Inspection on 13/09/07 for Aspen Lodge Care Home

This inspection was carried out on 13th September 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

Aspen Lodge Care Home 07/05/09

Aspen Lodge Care Home 26/11/08

Aspen Lodge Care Home 21/02/07

Aspen Lodge Care Home 11/10/06

Similar services:

St Vincents

The Cotswold Home

Winton House

Newbeech House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Aspen Lodge Care Home 222 Weston Lane Weston Southampton Hampshire SO19 9HL Lead Inspector Laurie Stride Unannounced Inspection 13th September 2007 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 Aspen Lodge Care Home DS0000066715.V344351.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. Aspen Lodge Care Home DS0000066715.V344351.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Aspen Lodge Care Home Address 222 Weston Lane Weston Southampton Hampshire SO19 9HL 023 8042 1154 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) Aspen Care Ltd Vacant post Care Home 13 Category(ies) of Dementia - over 65 years of age (13), Mental registration, with number disorder, excluding learning disability or of places dementia (13), Mental Disorder, excluding learning disability or dementia - over 65 years of age (13), Old age, not falling within any other category (13), Physical disability (2), Physical disability over 65 years of age (2) Aspen Lodge Care Home DS0000066715.V344351.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users in the categories DE, MD and PD must be at least 55 years of age. A maximum of two service users in the categories PD and PD(E) are to be accommodated at any one time. 21st February 2007 Date of last inspection Brief Description of the Service: Aspen Lodge is a registered home providing care and accommodation for up to thirteen older people. The home is situated in Weston, close to a park and local shops. Public transport bus stops are located nearby. The property is an extended older detached house with car parking to the front and a patio and large garden to the rear. Although registered for people with a physical disability the home does not have level or ramped access to the front or rear of the property. The home provides private accommodation in thirteen single bedrooms (one en-suite), some on the ground floor and others on the first floor accessible via a shaft lift. Bathrooms and WCs are located around the home. The home was purchased in March 2006 by Aspen Care Ltd, responsible individual being Mr C S Meepegama. At the time of this key inspection the acting manager had applied for registration. Weekly fees range from £335.23 to £395.64, dependant on assessed needs. This information was obtained at the time of the inspection visit. Members of the public may wish to obtain more up-to-date information from the care home. Aspen Lodge Care Home DS0000066715.V344351.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection visit, which lasted nine hours, during which we met most of the people who use the service and also spoke with the proprietor, the home’s acting manager and four staff members. As part of the information gathering process questionnaires were sent to four external professionals who have contact with the home and to six relatives. Comments were received from two relatives and one care manager. Seven service user and twelve staff questionnaires were sent to the home. Five people who use the service responded and were helped by staff to complete the forms. Nine completed staff questionnaires were also received. Samples of the homes records were seen and a tour of the premises was undertaken. The home’s acting manager had also provided information about the service in the annual quality assurance assessment (AQAA). The findings of the previous inspection report of 21st February 2007 were also reviewed as part of the evidence used for this inspection report. What the service does well: What has improved since the last inspection? Risk assessments are now held in individual’s files and not in a general risk assessment folder. This promotes confidentiality. The home now has a clear adult safeguarding policy and procedure for reporting concerns. Aspen Lodge Care Home DS0000066715.V344351.R01.S.doc Version 5.2 Page 6 Evidence of pre-employment staff checks are available in the home for inspection, to demonstrate that people who use the service are protected. Since the last inspection there are more qualified care staff working in the home and they are now receiving regular formal supervision. The proprietor has put in place procedures to reduce the risk of Legionella in the home’s showerheads. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Aspen Lodge Care Home DS0000066715.V344351.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 Aspen Lodge Care Home DS0000066715.V344351.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s comprehensive assessment procedures ensure that those people who are admitted will have their needs met. The home does not provide intermediate care, therefore this standard is not applicable. EVIDENCE: Five people who use the service and who returned questionnaires confirmed that they received enough information about the home before they moved in, so they could decide if it was the right place for them. One said that their family were also involved in the decision and that they were invited to visit prior to admission, which helped them a lot. We saw the records of two people recently admitted to the home. The acting manager had assessed their individual needs to determine if these can be met by the service. A comprehensive pre-admission assessment document had Aspen Lodge Care Home DS0000066715.V344351.R01.S.doc Version 5.2 Page 9 been used to gather this information, which together with the relevant care managers’ and health professionals’ assessments, had been used to generate provisional care plans for the individuals. We saw that the care plans continued to be updated as the individuals settled into living at the home. The acting manager had visited one of the individuals in hospital as part of the assessment process. Both individuals had a contract/terms and conditions of residency on file, signed either by the person or their representative. Four people who use the service, who returned questionnaires, said they had received a contract. One said they did not know. Aspen Lodge Care Home DS0000066715.V344351.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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. Health and personal care services are based on individual needs and the principles of respect, dignity and privacy are put into practice. EVIDENCE: The home’s annual quality assurance assessment (AQAA) stated that the health, personal and social care needs of people who use the service are set out in individual care plans. A staff training programme has commenced to ensure that people’s health and personal care needs continue to be met. We saw that care plans clearly identify the individuals’ health, social and care needs and how these should be met. Staff members keep daily records monitoring any changes in people’s care needs. The acting manager or keyworkers review the care plans on a monthly basis and there is also a wider annual review. Staff members who returned comment cards said they are always given up to date information about the needs of the people they support or care for. One said there are frequent reviews and staff inform each other of any changes. Discussion with staff members confirmed they receive Aspen Lodge Care Home DS0000066715.V344351.R01.S.doc Version 5.2 Page 11 training, including an induction that promotes the understanding and implementation of the General Social Care Council code of practice. Care plans provide guidance for staff on how to meet individual needs in a way that promotes the person’s independence, privacy and dignity. For example, encouraging people to self-care, choose what to wear and to take part in daily routines such as making their bed. A service user satisfaction survey carried out by the home in July 2007 indicated that people feel that they are treated with respect and their right to privacy and dignity is met. There is a rota for staff that ensures people who use the service receive regular hand and nail care. One person who lives in the home commented that they thought this was good practice. Throughout the inspection visit staff were observed interacting in a friendly and respectful manner with people who use the service. Three people who provided comments indicated that they always receive the care and support they need. Another two said they usually do. Three said that staff are usually available when they need them, while two said staff were always available. All indicated that they receive the medical support they need. Medical appointments and the outcome of these are recorded and monitored in care plans. Staff confirmed that people who use the service have access to healthcare professionals, who also visit the home if the individual is unable to travel. Comments received from a care manager indicated that individuals’ health care needs are properly monitored and attended to by the service. We viewed a sample of the medication administrations records and these were fully completed. The previous inspection report for 21st February 2007 identified that all staff had received training in the administration of medication. At the time of this visit, two relatively new staff members were on duty and the acting manager was administering the medication, in line with the home’s procedures. The acting manager was observed explaining to a person who lives in the home about a prescribed change in their daily medication. Medications are stored in a suitable secure medications trolley, which is attached to the wall when not in use. At the last inspection visit a requirement was made that individual risk assessments must be held within the relevant individuals’ folder and not in a general risk assessment file. During this visit we saw that this requirement had been met and risk assessments were held in individual’s files. New and more detailed risk assessment forms are beginning to be used and the proprietor and acting manager had attended risk assessment training. Aspen Lodge Care Home DS0000066715.V344351.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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. People who use the service continue to be able to make choices and have control over their lives. The home provides a variety of activities and the acting manager has developed an activities programme to meet the likes and needs of individuals. EVIDENCE: The acting manager has introduced an activities programme and showed us the recordings she has undertaken of activities provided in the home and the responses and involvement of individuals who use the service. There is now an ongoing evaluation record of activities that is completed by staff. Activities include bingo, playing cards, billiards, news and actuality awareness, beauty sessions, hand massage therapy, physical exercise and mobility and outings to the local park. Evidence was seen in the daily records and during the visit of staff providing mental stimulation for people. During the day a visiting musician came to the home to entertain people. Aspen Lodge Care Home DS0000066715.V344351.R01.S.doc Version 5.2 Page 13 Four people who use the service, who returned questionnaires, said there are usually activities arranged by the home that they can take part in. One said there sometimes are. The previous inspection report identified that people’s friends and relatives were able to visit at any time and that they were welcomed into the home. Comments from a relative indicated that they are always able to keep in touch. The home has established links with a local church in Weston and staff confirmed that the vicar comes to the home on a regular basis. A service user satisfaction survey carried out by the home in July 2007 indicated that people feel that staff listen to them and respect their decisions. One person who uses the service likes to take part in the daily routines and is encouraged to make their own bed and go to the shop independently. This is recorded in the person’s care plan. One person commented that they would like some deck chairs for the garden. The acting manager reported that she had assisted people who use the service to re-register their right to vote and now have the opportunity to vote by post if they wish. People who use the service informed us that they were happy with the meals provided at the home. The home employs a cook six days per week. The cook is also responsible for the food shopping and informed us that she is able to spend whatever she likes to provide the meals requested by the people who live in the home. A menu plan was seen, however the cook does vary this depending on the wishes of individuals. The cook stated that fresh fruit and vegetables are provided and we saw that the kitchen cupboards were well stocked. Throughout the day people were seen being offered and provided with hot and cold drinks. Evidence was seen that a previous requirement that the home provide suitable alternatives for people with special diets specifically sweeteners, if wanted, in hot drinks had been met. However the individual that this requirement had applied to was no longer living at the home. Aspen Lodge Care Home DS0000066715.V344351.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has suitable procedures for dealing with concerns and people who use the service are protected by the home’s policies and procedures. EVIDENCE: The complaints procedure is included within the Service Users’ Guide. Discussions with people who use the service indicated that they had no complaints or concerns and that if they had concerns they would probably say something to a member of staff. Those people who use the service and who returned questionnaires indicated that they know who to speak to if they are not happy. All indicated that they know how to make a complaint and that the staff listen and act on what they say. All nine staff members who returned questionnaires said they know what to do if a person living at the home or their representative has concerns about the home. Two said they would report it to the manager, in discussion another said they would know if an individual living in the home had concerns, by observing changes in the persons behaviour. One relative who returned a survey questionnaire said they know how to make a complaint. Another said they did not know. Aspen Lodge Care Home DS0000066715.V344351.R01.S.doc Version 5.2 Page 15 The acting manager reported that there had been one complaint since the last inspection. There was a record of this that showed that the home had taken appropriate action. There is a complaints form, on which details of concerns and the action taken to address them can be recorded. Following the previous inspection a requirement was made that the home must have a clear adult protection policy and procedure which links to the locally agreed procedures for reporting concerns. During this visit we saw that the home has clear written procedures and the acting manager and proprietor demonstrated awareness of the action that they should take in the event of a suspicion of adult abuse. Staff spoken to also understood the reporting procedure and confirmed they had received the relevant training. One member of staff said that since this training had been undertaken, improvements had been made in the way that staff monitored the wellbeing of people who use the service, through handovers, written communications and care reviews. This staff member also said that training in managing challenging behaviour had been very helpful and informative. Aspen Lodge Care Home DS0000066715.V344351.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Improvements continue to be carried out to ensure that the environment is safe, clean and comfortable and meets the needs of people who use the service. EVIDENCE: The home is situated in a residential area of Southampton, close to a public park and with bus links to other areas of Southampton. The home is an extended detached house with a large garden to the rear and parking to the front. A shaft lift provides access to the first floor bedrooms. Since purchasing the home the proprietor has continued implementing a programme of redecoration and refurbishment, including for example non-slip flooring in bathrooms, re-carpeting in bedrooms, hallway and communal areas, a bath hoist has been fitted, the dining room and lounge have been redecorated and new furniture and fittings have been provided in bedrooms. A building file has Aspen Lodge Care Home DS0000066715.V344351.R01.S.doc Version 5.2 Page 17 been created for reporting maintenance issues to the proprietor and recording work undertaken. The acting manager reported that this internal communication procedure has improved efficiency in the planning of safety and security on the premises. The home has a communal lounge located at the rear of the property and a dining room to the front. Both are of a suitable size to accommodate all the people who live in the home at one time if required. Furnishings within communal rooms are domestic in style and suitable for use by people who live in the home. The home does not have a separate room for private visits however the dining room could be used outside of meal times. The annual quality assurance assessment states that the acting manager has informed people about the new smoking legislation and the home has decided to go smoking-free, however people who use the service can smoke in designated areas. One bedroom contained an oxygen cylinder, prescribed for the individual. The proprietor and acting manager reported that the relevant healthcare professional had advised them on this arrangement. We advised that the home contacts the fire officer for their views and any further guidance on the safe storage of the cylinder. The home has a large rear garden with patio area. As identified in the previous reports there are some access concerns with the garden. The garden is accessed via the lounge and by sliding patio style doors, which have a raised lip at the bottom through which the doors slide as opposed to one which is flush to the floor. A portable ramp is available for use at the front or rear of the home for people with limited mobility. The proprietor is seeking advice with environmental and exterior designers with plans to transform the garden and facilities. The home has a rota of cleaning duties to ensure that good hygiene standards are maintained. Most of the people who returned questionnaires about their home, indicated that it is usually kept clean. On the day of the visit all rooms seen were clean and tidy, including the kitchen, which was remarked upon as commendable. Care staff confirmed they have supplies of disposable aprons and gloves and boxes of gloves were seen in the laundry room. Infection control training is also provided and certificates were seen on staff members’ files. Soap dispensers and paper towels are available in the bathroom and toilets. The laundry room is sited where linen to be washed is not taken through areas where food is stored, prepared or eaten. Aspen Lodge Care Home DS0000066715.V344351.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. JUDGEMENT – we looked at outcomes for the following standard(s): 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. Suitable numbers of staff are provided to support people who use the service. Staff receive training to enable them to meet the needs of individuals and the homes’ staff recruitment procedures ensure people are protected. EVIDENCE: Nine members of staff who returned surveys said their employer carries out relevant checks before they started work. Five said their induction covered everything they needed to know to do the job when they started ‘very well’; four said ‘mostly’. All said they are being given training which is relevant to their role, helps them understand and meet the individual needs of people who use the service and keeps them up to date with new ways of working. One staff member commented that they read articles that the acting manager puts on the kitchen notice board. Eight said they always feel they have the right support, experience and knowledge to meet the different needs of people who use the service; one said usually. All staff spoken to during the visit expressed commitment to providing quality care to people who live in the home. The staff rota was seen and this indicated that two care staff are on duty during the day with one awake and one sleep-in at night. Staff and the acting manager confirmed that this is the usual number of staff deployed in the home to support people who live there. The acting manager works six days per week Aspen Lodge Care Home DS0000066715.V344351.R01.S.doc Version 5.2 Page 19 and in addition to the care staff a cook is available six days per week and a domestic worker six mornings a week. The annual quality assurance assessment states that the proprietor spends two days a week at the home. The two care staff on duty during the morning of the visit were both completing their induction period. The acting manager said it is usual practice to have at least one more experienced staff member on shift, who also administers the medication in line with the home’s policy. However a situation had arisen whereby a staff member who usually works on the early shift had requested to work in the afternoon. The new staff members both appeared confident and relaxed interacting with people who live in the home. The acting manager was observed administering the medication. Of eleven care staff, the acting manager reported that eight had obtained an NVQ level 2 or are currently working to achieve the award. A further three staff were reported to be due to start and there was documentary evidence to support this. This is also an improvement since the last inspection, with more qualified staff working in the home. The homes’ annual quality assurance assessment states that all who have worked in the home in the last twelve months had satisfactory preemployment checks. Further evidence of this was seen at the time of the visit through a sample of two new staff members’ recruitment records. These files contained the required information, such as dates of employment and completed job application forms, two written references and evidence of satisfactory Protection of Vulnerable Adults (POVA) and Criminal Records Bureau (CRB) checks. This demonstrates that a previous requirement has been met and people who use the service are being protected. The home has an induction process involving workbooks obtained from the General Social Care Council and overseen by the acting manager who is a qualified social worker with a background in dementia and older persons mental health care. Evidence of the induction training was seen in the records and confirmed through discussion with the acting manager and staff on duty. Evidence of further training was seen in a sample of staff records seen during the visit. Certificates were seen for training in infection control, moving and handling, health and safety, food hygiene, safe handling of medication, abuse and neglect, and challenging behaviour. Updates in fire safety and first aid are planned for October and staff on duty confirmed this. The acting manager has requested training from the optical health service in order to develop staff competence in supporting people who have a visual impairment. Aspen Lodge Care Home DS0000066715.V344351.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed and the views of people who use the service are sought, in order to ensure the service is run in their best interests. This would be enhanced through a wider formal survey of stakeholders. Staff are appropriately supervised and the health, safety and welfare of people who use the service are protected. EVIDENCE: The acting manager assisted throughout the inspection visit, demonstrated a clear understanding of the needs of people who use the service and a commitment to providing a quality service. The acting manager is a qualified social worker with a background in dementia and mental health and has applied for registration with the Commission for Social Care inspection in respect of this service. Aspen Lodge Care Home DS0000066715.V344351.R01.S.doc Version 5.2 Page 21 The results of the home’s service user satisfaction survey were seen and these were very positive overall. This matched comments made by individuals who live in the home. During this visit we recommended that a wider stakeholder survey be periodically undertaken, to formally seek the views of relatives and visiting professionals on how the home is achieving outcomes for people who use the service. The proprietor said he plans to put a suggestions box in the hall so that people who wish to make comments can do so anonymously if they wish. The acting manager and a member of staff said they speak regularly with the relatives of people who live in the home. The proprietor confirmed that the home continues to be not directly involved in the management of individuals’ personal finances. A record is kept of the invoices sent to the individuals or their representatives that detail what additional services are being charged such as for chiropody and hairdressing. Following the previous inspection a requirement was made that care staff must receive formal supervision at least six times per year. This has been met. Staff supervision and assessment records were seen on file. One staff member we spoke to confirmed that they received formal one-to-one supervision. Another said they had signed the record of an observational assessment of their work carried out by the acting manager. The nine staff members who completed questionnaires said that the acting manager regularly or often meets with them to give them support and discuss how they are working. Evidence was seen that safe working practices are in place in the home. A comprehensive staff training programme is in place. A fire drill had been carried out and recorded on 31/08/07 and there is a fire safety maintenance checklist and fire risk assessment for the building. Routine checks on the homes gas, electric and water services are undertaken. Thermostatic mixer valves are fitted to hot water outlets in bedrooms, to reduce the risk of scalds and staff also check and record the water temperatures. Following the previous inspection a requirement was made that the proprietor consult the local environmental health officer to determine the correct solution that should be used and frequency that showerheads should be disinfected to reduce the risk of Legionella. This has also been met. The proprietor said he had contacted a care association regarding the relevant legislation and both he and the acting manager demonstrated knowledge of the procedures, which they confirmed are now in place. The proprietor said that these procedures are an interim measure and that the planned building work included fitting specific valves to regulate and reduce the risk. Aspen Lodge Care Home DS0000066715.V344351.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 X X 3 X X N/A 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 3 X 3 X 3 3 X 3 Aspen Lodge Care Home DS0000066715.V344351.R01.S.doc Version 5.2 Page 23 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. Standard Regulation Requirement Timescale for action 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 OP33 Good Practice Recommendations A wider stakeholder survey is periodically undertaken, to formally seek the views of relatives and visiting professionals on how the home is achieving outcomes for people who use the service. Aspen Lodge Care Home DS0000066715.V344351.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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. Extracts may not be used or reproduced without the express permission of CSCI Aspen Lodge Care Home DS0000066715.V344351.R01.S.doc Version 5.2 Page 25 - 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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