Inspection on 24/07/06 for Ashley Lodge

This inspection was carried out on 24th July 2006.

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 16/02/06

Ashley Lodge 20/09/05

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 West Midlands B13 9SJ Lead Inspector Brenda O’Neill Key Unannounced Inspection 24th July 2006 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 Ashley Lodge DS0000063042.V301697.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. Ashley Lodge DS0000063042.V301697.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashley Lodge Address Colmore Crescent Moseley Birmingham West Midlands B13 9SJ 0121 449 1503 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) Ashley Lodge RH Ltd Mrs Linda Joy Phillips Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places Ashley Lodge DS0000063042.V301697.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. That the registration category is 26 older people not falling within any other category. 26 (OP) Hot water restrictors valves to be fitted to all hot water outlets accessible to service users within 6 months of registration. 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 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. 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. Bedroom doors will 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. 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. 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. Pipe work that is exposed in the bathrooms and along corridors to be boxed in within 6 months of registration. 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. 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 DS0000063042.V301697.R01.S.doc Version 5.2 Page 5 4. 5. 6. 7. 8. 9. 10. 11. Ashley Lodge plan within 3 months of registration. 12. 13. 14. 15. Permanent ramped access in to the home to be provided within 6 months of registration. The sluice sink which is located within a service user toilet to be removed and relocated or separated from the toilet within 6 months of registration. 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. 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. 16th February 2006 Date of last inspection 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 residents 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. The fees at the home were £450.00 per week. Ashley Lodge DS0000063042.V301697.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over one day in July 2006. During the inspection a tour of the building was carried out, three resident and one staff file were sampled as well as other care, training and health and safety documentation. The inspector spoke with the manager, deputy manger, proprietor, one staff member, two visitors and six of the twenty five residents. Prior to the inspection the manager had forwarded a completed pre inspection questionnaire which detailed some information about the home. What the service does well: The home had a very friendly atmosphere and friendly relationships were evident between the staff and residents. The home continued to have a very stable staff team, which was good for the continuity of care of the residents. Adequate numbers of staff were on duty to ensure the needs of the residents could be met. All the comments received about the staff team from residents and visitors were very positive and included: ‘I’m always made welcome and staff could do no more.’ ‘The carers are very nice.’ ‘If you mention anything to the managers they sort it out.’ ‘They listen to what we say.’ ‘If I have raised anything it is taken seriously.’ The assessment procedures in the home ensured the needs of the residents were known and could be met by staff and prospective residents were able to visit the home prior to admission. Care plans for the residents were quite comprehensive and included details of the needs of the residents and how these were to be met by staff. There was evidence that the residents had been consulted about their care plans. There was documented evidence that where staff had identified a health care need this was followed up and monitored. The system for administering medication was very well managed and ensured the residents received the right medication at the appropriate times. There were no rigid rules or routines in the home and there were activities available for residents to take part in if they wished both inside and out of the home. There were no restrictions on visitors within reasonable hours and they were made welcome by staff. Residents spoken with were happy with the food being served at the home and there was evidence that the chef discusses the menus with the residents Ashley Lodge DS0000063042.V301697.R01.S.doc Version 5.2 Page 7 prior to changing them. The menus evidenced a wide variety of food being offered to the residents with choices available. It was evident that a great deal of effort goes into the presentation of food at the home. The home had an appropriate complaints procedure and all residents had received a copy of this in the service user guide. No complaints had been lodged at the home and none had been lodged with the CSCI. The recruitment procedures for new staff were robust and safeguarded the people living in the home. Staff received ongoing training in a variety of topics and over 50 of staff were qualified to NVQ level2. The home offered residents clean, comfortable and generally spacious accommodation. The heath and safety of the residents and staff was well managed. What has improved since the last inspection? What they could do better: The manager needed to ensure that all care plans were updated as the needs of the residents changed and that all necessary risk assessments were in place to ensure any identified risks were minimised. The daily records for the residents needed to be improved to ensure they gave an overview of the general welfare of the residents and how they were spending their days. Staff needed to be mindful of the terminology used when recording about residents to ensure they were fully understood by other staff who were reading them. The records of the food provided for residents needed to be improved and kept in sufficient detail to enable anyone inspecting them to determine whether the Ashley Lodge DS0000063042.V301697.R01.S.doc Version 5.2 Page 8 diet was satisfactory in relation to nutrition and otherwise and of any special diets being catered for. The manager needed to ensure that the induction training offered to staff covered all the areas detailed by Skills for Care and that it was completed within the first twelve weeks of employment. This would ensure all staff were equipped with the necessary skills and knowledge to fulfil their roles. 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. Some further improvements were needed to the environment to ensure it was accessible and that residents had all the aids and adaptations they needed. 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 DS0000063042.V301697.R01.S.doc Version 5.2 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 Ashley Lodge DS0000063042.V301697.R01.S.doc Version 5.2 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): 3 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The assessment procedures in the home ensured the needs of the residents were known and could be met by staff. Prospective residents were able to visit the home prior to admission to assess the facilities available. EVIDENCE: Two of the three files sampled were for residents recently admitted to the home. Both the files included evidence that the staff at the home had undertaken a pre admission assessment that covered all the required areas and that one of the residents had chosen to visit the home prior to admission. One of the files also included a copy of the social worker’s assessment as the individual was not privately funded. Ashley Lodge DS0000063042.V301697.R01.S.doc Version 5.2 Page 11 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 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The care planning system in the home was good but staff needed to ensure they were updated as the needs of the residents changed. Some improvements were needed to the risk assessments to ensure they were undertaken for all residents and reflected the current risks of the individuals. The medication system was well managed and safe. Residents were treated with respect and their rights to privacy upheld. EVIDENCE: Three resident files were sampled, two for new admissions to the home and one for a resident who had lived there for some time. All the files included quite comprehensive care plans that detailed the needs of the residents and how these were to be met by staff. Areas covered in the care plans included personal hygiene, mobility, social and cultural needs, communication and nocturnal needs. One was very well detailed in relation to communication due to the individual’s sensory impairment. The care plans gave details of the residents’ likes, dislikes and preferences and to what extent they were able to self care. There was evidence that the residents had been consulted about their care plans and that they were being reviewed every month. It was Ashley Lodge DS0000063042.V301697.R01.S.doc Version 5.2 Page 12 evident from the daily records that one of the residents had deteriorated and a psycho geriatrician had been requested to visit however this had not been updated into the care plan. Two of the files included detailed falls risk assessments which included the actions to be taken by staff in the event of a fall including the equipment to be used. They also included manual handling risk assessments which detailed any other times the residents may require assistance with moving. The third file did not have either of these risk assessments completed. The personal risk assessments had been further developed since the last inspection and were included on all the files sampled and covered such areas as deafness, pain and discomfort, oral hygiene and short term memory loss. It was noted that the risk assessment for one resident had not been updated as her agitation had increased. All the files sampled included tissue viability assessments and nutritional screenings however one of these indicated the individual was at risk of developing pressure sores but there was no corresponding care plan stating how this was to be minimised. There was documented evidence that where staff had identified a health care need this was followed up and monitored. There was evidence of visits from G.P.s, district nurses, opticians and so on. Residents were being weighed on a regular basis. The daily records for the residents were very brief and did not give an overview of the general welfare of the individual or how they were spending their day. Specific incidents of challenging behaviour were being documented however at times the terminology being used was in appropriate. Staff needed to be vigilant when recording and detail only fact and not opinion to ensure that when other staff were reading the records they would know exactly what had happened, for example, ‘mythered’, ‘agitated’ and ‘been terrible all evening’ could imply several things. Only senior staff were administering medication and all were undertaking an accredited course in handling medication. Medication was being administered via a 28 day monitored dosage system which was very well managed. Since the last inspection a new drug trolley had been obtained and this enabled all the medication being administered to be kept in one place. Medication was being acknowledged when it came into the home and any balances left at the end of the month were being carried forward to the next medication record making the system easy to audit. All the medication audited at the time of the inspection was correct with the exception of a minor error in the controlled medication however this had not put the residents at risk. At the time of the inspection there were no individual written protocols for staff to follow when administering PRN (as and when necessary medication) however these were completed a little after the inspection and copies were faxed to the inspector. Ashley Lodge DS0000063042.V301697.R01.S.doc Version 5.2 Page 13 No issues arose during the course of the inspection in relation to the privacy and dignity of the residents. Staff addressed residents appropriately and help with personal care was offered sensitively. Care plans detailed issues of privacy and dignity in relation to the residents and staff were to address these. Visits from health care professionals took place in the privacy of bedrooms or the treatment room. The vast majority of the bedrooms had locks fitted with keys available for the residents. The remaining rooms were being fitted with locks as part of the ongoing refurbishment of the home. Residents were able to spend time in their rooms if they wished without being disturbed by staff. Ashley Lodge DS0000063042.V301697.R01.S.doc Version 5.2 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 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. There were no rigid rules or routines in the home and there were activities available for residents to take part in if they wished. There were no restrictions on visitors within reasonable hours and they were made welcome by staff. Residents spoken with were satisfied with the catering arrangements at the home. EVIDENCE: There did not appear to be any rigid rules or routines in the home. Residents were seen to wander freely around the home sit talking to each other and their visitors, spend time in their bedrooms, listening to music and reading. One of the residents spoke to the inspector about taking part in a knitting group and some of the residents were learning to crochet. Activities available for the residents were documented in the pre inspection questionnaire and included regular visits from outside entertainers, reminiscence sessions, board games, skittles, church services and sing a longs. Activities out in the community included shopping trips, walks and pub lunches. Staff were not always recording the activities that the residents were being offered and as stated previously this needed to be included in the general overview of the residents’ day to evidence their social needs were being met. Ashley Lodge DS0000063042.V301697.R01.S.doc Version 5.2 Page 15 There were no restrictions on visitors during reasonable hours and visitors were seen to come and go throughout the inspection and appeared to be made very welcome by staff. The inspector spoke with two visitors and they were very positive about the home, the staff group and the service offered. There were no restrictions on residents going out with relatives if they wished. Residents were encouraged to exercise choice and control over their lives. They were consulted about their care plans and their preferences, likes and dislikes were documented these included preferred rising and retiring times, bedtime routines, dietary preferences, social preferences and so on. Care plans also detailed where residents were to be offered choices if they could not make this known to staff on a daily basis. Bedrooms were personalised to the occupant’s choosing. Residents spoken with were happy with the food being served at the home and there was evidence that the chef discusses the menus with the residents prior to changing them. The menus evidenced a wide variety of food being offered to the residents with choices available. It was evident that a great deal of effort goes into the presentation of food at the home. Staff were aware of the likes and dislikes of the residents and these were also detailed in the care plans. The home was catering for medical and vegetarian diets at the time of the inspection. Staff needed to ensure that the records of food were always completed to evidence that residents were receiving a balanced diet with choices available on an ongoing basis. Ashley Lodge DS0000063042.V301697.R01.S.doc Version 5.2 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 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. There was an appropriate complaints procedure at the home and residents had all been issued with a copy. Staff had undertaken training in adult protection awareness ensuring they were equipped with the necessary skills and knowledge to be able to recognise and report appropriately any incidents or suspicions of abuse. EVIDENCE: The home had an appropriate complaints procedure and all residents had received a copy of this in the service user guide. No complaints had been lodged at the home and none had been lodged with the CSCI. The relatives spoken with commented: ‘If you mention anything to the managers they sort it out.’ ‘They listen to what we say.’ ‘If I have raised anything it is taken seriously.’ The adult protection procedures were not viewed at this inspection but they complied with the multi agency guidelines at previous inspections and had not been changed. All staff had received training in adult protection issues to ensure they were able to recognise and report any incidents or suspicions of abuse. Ashley Lodge DS0000063042.V301697.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24, 25 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home offered residents clean, comfortable and generally spacious accommodation. Improvements to the environment were ongoing to ensure the residents had all the appropriate facilities. 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 others had been partially met. Some areas of the home were in need of redecoration as paintwork was chipped and some areas looked a little shabby however there was ongoing refurbishment of the home and all the redecoration was being incorporated in this. Due to the extent of the works being undertaken during the refurbishment of the home it is going to be a considerable amount of time before it is completed. The requirements made by the fire officer had been met. Ashley Lodge DS0000063042.V301697.R01.S.doc Version 5.2 Page 18 The home had ample communal space with two lounge areas, a visitor’s lounge and a large dining room. Decoration was of an acceptable standard and it was proposed to replace some of the furnishings as the refurbishment of the home progressed. Progress was being made on the bathing/showering facilities. The shower in the treatment room, which was floor level and accessible to the residents, could be used. The room being converted to an assisted shower room on the first floor was almost complete. Access to the ground floor bathroom, which had a bath lift, was via a small step. The step cancelled out some of the positive features of having a bath lift and there were plans to extend this room, have the entrance resited so that there was no step and install a parker bath. There were some aids and adaptations throughout the home including a small shaft lift, emergency call system hand and grab rails, a freestanding hoist and wheelchairs. Additional handrails were due to be fitted along some of the corridors just after the inspection. The front entrance of the home and the exit to the garden needed to have fixed ramps however the proprietor had had to apply for planning permission for this, as the home was a listed building and was awaiting their response. A temporary, portable ramp was left in situ at all times at the front entrance. There had been numerous improvements to the bedrooms since this proprietor had taken over the home. The small rooms had either been taken out of use or extended, several rooms had been completely refurbished and had new fitments in the en-suites, new furnishings, new linen, new flooring, new beds and had been redecorated. As rooms were being refurbished all the requirements of the National Minimum Standards were being incorporated in the rooms, for example, two double electrical sockets, locks to doors and a lockable facility. The manager had audited all the rooms against the minimum standards and was updating this as more rooms were completed. All the radiators in the home had been guarded and the hot pipe work boxed in. There were still some wash hand basins that did not have thermostatic mixer valves fitted but this was being addressed. On the day of the inspection the home was found to be clean and odour free. The laundry and kitchen were appropriately located and equipped. It was strongly recommended that fly screens were fitted to the kitchen windows so that they could be opened during the warmer weather. Ashley Lodge DS0000063042.V301697.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Appropriate staffing levels were being maintained by a stable staff group that could meet the needs of the residents. The recruitment procedures were robust and safeguarded the people living in the home. The manager needed to ensure all the required areas were covered in the induction training for staff to ensure they were equipped with all the necessary skills and knowledge to fulfil their roles. EVIDENCE: The home was fully staffed at the time of the inspection and there had been very little staff turnover since the last inspection. Many of the staff had worked at the home for a considerable amount of time which was good for the continuity of care of the residents. Throughout the course of the inspection it was evident that relationships between the staff and residents were very good. All the residents were very happy with the staff team and the service they received. The visiting relatives spoken with were also very positive about the staff team. The home was maintaining adequate staffing levels to meet the needs of the residents. The recruitment records for the one employee were sampled. The file evidenced that a POVA first check had been undertaken prior to employment and a CRB check had been completed. The majority of the other required documentation was also on the file including, completed application forms and two references. It was noted that the individual’s residence permit had expired Ashley Lodge DS0000063042.V301697.R01.S.doc Version 5.2 Page 20 however evidence that the person was allowed to remain and work in the country was faxed to the inspector after the inspection. The manager was also keeping copies of the interview notes. The inspector was informed that the new employee had undertaken some induction training but there was no record of this site. The induction check list for the home was seen but the manager needed to ensure this was cross referenced to the specifications laid down by skills for care and that all the required areas were covered in the first twelve weeks of employment and that a record was kept. Over 50 of the care assistants were qualified to NVQ level 2 and staff received ongoing training in a variety of topics, for example, adult protection awareness, food hygiene, manual handling and health and safety. Ashley Lodge DS0000063042.V301697.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The manager ensured the smooth running of the home in a competent manner. 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: Since the last inspection the manager had gained her Registered Manager’s Award and was undertaking her NVQ level 4 in care. She had worked at the home for a considerable amount of time and demonstrated a good knowledge of the needs of the residents in her care and the running of a residential home. The staff team had continued to work hard since the last inspection to meet the requirements from previous inspections. Ashley Lodge DS0000063042.V301697.R01.S.doc Version 5.2 Page 22 The staff team appeared to work very well together and relationships within the team and with the manager appeared to be very good. No progress had been made on implementing a formal quality assurance system. There were numerous in house health and safety audits were being undertaken, there were staff and resident meetings and residents had their own notice board to keep them informed of what was going on. Visitors spoken with also confirmed that they were kept informed of any events in the home and any issues in relation to their relatives. Questionnaires were occasionally given to residents and their relatives to get their views on the service offered. All of the above needed to be formalised and information from these collated and a report produced to indicate how the service was to be improved. The manager was keeping very small amounts of money for three of the residents to enable them to have some shopping done for them. Records for this money was being kept on the envelopes containing the money. Although these were relatively small amounts the manager was advised she needed to set up records that detailed all income and expenditure and obtain receipts for expenditure wherever possible, any expenditure also needed to be witnessed by two staff signatures. Copies of the records that had been set up were faxed to the inspector prior to the issuing of this report therefore no requirement was made. A system of staff supervision had been set up and the manager had simplified the system since the last inspection. It appeared that the target of six supervision sessions per year would be met. Health and safety were well managed. Staff received training in safe working practices and numerous in house health and safety checks were being carried out on an ongoing basis, for example, water temperatures and fire exits checked. All the in house checks on the fire system were up to date, there had been fire training for staff and a fire drill had been undertaken. There was evidence on site that the majority of the equipment had been serviced with the exception of the gas equipment which was just out of date. There was a fire risk assessment that had been carried out by an outside agency and a premises risk assessment that had been carried out by the manager however this was in need of review. Accident and incident recording and reporting were seen to be appropriate. Ashley Lodge DS0000063042.V301697.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 X X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 2 2 X 2 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 3 X 2 Ashley Lodge DS0000063042.V301697.R01.S.doc Version 5.2 Page 24 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 OP1 Regulation 4(1)(c) Sch1(3, 16) Requirement The statement of purpose for the home must include the numbers of staff and the room sizes. Previous time scale of 01/04/06 not assessed for compliance at this visit. All care plans must be regularly updated to reflect the current needs of the residents. Previous time scale of 01/04/06 not met. All personal risk assessments must be updated as the needs of the residents change. Previous time scales of 01/11/05 and 01/04/06 not met. All residents must have manual handling risk assessments that detail the actions to be taken by staff in the event of a fall. Where a risk of developing pressure areas has been identified there must be a plan in place stating how this is to be minimised. Daily records must include sufficient detail to evidence that the needs of the residents in relation to their general welfare DS0000063042.V301697.R01.S.doc Timescale for action 01/09/06 2. OP7 15(2)(b) 31/08/06 3. OP7 13(3)(c) 31/08/06 4. OP7 13(5) 31/08/06 5. OP8 13(3)(c) 31/08/06 6. OP88 12(1)(a) 31/08/06 Ashley Lodge Version 5.2 Page 25 are being met and give an overview of their day. Daily records must only detail fact and not opinion and staff must be vigilant to use only appropriate terminology. Records of the food provided for residents must be kept in sufficient detail to enable anyone inspecting them to determine whether the diet is satisfactory in relation to nutrition and otherwise and of any special diets being catered for. All areas of the home must be kept reasonably decorated. Previous time scale of 01/03/06 not met. Improvements must be made to the assisted bathing facilities and the availability of toilets in relation to the lounge areas. Previous time scales of 01/09/05, 31/01/06 and 01/04/06 not met. A permanent ramp must be installed to the main entrance of the home. Previous time scales of 31/12/05and 01/04/06 not met. 7. OP15 17(2) schedule 4(13) 31/08/06 8. OP19 23(2)(d) 01/12/06 9. OP21 23(2)(j) 01/12/06 10. OP22 23(2)(n) 01/12/06 11. OP24 16(2)(c) 12. OP25 13(4)(c) A ramp must be installed to the exit from the lounge into the garden. All bedrooms must be audited for 01/12/06 furniture against the National Minimum Standards and arrangements made to provide items that are not currently in place. Previous time scale of 10/12/05 and 01/04/06 partially met. The remaining hot water outlets 01/10/06 that do not have thermostatic mixer valves fitted must be addressed and CSCI must be notified when this is completed. DS0000063042.V301697.R01.S.doc Version 5.2 Page 26 Ashley Lodge 13. OP30 18(1)(a) Previous time scale of 31/12/05 partially met. The manager must ensure that the induction training offered in the home covers all the topics and is completed within the time scales laid down by Skills for Care and that a record of the training is maintained. Previous time scales of 31/12/05 and 01/04/06 not met. The manager must be qualified to NVQ level 4 in care and management. Previous time scales of 31/12/05 and 01/04/06 partially met. The home must have effective quality assurance and quality monitoring systems in place, based on seeking the views of the residents. Previous time scale of 01/01/06 not met. Copies of the monthly visit reports made by the representative of the company must be available for inspection. Previous time scale of 01/04/06 not assessed for compliance at this visit. There must be evidence on site of an up to date service of the gas equipment. The premises risk assessment must be reviewed and updated if necessary. 01/09/06 14. OP31 9(1)(b)(i) 01/12/06 15. OP33 24(1)(2) (3) 01/10/06 16. OP37 26 01/10/06 17. 18. OP38 OP38 23(2)(c) 13(4)(a) 14/08/06 14/08/06 Ashley Lodge DS0000063042.V301697.R01.S.doc Version 5.2 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. Refer to Standard OP26 Good Practice Recommendations It is strongly recommended that fly screens were fitted to the kitchen windows so that they could be opened during the warmer weather. Ashley Lodge DS0000063042.V301697.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Birmingham 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 DS0000063042.V301697.R01.S.doc Version 5.2 Page 29 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!