St Marks Church and a GPs surgery, both of which are easily accessed. The metro line has a station within walking distance from the home. In addition, there is a regular bus service, which stops opposite the home. Ashlea Lodge is situated relatively close to a shopping area, which has a post office, grocers and public houses. The home is registered to admit 40 people who may have physical disabilities or who may have dementia type illness. The home is owned by Winney Care Limited. Ashlea Lodge Residential Home DS0000034296.V253986.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was conducted over two days and involved two inspectors. The main inspection activities took place on the 29.11.05 followed by additional visit by the two inspectors on 9/12/05 to conclude the inspection. The total time spent by the two inspectors on the inspectors was 12 hours and 35 minutes due to recent changes on the day-to-day management arrangement of the home. The registered manager has recently been on long-term sick leave and in his absence the Regional Manager for the company took management responsibility to the running of the home. After just a few weeks of managing the home, she took up a post with another company. To maintain a management presence in the home, the Operational Manager for the company assumed the role of temporary manager with support from a registered manager (supporting manager) from one of the company’s other homes. Shortly after taking responsibility for the management of the home, the Operational Manager advised the Commission of his dissatisfaction with some aspects of the management of the home by the registered manager who remains on sick leave. As a result, the inspector decided to bring forward the planned unannounced inspection to an earlier date. Observations in this report largely relates to the period during which the registered manager was in charge of the home. This inspection process involved talking to service users, visitors, sitting in the lounge and observing staff interaction with the service users, discussions with the Interim Manager and care staff, tour of the house, examination of health and safety records and service users’ personal file including care plans. The standards relating to the premises were not inspected on this occasion as all of these were inspected at the last inspection and found to be satisfactory. The home has maintained the satisfactory conditions and continues to do so. This part of the report therefore should to be read in conjunction with the last inspection report of the 3 June 2005. At the time of the inspection a recruitment process was in place to appoint a new manager for the home. Ashlea Lodge Residential Home DS0000034296.V253986.R01.S.doc Version 5.0 Page 6 What the service does well: What has improved since the last inspection? What they could do better:
Accountability regarding service uses monies could not be established. Two service users claimed to have deposited personal monies with the registered manager but no record of such transactions were available in the home. Risk assessments relating to smoking and self-medication by service users had not been carried out. Also risk assessment relating to the storage of oxygen cylinder in a service user’s room had not been carried out. One-to-one supervision had not been offered to some of the staff in recent months. Staff had no training in care planning and were ask asked to do care plans without the necessary training. This accounted for the poor quality of the care plans that were examined during the inspection. Examination of staff records indicated that some staff members had no CRB checks done for them. An immediate requirement notice has been issued on the registered provider to make suitable arrangements for immediate checks to be done for those staff. Staff records were poorly maintained. One record did
Ashlea Lodge Residential Home DS0000034296.V253986.R01.S.doc Version 5.0 Page 7 not contain application form, no references and no evidence ID checks. Such serious lapses in employment practices exposes the service users to possible abuse by people who would otherwise be deemed as unsuitable to work with vulnerable people. The organisation of service users files is poor. The daily report sheets do not follow date order. It was there difficult to follow the progress of the service users using the daily recording sheets. Fire instructions for staff were not taking place as required. One fire instruction/drill was carried out in April 2005 and none till November 2005. It only listed two recently appointed staff as being present during the drill. There was no staff list to indicate which day staff members have received the required two fire instructions per year. There was no indication of night staff having such fire instructions. The monthly fire equipment checks have not been done between August and November. These lapses have serious implications for fire safety and the safety and welfare of the service users. In talking to staff it would seem that statutory training have been provided for the staff. However, in the absence of training records it was not possible to determine what training had been provided for each staff member. The general premises risk assessment form in its current format is not useful in clearly identifying risks and plans in managing those risks within the home. Moving and handling risk assessments had been done but this only identifies the problem. It does not offer ways of managing those risks or problems. The format also did not provide a clear distinction for the “Yes” and “No” answers. There had been no organised bus rides or trips for the service users recent months. This was commented on by both staff and service users. In discussions with the day staff it was evident that there was no general attempt to encourage service users to have a lie-in. At 09:10 on the day of the inspection, a number of service users were found to be fast asleep in the lounge. Day staff confirmed that it is normal practice to find all service up and sitting in lounge when they arrive on duty at 08:00. This practice must be reviewed to offer service users choice of when to rise in the morning Service users also spoke about meals being served on cold plates. On the day of the inspection the inspector was able to verify this. Service users spoke about the registered manager not responding promptly to requests made by them. The complaints record consists of two loose sheets of paper. The record did include details of outcome of the complaints. It therefore fails to provide full details of complaints received by the home and how these were dealt with by the registered manager. There are two service user guides in circulation at the moment. One of them do not meet the requirement as it did not include the details that are required Ashlea Lodge Residential Home DS0000034296.V253986.R01.S.doc Version 5.0 Page 8 to be included in a service user guide. However, the other one is more up to date and should be the one to be given to service users. Staff expressed concerns about how the supporting manager and the changes that she made without consultation or discussion with the staff. Her style of management was described as “like a bull in a China shop”. Some staff expressed concerns that rotas were changed without consultation or explanation by the Interim Manager. 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. Ashlea Lodge Residential Home DS0000034296.V253986.R01.S.doc Version 5.0 Page 9 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 Ashlea Lodge Residential Home DS0000034296.V253986.R01.S.doc Version 5.0 Page 10 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3. The home has a service user guide, which provides information to prospective service users about the service. The home provides information to prospective service users about contracts and also about the home’s policy on pre-admission visits to the home. EVIDENCE: The service users files that were examined contained copies of terms of conditions of residence. It is the home’s policy to regard the first six weeks of residency as a trial period. Two service users were spoken with and they both confirmed that they were offered the opportunity to discuss the terms and conditions of residence with the registered manager. One family said that the daughter of the service user signed the document on her mother’s behalf. This ensured that the family and the company had a clear understanding what each other’s obligations are. Ashlea Lodge Residential Home DS0000034296.V253986.R01.S.doc Version 5.0 Page 11 All prospective service users are invited to visit the home to meet with other service users and staff. This arrangement is included in the Service User Guide, copies of which are available to all service users. Service users described their experience of visiting the home with the families before deciding on making the final decision to come and live at Ashlea Lodge. One service user described this as a very useful opportunity to view the home, meet other service users, the staff and have the opportunity to ask questions about the service. Ashlea Lodge Residential Home DS0000034296.V253986.R01.S.doc Version 5.0 Page 12 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11 The healthcare needs of the service users are fully met. There is a risk to service users’ welfare as the home failed to carry out risk assessments for those who manage their own medicines. Staff have good understanding of how best to support service users and their family at the time of their death. EVIDENCE: All the service users files that were examined were found to provide details of their medical care needs. The files contain details of visits to GPs, hospital consultants, chiropody treatment, opticians, dentists and other healthcare professionals. Three service users confirmed that there are suitable arrangements in place for meeting their healthcare needs. They stated that staff would always make appointments for them to see their GPs and other professionals. However, one service user expressed his displeasure at the registered manager not taking timely action to obtain a medical device for him for several months.
Ashlea Lodge Residential Home DS0000034296.V253986.R01.S.doc Version 5.0 Page 13 In discussions with two visiting relatives, they all confirmed that the service users’ healthcare needs are met within the home and feel that the staff take active role in promoting this. The files of two service users who manage their medication were examined. It was noticed that no risk assessments had been carried out to ensure that appropriate measures are in place to enable them to manage their medicines safely. At the last inspection the registered manager was advised to seek advice from their pharmacist regarding the ventilation and high temperature in the medicines room as this may affect the integrity of the medicines stored there. This had not been addressed as recommended. Two staff members were specifically spoken with about the issues surrounding death. They described the general policy on caring for the dying. Staff described the care routines and the general support given to the family and the wishes of the service user at such times. Staff showed good understanding of the need to provide the right kind of care in these circumstances. Staff spoke about the wishes of the service user and their family and the role of the staff when dealing with death. Staff described how they would support the person and the family, including the opportunity for a family member to stay in the home with the service user if they wish. This provides reassurance to families that their loved one would be properly care for when a service user is approaching death. Ashlea Lodge Residential Home DS0000034296.V253986.R01.S.doc Version 5.0 Page 14 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14. On the whole, the practices in the home enable service users to exercise choice and to maintain lifestyle that is not too dissimilar to what they would want. This promotes healthy lifestyle for them. EVIDENCE: Four service users’ files were examined which showed, amongst other details, the service users’ interests. The staff confirmed that in the absence of the activities coordinator, they try to provide social and creational activities for the service users. They listed music, keep fit, dancing and bingo. On the day of the inspection the service users and staff were engaged in small group discussions and music session. Some service users choose not to take part and stayed in the other lounges or in their rooms to watch TV. Service users emphasised that no one is made to join in any organised activities if they did not wish to, thus promoting their independence, choice and respecting their wishes. The service users regularly use community facilities such as the local shops, visits to the hairdresser, GP appointments and local church. Staff commented that the local Salvation Army visits the home regularly to talk to the service users. The local church vicar calls on regular basis to offer prayers and
Ashlea Lodge Residential Home DS0000034296.V253986.R01.S.doc Version 5.0 Page 15 communion to those who want it. This provides the opportunity for individual service users to continue to practice their religion. However, a number of service users commented that there is nothing to do and that they would like meaningful activities such as bus trip to places of interest and bus rides along the coast. It was pleasing to note that special arrangements had been made for one gentleman to visit his local pub on a daily basis. Other service users spoke about the excellent support they get from the staff to enable them to maintain community contacts. Ashlea Lodge Residential Home DS0000034296.V253986.R01.S.doc Version 5.0 Page 16 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17, 18. While there are suitable arrangement for ensuring that service users are protected from any form of abuse, the staff recruitment procedure has not been followed and this exposes service users to possible abuse. EVIDENCE: The home’s complaints procedure is displayed in the home. It is also included in the service user guide thus making it accessible to both service users and visitors. Service users who were spoken with stated that they are aware of the complaints procedure. Two recently admitted service users confirmed that this was not only available in written form but the procedure was explained to them by staff members. Suitable training on the protection of vulnerable adults (POVA) has been provided for the majority of the staff working in the home. The staff who were spoken with showed an understanding of the POVA procedures and an awareness of the need to protect service users from all forms of abuse. However, in the absence of detailed staff training documentation it was not possible to verify this training for the staff. The current interim manager is reviewing the staff files and it has been noticed that some staff have not had CRB clearance done for them. One staff file did not contained application, references, ID checks or CRB check. Such serious lapses do expose service users to abuse from people who otherwise would have been deemed unsuitable to work with vulnerable people. An immediate
Ashlea Lodge Residential Home DS0000034296.V253986.R01.S.doc Version 5.0 Page 17 requirement noticed has been issued on the provider to ensure that immediate action is taken to address this. Those service users who were spoken with indicated that if they have any concerns they felt confident to raise it with whoever is in charge or any staff without fear of intimidation. Some service users also confirmed that they feel their rights are respected by the staff. This was also confirmed by the relatives who were spoken with. Some service users spoke about their past involvements in postal voting during local and national elections. Staff confirmed that all service users have been registered to receive postal votes. This ensures that the service civic rights are protected. Ashlea Lodge Residential Home DS0000034296.V253986.R01.S.doc Version 5.0 Page 18 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected on this occasion as they were all inspected at the last inspection and found to be satisfactory. EVIDENCE: Not inspected on this occasion. Ashlea Lodge Residential Home DS0000034296.V253986.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29, 30. The home maintains staffing numbers and skill that meet the needs of the service users. The home’s recruitment policy has not been followed by the registered manager. This exposes service users to abuse by people who are not properly vetted. EVIDENCE: Details of staff rotas were examined during the inspection. It was noted that the home consistently maintains adequate staffing levels to meet the needs of the service users. Service users confirmed that they feel there is always sufficient staff on duty to meet their immediate personal care needs. Staff also confirmed that adequate staffing levels have always been maintained to meet the needs of the service users. Staff maintain that they have had training in moving and handling, first aid, protection of vulnerable adults, health and safety, food hygiene and nutrition. The staff who were interviewed confirmed the training they had received and felt that these had equipped them to do their jobs better. Staff records were examined with the view to determine whether or not the company adheres to proper employment policies in recruiting staff. It was evident from the two staff files that proper recruitment procedures have not been followed by the registered manager. For one recently appointed carer,
Ashlea Lodge Residential Home DS0000034296.V253986.R01.S.doc Version 5.0 Page 20 there was no application form, references, ID checks and CRB checks. Evidence of CRB checks could not be found some other files. Recruitment procedures have been put in place by the company to ensure further protection of service users from possible abuse from applicants who would otherwise be deemed as unsuitable to work with vulnerable people. In this case the registered manager had not followed the procedures, and therefore exposing service users to possible risk of abuse by not making the necessary checks as required. The company places great emphasis on training the care staff to NVQ Level 2 or above. Staff confirmed that a number of them have completed the NVQ Level 2. However, in the absence of records relating to staff training it has not been possible to verify this. The interim manager is conducting a complete review of staff training and to provide the Commissions with his findings. Staff who confirmed their completion of NVQ training indicated that the training had enhanced their confidence and self-esteem and are therefore able to provide good quality care for the service users. Ashlea Lodge Residential Home DS0000034296.V253986.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37, 38. Recent event surrounding the registered manager indicated poor management and lack of leadership. This has had adverse effect on the quality of the service offered. EVIDENCE: At the time of the inspection, the home could be regarded as not having a suitably qualified person to manage the home. The Commission was advised in a letter that the registered manager is on long-term sick leave. The Regional Manager for the company took charge of the running of the home but two weeks later she left her post as Regional Manager for the company. To maintain a management presence in the home, a manager from one of the company’s other homes (to be referred to as Supporting Manager for the purpose of this report) was asked to support the Operational Manager in taking on management responsibility until a new manager is appointed.
Ashlea Lodge Residential Home DS0000034296.V253986.R01.S.doc Version 5.0 Page 22 The Operational Manager had effectively assumed responsibility for the management of the home on a temporary basis with support from the supporting manager until a suitably qualified person is appointed. They were also to be supported by another regional manager when needed. The current management arrangement is not considered to be ideal and therefore the plan to appoint a suitably qualified manager in the next few weeks must be pursued to safeguard the safety and wellbeing of the service users. The deputy manager confirmed that the home does not manage money for any of the service users, except for personal allowances. However, it has been brought to attention of the company by two service users that they each handed money over to the registered manager for safe-keeping. The deputy manager was not aware of such money being deposited with the registered manager. No record could be found in the home or a statement in the service users files to say that such monies had been given to him for safe keeping. The company has since made arrangements to refund the monies to the two service users concerned. However, this is considered to be very poor practice, and therefore an effective financial management system must be put in place safeguard service users. Some staff stated that they believe the registered manager run the home for the benefit of some staff members and not for the service users. They alleged that the registered manager often allowed some members of staff to dictate the way the rotas are organised. Two service users also spoke about the registered manager not taking prompt action to address issues raised by them. One described his management style as “free and easy” attitude, which they believe affected the quality of care provided in the home to the detriment of the service users. Records relating to service users and staff are poorly organised and poorly maintained. Care plans information did not fully represent the needs of the service users. Staff commented that they have not been given training in writing care plans yet they have been given the task of writing these up, hence the poor quality of the care plans that were examined. The lack of detailed care plans and proper risk assessment relating to smoking and self medication seriously compromise the safety and welfare of the service users. Supervision of staff has taken place in some cases but the staff files that were examined showed that this had not been consistently done in order to have the desired effect. Some staff have not received supervision for a considerable time now, and one carer confirmed that she has not received any supervision from the registered manager even though she has she been working in the home for a number of years now. There was no central record for staff training and therefore it was difficult to establish which staff have had training in the fire safety, first aid, moving and handling, food safety and health and safety. However, some staff confirmed
Ashlea Lodge Residential Home DS0000034296.V253986.R01.S.doc Version 5.0 Page 23 that they have had these training but they were not sure of the specific dates when these took place. These could not be verified in the absence of records on individual files. The fire logbook shows that the required number of instructions for day and night staff have not been met. This is a serious breach of fire safety and other safety measures in the home and as a result the registered provided was issued and immediate requirement notice to require him to make suitable arrangement for such fire instructions to be carried for all the staff. A number of other records relating to health and safety issues in the home were examined. These include electrical maintenance test certificate, water treatment certificate, lift and hoist servicing records. These show evidence of servicing and maintenance being up to date, thus ensuring some safety for the service users. Ashlea Lodge Residential Home DS0000034296.V253986.R01.S.doc Version 5.0 Page 24 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 1 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 2 X X X X X X X X STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 1 2 X 1 2 1 2 Ashlea Lodge Residential Home DS0000034296.V253986.R01.S.doc Version 5.0 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13(4)(a) Requirement Risk assessments must be carried out for service users who are responsible for the safekeeping of their medication. The home must review the social activities provided in the to ensure that such activities take account of the wishes of the service uses. In deciding when to rise or retire to bed, the home must take account of the wishes of the service users. These must be clearly set out in the individual care plans. Proper records must be maintained of all complaints received in the home. A system must be put in place to account for monies deposited by service users for safe-keeping An audit of staff training must be carried out to identify staff who have not had training in moving and handling, health and safety, COSHH, first aid and food hygiene, and arrangements must be made to provide such training for those who have not had one.
DS0000034296.V253986.R01.S.doc Timescale for action 09/01/06 2 OP12 16(2)(m) 05/01/06 3 OP14 15(2)(c) 05/01/06 4 5 6 OP16 OP18 OP27 22(1) 13(6) 13(3)(4) (5)(6) 01/03/06 01/03/06 01/04/06 Ashlea Lodge Residential Home Version 5.0 Page 26 7 8 OP28 OP29 23(4)(d) (e) 19(1)(b) (c) 9 10 11 OP30 OP31 OP32 14(2) 8(a) 12(5)(a) 12 OP36 18(2) 13 OP37 17(1)(a) 14 OP38 13(4)(a) 15 OP38 23(4) Suitable arrangements must be put in place for the training of staff in fire safety. Appropriate action must be taken to ensure that the company’s employment policy is followed, including completion of application form, obtaining references and CRB checks. All care must receive training in the formulation, implementation and review of care plans. A suitably qualified manager must be appointed as a matter of urgency. The home must be managed in a manner that promotes good working relationship between management and the staff. Suitable arrangements must be put in place to ensure that all care staff receive appropriate one-to-one supervision. Records relating to service users and staff are poorly organised and arrangements must be made to address these as a matter of urgency. Risk assessments must be carried out for service users who smoke and responsible for the safe-keeping of the cigarettes and lighters. The general risk assessment form must be modified for purpose. The form in its current form does not fully identify the risk areas in the home. 09/01/06 09/01/06 01/04/06 01/04/06 09/12/05 01/02/06 01/02/06 09/12/05 01/02/06 Ashlea Lodge Residential Home DS0000034296.V253986.R01.S.doc Version 5.0 Page 27 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. Refer to Standard OP9 OP12 Good Practice Recommendations Advice of the pharmacist should be sought regarding ventilation in the rooms where the medicines are stored. The hours allocated for the activities coordinator to provide activities for the service users should be reviewed to ensure that the hours are adequate to meet the needs of the service users. The system for serving diner should be review to avoid serving hot meals on cold plates. 3 OP15 Ashlea Lodge Residential Home DS0000034296.V253986.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection South of Tyne Area Office Baltic House Port of Tyne Tyne Dock South Shields NE34 9PT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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