Inspection on 15/11/05 for Ashton Lodge

This inspection was carried out on 15th November 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Ashton Lodge 09/07/09

Ashton Lodge 20/08/07

Ashton Lodge 30/05/06

Ashton Lodge 29/06/05

Ashton Lodge 01/11/04

Ashton Lodge 01/07/04

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 Ashton Lodge Spelthorne Grove Sunbury On Thames TW16 7DA Lead Inspector Mary Williamson Announced Inspection 15th November 2005 10:30 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 Ashton Lodge DS0000017589.V266267.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. Ashton Lodge DS0000017589.V266267.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ashton Lodge Address Spelthorne Grove Sunbury On Thames TW16 7DA 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) 01932 761761 Ashton Lodge Limited Sheila Kistner Care Home 45 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (25) of places Ashton Lodge DS0000017589.V266267.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate residents from the age of 60 years Date of last inspection 29th June 2005 Brief Description of the Service: Ashton Lodge is part of Sovereign Group. It is a purpose built home providing nursing care and accommodation for forty- five service users some of whom have mental health problems. The home is arranged in two units, one providing nursing care, and the other providing nursing care to people who also have dementia. The home is situated close to the M3 motorway in a built up residential area. The home is within easy access to the local shops and amenities, with good access to public transport. All the bedrooms are en-suite and situated on the ground floor. The home is currently undergoing major building work to increase its number of registered placements to 100. It is anticipated this will be completed by May 2006. Ashton Lodge DS0000017589.V266267.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced and the second in The Commission for Social care inspection programme year 2005/2006. Mrs Mary Williamson the Lead Inspector for the home undertook the inspection. Mrs Sheila Kistner the Registered Home Manager was present throughout the inspection. Mr A. Sheikh The Provider, and the building Site Manager were present for the first part of the inspection. A site visit was undertaken along side this inspection to commission twelve bedrooms. This is phase one of the current major variation to the home to provide one hundred beds in total on completion. The bedrooms commissioned are necessary to move service users in order to proceed with phase two of the development. The home was functioning efficiently with the minimum disruption to service users as possible during the current development. The inspector had the opportunity to meet all the service users, and talk with several of them individually. They all stated that the care they receive was good and that they were happy living at Ashton Lodge. Two service users stated that the current building work “was inconvenient but worth in the end” Service users were sitting in both lounges some were watching television, some were reading their newspapers and others chatting amongst themselves. The service users who were being nursed in bed were receiving good quality nursing care. Three relatives were spoken to during the inspection all of whom expressed satisfaction with the home and the staff. Nine service users comment cards, three relative comment cards, and two GP comment cards were received by the inspector all with positive feedback. A tour of the premises was undertaken and records relating to the care of the service users and the management of the home were examined. The interaction between the staff and service users was seen to be respectful, professional and positive. The safety of the service users during the current building work is paramount and the site manager has risk assessments in place to cover all eventualities. These were seen and discussed with both the home manager and the site manager. The inspector would like to thank the service users, staff and management team for their hospitality and positive contribution to this inspection. Ashton Lodge DS0000017589.V266267.R01.S.doc Version 5.0 Page 6 What the service does well: What has improved since the last inspection? The standard of decoration throughout the home has improved since the last inspection. Twelve new bedrooms have now been built all with en-suite facilities. These have been decorated and furnished to a high standard. Several bathrooms have been refurbished and include assisted baths. A new shower room has also been provided. The company now employs a trainer who is responsible for all the training in the home. Ashton Lodge DS0000017589.V266267.R01.S.doc Version 5.0 Page 7 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. Ashton Lodge DS0000017589.V266267.R01.S.doc Version 5.0 Page 8 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 Ashton Lodge DS0000017589.V266267.R01.S.doc Version 5.0 Page 9 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): These standards have not changed since the last inspection. Please see the previous inspection report dated 29th June 2005. EVIDENCE: Ashton Lodge DS0000017589.V266267.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, and 10. Arrangements are in place to ensure that the service users health and personal needs are being met as outlined in individual care plans, with dignity and respect. EVIDENCE: Individual care plans are in place. These are written with input from the service user whenever possible. Information gathered from relatives, the preadmission needs assessment, and specialist reports are also used in this process. Three care plans were sampled and found to be well maintained and informative. However on discussion with the unit manager it was noted that a particular care issue had not been documented. It is a requirement that all care needs to include the management of behaviour is included in individual care plans. Risk assessments are also included in care plans, which include moving and handling, risk of developing pressure sores, and nutrition. All the service users are registered with a local GP who visits the home weekly or more frequently if required. The GP provided a feedback comment care for Ashton Lodge DS0000017589.V266267.R01.S.doc Version 5.0 Page 11 the purpose of this inspection, which was supportive of the care being provided. There are also visits from the chiropodist, dentist and the visiting outside optician service. The psychiatrist visits to discuss the management of the service users with dementia and there is also support from the CPN if required. Physiotherapy can be arranged on request. A record is kept in individual care plans when all these visits take place. Privacy and dignity is respected and staff were observed to knock on service users doors prior to entering. Staff were also seen to address service users in a respectful manner. Ashton Lodge DS0000017589.V266267.R01.S.doc Version 5.0 Page 12 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, and 15. Appropriate leisure activities meet the assessed needs of the service users. The catering arrangements are suitable for the nutritional needs of service users. EVIDENCE: The home employs an activities coordinator who produces an activities programme on a monthly basis. Activities include board games, card games, bingo, art and craft, and gentle exercise. Trips to the local shops or places of interest are also organised. Some service users like to sit and read the daily newspaper or listen to music. The activities coordinator will provide activities on a one to one basis for service users on the dementia unit if group activities are not suitable. Various events are celebrated for example, birthdays, summer fetes, Halloween, and festive holidays and there are several photographs on display supporting these events. Outside entertainment is also provided in the form of old time music afternoons. Family links are maintained and two relatives stated that they are made welcome in the home at any time. Relatives are also involved in the care planning process, and also attend care reviews and social events. Spiritual needs are met and various clergy visit the home on a regular basis. Ashton Lodge DS0000017589.V266267.R01.S.doc Version 5.0 Page 13 The catering arrangements in the home are good and meet the nutritional needs of the service users. The chef plans the menus with input from the service users and knowledge of the service users likes and dislikes. There is a choice of two main courses for lunch and there is also a wide choice of supper dishes. The food offered is appetising, wholesome and nutritious. Special diets are catered for. Several service users stated that the food was very good. Ashton Lodge DS0000017589.V266267.R01.S.doc Version 5.0 Page 14 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 There is a complaints procedure in place and a copy of this procedure is given to all service users on admission. EVIDENCE: The home has a complaints procedure in place. This forms part of the service users guide, which is given to all service users and their relatives on admission to the home. Two relatives spoken to confirmed that they had confidence in this process. There have been two complaints since the last inspection. One was investigated by the Commission for Social Care Inspection and was partly upheld. The second was investigated by the home and a response sent to The Commission for Social Care Inspection. This was not upheld. Ashton Lodge DS0000017589.V266267.R01.S.doc Version 5.0 Page 15 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, 23, and 26 Due to the continued building work parts of the home fall below the minimum environmental standards, while other parts are tastefully refurbished. EVIDENCE: The home is currently undergoing major building work. The home is operated in two units. One unit provides nursing care for people who have dementia, and the other unit provides nursing care for older people. The standard of accommodation varies throughout the home. On the nursing care unit the large lounge has some of its natural light obstructed with boards due to the building work outside these windows. The service users commented, that “although it is inconvenient this will be worth it.” The bedrooms on this unit all have en-suite facilities and have been personalised to reflect individual personalities. Twelve new bedrooms have been built on this unit as phase one of the current construction work. This has been necessary to move service users to enable phase two to continue. A site visit was undertaken along side the inspection with the director and site manager to commission these twelve rooms. Ashton Lodge DS0000017589.V266267.R01.S.doc Version 5.0 Page 16 The lounge carpet on the dementia unit had been shampooed the previous day but still had malodour. The manager stated that this unit was due for refurbishment in phase two of the building project and this included new carpets. The bedrooms in this unit also have en-suite facilities. The inspector was informed that all these bedrooms are also due for refurbishment. There are ample toilets and bathrooms situated throughout the home. Some of these have been replaced with new assisted bathrooms as part of the development programme, and phase two includes the remainder of these. The home has been adapted to meet the mobility needs of the service users and includes ramps, hoists, grab rails, raised toilet seats, wheelchairs, call bells and shaft lifts. There is an infection control policy in place and the staff confirmed that they receive training in this policy. Staff are provided with gloves and aprons and the laundry has facilities to was infected laundry separately. Arrangements are in place for the collection of clinical waste. Ashton Lodge DS0000017589.V266267.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29, and 30. The skill mix of staff meets the assessed needs of the service users, and they are protected by the recruitment procedures in the home. EVIDENCE: The duty rota was seen and the number and skill mix of staff on duty reflected the assessed needs of the service users. One unit manager confirmed this. On the day of the inspection there was two qualified nurses, eight carers, two cleaners, one chef, one kitchen assistant, one laundry assistant, and a maintenance person on duty. The staffing levels will continue to be monitored as the home expands. The organisation now has a trainer who is responsible for all the training in the home. Currently there are five staff undertaking NVQ level 2 at West Thames College and three staff undertaking NVQ level 3. All staff undertake induction training, which is followed by foundation training. All mandatory training is carried out and recorded by the training manager. The recruitment policy in the home is robust and protects the safety of the service users. All the required employment documentation is in place. Ashton Lodge DS0000017589.V266267.R01.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 36, and 38. The management structure in the home is efficient and safeguards the service users living there. Health and safety is promoted and protects the service users. EVIDENCE: The registered home manager is a qualified nurse and has several years experience in the provision of care for older people. She is well supported by two unit managers. One unit manager has responsibility for the nursing unit and has an RGN qualification. The other unit manager has responsibility for the dementia unit and has a Mental Health qualification to support this. Daily handovers take place and staff are involved and included in the management of care for service users. Formal staff supervision is in place and undertaken by the senior staff team. This is recorded and retained on staff files. Two staff confirmed this. Ashton Lodge DS0000017589.V266267.R01.S.doc Version 5.0 Page 19 There is a wide range of policies and procedures in place relating to health and safety. The training manager is responsible for introducing new staff to these and updating staff in first aid, manual handling, food hygiene, fire safety, and COSHH. The fire safety records were examined and are well maintained. Fire alarms are tested weekly and there is a contract in place for the maintenance of fire fighting equipment. The site manager, home manager, director, and the inspector had a meeting to discuss the building development and the health and safety risks. The site manager has a detailed risk assessment for all identified risks and all potential risks associated with the building work. The home is secure and all exits that lead to the site are locked and made safe. The site manager is in daily contact with the home manager and weekly meetings take place between the site manager, home manager and director to discuss developments and solve any problems encountered by service users, or any issues that may occur due to this development. The whole team are committed to cause the least possible disruption to service users during this project. Ashton Lodge DS0000017589.V266267.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 2 2 3 3 X 2 X 2 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X X 3 X 3 Ashton Lodge DS0000017589.V266267.R01.S.doc Version 5.0 Page 21 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 7 Regulation 15(1) Requirement The registered person must keep the care plan up to date and include all relevant information following case reviews. The registered person must ensure that all parts of the care home are kept clean and reasonably decorated. The registered person must keep the home free from offensive odours. Timescale for action 21/12/05 2 19, 20, and 24 26 23(2)(d) 21/12/05 3 16(2)(k) 21/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Ashton Lodge DS0000017589.V266267.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Ashton Lodge DS0000017589.V266267.R01.S.doc Version 5.0 Page 23 - 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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