Inspection on 30/05/06 for Ashton Lodge

This inspection was carried out on 30th May 2006.

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 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 Mary Williamson Key Unannounced Inspection 30th May 2006 10:00 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.V297142.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. Ashton Lodge DS0000017589.V297142.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 Limited Sheila Kistner Care Home 53 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (33) of places Ashton Lodge DS0000017589.V297142.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate residents from the age of 60 years Date of last inspection 15th November 2005 Brief Description of the Service: Ashton Lodge is owned by Sovereign and is a purpose built home providing nursing care and accommodation for fifty -three 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 September 2006. Ashton Lodge DS0000017589.V297142.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and was undertaken by Mrs. Mary Williamson who is a Regulation Inspector. Mrs Sheila Kistner who is the Registered Home Manager was the representative for the organisation during the inspection. Both unit managers also had an input to this inspection. On arriving at the home the senior staff team were busy reviewing medication and treatments of service users with the GP. Members of the staff team were very welcoming and introduced the inspector to several service users. The home was functioning efficiently with the minimum disruption to service users as possible during the ongoing building work. It was possible to read needs assessments and care plans for FM, MC, MG, and LM, and talk to these service users regarding their experiences about living in the home. A tour of the premises was undertaken which included the new top floor, which is due to be completed soon. It was also possible to talk with several service users in the privacy of their own rooms. The kitchen was visited and a discussion took place between the chef and the inspector. Menus were seen and all the required documents relating to environmental legislation is in place. Several staff were spoken to and all confirmed that they undertake training at various levels and stated that this is ongoing. One member of staff showed the inspector the new laundry, which has recently been extended and refitted. Staff have a good understanding of service users individual needs and were observed to be confident in the delivery of care. There was positive feedback from service users regarding the staff team and the care provided. Records relating to the care of service users and the management of the home were examined. The safety of the service users during the current building work is paramount and the building site manager has risk assessments in place to cover all eventualities. These were discussed with the home manager. The inspector would like to thank the service users and all the staff team for their hospitality and help during this inspection. Ashton Lodge DS0000017589.V297142.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The recruitment procedures in the home need to be reviewed as a matter of urgency. Several employment files seen did not have appropriate references and did not have a CRB (Criminal Records Bureau) disclosure in place. Fire safety records were not available for inspection and a requirement was made accordingly. Ashton Lodge DS0000017589.V297142.R01.S.doc Version 5.2 Page 7 The mal odour in the dementia unit needs to be monitored and managed effectively. Photographs need to be provided on all medication-recording charts. 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.V297142.R01.S.doc Version 5.2 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.V297142.R01.S.doc Version 5.2 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): 1, 2, 3, and 6. Quality in this outcome area is good. Judgement has been made using available evidence including a visit to the service. Prospective service have access to information regarding the home in order to help them make a decision about living there. Individual pre admission needs assessments determine the suitability of the home to meet service users needs. Contracts of occupancy are in place. Intermediate care is not offered. EVIDENCE: The home has a statement of purpose and service user guide in place. All prospective service users and their relatives have access to a copy of this to help them make an informed decision about living in Ashton Lodge. Pre admission needs assessments were seen for FC, MC, MG, and LM. These were undertaken by a senior nurse with the relevant experience, and were detailed and informative. The manager stated that service users and relatives are encouraged to participate in these assessments. Some service users were not able to confirm this statement. Ashton Lodge DS0000017589.V297142.R01.S.doc Version 5.2 Page 10 Contracts of occupancy are in place. These contain terms and conditions of occupancy to include fees paid, room to be occupied, and additional charges if necessary. A signed copy is retained on the service users file. The home does not provide intermediate care but can offer respite care. Ashton Lodge DS0000017589.V297142.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, and 10 Quality in this outcome area is good. Judgement has been made using available information including a visit to the service. Individual care plans are in place. Health and medication arrangements in place promote the wellbeing of the service users in a dignified manner. EVIDENCE: Care plans were seen for FM, MC, MG, and LM. These were well written using information gathered at the pre admission needs assessment, information obtained from the service user when possible, contribution from relatives and other health care professionals. Care plans are reviewed regularly by the senior staff and care team and updated when necessary. Daily records are also kept. All the service users are registered with a local GP who visits the home on a regular basis. Two service users stated that they can always see a doctor if they need to. On the day of the inspection the GP spent several hours in the home reviewing the treatment and medication for all the service users. He had his lap top computer, which was linked to the surgery in order to update records and record necessary information. Ashton Lodge DS0000017589.V297142.R01.S.doc Version 5.2 Page 12 The chiropodist was also visiting the home during the inspection and all service users have access to chiropody treatment. One service user stated that she has her eyes tested in the home. A record in a care plan confirmed that the dentist also provided dental treatment in the home. Specialist support can be accessed by a GP referral and the tissue viability nurse and CPN also visit the home on request. The home has a medication policy in place and all staff who administers medication are familiar with this document. Medication records in place are generally well maintained, however there was no photograph in place for ML, and LM. The home has a contract with Moss Pharmacy who also undertake medication audits. The arrangements for the administration of controlled medication are satisfactory. Currently the home operates two units with medication cupboards and records on both units. Arrangements were only inspected on the general nursing unit. All the service users bedrooms are single with en-suite facilities. Locks are provided on doors if required. There is also a lockable facility in bedrooms for service user valuables. The inspector observed staff to knock on bedroom doors prior to entering, and to address service users in a respectful and caring manner. Ashton Lodge DS0000017589.V297142.R01.S.doc Version 5.2 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 the following standard(s): 12, 13, 14, and 15. Quality in this outcome area is good. Judgement has been made using available evidence including a visit to the service. The activities programme in place meets the individual and collective needs and choice of service users. Family links are maintained and the nutritional needs of the service users are met. EVIDENCE: There is an activities co-ordinator in post who works twenty-seven hours per week. She produced an activities programme on a monthly basis, which includes board games, card games, art and craft, bingo, and gentle exercise. Other activities include mobile library, clothing sales, outside entertainers, garden parties, and celebrating special events. On the day of the inspection some service users were sitting in the lounge in groups either listening to music or reading their newspaper others were sitting in their rooms reading or watching TV, and some service users were being nursed in bed. On the dementia unit staff were interacting with service users on a one to one basis and encouraging them to respond. One service user stated that she did not have any interest in activities and her preferences were respected. The spiritual needs of service users are supported and several members of local clergy visit the home on request. Ashton Lodge DS0000017589.V297142.R01.S.doc Version 5.2 Page 14 Family links are maintained and visitors are welcome into the home at any reasonable time. Two relatives confirmed that they can come and help with feeding and were consulted during the initial assessment. They also confirmed that they are kept informed of service users changing needs. The kitchen was visited and there was the opportunity to talk with the chef. The kitchen was well organised and all relevant documentation was in place. The menus are planned by the chef on a four weekly basis and are seasonal. There is a choice of two main courses for lunch and several options for supper. One service user confirmed that her sister has a very poor appetite and the kitchen staff will always supply an alternative meal if she did not like what was on offer. Lunch offered on the day of the inspection was chicken breast, roast and boiled potatoes, and a selection of vegetables, or corned beef hash. There was a wide range of deserts also available. The food was wholesome and well presented. Special diets are catered for and staff were observed on the dementia unit offering sensitive support to service users who required help with feeding. Ashton Lodge DS0000017589.V297142.R01.S.doc Version 5.2 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 the following standard(s): 16, and 18. Quality in this outcome area is good. Judgement has been made using available evidence including a visit to the service. The complaints procedure is displayed in the home and procedures in place protect service users from abuse. 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. A service user confirmed that she has not had a reason to use this procedure as if there are issues than they are usually resolved immediately. One service user stated that she complained verbally about the length of time it took to answer a call bell and this was resolved but felt confident that there was a procedure in place. The home has a copy of Surreys Multi Agency Policies and Procedures on Safeguarding Vulnerable Adults in place. The home manager and senior staff have attended training and updates on these procedures. There is also an organisation policy in place for abuse awareness. All staff have training in abuse awareness during induction training. Ashton Lodge DS0000017589.V297142.R01.S.doc Version 5.2 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 the following standard(s): 19, 20, 24, and 26. Quality in this outcome area is adequate. Judgement has been made using available evidence including a visit to the service. The standard of individual and communal accommodation varies throughout the home, and currently does not meet the national minimum standards. Mal odour in the dementia unit needs to be monitored. EVIDENCE: The home is undergoing major building work in the form of a second floor being constructed to increase the number of registered beds to one hundred. There is a temporary entrance to the home as a new reception area is under construction. The lounge on the nursing care unit is currently being refurbished and overlooked the building work, which is not pleasant for the service users who sit in this area. This group of service users stated that they did not mind and looked forward to the completion of the work. There was mal odour in the lounge on the dementia unit. This is an ongoing problem and must be monitored until this unit is relocated upstairs when a Ashton Lodge DS0000017589.V297142.R01.S.doc Version 5.2 Page 17 refurbishment is due to take place. The lounge carpet must be shampooed regularly. The standard of individual accommodation varies. The newly commissioned bedrooms are all en-suite, comfortable, well decorated and meet the service users needs. The standard of accommodation on the nursing care unit is also satisfactory with bedrooms personalised to reflect service users personalities and interests. The dementia care unit is showing signs of were and tear and in need of refurbishment, which is scheduled in phase three of the building project. There is a control of infection policy in place and one cleaner was able to demonstrate her understanding of this procedure. The laundry has been extended and equipped with new washing machines, and dryers to provide for the extra bedrooms being built. Arrangements are in place for the collection for clinical waste. Ashton Lodge DS0000017589.V297142.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, and 30. Quality in this outcome area is poor. Judgement has been made using available evidence including a visit to the home. The number and skill mix of staff on duty was adequate to meet the assessed needs of service users. The recruitment procedures in the home do not protect the service users living there. EVIDENCE: The duty rota was seen and the number of staff on duty was adequate to meet the assessed needs of the current service users in the home. One service user stated that in her opinion there was not enough staff on duty to answer call bells in an acceptable length of time. It was not possible to confirm this as all the bells rung during the inspection were responded to in a reasonable time. A discussion took place with the manager to review staffing arrangements for the new extension. She confirmed that recruitment was in progress and was going “very well”. The organisation has a recruitment policy in place. However several shortfalls were observed in this during the inspection. There are two staff working in the home since April 2006 and their employment details were available in the home for inspection. Files sampled for MM has one unacceptable reference, no CRB disclosure, and no photograph, SS had no references, no employment history, only one written reference and no CRB disclosure, JD had only one reference, no photograph, and no CRB disclosure. This poor practice does not Ashton Lodge DS0000017589.V297142.R01.S.doc Version 5.2 Page 19 safeguard the wellbeing of the service users living in the home. A requirement has been made accordingly. Training records confirmed that five staff are undertaking NVQ Level 2 at west Thames College, and three staff have enrolled to undertake NVQ Level 3 in September. Further training undertaken includes fire safety awareness, abuse awareness, food hygiene, manual handling, stroke awareness, dementia awareness, pressure area care, infection control and first aid. Ashton Lodge DS0000017589.V297142.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, and 38. Quality in this outcome area is adequate. Judgement has been made using available evidence including a visit to the service. The management structure in the home supports the service users living there. Health and safety is promoted however fire safety records were not available for inspection. EVIDENCE: The registered home manager is a qualified nurse and has several years experience in the provision of care to 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. Daily meetings take place on the respective units and changing needs of service users discussed with the care team and care plans updated accordingly. Ashton Lodge DS0000017589.V297142.R01.S.doc Version 5.2 Page 21 The home has an administrator in post for the past three weeks. It is anticipated that she will be based at the new reception area once the telephones and computer links have been connected. Formal staff supervision is in place and undertaken by the senior staff team. This is recorded and retained on staff files, which was observed during the inspection. Relatives manage service users finances. Invoices are sent for hairdressing and newspapers. There is a wide range of policies and procedures relating to health and safety available in the home and staff are introduced to these policies and procedures by the organisations training manager at induction. This training includes manual handling, food hygiene, COSHH, risk assessment, fire safety and first aid. The fire safety records were not available for inspection. A requirement has been made accordingly. The arrangements from the last inspection have remained unchanged regarding the risk assessments in place during the building project. The site manager has detailed risk assessments in place for all identified risks and all potential risks associated with the building work. The home is secure at all exits that lead to the site and doors 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 the director to discuss development and resolve any problems encountered by the service users during this period. The whole team are committed to keep disruption to service users to a minimum during this building project. Ashton Lodge DS0000017589.V297142.R01.S.doc Version 5.2 Page 22 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 X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 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 2 2 X X X 2 X 2 STAFFING Standard No Score 27 3 28 X 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Ashton Lodge DS0000017589.V297142.R01.S.doc Version 5.2 Page 23 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 OP9 Regulation 13(2) Requirement The registered person shall arrange for photographic identification to be in place on medication recording charts. The registered person must ensure that all parts of the care home are kept clean and reasonably decorated. The registered person must ensure that the communal lounge areas kept clean and reasonably decorated. The registered person must ensure that the home is kept free from offensive odours. The registered person shall not employ a person to work in the care home unless the person is fit to work in the home and all documentation listed in Schedule 2 is in place. This must include appropriate references and CRB disclosure. The registered person shall maintain in the care home records specified in Schedule 4. A record of every fire practice, drill, or test of fire equipment conducted in the home. These DS0000017589.V297142.R01.S.doc Timescale for action 31/07/06 2. OP19 23(2d) 31/07/06 3. OP20 23(2d) 31/07/06 4 5. OP26 OP29 16(2)(k) 19(1)(a) (b) 31/07/06 31/07/06 6 OP38 17(2) 31/07/06 Ashton Lodge Version 5.2 Page 24 records must be available for inspection. 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.V297142.R01.S.doc Version 5.2 Page 25 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.V297142.R01.S.doc Version 5.2 Page 26 - 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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