Inspection on 20/08/07 for Ashton Lodge

This inspection was carried out on 20th August 2007.

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 30/05/06

Ashton Lodge 15/11/05

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 Christine Bowman Unannounced Inspection 20th August 2007 11:30 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 DS0000017589.V345443.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. DS0000017589.V345443.R01.S.doc Version 5.2 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@yahoo.co.uk Ashton Lodge Limited Wendy Hurley Care Home 100 Category(ies) of Dementia - over 65 years of age (0), Old age, registration, with number not falling within any other category (0) of places DS0000017589.V345443.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th May 2006 Brief Description of the Service: Ashton Lodge is owned by Sovereign and is a purpose built home providing nursing care and accommodation for one hundred service users. 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. It is within easy access of the local shops and amenities, with good access to public transport. The bedrooms are en-suite and are situated on both the ground floor and the first floor. The home has recently undergone major building work to increase its registered beds from 53 to 100. The lowest fee is £600 per week and the highest is £800. Extra costs include chiropody, which is £18 per treatment, hairdressing, which has varied charges including - £7 for a shampoo and set and £25 for a perm, and newspapers according to personal choice. DS0000017589.V345443.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit was conducted as part of a key inspection using the Commission’s ‘Inspecting for Better Lives’ (IBL) process. The site visit took place over six hours commencing at 11.30 am and ending at 17.30 pm and was undertaken by Ms Christine Bowman, regulation inspector. The registered manager, Mrs Wendy Hurley kindly changed her schedule and made herself available throughout the day to assist with the inspection process. Since the previous site visit, major building work had been carried out on the home and a second floor had been constructed, increasing the capacity of the home to one hundred registered beds. A new bright and welcoming reception area had also been constructed. The files of four people, who live at the home, were inspected including their assessments and care plans, risk assessments, medical information, activity schedules and menus. The recruitment process of two staff members was inspected and their training and development logs viewed. Staff rotas and the overview of staff training, health and safety certificates and records and the complaints and compliments logs were sampled. A tour of the premises was undertaken and four of the people, who live at the home, were spoken with. Nurses and care staff were observed carrying out their duties and several were spoken with throughout the day. The atmosphere within the home was calm and purposeful, the staff were cheerful, friendly and helpful and the residents’ demeanour was one of contentment. Fourteen surveys completed by relatives, carers or advocates were returned and their comments have been included in the report. The Annual Quality Assurance Assessment completed by the home and other information received and recorded on the inspection record since the previous site visit were also used in compiling this report. Since the previous site visit, a pharmacist inspection had taken place on 13th October 2006. The overall judgement was adequate and with, respect to record keeping, there were areas, which needed improving. Three requirements had been made and the home’s actions to improve in the areas identified were checked during the site visit. Thanks are offered to the management, the staff and the residents of Ashton Lodge for their assistance and hospitality on the day of the site visit and to all those who completed comment cards for their contribution to this report. What the service does well: Thorough healthcare and risk assessments are carried out by trained nurses, prior to residents being accepted for admission, to ensure the home is able to meet their needs. DS0000017589.V345443.R01.S.doc Version 5.2 Page 6 The home has two activity co-ordinators and resident’s activity plans are set up with assistance from relatives and representative where necessary to compile a list of the individual’s likes and dislikes, hobbies and interests and other personal preferences. The home’s activity plans were detailed and included a variety of events including, bingo, art and craft, armchair excercises, sing-along, games, quizzes, manicures, cinema, reminiscence and conversation, ‘horse racing’, one-to-one time, birthday celebrations and much more. ‘They seem to have a lot of activities going on,’ a relative commented. The home welcomes complaints and sees them as a positive lever for improving the service. Complaints and safeguarding issues had been addressed appropriately to ensure the best outcomes for the residents and to protect them. The large garden, which was accessible from the main sitting room on the ground floor, was secure to enable the residents from the first-floor unit, which catered for elderly frail residents, to enjoy some time outside safely. The area was equipped with outdoor furniture and sunshades, contained mature trees and well-maintained lawns. Decking had been laid around the perimeter of the home and the downstairs bedrooms benefited from individual courtyards, accessed via French windows. Some residents had colourful displays of potted plans displayed on the decked areas, which provided them with a private area in which to sit outside in seclusion should they wish to do so. The staff treated the residents with the utmost respect and were cheerful and considerate in their interactions with them. One relative commented, ‘ My husband was admitted to Ashton Lodge a few months ago and I would like to write that it is a wonderful home. Nothing is too much trouble for the staff and he is so comfortable. They look after my husband with great care and I am so happy that he is there’. Another relative commented,’ I am impressed with most of the staff. Their friendly smiles mean so much when visiting a loved one.’ ‘I feel they really do care about my mum – and in such a large home that speaks volumes.’ A well-qualified, experienced and enthusiastic manager with an inclusive, open and empowering management style manages the home in the best interests of the residents. The home is good at consulting with stakeholders and taking action as a result of comments received from the home’s own quality assurance questionnaires and feedback from resident/representatives meetings. One relative commented, ‘ There is an excellent liaison with relatives.’ Another relative commented, ‘the home is very clean, the food is excellent and the attitude of the staff to the residents is very good. Their kindness and care at all times, and this applies to all the staff, shows they really do care.’ DS0000017589.V345443.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: More information with respect to equality and diversity requested on the assessment form would support more holistic and person-centred care planning and ensure the residents social, cultural and personal care needs and preferences were recorded and considered prior to admission. It should be noted, however, that this information is collected after admission and every effort is made to ensure the individual needs of the residents are met. Not all the staff personnel files contained a recent photograph to confirm their identity to safeguard the residents. The Criminal Record Bureau information was not recorded stored of destroyed in line with good practise guidelines to DS0000017589.V345443.R01.S.doc Version 5.2 Page 8 protect the sensitivity of the confidential documents. Equal opportunities monitoring forms had not been completed by applicants to ensure procedures were fair and in keeping with current legislation and the staff personnel files had not been bound to ensure the confidential documents could not go astray. Areas for improvement identified in the relatives and representative’s comment cards with respect to staffing, communication and the laundry, and mentioned in the report, had already been included in the home’s development plans. This is a home, which is managed in an open and inclusive way and which actively seeks suggestions for improvements from its stakeholders, planning action to meet identified shortfalls, and continuously working towards the provision of a better service in the best interests of the residents. One relative commented to the question of how the home could improve by stating, ‘Pleased to say – I can’t think of anything.’ 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. The summary of this inspection report can be made available in other formats on request. DS0000017589.V345443.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 DS0000017589.V345443.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1,3,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient information is available to prospective residents and their relatives and representatives to enable them to decide if the home is able to meet their needs. Detailed assessments of prospective resident’s needs carried out by qualified nurses ensure the home accepts only those, whose needs can be met at the home. The home does not provide intermediate care. EVIDENCE: The service user guide and statement of purpose were inspected and both had been reviewed in April 2007. These documents contained all the information prospective residents and their relatives and representatives would need to decide if the service was suitable for their requirements. 75 of the relatives and representatives, who completed comment cards, confirmed they received sufficient information to help with decision-making. Resident’s files inspected contained initial referral forms, which were predominantly health orientated but contained some personal information with respect to prospective DS0000017589.V345443.R01.S.doc Version 5.2 Page 11 residents. The manager stated that she always ensures a health needs assessment is received from care management prior to the home sending out a nurse to complete the pre-admission assessment for those who are local authority funded. The pre-admission assessments viewed on resident’s files were very thorough with respect to physical, healthcare, behavioural, personal care, nursing intervention, pressure area and independence with respect to self-help skills and indicated risk levels associated with each category and the level of staff intervention required. The manager explained that after the decision is made with respect to the nursing care needs of the prospective resident, relatives and/or representatives of the prospective resident are invited to visit the home and are supplied with the Statement of Purpose and the Service User guide. The home also has a web site, which prospective residents and their representative can visit to gain information about the home. The pre-admission form requested information with respect to the prospective resident’s religion but other information with respect to equality and diversity such as ethnic and cultural background, social history, interests and hobbies was not requested. ‘After admission the assessment process continues and more information is gathered with respect to the holistic needs of the residents’, the manager stated. Improvements planned include training more staff in assessment so that continuity is assured for new residents, in that the nurse who carries out the pre admission assessment is the one who is on duty when they are admitted and who also completes the admission paper work and helps them settle into the home. Also that a Key Worker is allocated to prospective new residents prior to admission and they also are on duty so they can build up a relationship and be a point of contact for the new resident. A relative commented, ‘My brother has only been at Ashton Lodge on trial and he is happy there and has settled down.’ DS0000017589.V345443.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s health and personal care needs are recorded in individual care plans and specialist health and social care support is provided according to their assessed needs. Medication is handled, stored and recorded safely and policies and procedures are in place to instruct the staff. Residents are treated with respect, their privacy is promoted and personal and health care is carried out in a dignified manner. EVIDENCE: The files of four residents were viewed. All had detailed care plans covering all aspects of health and personal care needs, with instructions to the staff of actions to meet those needs. Instructions included the promotion of privacy and maintaining dignity, promoting confidence and explaining the procedures to the resident to encourage self-performance. An agreement form was included, which had been signed by the resident or a representative to confirm their agreement. The care plans were hand-written by the nursing staff and had been reviewed monthly or more frequently as necessary with respect to the changing needs of the residents. The manager confirmed that the holistic DS0000017589.V345443.R01.S.doc Version 5.2 Page 13 care plans had been discussed and agreed with all relevant individuals, where possible, and that resident’s wishes were always taken into consideration when devising the care plan and their preferences were highlighted. Risk assessments had been completed in relation to moving and handling, falls, mental health, waterlow scores, skin, cot sides, nutrition and where relevant for challenging behaviour. ‘Social and healthcare professionals visit residents regularly as required’, the manager stated, ‘and these included speech and language therapists, continence specialists, Parkinson’s nurses, diabetic nurses, psychiatrists, Community Psychiatric Nurses, stoma nurses, tissue viability nurses, chiropodists, opticians, palliative care nurses and dentists. The Home had a General Practitioner who visits weekly and also as required and, ‘relatives and representatives were encouraged to discuss concerns with the GP on these visits’, the manger stated, ‘and referrals to specialist such as to physiotherapists are made through the GP’. 30 of the relatives and representatives who returned comment cards felt the home always met the needs of their relative/friend and 70 thought it usually did. Comments included, ‘care is exceptional,’ and, ‘we are overall very pleased with the home, there is an excellent attached GP’, and, ‘the nursing home should be commended for the care and attention to residents and relatives requests.’ With respect to equality and diversity, 50 of the surveys returned indicated that the home always met the different needs of the people and 30 that it usually did. Comments included, ‘From my point of view it appears that all are treated individually,’ and, ‘care is given to a high standard, including all personal hygiene/dressing to give residents pride in their presentation and appearance, which is extremely important if residents are unable to complete these tasks alone.’ Since the previous site visit, a pharmacy inspection had been carried out on 13th October, 2006, and three requirements had been made with respect to producing protocols for medication prescribed ‘as required’, keeping accurate records when medication is not administered together with the reason it was not given and ensuring variable doses of medication are recorded accurately, and that policies and procedures relating to the handling of medication must be reviewed to reflect current practise. The medication policies and procedures relating to the handling of medication were viewed and had been reviewed and updated to reflect current practices. The medication administration records of two residents were viewed and records were accurately kept. Photographs were in place on resident’s records viewed. Two nurses explained how the information would be recorded should a prescribed dose of medication not be taken. Controlled drugs were appropriately stored in a metal cabinet inside a metal cabinet and securely attached to the wall. All recording of controlled drugs had two signatures and a DS0000017589.V345443.R01.S.doc Version 5.2 Page 14 running balance. One balance was checked and found to be accurate. A list of signatures of those responsible for the administration of medication was kept with the MAR charts and individual protocols had been produced for residents Whose medication was ‘as required.’ The home had changed the supplying pharmacist to improve the level of service and support. The change had taken place this month so the home was still assessing if it had been effective. DS0000017589.V345443.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Activity plans meet the collective social, cultural, religious and recreational needs of the residents and take into consideration their individual preferences by offering choice. Contact with relatives, friends and representatives is promoted and residents benefit from a wholesome, balanced and appealing diet. EVIDENCE: ‘When residents cannot provide the information themselves’, the manager stated, ‘families were asked to help to complete a social history of their relative, draw up a list of their likes and dislikes with respect to food, other personal preferences and provide information with respect to their hobbies and interests. The staff add to this list as more individual preferences and interests are identified. Residents’ activity plans were a separate document from their health and personal care plans and had input from the activities co-ordinators. A complete activities plan of the home for the month of August was viewed. ‘This plan is also available to relatives and representatives of the residents’, the manager stated, and the activites for the day were posted on the notice board for everyone to see with reminers of special events throughout the week and regular events. The hair salon price list, the mobile library visiting times, a DS0000017589.V345443.R01.S.doc Version 5.2 Page 16 planned visit from a Catholic priest to carry out a religious service and the details of a forthcoming fund-raising event were viewed on the notice board. Each day was set out with a variety of events including, bingo, art and craft, armchair excercises, sing-along, games, quizzes, manicures, cinema, reminiscence and conversation, ‘horse racing’, one-to-one time, birthday celebrations and much more. One relative commented, ‘the home is trying to improve the stimulation for residents- there is a way to go but they are trying. More mental stimulation would be an improvement,’ and another relative stated, ‘they seem to have a lot of activities going on’. There were no organised outings on the August schedule, but there were photographs in the living areas of residents enjoying outings and the manager confirmed that there were close links with two transport companies, which the home uses. With respect to equality and diversity the service was planning to compile a list of local points of contact for different religions including out of hours contact numbers where possible. The home provided areas in which residents could receive visitors in privacy, in addition to their bedrooms. ‘Families and friends are encouraged to be involved with activities and outings as much as possible and are invited to special events such as seasonal celebrations and bar-b-cues’, the manager stated. Some residents were observed entertaining visitors on the day of the site visit. The manager confirmed that the home had open visiting hours and that relatives and friends were encouraged to visit as much as possible. They were also wecome to take a meal and always offered refreshments. Minuted residents and family meetings were held to discuss daily life and gather suggestions and ideas for improvements. One relative commented, ‘It is sometimes difficult to get through to someone on the telephone, as the phone is in the office and not always heard. At times this can be frustrating, but I know they are dealing with the residents and are very busy.’ Some residents had private telephones installed in their rooms and residents could use the office telephone in private, a staff member stated. There were plans in place to purchase cordless telephones to enable residents to make and receive calls in private more easily. 70 of comment cards returned by residents’ relatives and representatives confirmed they were always kept up-to-date with important issues. Three meals were provided each day, lunch being the main meal of the day. The four-weekly menu provided two choices for main meals and a variety of vegetables each day. The menus, which were displayed for residents to see, confirmed they were offered a wholesome balanced and appealing diet. Snacks were also available upon request and drinks were served routinely seven times a day and upon request. Residents had access to drinking water/juice in their rooms. The manager stated that menus had been improved to provide more choice and variety based on feedback from residents. ‘Excellent food and variety’, was a comment made by a relative, and residents spoken with expressed their satisfaction with the meals provided. DS0000017589.V345443.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints are welcomed and responded to appropriately in the best interests of residents and their representatives. Residents are protected from abuse by well-informed staff. EVIDENCE: No complaints had been referred to the Commission for Social Care Inspection, however the home had received a complaint with respect to staffing levels when extension work was being carried out. This had been responded to in a timely and appropriate way. Many compliments had been recorded including, ‘Superb nursing staff, I was especially grateful for the excellent care afforded my father yesterday, but they are always excellent.’ ‘It is a very nice place and the staff are lovely’. ‘ This is an excellent facility even a short visit shows the caring ethos which governs the activity. It is a fantastic place for all the people to rest in their old age and it is so spotless, clean and very hygienic.’ ‘I think the home is superb, beautifully kept, lovely rooms and furniture and wonderful, caring staff, thank you.’ ‘All the staff are friendly, helpful and will attend resident’s needs as required. My mother is always clean and looks much better.’ ‘My father has been cared for over a year. During that time we have observed the love and care given to dad. The fact that everybody has looked after him in such a Christian loving way has made us very happy.’ ‘The home welcomes complaints and sees them as a positive lever for improving the service’, the manager stated. The complaints policy and DS0000017589.V345443.R01.S.doc Version 5.2 Page 18 procedure was displayed in the home and available in the service user guide. 60 of the resident’s relatives and representatives who completed comment cards stated they knew how to make a complaint about the care provided by the home if they needed to, 20 stated they didn’t, 10 could not remember, and 10 commented that, ‘ Occasion to complain has never arisen.’ 50 thought the service always responded appropriately if they or the person using the service had raised concerns about their care and 30 thought it usually did. One relative stated they sometimes did and commented, ‘Regarding requests of preference rather than concern, but when it came to medical treatment for my husband, I was not too impressed.’ Three safeguarding referrals had been made since the previous site visit with respect to the challenging behaviour of three residents and the risk this presented to other vulnerable and frail residents. As a result of a safeguarding referral being taken up and an investigation having taken place, two residents had been transferred to more suitable accommodation and a third resident had settled down with challenging behaviour plans in place to support them. The manager stated, ‘ this situation would be unlikely to arise again due to the thorough assessments carried out currently on prospective residents, which ensure the home offers placements only to those residents whose needs can be met at the home. Safeguarding policies and procedures reflecting the local authority multi-agency policies and procedures were in place to inform the staff. The staff training matrix confirmed that the Protection of Vulnerable Adults training was updated regularly. DS0000017589.V345443.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19,20,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a comfortable, well-maintained, clean and safe environment, which meets their needs. EVIDENCE: A tour of the premises confirmed the requirements of the previous inspection with respect to cleanliness, redecoration and offensive odours had been met. The work had been completed on the first floor and all the bedrooms on the ground floor, except for one, which was scheduled within the next week, had benefited from complete refurbishment and redecoration. The bedrooms viewed were furnished to a high standard with good quality solid furniture, ensuite facilities, domestic lighting and colour co-ordinated soft furnishings. Emergency call bells were present in bedrooms and en-suites and suitable infection control measures were provided. Resident’s bedrooms viewed had been personalised with photographs, pictures and other personal items and DS0000017589.V345443.R01.S.doc Version 5.2 Page 20 residents spoken with confirmed they were happy with the accommodation. Decking had been laid around the perimeter of the home and the downstairs bedrooms benefited from an individual sectioned off decked area, accessed via French windows. Some residents had colourful displays of potted plans displayed on the decked areas, which provided them with a private area in which to sit outside in seclusion should they wish to do so. The large garden, which was accessible from the main sitting room on the ground floor, was secure to enable the residents from the first-floor unit, which catered for elderly frail residents, to enjoy some time outside safely. The area was equipped with outdoor furniture and sunshades, contained mature trees and well-maintained lawns. There was sufficient shared accommodation on both floors, each having a large sitting room with comfortable and appropriate seating arranged in groupings to split the large space into smaller areas. Some residents were watching a television programme, others were relaxing, and another group was actively engaged in a quiz with the activities co-ordinator. Some residents were also enjoying visits from their relatives and one resident was sitting outside. Smaller sitting areas were available for entertaining guests. The dining rooms on both floors were nicely decorated with pictures, wall lights and tablecloths. Seating was arranged in tables of four and in one area two tables had been placed together, the manager stated that a group of residents like to sit together for meals and enjoy each other’s company. Beside the large wellequipped kitchen was a tea-making area and on the first floor was a cinema room with a large screen. The manager stated that this room would be supplied with sensory equipment in the near future. Several residents were using the well-equipped hair salon facilities on the first floor. The laundry was equipped with industrial washing machines with sluice facilities and the surfaces were impermeable to enable easy cleaning. The home was clean and hygienic throughout and free from offensive odours. One relative commented on the laundry, ‘The only issue I have is the laundry service –the loss and damage to clothing is constantly ongoing, but I cannot fault the care given to the residents, which is at the end of the day most important.’ Comment cards from relatives confirmed their satisfaction with the environment including, ‘it is a very clean home – myself and my family are very satisfied,’ ‘Very clean’, and, ‘Clean and friendly environment.’ The manager was booked in to do training in, ‘Infection control for managers’ in October and stated that she would be implementing ‘The Essential Steps’ guidance provided by the Department of Health. The staff-training matrix confirmed that 70 of the staff had received infection control training. DS0000017589.V345443.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient, qualified and experienced staff are employed to meet the assessed needs of the residents. Safe recruitment practices protect the residents from potentially abusive or harmful situations. EVIDENCE: The duty rota was discussed with the manager, who confirmed that sufficient staff for the assessed needs of the residents were on duty at all times. Four trained nurses were scheduled to be on duty at all times and the two unit managers and the registered manager were supernumerary. During the tour of the premises the staff were observed working with the residents and there was no indication that residents were kept waiting for attention. All the residents were calm and appeared to be contented. The staff treated the residents with the utmost respect and were cheerful and considerate in their interactions with them. However, some of the comment cards returned by relatives and representatives of residents felt staffing was an area the home could improve upon. ‘More staff are required now the home is full. Sometimes when I visit I notice a shortage of staff,’ one relative wrote and another commented, ‘more staff, increase in the care staff/resident ratio by a small amount.’ In addition to the sixteen qualified nurses employed at the home there were fifty full-time care assistants, two activities co-ordinators, two chefs supported by a team of catering staff, a housekeeper, a maintenance operative, an administrator and a team of domestic cleaning staff. DS0000017589.V345443.R01.S.doc Version 5.2 Page 22 The manager confirmed that more than 50 of the workforce had either gained a National Vocational Award at level 2 or above, were working towards achieving one or had already gained a higher qualification. This information was recorded on the staff training matrix. Newly recruited staff, who had not previously completed the common induction standards, worked through them in the first weeks of employment and certificates of completion were viewed in staff training logs. In addition to the mandatory training, for which there was a rolling programme of updates, care planning, person-centred dementia care and challenging behaviour training had been accessed by a number of staff. 50 of the relatives and representatives who returned comment cards thought the care staff always had the right skills and experience to look after the people properly and 40 thought they usually did. Comments included, ‘I have never seen a member of staff who appears inexperienced or unfit to provide care,’ and ‘I have no complaint on their skills/experience. There are, however, a few communication problems with some of the overseas staff, but this is improving.’ Another relative stated, ‘99 of the care staff seem to be very competent and I do watch this very closely especially the change in the weekend versus weekday staff.’ Staff personnel files were sampled including the files of the two most recently recruited staff. Records confirmed that essential checks to safeguard the residents had been carried out prior to the offer of a post including Criminal Record Bureau (CRB) and Protection of Vulnerable Adults First checks (POVAFirst) and two appropriate references had been received. It is recommended that the CRB website is accessed for guidelines on the recording, storage and destruction of this sensitive information. The application form required the applicant to give a full employment history, record and explain gaps in employment and reasons for leaving posts involving children and vulnerable adults. The files would benefit from some form of binding to safeguard the documents and an audit sheet to record the contents. A clear photograph to confirm the identity of the staff member was not included in all files, and equal opportunities documentation had not been completed to confirm that processes had been carried out fairly and without discrimination. General comments from relatives with respect to the staff included, ‘Care is good in the wider sense. The home uses care staff that are both pleasant and considerate,’ ‘ the home provides supportive staff, who are always cheerful’ and, ‘the care staff are excellent.’ DS0000017589.V345443.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,33,35,38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. An experienced and well-qualified manager with an inclusive and empowering management style manages the home. The home is run in the best interests of the residents through consultation processes, which influences the development of the home. The health, safety and welfare of the residents are promoted and their finances are safely managed. EVIDENCE: The registered manager is a registered nurse and was well qualified and experienced, having worked in care homes for fourteen years, eleven of which had been at management level. She held a National Vocational Qualification Certificate at level 4 in management, had been in her present role since October 2006, and was enthusiastic about creating an environment which DS0000017589.V345443.R01.S.doc Version 5.2 Page 24 values and enpowers both its clients and its staff. Her positive leadership qualities were evident throughout the day in interactions observed with clients and staff and in the calm and purposeful manner in which the daily business of the home was conducted. Her positive management skills were also highlighted in the open responses recorded in the Annual Quality Assurance Assessment, which clearly highlighted areas for improvement in the development of the service, progress on those improvements identified and future plans over the forthcoming year. The manager stated that she keeps herself up-to-date with current legislation and best practise by attending study days, reading literature and visiting web sites. The Complany has a Director of Nursing, who supports the Home Manager, and carries out the Regulation 26 visits on behalf of the provider. There was a clear management structure consisting of the registered manager, two unit managers, a team of sixteen qualified nurses and two activities co-ordinators supporting a team of fifty fulltime care assistants. A Quality Assurance System was in place with questionnaires sent to all stake holders and staff annually. The collated results of the surveys were viewed and it was clear that the manager was taking the views of the stakeholders into account in the home’s action plan. Resident/representatives meetings were arranged and minutes recorded and a suggestion/compliments book was also provided in which resident’s relatives and representatives had recorded comments. Some of the changes made as a result of taking into account the views of the residents and their representatives included ensuring refreshments are available for residents and their relatives/representatives/ friends in the lounge areas at all times, reviewing the menus to include more soft options choices, changing the layout of bedrooms to accommodate resident’s needs, providing more garden furniture, displaying the activity programme each month for relatives to also see, and rearranging seating in the lounge areas to suit resident groups. Other planned changes included organising more in house activities by bringing in singers to entertain the residents and installing sensory equipment into cinema room. Resident’s financial affairs were taken care of by relatives and representatives and only small amounts of cash were stored individually in the manager’s office to enable residents to purchase newspapers, hairdressing and other extra items. Records were kept of all transactions. ‘However, where possible’, the manager stated, ‘we encourage the residents to control their own money and they have lockable facilities in their bedrooms.’ The manager held a recognised Health and Safety qualification and safe working practices were promoted by ensuring the equipment was maintained with timely service checks. Certificates sampled were up-to-date. The staff training matrix confirmed that moving and handling, infection control, fire, food hygiene, health and safety, First Aid were regularly updated and fire records were available for inspection. The most recent fire drill had taken DS0000017589.V345443.R01.S.doc Version 5.2 Page 25 place on 20th April 2007, risk assessments had been completed and a fire plan had been completed. Records showed that fire equipment checks were carried out monthly. Comments from relatives included, ‘So far I am happy with everything- my husband is treated very well – the food is good,’ ‘Very clean home, excellent food and the attitude of the staff to the residents is very good. Their kindness and care at all times, and this applies to all the staff, they really show they care.’ ‘Excellent liaison with relatives, and you cannot improve on an already excellent service,’ DS0000017589.V345443.R01.S.doc Version 5.2 Page 26 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 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 X X 3 DS0000017589.V345443.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No 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 OP29 Regulation 19 Schedule2 Requirement Information held on file with respect to staff should include a recent photograph to confirm their identity. Timescale for action 15/10/07 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 OP3 Good Practice Recommendations More information with respect to equality and diversity requested on the assessment form would support more holistic and person-centred care planning and ensure the residents social, cultural and personal care needs were recorded and considered prior to admission. The Criminal Record Bureau website should be accessed for guidelines on the recording, storage and destruction of CRB and POVAFirst checks. Staff personnel files should be bound to protect the confidential documents. Equal opportunities monitoring forms should be completed by applicants to ensure procedures are fair and in keeping with current legislation. 2. OP29 DS0000017589.V345443.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. 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