Inspection on 04/07/06 for Ashwood Lodge Care Home

This inspection was carried out on 4th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Ashwood Lodge Care Home 05/05/10

Ashwood Lodge Care Home 16/06/09

Ashwood Lodge Care Home 27/06/08

Ashwood Lodge Care Home 29/06/07

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE The Haven Nursing Home Bedale Avenue Billingham Stockton-on-Tees TS23 1AJ Lead Inspector Jane Bassett Ken Unannounced Inspection 4th July 2006 09:30 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 The Haven Nursing Home DS0000066294.V301322.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. The Haven Nursing Home DS0000066294.V301322.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Haven Nursing Home Address Bedale Avenue Billingham Stockton-on-Tees TS23 1AJ 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) 01642 361122 01642 652122 Nationwide Healthcare Limited Mrs Sarah Kitching Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places The Haven Nursing Home DS0000066294.V301322.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. That a maximum number of 5 places may be used at any one time for the accommodation of persons who are 50 years and over. Date of last inspection Brief Description of the Service: The Haven is a care home registered to provide both personal and nursing care for 27 older people. The home is situated in a residential area of Billingham. All rooms used and occupied by the residents are on the ground floor. The home provides both single and shared bedroom accommodation. Two of the rooms have en suite toilet facilities. Both lounge and dining areas are provided for those residents who wish to socialise. The home has a lawned garden, and has external areas accessible to residents. The home provides car-parking facilities for visitors. The home has recently been purchased by new providers, who have informed CSCI that they are to complete a programme of refurbishment of the environment and development of systems used within the home. The previous manager has left and the providers are in the process of recruiting for the position. The previous deputy manager is currently acting up in this role. The fees at this home range from £327 to £466. The Haven Nursing Home DS0000066294.V301322.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was carried out by two inspectors over a period of six hours. During the inspection four residents, two relatives, three staff, the acting manager and the Registered Provider spoke to the inspector. Documentation including plans of care, staff files, maintenance records, medication records and quality assurance were examined. At the present time the home does not have a registered manager, it is understood the Registered Provider is currently advertising the position. What the service does well: What has improved since the last inspection? What they could do better: The home must ensure that appropriate assessments take place and all identified needs have specific plans of care and risk assessments that are reviewed, evaluated and agreed. Plans of care must reflect resident’s current needs and how these are to be met to promote resident’s safety, comfort and well-being. The Haven Nursing Home DS0000066294.V301322.R01.S.doc Version 5.2 Page 6 Recording of medication and residents personal allowances should be more robust to promote the safety of residents. Work should continue to improve the environment including action to address the stained carpet and unpleasant odours. Recruitment of staff must be more robust and include CRB and appropriate references prior to employment to promoter resident’s safety. Development of staff training, policies, procedures, fire risk assessment, accident analysis, and quality assurance would enhance the resident’s safety and well-being. 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 Haven Nursing Home DS0000066294.V301322.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Haven Nursing Home DS0000066294.V301322.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Assessments are carried out that should ensure that residents needs are met. EVIDENCE: During the inspection one file of a resident who had recently been admitted was examined. This was found to contain information from the social service care manager and a pre admission assessment carried out by a member of staff from the home. The Haven Nursing Home DS0000066294.V301322.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, & 10. Quality in this area is adequate. This judgement has been made using available evidence including a visit to the service. Plans of care seen were confusing, it was difficult to establish residents current needs and if they were being met. There was no evidence that risks have been assessed and actions agreed. Medication records were generally up to date for individual residents and medications received, administered and disposed of are recorded. EVIDENCE: Three long term residents’ files were examined. These were found to be confusing as to the resident’s current needs and how these were to be met. Files contained assessment documentation, plans of care, reviews and daily recordings, however information was not always clear as to current need. The Haven Nursing Home DS0000066294.V301322.R01.S.doc Version 5.2 Page 10 Areas of need identified within the assessments and other documentation did not always have a specific plan of care as to how that need was to be met. Plans of care should be reviewed and evaluated to record any changing needs of the resident. Assessments must be carried out in relation to those residents who have a continence problem including the appropriate resources to meet individual needs. It was noted that a number of residents used lap straps in wheelchairs and bed rails. No evidence was found of risk assessments and consultation being carried out in relation to their use. Concern was raised by the inspector that the terminology within some of the plans of care could be open to misinterpretation and should be more specific. Resident’s files also contained Reminiscence sheets that recorded discussions with key workers regarding elements from the resident’s life history. Those seen included relevant information, however it was noted that no sessions were recorded in the past 2 years. Both the residents and the relatives that spoke to the inspector expressed satisfaction with the care that they receive. One resident said they ‘were happy with the care’ another said they had ‘ no complaints’. It was evident through observation and response to questions residents were treated with dignity and respect. Staff were observed knocking on doors prior to entering bedrooms. The home has a policy and procedure in relation to the administration of medication. The inspector was told that this was to be developed to reflect good practice guidance. A sample audit of medication found no major concerns with ordering, storage, administration and disposal of medication. However hand written entries on Medication Administration records should include the signature of the person transferring the information and a second signature to confirm the accuracy. The Haven Nursing Home DS0000066294.V301322.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, & 15. Quality in this outcome group is Good. This judgement has been made using available evidence including a visit to the service. Family and friends feel welcome and can visit at any time. The home provides seating areas within the communal areas of the home where residents can meet visitors, in addition to the privacy of their own room. It is clear that the home encourages individuals and groups from the community to visit the home. EVIDENCE: The inspector was told activities including trips, dominoes and games take place. Relatives who spoke to the inspector said staff were friendly and people were made to feel welcome. One resident said she was happy at the home and said of the staff ‘ they are all canny lasses’. The home has a ‘Friends of The Haven’ group who fund raise and organise activities. The Haven Nursing Home DS0000066294.V301322.R01.S.doc Version 5.2 Page 12 On the day of the inspection it was noted a local church group visited the home. Those residents who spoke to the inspector told her they were ‘ happy’ at the home and were given choice in how they spent their day. The home has a four week menu but offer alternatives if requested. The lunch was seen to well presented and nutritious. One resident said ‘ the food is lovely and we get choice’ another stated ‘food is good’. Table clothes were seen to be worn and torn at the edges, provision of new table linen would enhance the dining room. The Haven Nursing Home DS0000066294.V301322.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to the service. Residents and others state that they are satisfied with the service provision and feel safe. EVIDENCE: The home has a procedure in relation to handling complaints. The inspector was told that this was to be developed to include current best practice and guidance. This should also include contact details of the local authorities that fund placements within the home. Copies of the current procedure were seen to be displayed and available to all. Records of complaints were seen, the inspector was told that the last received complaint was in 2003. Relatives and residents who spoke to the inspector confirmed they knew who to speak to if they had a concern. One commented ‘I have no complaints’. Staff who spoke to the inspector confirmed that they had received training in relation to the prevention of abuse and were aware of how to raise concerns. The home has a copy of the ‘ no secrets’ guidance. The Haven Nursing Home DS0000066294.V301322.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to the service. The service provides a homely environment. comfortable, the home is clean, warm and tidy. Residents say they are EVIDENCE: The inspector was told the home was to undergo a programme of refurbishment and decoration. The home presents as homely but tired in areas. Decoration has taken place and new furniture provided in the entrance hall. Resident’s bedrooms were seen to be personalised to individual taste with furniture, ornaments and pictures. It was noted that the carpet in one bedroom was stained and required cleaning or replacing. The Haven Nursing Home DS0000066294.V301322.R01.S.doc Version 5.2 Page 15 Residents who spoke to the inspector expressed satisfaction with the home and the environment. The home was generally clean and odour free, however there were two areas that had an offensive odour. The Haven Nursing Home DS0000066294.V301322.R01.S.doc Version 5.2 Page 16 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 & 30. Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to the service. The home must continue to pursue the missing information in relation to recruitment of staff ensuring the process is robust and promotes the safety and well being of residents. EVIDENCE: CSCI had been notified by the Registered Provider that they could not evidence references or Criminal Record Bureau Checks for a number of staff employed at the home prior to their purchase of the service. CSCI was also told that action is being taken to address this concern. During the visit the inspector examined four files of staff recently recruited. Of these two contained no evidence of a Criminal Record Bureau or PoVA check. Two files contained only one reference. Staff files contained evidence of recent video training in relation to Health & Safety, Challenging Behaviour, Food Hygiene, and Prevention of abuse. There was little evidence of all staff receiving recent training in relation to Fire safety and Manual Handling. The inspector was told that further training is planned. The Haven Nursing Home DS0000066294.V301322.R01.S.doc Version 5.2 Page 17 The inspector was told six staff have completed NVQ 2 or above. A further 8 staff are currently undertaking the qualification. Staff receive an annual appraisal and have received supervision, however this has not always taken place six times a year. The Haven Nursing Home DS0000066294.V301322.R01.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, & 38. Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to the service. The home generally operates in a way that protects the residents safety and well-being, however further development should be carried out. EVIDENCE: The acting manager is a first level nurse, she told the inspector that she has also achieved the Registered Manager Award. The home has recently carried out a quality survey. The responses received confirmed that residents were satisfied by the care provided by the home. However it was evident that a number of these forms had been completed by the staff on behalf of the resident. The Haven Nursing Home DS0000066294.V301322.R01.S.doc Version 5.2 Page 19 Residents who spoke to the inspector confirmed that they were satisfied with the service provided and had felt no adverse impact from the recent change of provider. A number of residents and relatives commented that staff, the acting manager and the new owner were approachable and easy to talk to. An audit of personal allowances found no major concerns. New recording sheets have been introduced, however these did not always contain two signatures. Records seen indicated that fire drills and tests are carried out as required. Fire alarms, fire equipment and emergency lighting are checked as required. However there was no evidence of a Fire Risk Assessment. Hot water temps were seen to be recorded. The home has two bathing hoists, one of which did not have evidence of the required service and check. Accidents were seen to be recorded appropriately, however the accident audit should be developed further in relation to identifying individual risks and necessary actions to minimise these. The inspectors were told that all policies and procedures are to be developed to reflect current good practice and guidance. The Haven Nursing Home DS0000066294.V301322.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 X X 2 The Haven Nursing Home DS0000066294.V301322.R01.S.doc Version 5.2 Page 21 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 OP7 OP8 2 3 OP26 OP29 23 19 Regulation 15 Requirement Residents must have appropriate assessments and clear specific plans of care that are evaluated and changed to reflect needs. Action must be taken in relation to offensive odours. All staff must have appropriate checks including CRB and two written references prior to employment. All staff must receive training in relation to Fire Safety and Manual Handling. The home must appoint a manager and submit an application for registration to CSCI. A fire risk assessment must be developed. Appropriate checks must be carried out in relation to the bath hoist as required in the Lifting Operations and Lifting Equipment Regulations 1998. Timescale for action 01/11/06 01/10/06 01/08/06 4 5 OP30 13 8 01/11/06 01/09/06 OP31 6 OP38 13 01/09/06 The Haven Nursing Home DS0000066294.V301322.R01.S.doc Version 5.2 Page 22 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 6 7 Refer to Standard OP9 OP19 OP33 OP33 Good Practice Recommendations Hand written entries on MAR sheets should contain two signatures to confirm accuracy of information. Decoration and refurbishment should continue to enhance the environment. Policies and procedures should be developed to reflect current best practice and guidance. The complaints policy and procedure should be developed to include details of the local authorities funding care placements at the home. Records of all transactions in resident’s personal allowances should include two signatures. Staff should receive supervision 6 times per year. The accident analysis should be developed further in relation to identifying individual risks. OP35 OP36 OP38 The Haven Nursing Home DS0000066294.V301322.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX 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 The Haven Nursing Home DS0000066294.V301322.R01.S.doc Version 5.2 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. 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