Inspection on 20/09/05 for Ashley Lodge

This inspection was carried out on 20th September 2005.

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

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

Other inspections for this house

Ashley Lodge 04/06/08

Ashley Lodge 05/06/07

Ashley Lodge 24/07/06

Ashley Lodge 16/02/06

Ashley Lodge 10/03/05

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Ashley Lodge Colmore Crescent Moseley Birmingham B13 9SJ Lead Inspector Brenda ONeill Announced 20 September 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. Ashley Lodge E54 S63042 Ashley Lodge V243982 200905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Ashley Lodge Address Colmore Crescent Moseley Birmingham B13 9SJ 0121 449 1503 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) Ashley Lodge RH Ltd Linda Phillips Care Home 26 Category(ies) of Older People registration, with number of places Ashley Lodge E54 S63042 Ashley Lodge V243982 200905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the registration category is 26 older people not falling within any other category. 26 (OP) 2. Hot water restrictors valves to be fitted to all hot water outlets accessible to service users within 6 months of registration. 3. All radiators to be risk assessed and guarded or replaced with LST radiators to reduce risks of scalding. All radiators in bathrooms and toilets and those near to beds or in restricted places will need to be guarded as a matter of priority. Within 3 months of registration for high risk radiators and six months for the remainder 4. Window restrictors to be fitted to the side opening windows. The limit of the opening should be restricted to approximately 10 cms within 3 months of registration. 5. The two external fire-escapes to be refurbished and receive essential maintenance. The handrails on the fire escapes to have loose paint removed and be re-painted. The treads of the stairs to have the mildew removed. Doors leading onto the fire escapes to be alarmed in some way to alert staff that the doors have been opened. The door leading from the first floor landing onto the ‘back stairs’ to be attended to so that it closes properly into the rebate, the use of these stairs by service users to be risk assessed. Within 3 months of registration. 6. Bedroom doors to be fitted with suited locks which can be used by service users but enable access by staff in the event of an emergency within 12 months of registration. 7. Bedrooms to be audited for furniture against the National Minimum Standards and arrangements made to provide items that are currently not in place. This is to include lockable item of furniture. Within 12 months of registration. 8. Electrical sockets within service users bedrooms to be audited against the National Minimum Standards and additional sockets fitted as needed within 12 months of registration. 9. Pipe work that is exposed in the bathrooms and along corridors to be boxed in within 6 months of registration. 10. Requirements as identified in the homes own fire risk assessment (if any remain outstanding) to be addressed. Bedroom doors that have been identified as in need of door closure devices to have these fitted as per time-scales previously identified. 11. Access into the ground floor bathroom which currently has a bath lift, to be reviewed. The step that needs to be negotiated cancels out some of the positive features of having a bath lift and it may be that the room currently used as a treatment room/store could be utilised as an assisted bathroom if a toilet was fitted and an alternative space for current use sought. Completion of review and submission of an action plan within 3 months of registration. 12. Permanent ramped access in to the home to be provided within 6 months of registration. 13. The sluice sink which is located within a service user toilet to be removed Ashley Lodge E54 S63042 Ashley Lodge V243982 200905 Stage 4.doc Version 1.40 Page 5 and relocated or separated from the toilet within 6 months of registration 14. Two of the bedrooms are quite small and are below 9.3 square metres. Plans will need to be submitted advising how it is intended to extend these rooms within 12 months of registration. 15. The service manager, Mrs. Vanessa Nuttall, will cover the position of manager for this home until a registered manager is employed. 16. In addition to the manager and ancillary staff maintain minimum staffing levels of three care staff throughout the waking day and two care staff on night duty one of whom should be designated senior. Date of last inspection 10 March 2005 Brief Description of the Service: Ashley Lodge is a care home providing care and accommodation for 26 older people. The home is located about a mile from the centre of Moseley in Colmore Crescent, which surrounds St Agnes Church. There is a bus service that runs regularly into Birmingham and in the other direction to Hall Green that can be accessed by a ten-minute walk to the Wake Green Road. The area where the home is situated has a village feel and is about 5 miles from the centre of Birmingham. The home itself is situated in a grade 2 listed building and many of its original features remain. The home has well maintained grounds that can be viewed by the residents from the lounge areas. There is some car parking facility in the driveway of the home as well as the facility to park in the street, which had no restriction at the time of writing. The home has one double bedroom the rest of the service users having single bedrooms. All but two of the bedrooms have an ensuite toilet and wash hand basin. Some rooms have ensuite showers. The home has two assisted bathrooms. The home is on two floors with a shaft lift or spacious staircase to the first floor. Ashley Lodge E54 S63042 Ashley Lodge V243982 200905 Stage 4.doc Version 1.40 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The announced inspection was carried out by two inspectors over one day and was the first of the statutory inspections for the home for 2005/2006. During the visit a tour of the premises was carried out, three resident and three staff files were sampled as well as other care and health and safety records and some policies and procedures. The inspectors spoke with the manager, the deputy, the proprietor, other staff on duty and six of the residents and one visitor. What the service does well: The comments received from residents and relatives prior to and during the inspection evidence that Ashley Lodge offers a good standard of care to the residents and has done so for a considerable amount of time. Comments received were also very positive about the staff team and included: ‘ From day one we can’t praise the staff enough.’ ‘He looks much healthier than he has done for years.’ ‘My mother has been at Ashley Lodge for 6 years and her care has always been of the highest standard.’ ‘A great bunch of caring girls.’ ‘The new management seem very experienced and have brought on more activities, staff and changes for the better in the home.’ ‘I am very satisfied with the care.’ I am well looked after and the food is good.’ ‘ The home has improved since it changed hands, chiefly in the provision of occupying residents.’ There had been no staff turnover at the home since the last inspection and many of the staff had worked there for a considerable amount of time which is very good for the continuity of care for the residents. There were very friendly but professional relationships evident between the staff and residents. The assessment procedures for new residents were good ensuring the needs of the residents were known and that they could be met by the staff. There was documented evidence that staff were identifying health care needs, following them up and monitoring them. All the residents spoken with were happy with the meals at the home stating the food was ‘good’ or ‘very good’. Residents were able to eat in their bedrooms or the lounge instead of the dining room if they wished. Ashley Lodge E54 S63042 Ashley Lodge V243982 200905 Stage 4.doc Version 1.40 Page 7 Residents confirmed there had been a meeting with the cook to discuss the menus and that the menus had been revamped taking into account what was said at the meeting. Staff received induction and ongoing training in a variety of topics to ensure they had the necessary skills and knowledge to fulfil their roles. The required minimum staffing levels were always maintained. What has improved since the last inspection? What they could do better: All residents or their representatives needed to be provided with a contract or statement of terms and conditions of residence so that they were aware of the conditions of their stay at the home. The home needed a formal quality assurance system in the home based on seeking the views of the residents to ensure the quality of care being provided is in keeping with the aims and objectives of the home. For the protection of the residents the manager needed to ensure that all the required documentation was obtained for new staff prior to their commencing their employment. To ensure the safety of the residents the radiators and any exposed hot pipe work needed to be covered. Some improvements were needed to the environment to ensure it was accessible and that residents had all the aids and adaptations they needed. Ashley Lodge E54 S63042 Ashley Lodge V243982 200905 Stage 4.doc Version 1.40 Page 8 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. Ashley Lodge E54 S63042 Ashley Lodge V243982 200905 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Ashley Lodge E54 S63042 Ashley Lodge V243982 200905 Stage 4.doc Version 1.40 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 standard(s) 1, 2, 3 and 4. The assessment procedures in the home were good ensuring the needs of the residents were known and could be met by the staff. Residents needed to have a signed contract/statement of terms and conditions with the home at the point of admission to ensure they were aware of the terms and conditions of their stay. EVIDENCE: The statement of purpose and service user guide for the home were viewed. All residents were being issued with a service user guide and these were visible in all bedrooms however there was no evidence that they were being issued with a contract or statement of terms and conditions of residence at the point of admission to the home. The statement of purpose needed to be updated and include the numbers of staff and the room sizes however as it was planned for their to be some changes to some rooms it was agreed this could be completed once the changes had taken place. Where applicable social workers had undertaken assessments for prospective residents and drawn up the initial care plans. In addition the home’s manager was carrying out her own assessments and the documentation being used covered all the required areas. Ashley Lodge E54 S63042 Ashley Lodge V243982 200905 Stage 4.doc Version 1.40 Page 11 The practices observed throughout the inspection evidenced that staff were able to meet the needs of the residents, for example, interactions with residents with dementia and appropriate terms of address. There was documented evidence of personal care needs being met. There was good documentation that the assessed medical needs of the residents were met including specialist services, for example, referrals to psychiatrists. There were aids and adaptations throughout the home to assist those residents with mobility difficulties. Ashley Lodge E54 S63042 Ashley Lodge V243982 200905 Stage 4.doc Version 1.40 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 standard(s) 7, 8, 9, and 10. The care planning system in the home was good but some additional detail was needed in relation to personal care needs to ensure staff knew how to meet all identified needs. Some improvements were needed to the risk assessments to ensure they were up to date and any identified risks were minimised. Some improvements were needed to the medication system to ensure it was safe for the residents. The privacy and dignity of the residents was being maintained. EVIDENCE: Three resident files were sampled and it was evident that staff had worked very hard since the last inspection to improve the care plans, risk assessments and reorder the files. The files included care plans which covered areas including mobility, physical care, social and cultural needs and eating and drinking. These were generally well detailed and included how staff were to meet the identified needs. However the residents’ personal care needs needed to be more detailed, for example, one care plan was very specific about what the resident was able to do for themselves but another was not, one included details of oral hygiene needs another did not. The files all included needs assessments which detailed the residents likes, dislikes and preferences at night and these were well detailed. Ashley Lodge E54 S63042 Ashley Lodge V243982 200905 Stage 4.doc Version 1.40 Page 13 All the files sampled included very detailed falls risk assessments, however, where the use of a hoist was detailed the sling size needed to be included. There were also manual handling risk assessments, nutritional screenings, tissue viability assessments and mental health assessments which had been completed appropriately. The personal risk assessments sampled did not include all identified issues, for example, where bed sides were being used there was no risk assessments and it was noted one of the residents zimmer frames was being removed for health and safety reasons and this was not detailed in any risk assessment or on the care plan. Without the appropriate documentation these actions could be misconstrued as restraint. It was also noted that one of the risk assessments had not been updated although the resident’s behaviour had changed. There was documented evidence of health care needs being identified, followed up and monitored by staff. There was evidence of visits from doctors, referrals to psychiatrists, blood tests being taken, optician and chiropody visits to the home. The home were taking part in a programme where they were receiving regular visits from a physiotherapist and occupational therapist who were assessing residents for any equipment needed, for example, wheelchairs and advising staff where they had any concerns about residents. The medication was being administered via a 28 day monitored dosage system. Only senior staff administered medication. There needed to be a specimen signature sheet for any staff who were administering medication so that it could be determined who had been responsible for the medication at any given time. Issues that arose during this inspection included, a controlled drug being stored in the drug trolley not the controlled drug cabinet and only recorded on the MAR chart and not in the controlled drug register, there was no running balance for some of the homely remedies, it could not be ascertained for some of the paracetamol how many had been administered therefore they could not be audited and there needed to be written guidelines for staff for the administration of PRN (as and when necessary) medication. At the time of the inspection staff were administering insulin to one of the residents. The inspectors were concerned about the responsibility on staff for doing this, as they had not received any training to ensure they were competent to carry out this procedure. This was discussed with the manager who was to pursue this issue with the district nurses. The day after the inspection the issue was resolved and the district nurses took over the task. No issues were raised in relation to the privacy or dignity of the residents. Staff were seen to knock on bedroom doors before entering, medical consultations took place in the privacy of the residents’ bedrooms or the treatment room and there was a lounge where residents could meet with their visitors in private if they wished. Ashley Lodge E54 S63042 Ashley Lodge V243982 200905 Stage 4.doc Version 1.40 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 standard(s) 12, 13, 14 and 15. There were no rigid rules or routines in the home and activities were available to offer stimulation to residents. Residents could receive visitors when they wished and were able to meet them in private. The meals in the home were good with choices available for residents. EVIDENCE: There did not appear to be any rigid rules or routines in the home. Residents were observed spending time quietly in their rooms, watching television, taking part in an activity to do with the harvest festival service that was due to take place in the home and meeting with visitors. Preferred social activities were recorded on care plans and documented activities on daily records included such things as, going out into the garden, out for a walk, attended church, reading, gentle exercise and outing to Hatton. There had been a recent garden fete that all the residents spoken with had very much enjoyed. The money raised from this was to be used for further activities both in and outside the home. There was a notice board in the entrance hall detailing any forthcoming activities. Comments received, prior to the inspection, on the completed comment cards included: ‘The staff have begun since Christmas, a programme of activities in and outside the home and have raised monies for these.’ Ashley Lodge E54 S63042 Ashley Lodge V243982 200905 Stage 4.doc Version 1.40 Page 15 ‘The home has improved since it changed hands, chiefly in the provision of occupying residents.’ ‘Manager and her colleagues provide numerous and innovative activities that both entertain and stimulate the residents.’ ‘The new management seem very experienced and have brought on more activities, staff and changes for the better.’ There were no restrictions on visitors to the home and they were seen to come and go throughout the course of the inspection. There was evidence on the daily records of residents receiving visits from families and friends and going out with them if they wished. There were details on the care plans and assessments sampled of residents’ likes, dislikes and preferences, where they were to be offered choices and for most to what extent they were able to care for themselves. Residents made ongoing choices about what to wear, what to eat, when to get up and go to bed and how they spent their time. Residents could continue to manage their financial affairs if they were able. Residents were encouraged to personalise their bedrooms to their choosing and personal possessions were observed in all the bedrooms. The menus at the home were varied and nutritious with choices available. The inspectors had lunch with the residents and the meal was well cooked and very well presented. All the residents spoken with stated the food was very good and some commented that they had attended a meeting with the chef to discuss their likes, dislikes and preferences and the menus had been rewritten taking the outcome of the meeting into consideration. There were menu cards on the dining room tables at lunch time detailing the choices available, however it was strongly recommended these were made available in larger print. The dining room had been relocated into what was a very large visitors lounge which gave the residents much more space. Food records were being kept but these needed to be more detailed and include the choices made by residents and any special diets being catered for. Ashley Lodge E54 S63042 Ashley Lodge V243982 200905 Stage 4.doc Version 1.40 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 standard(s) 16 and 18. There was an appropriate complaints procedure for the home and residents appeared confident that any issues they raised would be addressed. Staff needed to undertake training in adult protection awareness to ensure they were equipped with the appropriate skills and knowledge to recognise and be able to report any events or suspicion of abuse. EVIDENCE: There was an appropriate complaints procedure on site. The home had not received any complaints and none had been lodged with the CSCI. Residents that were asked stated they would have no hesitation in raising any concerns with the manager and felt they would be addressed. It was strongly recommended that staff record any ‘grumbles’ that residents may have and any actions that they take to address them as evidence that daily concerns are addressed. There were policies and procedures on site in relation to adult protection, whistle blowing and restraint. Staff needed to undertake training in adult protection awareness to ensure they were equipped with the appropriate skills and knowledge to recognise and be able to report any events or suspicion of abuse. Ashley Lodge E54 S63042 Ashley Lodge V243982 200905 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 23, 24, 25 and 26. The home offered residents clean, comfortable and generally spacious accommodation some issues needed to be addressed to ensure the safety of the residents. EVIDENCE: The location and layout of the home were generally suitable for its stated purpose. Several conditions of registration had been imposed on the proprietor some of which had been met or partially met, others were still within the time scales given. Some areas of the home were in need of redecoration as paintwork was chipped and some rooms were looking a little shabby. It was also noted that the exterior window frame of the bedroom 19 was badly in need of repair. The home had ample communal space with two lounge areas, a visitor’s lounge and a large dining room. Ashley Lodge E54 S63042 Ashley Lodge V243982 200905 Stage 4.doc Version 1.40 Page 18 Decoration was of an acceptable standard however the dining room furniture was looking quite worn but was due to be replaced and the lounge chairs were all exactly the same which did not give a very homely feel. Again these were to be replaced as the proposed redecoration and refurbishment of the home progressed. There were two assisted bathing facilities in the home however access to the ground floor bathroom which currently had a bath lift, needed to be reviewed. The step that needed to be negotiated cancels out some of the positive features of having a bath lift and it may be that the room currently used as a treatment room/store could be utilised as an assisted bathroom if a toilet was fitted and an alternative space for current use sought. The proprietor of the home informed the inspector he plans to extend the bathroom with the step and make it level access and incorporate a parker bath. There was no toilet facility within easy travel distance of the lounge areas. The proprietor was looking at ways of addressing this issue also. These issues need to be progressed as quickly as possible. There were some aids and adaptations throughout the home including a small shaft lift, hand and grab rails, a freestanding hoist and wheelchairs. Additional handrails were needed along some of the corridors however this was difficult due to the size of some of the radiators. This was discussed with the proprietor and he was to explore the possibility of the handrails being incorporated with the radiator covers. The front entrance of the home needed a fixed ramp, as there was only a portable ramp available however the proprietor had had to apply for planning permission for this, as the home was a listed building. It was known by the inspector that two of the bedrooms were below 9.3 square metres and a condition of registration was that plans be submitted to the CSCI advising how these rooms would be extended. The proprietor was in the position to alter these rooms as one had become vacant and the work was to commence shortly. Bedrooms were generally quite comfortable. One of the bedrooms had recently been refurbished and had an en-suite shower installed, another had had access to the en-suite improved so that it was accessible for the occupant’s wheelchair and enabled him to use the toilet unassisted. Some of the bedrooms had new locks fitted that were accessible to staff in case of emergency and residents could have keys if they wished. Wardrobes had been secured to the walls making them safe. Some bedrooms were in need of redecoration and this was being done as they became vacant. The proprietor was aware of the requirements for the bedrooms in relation to the minimum standards. The manager of the home had audited the bedrooms against the standards and identified where there were any shortfalls. The water temperatures checked during the course of the inspection were acceptable and the majority of the hot water outlets had mixer valves fitted. Ashley Lodge E54 S63042 Ashley Lodge V243982 200905 Stage 4.doc Version 1.40 Page 19 There were some bedroom sinks that did not have mixer valves but these did not pose a risk to the present occupants however this needed to be addressed. Some of the radiators had been guarded. The proprietor was aware of the requirement to either guard the radiators or have radiators with guaranteed low surface temperatures. It was also necessary to ensure all exposed hot pipe work was covered. There had been some difficulties with this as some of the radiators were very large and covers were difficult to obtain. Alternatives were explored with the proprietor. He needed to ensure that the radiators in high risk areas, for example, in en-suites and bedrooms, were guarded as soon as possible and notify the CSCI when this was complete. The home was found to be clean and odour free. There were systems in place for the disposal of clinical waste and protective clothing was available for the staff when needed. Staff needed to ensure that resident’s personal toiletries were returned to their rooms after use and that cleaning materials were not left lying around bathrooms. Ashley Lodge E54 S63042 Ashley Lodge V243982 200905 Stage 4.doc Version 1.40 Page 20 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, 28, 29 and 30. Appropriate staffing levels were being maintained by a stable staff group that could meet the needs of the residents. The recruitment procedures did not provide the safeguards to offer protection to the people living in the home. EVIDENCE: There had been no staff turnover since the last inspection and a lot of the staff had worked there for a considerable amount of time which was very good for the continuity of care of the residents. The home was being staffed in line with the conditions of registration which was a minimum of three care assistants throughout the waking day and two care staff on waking night duty. The manager’s hours were over and above this and cooks and domestic were also employed. Staffing levels appeared to be appropriate for the needs of the residents and were increased if the needs of the residents increased. Only one member of staff had been employed since the proprietor took over the home. The recruitment records for this person were inspected. Not all the required documentation had been obtained prior to employment, there was a completed application, proof of I.D. and a medical declaration however there was only one reference and the CRB check had been sent for but had not been returned to the home and there was no evidence that a POVA first check had been carried out. Thirty percent of the staff were trained to NVQ level 2 or 3 and others were undertaking the training. There was a training matrix for the home and staff also had individual training records. Ashley Lodge E54 S63042 Ashley Lodge V243982 200905 Stage 4.doc Version 1.40 Page 21 There were records of induction training and staff had completed most of the mandatory training and updates were ongoing. Staff had also recently undertaken training for dementia awareness. The manager needed to ensure that the induction and foundation training covered all the required topics and was within the required time scales as laid down by the Learning and Skills Council. Ashley Lodge E54 S63042 Ashley Lodge V243982 200905 Stage 4.doc Version 1.40 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32, 33, 35, 36 and 38. The manager ensured the smooth running of the home in a competent manner. Some issues needed to be addressed to ensure the safety of the residents. The home needed a formal quality assurance system in the home based on seeking the views of the residents to ensure the quality of care being provided is in keeping with the aims and objectives of the home. EVIDENCE: The manager of the home had recently been successful in gaining her registration with the CSCI and was undertaking the Registered Manager’s Award qualification. She had worked at the home for a number of years and demonstrated a good knowledge of the residents’ needs. She had worked hard since the last inspection, along with the staff team, to develop and update care plans and risk assessments, reorganise files and enhance the activities on offer to the residents in the home. Ashley Lodge E54 S63042 Ashley Lodge V243982 200905 Stage 4.doc Version 1.40 Page 23 The atmosphere in the home was very friendly and it was clear there were very good relationships between the manager, staff, residents and visitors to the home. Residents expressed the view that they would have no hesitation in approaching the manager with any issues that may arise. There was no formal quality assurance system in the home and the manager was aware of the requirement for this. There were regular resident and staff meetings and residents had their own notice board to keep them informed of what was happening in the home. There were also occasional resident questionnaires to get their views on the home. The manager was not handling any money on behalf of the residents. For those residents who were unable to handle their own finances the proprietor would purchase any items the residents required and then invoiced the appropriate person. The manager had developed a system of staff supervision and the records for this were sampled. The appropriate areas were being covered however the manager needed to ensure that all staff had a minimum of six supervision sessions per year. There was evidence on site of some visits made by the representative of the company however these were not being done on a monthly basis as required. Some issues were raised in relation to health and safety, for example, the need for radiators to be guarded. Staff had received training in safe working practices. There was evidence on site of the regular servicing and maintenance of all equipment, with the exception of the emergency call system, the water system had been checked for the prevention of legionella and all the in-house checks on the fire system were up to date. There were numerous risk assessments in place for the premises and an outside agency had completed the fire risk assessment. Accident recording and reporting were appropriate. Ashley Lodge E54 S63042 Ashley Lodge V243982 200905 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 1 3 4 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 2 3 1 2 2 2 1 2 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 2 3 1 x 3 2 2 2 Ashley Lodge E54 S63042 Ashley Lodge V243982 200905 Stage 4.doc Version 1.40 Page 25 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 4(1)(c) sch 1(3)(16) Requirement Timescale for action 31/12/05 2. 2 3. 7 4. 7 5. 7 6. 7. 7 9 The statement of purpose for the home must include the numbers of staff and the room sizes. (Previous time scale of 01/05/05 not met.) 5(1)(b) All residents must be issued with a contract/statement of terms and conditions at the point of admission to the home. (Previous time scale of 01/06/05 not met.) 15(1) Care plans must include all the personal care needs of the residents and detail how these are to be met by staff. (Previous time scale of 01/06/05 partially met.) 13(5) Where the use of a hoist is included on a falls risk assessment the sling size must be detailed. 13(3)(c) & All the risks identified for the 13(6) residents must be documented and include any actions that have been undertaken to minimise risks. 13(3) All personal risk assessments must be updated as the needs of the residents change. 13(2) There must be a specimen signature sheet for any staff E54 S63042 Ashley Lodge V243982 200905 Stage 4.doc 01/11/05 01/11/05 01/11/05 01/11/05 01/11/05 01/11/05 Page 26 Ashley Lodge Version 1.40 administering medication. 8. 9 13(2) There must be a complete audit trail for all medication in the home including any homely remedies. All controlled medication must be stored in the controlled drug cabinet and receipt and administration recorded in the conrolled drug register. There must be written guidance for staff to follow for the administration of PRN medication. There must be records of food served to the residents in enough detail to evidence that the diet is satisfactory, in relation to nutrition and otherwise, and of any special diets prepared for individual residents. Staff must undertake training in adult protection awareness. All areas of the home must be kept reasonably decorated. The window frame to room 19 must be repaired/replaced. Improvements must be made to the assisted bathing facilities and the availability of toilets in relation to the lounge areas. (Previous time of 01/09/05 not met.) Hand rails must be fitted to both sides of the corridors wherever possible. A permanent ramp must be installed to the main entrance of the home. Plans must be submitted to the CSCI advising how it is proposed to extend the two small bedrooms. (Previous time scale had not expired.) All bedrooms must be audited for furniture against the National 14/10/05 9. 9 13(2) 14/10/05 10. 9 13(2) 14/10/05 11. 15 17(2) sch 4(13) 01/12/05 12. 13. 14. 15. 18 19 19 21 18(1)(a) 23(2)(d) 23(2)(b) 23(2)(j) 01/01/06 01/03/06 01/12/05 31/01/06 16. 17. 18. 22 22 23 23(2)(n) 23(2)(n) 23(2)(f) 01/12/05 31/12/05 10/12/05 19. 24 16(2)(c) 10/12/05 Page 27 Ashley Lodge E54 S63042 Ashley Lodge V243982 200905 Stage 4.doc Version 1.40 20. 24 16(2)(c) 21. 24 12(4)(a) 22. 25 13(4)(c) 23. 25 13(4)(c) 24. 25 13(4)(c) 25. 26 13(3) 26. 29 19 sch 2. 27. 28 18(1)(a) Minimum Standards and arrangements made to provide items that are not currently in place. (Partially met. Previous time scale had not expired.) Electrical sockets within service user’s bedrooms must be audited against the National Minimum Standards and additional sockets fitted as needed. (Previous time scale had not expired.) Bedroom doors must be fitted with locks which can be used by service users but enable easy access by staff in the event of an emergency. (Previous time scale had not expired.) The remaining hot water outlets that do not have thermostatic mixer valves fitted must be addressed and CSCI must be notified when this is completed. All radiators must be risk assessed and guarded or replaced with LST radiators to reduce risks of scalding. All radiators in bathrooms and toilets and those near to beds or in restricted places must be guarded as a matter of priority. CSCI must be notified of completion.(Previous time scale of 10/03/05 not met.) Pipe work that is exposed in the bathrooms and along corridors must be boxed in. CSCI must be notified of completion. (Previous time scale of 10/06/05 not met.) Personal toiletries and cleaning substances must be removed from communal bathrooms after use. Staff files must contain all the information required by Schedule 2. (Previous time scale of 01/06/05 not met.) 50 of care staff must be qulaified to NVQ level 2 or the 10/12/05 10/12/05 31/12/05 31/12/05 31/12/05 14/10/05 01/11/05 31/12/05 Page 28 Ashley Lodge E54 S63042 Ashley Lodge V243982 200905 Stage 4.doc Version 1.40 equivalent . 28. 30 18(1)(a) The manager must ensure that the induction and foundation training offered in the home covers all the topics and is completed within the time scales laid down by the Learning and Skills Council. The manager must be qualified to NVQ level 4 in care and management. (Previous time scale given had not expired.) The home must have effective quality assurance and quality monitoring systems in place, based on seeking the views of the residents. All staff must receive a minimum of six supervision sessions per year. Copies of the monthly visit reports made by the representative of the company must be available for inspection. There must be evidence on site that the emergency call system has been serviced. 31/12/05 29. 31 9(1)(b)(i) 31/12/05 30. 33 24(1)(2) (3) 01/01/06 31. 32. 36 37 18(2) 26 31/12/05 01/12/05 33. 38 13(3) 01/11/05 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 15 16 Good Practice Recommendations It is strongly recommended that the menu cards are made available in large print. It is strongly recommended that there is a grumbles book set up in the home to record any day to day issues raised by the residents and how these were addressed. Ashley Lodge E54 S63042 Ashley Lodge V243982 200905 Stage 4.doc Version 1.40 Page 29 Commission for Social Care Inspection Birmingham & Solihull Local Office 1st Floor, Ladywood House 45-46 Stephenson Street Birmingham, B2 4UZ 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 Ashley Lodge E54 S63042 Ashley Lodge V243982 200905 Stage 4.doc Version 1.40 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. 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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