Inspection on 24/11/05 for Ashlodge

This inspection was carried out on 24th November 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

Ashlodge 23/08/07

Ashlodge 22/08/06

Ashlodge 16/05/05

Ashlodge 27/11/04

Ashlodge 25/05/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Ashlodge Ashlodge 83 Cantelupe Road Bexhill on Sea East Sussex TN40 1PP Lead Inspector Niki Palmer Unannounced Inspection 24th November 2005 11:45 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 Ashlodge DS0000041416.V265675.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. Ashlodge DS0000041416.V265675.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ashlodge Address Ashlodge 83 Cantelupe Road Bexhill on Sea East Sussex TN40 1PP 01424 217070 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) Mr Balasingam Vijayakumar Mrs Kuhayini Vijayakumar Vacant Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Ashlodge DS0000041416.V265675.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. That only older people will be accommodated. That residents accommodated must be aged sixty five (65) years or older on admission. That the maximum number of residents to be accommodated will not exceed sixteen (16). That the home accommodates one named adult over the age of sixty five (65) years with dementia, whose needs can be accommodated by the home. 16th May 2005 Date of last inspection Brief Description of the Service: Ashlodge is a detached property situated a short distance from Bexhill seafront, and a short walk from the town centre with its shops and access to bus and rail routes. Accommodation is provided on two floors with a passenger lift to provide access to first floor accommodation. All bedrooms are of single occupancy with en-suite facilities. Eleven bedrooms are on the first floor, whilst five are on the ground floor. There are three spacious communal lounges, a dining area and access to a well-kept rear garden. The home is registered to accommodate 16 older people. The Registered Providers are Mr and Mrs Vijayakumar who have owned the home since May 2003. Mrs Vijaykumar is currently in the process of registration with the CSCI for the position of Registered Manager. Ashlodge DS0000041416.V265675.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001, uses the term ‘service user’ to describe those living in care home settings. For the purpose of this report, those living at Ashlodge will be referred to as ‘residents’. This unannounced inspection took place on Thursday 24th November 2005 between 11:45am and 4:15pm and was carried out by two Inspectors. The inspection began with discussions with Mrs Vijaykumar (Acting Manager) in respect of progress made since the last inspection. In order to gather evidence on how the home is performing, individual discussions took place with five residents, whilst other commented on their care over the lunchtime period, the Inspectors having been invited to join them for a meal, and two care staff. A detailed inspection of the premises and its facilities took place. 14 residents were accommodated at the time of the inspection. Other records and documentation inspected included: four care records, the home’s Statement of Purpose and Service Users’ Guide, medication practices, the provision of food, health and safety records, recruitment files and the home’s systems for dealing with complaints. In order that a balanced and thorough view of the home is obtained, this inspection report should to be read in conjunction with the previous inspection report carried out on 16th May 2005. What the service does well: What has improved since the last inspection? Since the last inspection access to the front of the building has been reviewed. The front door is now kept locked to ensure the safety of residents. Feedback has been sought from residents in the form of a ‘user questionnaire’ in relation to the care, services and facilities that are provided at the home. The vast majority of responses were very positive. Ashlodge DS0000041416.V265675.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ashlodge DS0000041416.V265675.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ashlodge DS0000041416.V265675.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. Sufficient information is provided to all prospective residents prior to admission. Adequate systems are in place to assess prospective residents. This ensures that no one is admitted to the home, whose needs cannot be met. EVIDENCE: Since the last inspection the home has reviewed and updated it’s Statement of Purpose and Service Users’ Guide. Both documents were found to contain details of the home’s aims and objectives, philosophy of care, admission policy and trial period offered, accommodation, activities, and the home’s complaints procedure. The home is required to ensure that previous relevant experience of management and staff are included and that the correct contact details of the Commission for Social Care Inspection (CSCI) are specified. Only one resident has been admitted to the home since the last inspection. Records confirmed that a through assessment of her needs had been carried out prior to admission. In discussion, this individual resident commented that she had visited and stayed at the home a number of times for short-term respite, prior to making a final decision to move in to the home permanently. Ashlodge DS0000041416.V265675.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Residents’ personal and healthcare needs are mostly met by the home’s care planning procedures. Although the systems for the administration of medication are on the whole good, shortfalls have been identified. EVIDENCE: A sample of care plans were seen on the day of inspection. It was pleasing to note that clear guidance for staff to follow had been recorded in relation to the management of diabetes, promotion of continence and maintaining nutrition. It was noted however that one particular resident’s care plan stated that she needed assistance with bathing, yet there were no guidelines in place to specify how this need should be met. In response to a complaint made to the CSCI in August 2005, the home was required to review the management of the prevention of falls and the procedure that is to be followed in the event of a person falling. Although the home has requested professional advice, this is outstanding. In addition it was concerning to note that clear risk assessments for the prevention of falls are still not in place. This should be prioritised and in accordance with guidance produced by the Department of Health specifically for older people. Ashlodge DS0000041416.V265675.R01.S.doc Version 5.0 Page 10 The home’s medication administration systems and records were viewed. The home uses a pre-packed system, which can be easily monitored. Whilst there was evidence to show that all medicines had been administered as prescribed, there was no written guidance in place for the use of PRN (as and when required) medication. The home is required to seek advice from residents’ prescribing General Practitioner’s regarding this. In addition, whilst the home is recording the receipt of medication from the pharmacy, there was no evidence to show that they are ensuring the medication received corresponds to that ordered. Following the last inspection the home has updated it’s code of practice to ensure that all staff knock on residents’ doors before entering to maintain their privacy and dignity. This was confirmed by residents on the day of inspection. Ashlodge DS0000041416.V265675.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13, 14 and 15. Whilst residents are supported by the home to make individual choices regarding many aspects of their lives, choice in relation to the provision of food is not promoted. EVIDENCE: In response to the previous inspection, the home has reviewed the main entrance in respect of security. The front door is now kept locked. Residents spoken with said that they could get up and go to bed when they wanted. Their preferred routines and choices were recorded within their plans of care. Staff said that although the home has a bathing rota in place, times are flexible and dependent on the needs and preferences of each resident. The Inspectors joined the residents for the lunchtime meal in the pleasantly decorated dining area. Although the food was homemade from fresh ingredients the service was slow; consequently not all of the meals served were hot. Residents commented on this. A vegetarian alternative was offered to one of the Inspectors, however residents spoken with said that they are not usually given a choice. Specialist diets such as low sugar are appropriately catered for, although the choice of dessert is limited. Three residents stated that the quality of evening meals provided was poor for example: fillings for Ashlodge DS0000041416.V265675.R01.S.doc Version 5.0 Page 12 sandwiches being tinned meat. These concerns were addressed with the Acting Manager of the home and a requirement made. Ashlodge DS0000041416.V265675.R01.S.doc Version 5.0 Page 13 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. This home has adequate systems in place to ensure that all complaints are dealt with appropriately, however it needs to ensure that up to date written policies and procedures are in place to safeguard residents from harm. EVIDENCE: The home has a copy of its complaints procedure on display in the main entrance area. Whilst this was comprehensive, it was not particularly inviting to encourage residents or visitors to the home to raise their concerns. The complaints procedure detailed in the Service Users’ guide however was. A recommendation has been made in respect of this. An anonymous complaint was made to the CSCI in August 2005, which was investigated under the home’s complaints procedure, however a considerable amount of support was provided by the Inspector throughout the investigation process. This complaint was found to be partly upheld, details of which have been referred to throughout this report. The home has a detailed adult protection policy/procedure and whistle-blowing policy in place. These specify what constitutes abuse, how to recognise it and who to report suspected abuse to, however the adult protection alerting procedure is not in accordance with local multi-agency guidelines. It needs to be amended to state that Social Services are now the lead agency. Ashlodge DS0000041416.V265675.R01.S.doc Version 5.0 Page 14 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): 25. Whilst the home is mostly well-maintained, not all areas are adequately heated. EVIDENCE: On the whole the home was found to be clean and well-maintained, however many residents commented that the conservatory at the front of the building does not have sufficient heating. This is of concern as this is an area of the home that many residents choose to use on a daily basis. The home is required to ensure that this area is maintained at a comfortable temperature without compromising the safety of residents i.e. the use of portable heaters. It is an outstanding requirement of the previous inspection report for the home to ensure that all radiators that pose a high risk to residents are guarded. This must be prioritised. Ashlodge DS0000041416.V265675.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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. Whilst adequate numbers of staff are employed to meet the assessed needs of residents, the standard of vetting and recruitment practices are inadequate. EVIDENCE: The home employs a total of 13 care staff, nine of which are working towards NVQ. Rotas seen on the day of inspection confirmed that staffing levels are adequate to meet the assessed needs of residents. Following a complaint made to the CSCI in August 2005 the home was required to review its night time on-call arrangements. The home has yet to document this. Three newly appointed staff recruitment files were seen. Although current Criminal Record Bureau (CRB) and POVA checks were in place, it was concerning to note that the authenticity of written references had not been checked, nor photo identification obtained. The importance of this was discussed with the Acting Manager and a requirement made. Although staff spoken with and the Acting Manager confirmed that a comprehensive TOPPS induction to the home is completed within the first six weeks of employment, not all records indicated this, for example of the six areas covered only four had been signed as complete. The Acting Manager was reminded of her responsibility to maintain accurate records within the home. A recommendation has been made for the Acting Manager to consult with their professional body in respect of the new Common Induction Standards issued by Skills for Care (replacing TOPPS). Ashlodge DS0000041416.V265675.R01.S.doc Version 5.0 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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 and 38. Ashlodge is adequately managed and run in the best interests of residents. EVIDENCE: An application was received by the CSCI in August 2005 for the Acting Manager to become registered with the CSCI. The application is currently being processed. She is due to finish her Registered Manager Award imminently. Residents and staff spoke positively of the management style and approachability of the Acting Manager. It was evident on the day of the inspection that good working relationships have been established between residents and staff. It was pleasing to note that active feedback from residents had been sought in respect of nutrition, communication, daily activities and the way in which care is delivered via a residents’ questionnaire. Although requirements have been made in respect of further consultation with Ashlodge DS0000041416.V265675.R01.S.doc Version 5.0 Page 17 residents regarding the provision and choice of food and heating within the home, the Acting Manager’s response to this on the day of inspection was positive. Small amounts of residents’ monies are kept securely in the home, for purchases such as hairdressing, toiletries and outings. Written records for each transaction including receipts were seen during the inspection and found to be in order. A number of the home’s health and safety checks and certificates were seen. It was pleasing to note that all equipment is regularly maintained and serviced. Certificates seen included the homes: boiler and heating system, fire equipment maintenance, emergency lighting and a recent environmental health inspection. In response to recommendations made by the Fire Safety Officer in May 2005, a small number of automatic door closures have been purchased. The home is required to ensure that they are fitted throughout the home. Ashlodge DS0000041416.V265675.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 X X X X X X 2 X STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Ashlodge DS0000041416.V265675.R01.S.doc Version 5.0 Page 19 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(1c)Sch1 (2&3)5(1f) Requirement Timescale for action 31/03/06 2. 3. OP7 OP8 4. OP9 5. OP9 6. OP15 That the Statement of Purpose and Service Users’ Guide specify the correct contact details of the CSCI and the relevant previous experience of management and staff. 12(1) That guidance for staff to assist residents with bathing is detailed within care plans. 13(4)(a-c) That the home reviews its falls procedure and implements risk assessments for the prevention of falls. These must be in accordance with guidelines produced by the Department of Health (NICE). 13(2) Sch2 That advice is sought from residents’ prescribing General Practitioner’s regarding the use of PRN (as and when required) medication. This must be clearly documented. 13(2) Sch2 All medication received in to the home must be checked to ensure that it corresponds to that ordered. A written procedure must be produced. 16(2)(i) The home must review the 12(2) arrangements for the provision DS0000041416.V265675.R01.S.doc 31/12/05 31/01/06 31/12/05 24/12/05 31/03/06 Ashlodge Version 5.0 Page 20 7. OP18 8. OP25 9. OP29 10. OP38 of food at mealtimes in full consultation with the residents. A record of this should be kept for inspection. 12(1)(a) That the home updates its Adult Protection policy and procedure in line with local multi-agency guidelines. It needs to state that Social Services are now the lead agency and provide the relevant contact details. 13(4)(a) That all radiators assessed as (c) posing a high risk to residents are guarded [THIS IS OUTSTANDING FROM THE LAST TWO INSPECTIONS]. 19(1) Sch2 That thorough recruitment checks are carried out for all new and existing staff. The authenticity of references must be checked. 23(4)(a) That automatic fire door closures are fitted throughout the home in accordance with the recommendations made by the Fire Safety Officer [THIS IS OUTSTANDING FROM THE PREVIOUS INSPECTION REPORT]. 31/12/05 31/03/06 24/12/05 31/03/06 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. 3. Refer to Standard OP16 OP28 OP30 Good Practice Recommendations That the home consolidates its two complaints procedures. That 50 of care staff are trained to NVQ level 2 by December 2005. That the home consult with their professional body in respect of the new Common Induction Standards issued by Skills for Care (replacing TOPPS). Ashlodge DS0000041416.V265675.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Ashlodge DS0000041416.V265675.R01.S.doc Version 5.0 Page 22 - 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!