Inspection on 29/06/05 for Ashton Lodge

This inspection was carried out on 29th June 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 15/11/05

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 Surrey TW16 7DA Lead Inspector Mary Williamson Unannounced 29/06/2005 10:00 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ashton Lodge h09-h58 s17589 Ashton Lodge v224353 030505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Ashton Lodge Address Spelthorne Grove, Sunbury On Thames, Surrey, TW16 7DA Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01932 761761 Ashton Lodge Ltd Sheila Tynan CRH N 45 Category(ies) of OP - Old Age - 25 registration, with number DE(E) - Dementia - over 65 - 20 of places Ashton Lodge h09-h58 s17589 Ashton Lodge v224353 030505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: The home may accommodate residents from the age of 60 years Date of last inspection 01/11/04 Brief Description of the Service: Ashton Lodge is owned by Sovereign and 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. The majority of the bedrooms are en-suite and are situated on the ground floor. The home is currently undergoing major building work to increase its registered beds to 100. It is anticipated that this will be complete by 2006. Ashton Lodge h09-h58 s17589 Ashton Lodge v224353 030505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and the first in The Commission for Social Care Inspection year 2005/2006. Mary Williamson who is the lead inspector for the service undertook the inspection. The registered manager Sheila Kistner (formally Sheila Tynon) was present throughout the inspection. The deputy manager Mr. Gaston Dzvuke was also present for a part of the inspection. The inspector had the opportunity to meet most of the service users and talk with six of them individually. Four staff were spoken to and two relatives. There was also the opportunity to meet three musicians who were providing entertainment in the home during the afternoon of the inspection. 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 home was functioning well and all service users were well cared for and relaxed. Some service users were sitting in both lounges, some were sitting in their bedrooms reading or watching television. One service user was celebrating her birthday with presents and a visit from her son. Some service users were being nursed in bed and the quality of care being provided was good. The interaction between the staff and service users was seen to be respectful, professional and positive. The home is currently undergoing major building work with a second floor being constructed. This will increase the number of beds to 100. At 2pm the inspector had a meeting with the Site Manager Mr. Martin Frisby and the home manager to discuss the safety of the service users during this building work. Risk assessments were seen for all eventualities and procedures in place to keep disruption to a minimum. The inspector would like to thank the service users, staff, visitors, and the management team for their positive and helpful approach to the inspection. Ashton Lodge h09-h58 s17589 Ashton Lodge v224353 030505 Stage 4.doc Version 1.30 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The standard of decoration varies throughout the home. The bathrooms and toilet areas on both units need to be redecorated and new flooring provided. Ashton Lodge h09-h58 s17589 Ashton Lodge v224353 030505 Stage 4.doc Version 1.30 Page 7 The lounge carpet on the dementia unit needs to be replaced. The mal- odour in the dementia unit needs to be managed effectively with consideration given to input from the continence adviser. 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 h09-h58 s17589 Ashton Lodge v224353 030505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Ashton Lodge h09-h58 s17589 Ashton Lodge v224353 030505 Stage 4.doc Version 1.30 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 standard(s) 1, 2, 3, and 5 The home was found to be operating effectively in respect of these standards. The information available to prospective service users and their representatives was adequate to enable them to make an informed choice about the home. EVIDENCE: The home has a statement of purpose and service users guide in place. This provides prospective service users, their families and designated representatives with the information necessary to make an informed decision about living at the home. Written contracts of occupancy are in place for all service users. These outline in detail the service to be provided and the fees payable. A signed copy is issued to all service users and a copy retained on file. The manager stated that she undertakes a pre admission needs assessment on all prospective service users. A selection of these assessments were randomly sampled which were completed using the homes own assessment format. Ashton Lodge h09-h58 s17589 Ashton Lodge v224353 030505 Stage 4.doc Version 1.30 Page 10 The manager stated that trial visits are encouraged whenever possible. Relatives visit on prospective service users behalf if they lack the capacity to do so for themselves. Ashton Lodge h09-h58 s17589 Ashton Lodge v224353 030505 Stage 4.doc Version 1.30 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, and 10 Evidence gathered during the inspection indicated that the assessed standards were met. Systems are in place to ensure that the personal and health care support is being provided. EVIDENCE: Individual care plans are in place, which outlines the care to be provided. The care plans are written with input from the service users whenever possible, their relatives, information gathered from the pre admission needs assessment, and past medical reports. Care plans were sampled on the dementia unit, which are well maintained and reviewed on a regular basis. These plans were discussed with the deputy manager who has responsibility for the dementia care unit. He demonstrated a good understanding of the assessed needs of the service users in his care. There was evidence that risk assessments are also undertaken for example, moving and handling, risk of developing pressure sores, and nutrition assessments, which are also included in the care plan. All the service users are registered with a local GP who visits the home weekly Ashton Lodge h09-h58 s17589 Ashton Lodge v224353 030505 Stage 4.doc Version 1.30 Page 12 or more frequently if required. There is also access to a chiropodist, dentist, and optician who visit the home regularly. Specialist services, for example visits from the psychiatrist, and CPN can be arranged. On discussion with two service users they confirmed that all the above visits take place. Service users privacy and dignity is respected and staff were observed to knock on bedroom and bathroom doors prior to entry. Staff were also seen to address service users in a polite and respectful manner. The home has a policy in place with regard to the privacy and dignity of service users and staff have training in these procedures. Ashton Lodge h09-h58 s17589 Ashton Lodge v224353 030505 Stage 4.doc Version 1.30 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, and 15 Evidence gathered during the inspection confirmed that the home meets each of the assessed standards. Appropriate leisure activities are provided and the nutritional needs of service users are met. EVIDENCE: There is a programme of activities in the home, which meets the collective and individual needs of the service users. This is overseen by the activities coordinator and includes board games, floor games, card games, outings, and shopping trips. Some service users enjoy reading the daily newspaper. Outside entertainment is also arranged and the inspector had the opportunity to meet with three musicians during the inspection who all spoke highly of the home. Service users are supported to maintain contact with their relatives who are encouraged into the home at any reasonable time. Community links are maintained and a meeting was held in the home with the local residents to discuss the building project. Arrangements were put in place for an alternative site entrance for heavy lorries to keep disruption to a minimum. The catering arrangements are flexible and offer a wide and varied diet. The chef plans the menus, with input from the service users. Lunch was observed which was appetising and wholesome. There was a choice of two main courses Ashton Lodge h09-h58 s17589 Ashton Lodge v224353 030505 Stage 4.doc Version 1.30 Page 14 and a selection of deserts. Special diets are catered for and staff were observed offering sensitive support to service users who require help with feeding. Several service users gave very positive comments on the standard of the meals available. Ashton Lodge h09-h58 s17589 Ashton Lodge v224353 030505 Stage 4.doc Version 1.30 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, and 18 Evidence gathered during the inspection indicated that the home meets each of the assessed standards, and that service users, and relatives are listened to and are adequately protected. EVIDENCE: The home has a complaints procedure in place and this is available to all service users and their families on admission to the home. A relative confirmed that although he did not have to complain he felt secure in the knowledge that he would be listened to in such circumstances. There is an abuse awareness policy in place and the manager stated that all staff receive training in this policy during induction training. Ashton Lodge h09-h58 s17589 Ashton Lodge v224353 030505 Stage 4.doc Version 1.30 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, and 26. Evidence gathered throughout the inspection confirmed that the home falls below the minimum environmental standards, with regard to the standard of decoration and odour control. EVIDENCE: The home is purpose built and accommodation is arranged over two units. One unit provides care for service users requiring nursing and the other unit provides care for service users with dementia also requiring nursing. The standard of decoration varies throughout the home. The communal areas in the nursing wing are generally well maintained. Some of the natural light is obscured in the hallways due to the construction work in progress. This was discussed with the site manager and the home manager and a projected date at the end of August is the target date for the completion of the first phase of the building work. An action plan has been requested outlining the timescales for the hallways returning to normal. Ashton Lodge h09-h58 s17589 Ashton Lodge v224353 030505 Stage 4.doc Version 1.30 Page 17 The lounge in the dementia unit was mal odorous and the carpet was badly stained. The manager stated that this is shampooed on a regular basis. This is a requirement brought forward from the previous inspection on 01/11/2004. It is required that the mal- odour be managed through a continence programme and that the lounge carpet is replaced. There are ample toilets and bathrooms situated throughout the home some of which are assisted to provide for the mobility needs of the service users. These are showing signs of wear and tear and need to be redecorated and new flooring provided. During the meeting with the site manager it was stated that these bathrooms were due to be refurbished in the building project. An action plan is required outlining the timescales involved. There are two cleaners employed in the home and the inspector had the opportunity to talk with them. They both received induction training and were aware of the infection control procedures within the home. Consideration should be given to employing an extra cleaner to manage the odour control problem in the home. Ashton Lodge h09-h58 s17589 Ashton Lodge v224353 030505 Stage 4.doc Version 1.30 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, and 30 Evidence gathered during the inspection indicated that the home meets each of the assessed standards. Staff support was sufficient and staff training a high priority. EVIDENCE: The staff duty rota was seen during the inspection and the number of staff on duty reflected the assessed needs of the service users. The home also employs two cleaners, two chefs, two kitchen assistants, a laundry assistant, and a leisure activities coordinator. The manager is committed to individual staff training and development. Currently there are five service users with NVQ level 2 and seven staff have enrolled in the local college to undertake this training. There are also two adaptation nurses in post undertaking conversion training. All staff undertake induction training followed by foundation training. A record of staff training is maintained. Staffing levels will continue to be monitored in view of the new building. Ashton Lodge h09-h58 s17589 Ashton Lodge v224353 030505 Stage 4.doc Version 1.30 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 37, and38 Evidence gathered during the inspection confirmed that the home meets each of the assessed standards and was seen to be well run. The standard of record keeping is good and promotes the health and welfare of the service users. EVIDENCE: The registered manager is a qualified nurse with several years experience in the provision of care to older people. She has overall responsibility for the home. The deputy manager is also a qualified nurse with a sound knowledge and understanding of people with dementia and has responsibility for the dayto-day management of the dementia unit. The standard of record keeping is good. Records sampled included care plans, risk assessments, staff duty rotas, employment documentation, and menus, which all promote the best interests of the service users. Ashton Lodge h09-h58 s17589 Ashton Lodge v224353 030505 Stage 4.doc Version 1.30 Page 20 There is a wide range of health and safety policies and procedures in place and these were viewed throughout the inspection. All staff have been trained in these procedures, which also includes first aid, fire safety, food hygiene, moving and handling, and COSHH. The fire safety records were seen and these are well maintained. Accidents are recorded and a record of these was examined. The inspector met with the site manager and the home manager to discuss the current building work and the effect it is having on the service users and the home. Risk assessments have been implemented by the building company and the organisation to make sure the service users are protected from all possible dangers. All access to building work has been made secure and procedures are in place to cover all eventualities. Weekly meetings take place between the site manager building manager and an organisation representative to discuss any problems and the plans for the forthcoming week. Ashton Lodge h09-h58 s17589 Ashton Lodge v224353 030505 Stage 4.doc Version 1.30 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 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 2 2 2 x x x x 2 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x x x x x 3 3 Ashton Lodge h09-h58 s17589 Ashton Lodge v224353 030505 Stage 4.doc Version 1.30 Page 22 N/A 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 19,20,and 21 26 Regulation 23(2)(d) Requirement The registered person must ensure that all parts of the care home are kept clean and reaasonably decorateed. The registered person must keep the home free from offensive odours. Timescale for action 31/08/05 2. 16(2)(k) 31/08/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 19, 20, 21, and 26 Good Practice Recommendations It is recommended that the organisation sends an action plan outlining timescales for the refurbishment of the home and the the restoration of natural light to the hallways by 31/08/2005. Ashton Lodge h09-h58 s17589 Ashton Lodge v224353 030505 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection 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 h09-h58 s17589 Ashton Lodge v224353 030505 Stage 4.doc Version 1.30 Page 24 - 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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