Inspection on 01/02/07 for Astral Lodge

This inspection was carried out on 1st February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Astral Lodge 11/12/07

Astral Lodge 29/11/05

Astral Lodge 01/09/05

Astral Lodge 13/12/04

Astral Lodge 10/09/04

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOME ADULTS 18-65 Astral Lodge Astral Lodge 2 Cumnor Road Sutton Surrey SM2 5DW Lead Inspector David Pennells Key Unannounced Inspection 1st February 2007 12:30p Astral Lodge DS0000019072.V329130.R01.S.doc Version 5.2 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 Astral Lodge DS0000019072.V329130.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 Adults 18-65. 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. Astral Lodge DS0000019072.V329130.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Astral Lodge Address Astral Lodge 2 Cumnor Road Sutton Surrey SM2 5DW 020 8642 1884 020 8661 7974 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) Astral Lodge Limited Mr Bennie Darkey Care Home 17 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (17) of places Astral Lodge DS0000019072.V329130.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. A variation has been granted to allow three specified service users over the age of 65 to be accommodated for as long as the service can adequately meet their needs. 29th November 2005 Date of last inspection Brief Description of the Service: Astral Lodge is a care home providing mental health nursing care for to up to a maximum of seventeen adults (two of whom would share a double occupancy room) who have enduring mental health problems. The home currently has a variation to provide care to two named service users who are over 65 years of age. The home provides 24-hour mental health nursing support to all service users, with care staff support provided under the nursing staff members supervision. The ethos of the establishment - established since June 1996 - is self-help within the understanding / context of the psychological and other social and physical needs of each individual. Accommodation is extensive and provided over two floors; a large lounge, a dining room and separate smoking room are provided. There are fifteen single and one double bedroom (currently singly occupied) situated over both floors of the home. Two toilets are situated on each floor, a bathroom is on the first floor and a shower room is situated on the ground floor. The home has a relatively small but pleasant garden, through which is a route to the external laundry facility. There is car parking for three on the hardstanding at the front of the house, with more spaces available at the side of the building. The home is very close to Sutton town centre (five minute walk away), with its associated excellent transport links and all shopping and leisure amenities. Astral Lodge DS0000019072.V329130.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection visit was conducted over an afternoon and early evening - the inspector leaving the house at 19:40pm. This phase of time enabled the inspector to encounter all service users, and to meet with two shifts of staff. The proprietor, Mr Bennie Darkey was available on site and assisted the inspector throughout the inspection visit. What the service does well: What has improved since the last inspection? New washing machines have been provided in the laundry area - this providing a better wash and a more reliable service to the service users - who are assisted to undertake their own laundry. The smoking room has also been provided with an extractor fan to ensure that the room remains relatively smoke-free - especially in the cold winter months when opening windows is less appropriate. Two bedrooms have been redecorated. A new extractor fan has been installed over the hob in the kitchen. Astral Lodge DS0000019072.V329130.R01.S.doc Version 5.2 Page 6 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. Astral Lodge DS0000019072.V329130.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Astral Lodge DS0000019072.V329130.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 4. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective service users can expect to find out adequate detail to make an informed choice when they try to decide whether to reside at the home, though some written material is now out of date. These documents are supplemented by the opportunity to visit the home on a visit / short stay basis, and find out about the home - before confirming their stay as permanent. The home ensures the appropriate service is provided to each individual based on both their own and other professional’s assessments. EVIDENCE: The home’s basic information documents - the Statement of Purpose and service User guide were reviewed and found to be out-of-date and therefore needing revision. Copies of the revisions must be sent to the Commission. New admissions made at the home since the last inspection visit had totalled four - of which three were still resident at the home. Two randomly chosen, but relatively new, service user’s files were selected and examined; a full Care Programme Approach (‘CPA’) Assessment was available - and full hospitalbased assessments also. These documents gave a very full picture of the situation pre-discharge from hospital, and the information had been translated into a care plan with associated risk assessments for the individual service Astral Lodge DS0000019072.V329130.R01.S.doc Version 5.2 Page 9 user’s time at the home. All needs had been clearly identified in specific care plan goals - in a previous audit, a service user’s relative had been involved in the process, too. All admissions are usually very carefully planned. Short visits (accompanied or otherwise) are followed by overnight and weekend stays to ‘get the feel’ of the house. Placements are reviewed after four weeks (or longer if necessary) - and are not confirmed as permanent placements until a CPA meeting takes place after six months of placement. The home rarely admits emergency or shortterm placements (though one was undertaken this year), due to the potential disruption to the ‘finely balanced’ community culture at the home. All service users are subject to a local authority three-way contract. The Registered Provider has inserted key contract terms into the Service User’s Guide; each document is signed by the service user and the Registered Provider - thus committing them both to the local rules / terms & conditions at the home. Astral Lodge DS0000019072.V329130.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be confident that the home will provide a care plan, based on current assessment, and reflecting a service user’s rights to exercise choice and autonomy both inside and away from the home, within a risk-assessed context. EVIDENCE: Service users each had a full comprehensive assessment of need and a resultant care plan, which covered all salient points for each individual. Daily records complemented the care plans. Care Plans clearly state the focus and purpose of any intervention / assistance provided. The Care Plan is reviewed regularly with the service user; the regularity depends upon changing needs; the longest gap being one month. Each service user has a Registered Mental Health Nurse as key worker, and an associate care worker is also allocated - to provide the more direct / personal Astral Lodge DS0000019072.V329130.R01.S.doc Version 5.2 Page 11 care and contact. Each service user also has a CPA (Care Plan Approach) Review meeting at least annually, and more frequently if needs change and precipitate such a review. Clinical risk assessments are undertaken for each service user in relation to their mental health - including relapse planning. The recording of all risk assessments was clear and appropriate; assessments were on file for service users detailing concerns over specific behaviours or activities. Many areas of practice noted in the home during the inspection have been risk assessed and are appropriately recorded; for example: service users going out against the advice of staff when mentally unwell; service users holding their own cigarette lighters and lighter fluid - some having these items looked after by staff. The mix of service users - male and female - young and older - strong and (relatively) frail - brings about a mixed community ‘feel’; the three women are all (coincidentally, but helpfully) located on the ground floor, relatively close to each other. Astral Lodge DS0000019072.V329130.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users at the home can be assured that they will be encouraged to participate in the life of the home and beyond - promoting the ethos of being an individual, through being encouraged to participate in both in-house and community-based opportunities and leisure activities. Relatives and friends of service users can be assured of a positive welcome at the home; their participation in the life of the home being welcomed to broaden horizons and maintain family / friendship links. Meals at the home are provided in good quantity - with a nutritious and attractive menu being provided, and opportunities for self-catering through inroom catering. EVIDENCE: The home promotes the independence of the service users as a key area of its focus. For many, the service user’s mental health inevitably affects their ability Astral Lodge DS0000019072.V329130.R01.S.doc Version 5.2 Page 13 / capacity to participate in independent activities; staff members have to work with service users to motivate and enable them to achieve as much as is practicable. Inside the home, most service users participate in doing their own laundry; the ‘laundrette’ in the garden now has good ‘domestic’ equipment. Most service users are independent in going out of the home, being able to undertake personal shopping, libraries visits and other community activities. All service users have London Transport ‘Freedom passes’, this enabling them to access public transport and opportunities farther afield. Day trips to ‘Sea World’ and Portsmouth have been recently enjoyed. Staff members support service users on local outings to the shops, local pubs and restaurants, and to enjoy swimming, bowling and the cinema. In-house activities at the home include regular quizzes, pool, video evenings, parties, and barbeques. Almost all service users have television and radios in their rooms - many also having kettles and drink-making facilities. Service users often spend time in their own rooms, regarding them as their own personal space - something like an independent ‘bed-sit’. There was clearly an element of ‘pride’ expressed by a number of service users in this space. Some service users attend Church services - and the home has monthly visits from the local Anglican Vicar and visitors from the local parish community. The sole Hindu service user chooses not to practice their faith. The home is very welcoming of visitors - either family or friends - or Church visitors, such as were met on the day of the inspector’s visit. Links / contact with family members are noted on individual care plans. The fact that all current service users have their own bedroom can be of advantage, though there will be times when the use of the bedroom is inappropriate for receiving visitors. Service users again reported that food provided at the home was ‘very good’ meals are served according to a rolling menu, but some service users have an alternative menu - including meeting cultural / religious needs. All staff members who undertake the cooking duties were credited with being ‘excellent’ in culinary skills - and were highly praised and valued. The proprietor spoke of a future intention to create a social / ‘rehabilitation’ facility in the existing garage area of the home; this is still a future project. Service users assist in the general communal routines of laying and clearing tables, etc. In the main, most have kettles and a fridge in their bedrooms; this enables a degree of independence and expression of individuality. Most service users do not use the main kitchen alone, this being a risk-assessed activity. Some service users do assist in the kitchen - a hygiene risk assessment is essential to ensure that food safety conditions are upheld - for the benefit of all who eat at the home. Astral Lodge DS0000019072.V329130.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can expect to be encouraged to independently maintain their personal, physical & mental health as much as possible, whilst the staff will provide such assistance as is appropriate / needed (including assistance with medication) to ensure their health and general wellbeing. EVIDENCE: Health Assessments under the ‘Health of the Nation’ initiative were in place for service users, providing clear care-planned approaches to physical health and mental health needs. Most service users have come to the home from a distance away (only a few are ‘Sutton placements’) - so the majority have had to register with the same local GP. The home enables access to optician, dentist and (occasional) chiropody appointments; the principal aim is always to encourage service users to engage with ‘ordinary’ services outside the home in the wider community. The only two admissions noted through ‘A&E’ in the last twelve months related to a service user with a specific epileptic condition. Astral Lodge DS0000019072.V329130.R01.S.doc Version 5.2 Page 15 Medication procedures were examined and the process of administration observed. Medication administration records were checked and found to be in order, consistently maintained and up-to-date. The nursing staff members at the home manage all the medication. The local advising pharmacist has provided accredited training in the handling and administration of medicines. No controlled drugs were used on site. The local GP practice and then pharmacist have a ‘fax relationship’, which ensures the swift and speedy making up and delivery of prescribed medication. Regarding personal care, most service users are generally independent in their personal hygiene / care - though some need substantial encouragement / prompts to keep up to standard - and some service users have great difficulty in this discipline. Staff members’ involvement in a service user’s personal care is to encourage and support them to maintain their independence and selfesteem, whilst having to be sensitively honest about the achieved standard of personal hygiene and self-presentation. Astral Lodge DS0000019072.V329130.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are confident that the management will handle comments and any complaints made both swiftly and appropriately. Service users can be assured that they will be protected from the possibility of physical, financial or any form of abuse. EVIDENCE: There is a clear and comprehensive complaints procedure for the home. The procedure indicates that service users can complain to the Commission at any point during the ‘in-house’ complaints process. The proprietor / manager stated in the pre-inspection questionnaire that there had been no complaints received in the last inspection year. The home’s Adult Abuse and Protection procedure has been relatively recently revised to ‘back up’ the Local Authority procedure, which was also in evidence. Staff members have undertaken training provided by the London borough of Sutton focusing on the ‘Vulnerable Adults’ heading. The safe keeping of cash service user’s valuables process was examined with the proprietor. Records for each service user are kept separately; four service users have individual savings accounts with HSBC (with individualised statements being received by each service user) and weekly personal allowance records are kept as appropriate. Astral Lodge DS0000019072.V329130.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides warm and comfortable communal environments for service users to feel ‘at home’ which can meet their individual needs and promote their independence. Bathrooms and toilets are in a generally poor condition - which does not encourage a positive attitude towards personal hygiene, or encourage pride in the accommodation. EVIDENCE: The washing machine provided at the home has been upgraded alongside the tumble dryer - both now being of a semi-industrial type and of a very reliable make. Service users and staff commented on this enhanced facility – which provides a better service than the previous, failing, model. The smoking room has now been provided with an extractor fan – obviating the need to open windows wide during the winter months. The environment was still not very attractive - and is in great contrast to the other (nonsmoking) communal rooms close by. A stronger focus on improving this smoking area could be beneficial. Astral Lodge DS0000019072.V329130.R01.S.doc Version 5.2 Page 18 The home at the time of the inspection was starting to appear - as openly expressed by the inspector to the proprietor - somewhat ‘shabby’. This impression was gained through the dark hallway, the poor standard / deteriorating carpeting on the staircase and first floor landing (which may soon become a trip hazard), and also the low standard of décor and cleanliness / hygiene in the toilets, bathroom and shower room. The ground floor shower room particularly - an ‘internal room’ - needs radical improvement; the presence of continuous damp leading to some mould forming. The upstairs bathroom, also, was stark, cold and certainly not a positive or conducive space to encourage activity with regard to hygiene. The dining area and sitting room were, by contrast, pleasant and comfortable. Some rooms occupied by service users were also well kept and attractive whilst others, principally due to mental ill health and negative habits, were of an unkempt / poor standard. One bedroom was particularly poorly maintained - but this is apparently, and sadly, a feature of the habits of the service user. The inspector recommends that a review of the entire premises be undertaken - to draw up a more focused plan of premises refurbishment / improvement for the near future. The ongoing refurbishment of what is a substantial house needs to be clearly ‘mapped’. Astral Lodge DS0000019072.V329130.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The service provides a stable and generally competent staff team; this, in part, is due to the fact that qualified nurses are available at all times in the home. Care staff remain in need of undertaking more mental-health focused training and vocational training to NVQ level - to enable them to work knowledgeably alongside the nursing staff; this development of expertise - especially in understanding mental health issues - will benefit the service users – especially when they are ‘in crisis’. The home implements a full recruitment process, thus ensuring the safety, protection and wellbeing of service users. The implementation of a full induction process, in line with the new ‘Skills for Care’ format, would benefit all at the home - both current and new staff. Support to members of staff, both through the holding of regular staff support meetings - and providing individual staff supervision - would improve the service provided, through enhancing communication between staff in general, and by encouraging their training and self-development. Astral Lodge DS0000019072.V329130.R01.S.doc Version 5.2 Page 20 EVIDENCE: Service users once again commented on the kindness and helpfulness of the staff members at the home. The inspector noted a positive tone of amiability and camaraderie throughout the inspection visit. Staffing is provided at a ratio of a constant trained member of nursing staff to three care workers during the working day, reducing to working with two care assistants beyond 5pm, and from 8pm to 8am there being a nurse and a care worker available - both remaining awake. The registered provider is still required to develop a staff training matrix & development programme that includes specific training for care staff in mental health - and focuses on care staff achieving their NVQs at, minimally, Level 2. At present, no staff members were indicated as having achieved their qualification at this level - this due to the attempt to link with Learn Direct not being a satisfactory experience. The proprietor indicated that a new initiative was being looked into Induction and Foundation Training (now known as Common Induction Standards for Adult Social Care) to Skills for Care specification - must be introduced to ensure that all staff members have a core underpinning knowledge base. The registered provider must also ensure that all staff members employed at the care home receive formal supervision, which must be recorded. This 1:1 process should occur at least six times per year. Individual meetings were still yet to be arranged on a consistently regular basis. The only sessions provided by the deputy manager, who had the delegated responsibility for this initiative, were for ‘troubleshooting’ / ‘support’ sessions specifically used to target issues. Staff meetings had been held - and minuted - over each month from April to August 2006, at which time the next was projected for September 2006 - but this never took place, nor were any meetings subsequently recorded. It is strongly recommended that the frequency of such meetings be increased to a minimum of six per year - held on a regularly spaced basis. It is worrying that such gaps of formal meetings could be allowed to happen - though staff did state that ‘informal’ gatherings were commonplace in the home. Astral Lodge DS0000019072.V329130.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 & 43. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users can be confident that a competent person, adequately qualified in the home’s specialist area, runs the home. Service users can expect their views and comments to be taken on board in regard to the quality of the service provided - though the manager needs to more proactive in this area. The safety of service users is generally well protected, though the number of staff trained in First Aid should be increased to ensure round-the-clock cover. The house equipment is serviced & maintained in a generally safe and appropriate way – though the monitoring of hot water temperatures is to be regularised to avoid the risk of scalding - and regular checks of fire escape routes must be enhanced to ensure the maximum safety of service users. The home is effective in its care service, though more recent deterioration in general accommodation standards leads the inspector to request evidence of viability and a projection of long-term prospects in a business & financial plan. Astral Lodge DS0000019072.V329130.R01.S.doc Version 5.2 Page 22 EVIDENCE: The proprietor, who also manages the home, is a Registered Mental Health Nurse; he has in the past completed the Certificate in Management Studies. He has extensive experience of managing care establishments; having both managed this home for over seven years and possessing ten year’s previous management experience in other mental health settings. Quality assurance measures taken by the home revolve around a questionnaire that is being circulated to service users. The service clearly should be working in a more proactive way to elicit opinions about the standard of the service from a broader span of stakeholders. On health and safety issues, more staff training must be provided to ensure that a member of staff is trained in First Aid to cover the rota for the house on a continuous ‘24/7’ basis (only two of the ‘duty officers’ were indicated as being so qualified). Checks on the home’s fire alarm systems, extinguishers, emergency lighting and other relevant house-related maintenance issues were generally well in order. The minimally weekly monitoring of hot water temperatures is (again) to be regularised - especially in bath and shower rooms - to protect against the risk of scalding; checks had inexplicably stopped. The on-site carpenter was able to resolve a concern about the fire exit from the basement - where the door was found to be door stuck closed - at the time of the inspection visit. There is clearly a need to increase the monitoring of such doors - and this factor is to be included in the home’s fire risk assessment. The other fire exit - that from the first floor to the rear garden, via a (generally unused) secondary staircase, was found to be ‘just’ workable - however, with the ongoing issue of continuous damp weather, the monitoring process must involve all possible exits on a continuous basis. The proprietor is required, in this report, to provide a Business & Financial Plan – evidencing the service’s intention to refurbish / improve the fabric of the home, as both proprietor and inspector agreed that there appeared little evidence of proactivity in maintaining and keeping ahead of the demands of wear and tear on the fabric of the home. Astral Lodge DS0000019072.V329130.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 3 29 X 30 2 STAFFING Standard No Score 31 X 32 1 33 X 34 3 35 1 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 1 2 Astral Lodge DS0000019072.V329130.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES 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 YA1 Regulation 4&5 Requirement The Statement of Purpose and Service User Guide must be reviewed and updated to ensure that all salient details are accurate and that the detail is relevant to the current time. A copy of this revised document to be sent to the Commission within the stated timescale. Carpets on the stairs to the first floor and along the first floor corridor must be replaced to ensure they are safe surfaces and to provide an adequate standard of furnishing. Bathrooms toilets & shower rooms must be urgently refurbished - and they must be kept to a high standard of cleanliness. This is particularly important bearing in mind the number of service users using the said facilities. Timescale for action 31/05/07 2. YA24 23(2)(c) 30/04/07 3. YA30 13(3) & 23(2)(d) 30/04/07 Astral Lodge DS0000019072.V329130.R01.S.doc Version 5.2 Page 25 4. YA32 18(1)(c) A minimum of 50 of care staff working in the home must be trained - or in the first instance signed up to undertake - to Level 2 NVQ in Care as soon as is practicable. (Previously a recommendation - now a requirement) Induction and Foundation Training (now to be known as Common Induction Standards for Adult Social Care) to Skills for Care specification - must be introduced to ensure that all staff members have a core underpinning knowledge base. (Timescales of 15.04.05, 30.10.05 & 31.01.06 not met.) The registered person must develop a staff training and development programme that should include specific (refresher) training in mental health - for all care staff. (Timescale of 30.11.04, 30.10.05 & 31.01.06 not met.) The registered person must ensure that all staff members employed at the care home are offered formal supervision which must be recorded. This 1:1 process should occur at least six times per year. (Timescales of 30.11.04, 30.10.05 & 31.01.06 not met.) Quality assurance processes must be developed and the outcome reported to both service users and the Commission. Training must be provided to ensure that the house is covered at all times by a DS0000019072.V329130.R01.S.doc 30/04/07 5. YA35 18(1)(c) 31/05/07 6. YA35 18(1)(c) 30/04/07 7. YA36 18(2) 30/04/07 8. YA39 24(1) - (3) 31/05/07 9. YA42 13(4) 30/04/07 Astral Lodge Version 5.2 Page 26 member of staff currently trained in First Aid. (Timescales of 30.10.05 & 31.01.06 not met.) 10. YA42 13(4) Hot water outflow checks must 03/02/07 be undertaken and recorded on a regular weekly basis - to ensure that all taps with valves can be monitored and observed for variation / failure. Evidence of professional checks of the emergency lighting system must be provided to the Commission. 30/04/07 11. YA42 23(4) 12. YA42 23(4) Following the discovery of a fire 03/02/07 door that was inoperable: Fire risk assessments must include the regular monitoring of the effectiveness of all fire exit doors leading from the building. A fresh business and financial plan must be evolved showing the future refurbishment / development plans for the service. A copy must be provided to the Commission. 31/05/07 13. YA43 24 & 25 Astral Lodge DS0000019072.V329130.R01.S.doc Version 5.2 Page 27 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 YA24 Good Practice Recommendations That a review of the entire premises be undertaken - to draw up a more focused plan of premises refurbishment / improvement for the near future. The smoking room would benefit from refurbishment / a stronger positive focus on facilities / furnishings to benefit the many service users who do use the facility. Staff meetings should be increased to a minimum of at least six per year - if not more. The proprietor should consider repeating / renewing CRB checks for those who were checked prior to the introduction of PoVA checks - to ‘regularise’ the staff member’s checks to the current ‘enhanced’ level. The office copy of the National Minimum Standards should be replaced by the revised [more modern] version. 2. YA28 3. 4. YA33 YA34 5. YA40 Astral Lodge DS0000019072.V329130.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Astral Lodge DS0000019072.V329130.R01.S.doc Version 5.2 Page 29 - 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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