Inspection on 18/08/06 for Atherton Lodge Nursing Home

This inspection was carried out on 18th August 2006.

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 but made no statutory requirements on the home.

Other inspections for this house

Atherton Lodge Nursing Home 22/04/09

Atherton Lodge Nursing Home 28/05/08

Atherton Lodge Nursing Home 22/05/07

Atherton Lodge Nursing Home 04/01/07

Atherton Lodge Nursing Home 30/12/05

Atherton Lodge Nursing Home 05/08/05

Atherton Lodge Nursing Home 16/03/05

Atherton Lodge Nursing Home 15/06/04

Atherton Lodge Nursing Home 05/02/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Atherton Lodge Nursing Home Atherton Lodge 202 Pooltown Road Ellesmere Port South Wirral CH65 7ED Lead Inspector Wendy Smith Unannounced Inspection 18th August 2006 10 am 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 Atherton Lodge Nursing Home DS0000018711.V304489.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. Atherton Lodge Nursing Home DS0000018711.V304489.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Atherton Lodge Nursing Home Address Atherton Lodge 202 Pooltown Road Ellesmere Port South Wirral CH65 7ED 0151 3554089 0151 3560141 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) Par Nursing Homes Limited Mrs Sue Maudsley Care Home 49 Category(ies) of Dementia - over 65 years of age (9), Old age, registration, with number not falling within any other category (40) of places Atherton Lodge Nursing Home DS0000018711.V304489.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for a maximum of 49 service users to include: * Up to 40 service users in the category of OP (old age not falling within any other category * Up to 9 service users in the category of DE(E) (Dementia over the age of 65 years) Date of last inspection 30th December 2005 Brief Description of the Service: Atherton Lodge is a two-storey detached property that has been converted and extended into a care home with nursing for 49 older people. It is situated within a mile of Ellesmere Port town centre and is close to local shops and amenities. Bedrooms are on both floors and are accessed by stairs, a passenger lift, a wheelchair lift and several ramps. On the ground floor there are three lounges and a dining room. Assisted baths and toilets are provided on both floors. The recently added dementia care unit has its own lounge/dining room and assisted bathroom. There are attractive gardens with access for residents from the lounge, and ample parking space. The home’s fees are from £343.34 to £417 per week. Atherton Lodge Nursing Home DS0000018711.V304489.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection process for Atherton Lodge included an unannounced visit to the home on 18th August 2006, with a further visit on 24th August 2006 to discuss findings with the manager and the home owner. Time was spent talking with the manager, staff, residents and visitors, and observing the day to day routines of the home and care staff as they provided support. The home had 49 residents, one of whom had been admitted to hospital and one had just arrived. The building was looked at to assess its suitability to provide a comfortable, homely environment and ensure the safety of staff and residents. A further extension to the building was completed and registered in July 2006. This has created a self-contained nine bed dementia care unit and has also improved a number of the other bedrooms and facilities. Before the visit, comments cards were sent to the home for residents and relatives to complete, but none were returned. Comments cards have also been sent to GPs and other professionals who visit the home. The home manager completed a pre-inspection questionnaire. During the visit a sample of care plans and other records was looked at. The home has been through considerable upheaval since the beginning of the year and the number of residents has increased from 35 to 49 within a short period of time. Unfortunately the recruitment of new staff has been problematic and the manager has been off work following a bereavement. The home now needs to have a period of stability and consolidation so that new residents and staff can settle in, and the routines of the home can be adapted to accommodate the change in size and structure of the establishment. What the service does well: Senior staff go out to assess all prospective residents before admission is arranged. The home employs a number of very experienced care staff who have worked at Atherton Lodge for a long time. The manager and deputy have both been in post for more than 10 years and the home owner visits regularly and is involved in the day to day running of the home. Good recruitment procedures are followed to ensure that unsuitable staff are not employed. Atherton Lodge Nursing Home DS0000018711.V304489.R01.S.doc Version 5.2 Page 6 All parts of the home were clean and tidy and there is a modern and wellequipped laundry. Residents’ personal money is handled appropriately. Records showed that all plant and equipment in the home is serviced and maintained in good condition. What has improved since the last inspection? What they could do better: There must always be enough staff on duty to meet the needs of residents and to have adequate time to spend with residents. A member of staff should be available to spend time with new residents as they arrive. Whenever it is identified that a resident requires the use of bedrails to prevent them from falling out of bed, the rails used must be safe and fitted with suitable protective covers to prevent injury or entrapment. Bedrails and any other restraint, for example cocoon beds, should only be used following a robust risk assessment and this must be kept under regular review. Ensure that all residents who are being cared for in bed, and any others who are identified as being at high risk of developing pressure sores, are adequately protected by the use of appropriate pressure relieving equipment. Make provision for the medicines prescribed for residents on the new unit to be stored and administered safely. Keep full records of medicines received and administered to all residents. Review the arrangements for meals for residents on the Charles Roberts unit. Provide suitable social activities for residents. Ensure that the manager has adequate time for management duties including auditing. Atherton Lodge Nursing Home DS0000018711.V304489.R01.S.doc Version 5.2 Page 7 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. Atherton Lodge Nursing Home DS0000018711.V304489.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Atherton Lodge Nursing Home DS0000018711.V304489.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are assessed before being admitted to the home to ensure that their needs can be met. EVIDENCE: Information provided by the manager indicated that the home has admitted 37 new residents in the last year. There have been 14 admissions since the extension was registered early in July 2006. This has clearly put considerable pressure on all of the staff who need to get to know the new residents and find out their individual needs and preferences. The Statement of Purpose has been updated to reflect the new unit and staff have received training about how to care for residents who have dementia. Atherton Lodge Nursing Home DS0000018711.V304489.R01.S.doc Version 5.2 Page 10 On 18th August 2006 a new resident was admitted during the busy morning period and was left alone sitting on her bed with unguarded bed rails up and her belongings in bags around her. Later she was sitting in a wheelchair in her bedroom with some visitors. The nurse on duty said that she had made some time to spend with the new resident, but this could have been a better experience for her. The manager said that either she or one of the other registered nurses goes out to visit prospective residents before admission is agreed. Records looked at showed that a social work assessment is also received and information from the relevant hospital where applicable. Information provided by manager indicated that 28 residents have dementia and during the time spent at the home all but one of residents spoken with were confused to some degree. There was no reason to believe that their needs could not be met at this home provided there are sufficient staff. Atherton Lodge does not provide intermediate care. Atherton Lodge Nursing Home DS0000018711.V304489.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Each resident has a care plan that details their needs. The health and safety and dignity of residents was at risk due to some unsatisfactory equipment and shortage of staff. Residents are at risk due to unacceptable medication practices. EVIDENCE: Two relatives spoken with were very satisfied with the care that their mother had received for the past two years at Atherton Lodge. They find all the staff and the manager and deputy are ‘absolutely brilliant’. Their mother was previously in another home, but they have found Atherton Lodge to be much better in every way and are pleased that she always looks well cared for. Another resident and her daughter said that ‘the staff are smashing’ but are very busy and she sometimes has to wait a long time for assistance. She would also like to have a bath more often than once a week. Atherton Lodge Nursing Home DS0000018711.V304489.R01.S.doc Version 5.2 Page 12 A member of staff said that she was told there would be ten carers on duty in a morning when the new extension was completed but this hasn’t happened. She felt that she didn’t have enough time to spend with residents and to assist them with a bath as often as she would like to. Information provided prior to the visit detailed that 25 residents have severe continence problems, 27 need a wheelchair for mobility and 25 need two staff to provide their personal care. It was noticed that some residents in the lounges had finger nails that were in need of attention but all were appropriately dressed. Information provided by the manager indicated that seven residents are regularly cared for in bed due to their frailty. These residents had charts to record repositioning and fluid and food intake. Some of the charts had few entries written on them including one that had nothing recorded between 6:15 am and 12:40 pm on the day of this visit. Some indicated that the resident is positioned on their back during the day and repositioned from side to side during the night. None of the five residents being cared for in bed who were visited had an alternating pressure mattress although three had an overlay mattress. Staff said that the home has only two or three specialist mattresses. Senior staff need to ensure that the type of mattress provided meets the needs identified by the pressure sore risk assessment for each resident. Some residents have a cocoon bed to prevent them from falling out of bed. Risk assessments were recorded a considerable length of time ago but there was no record of any reviews taking place. Other residents had bedrails that were badly fitted and had wide spaces which are easy to put arms and legs through. Some of these had thin covers that were not fixed in place and were not giving adequate protection, others had no cover. This is an outstanding requirement from the last visit. A resident was admitted to the home in June 2006 with a serious pressure sore. The treatment and progress of this was recorded in her care plan and the nurses spoken with said that it was improving. Documentation could be set out more clearly on a wound care plan and photographic recording would be very useful. A medicine trolley has been ordered for the new unit but has not come yet. Medicines have to be potted up for the new unit in the medicine room and this is not safe practice. The medicine records were not as good as at previous visits with some unexplained gaps on the administration sheets and some hand written entries that were not signed and dated and quantities received not always recorded. Atherton Lodge Nursing Home DS0000018711.V304489.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There was little time for consideration of resident’s social needs. EVIDENCE: There are three lounges in the main part of the home giving a choice for residents. The first lounge had five residents, all except one seemed to be unaware of their environment. There were no staff around but the laundry assistant seemed to be keeping an eye on them. A gentleman had spilled his drink on his trousers and seemed disturbed about this. He had to wait a long time before two members of staff could come and take him to change his trousers. The staff all appeared very busy and were rushing around. The second lounge had ten residents and three were spoken with; most of the others appeared to be asleep. The residents spoken with did not know what they were going to have for lunch but one lady said that the food is very good and the other said that she had a very poor appetite so couldn’t comment. They seemed satisfied that they are able to get up and go to bed at a time of their choosing, however it was apparent that these ladies had some degree of cognitive impairment, and one believed that she was in the Countess of Atherton Lodge Nursing Home DS0000018711.V304489.R01.S.doc Version 5.2 Page 14 Chester Hospital. Another resident was wandering about mumbling to herself and appeared very confused. The third lounge had seven residents. There were no conversations going on. In all the lounges at 12:10 pm there were tea cups left from the mid-morning drinks and a considerable number had not been drunk. Some residents did not have a table to put their cup on and two kept trying to drink from empty cups. There were no care staff in any of the lounges until they came to take the residents for lunch. Staff were very pleasant with the residents when they did arrive. A number of residents were being cared for in their bedrooms. The bedroom doors were closed and some had no radio, TV or any stimulation. The home does not have an activities organiser and it is part of the care staff duties to provide social activities for residents however there did not appear to be any time for them to do this. On the dementia care unit six residents were sitting in the lounge and there was a calm and relaxed atmosphere, but staff said that some residents tend to become agitated during the afternoon. One member of staff was sitting in the lounge with the residents. She said that they play board games in the afternoon and plan to develop more activities in the future. On this unit six residents sat at the dining table for their meal. The meals are carried through to the unit on trays, already plated. This means that they cannot be served out individually. There is no cupboard for crockery, cutlery etc and no provision to have any snacks on the unit. The meal looked appetising but condiments were not put on the table. Two residents didn’t want to eat their lunch and the staff didn’t seem sure how to deal with this. More flexibility with meals is needed for residents with dementia. A tray containing three uncovered liquidized meals had been left on the floor in an upstairs corridor. It was left there for at least 20 minutes. Two of the meals were untouched, the third looked as though a small amount had gone out of it. A nurse took the tray away eventually. No-one seemed to know who the other two meals were for and the nurse told me that three staff had gone off duty on a half day so it appeared that two residents had not been given their lunch. A residents said that she goes out three times a week in a taxi with her daughter but prefers to spend the rest of her time in her room. She said that she goes to bed early because she is bored. Atherton Lodge Nursing Home DS0000018711.V304489.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has policies and procedures for dealing with complaints and ensuring that residents are protected from abuse. EVIDENCE: One complaint had been recorded since the last inspection and this was investigated and responded to using the complaints procedure. One concern has been expressed to Commission for Social Care Inspection by a relative and this was about staffing on the new unit. All staff received training about the protection of vulnerable adults earlier in 2006. Atherton Lodge Nursing Home DS0000018711.V304489.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Considerable improvements have been made to the environment and all areas were clean EVIDENCE: There has been considerable investment in the environment and a recently completed extension has added 18 new bedrooms and improved 14 existing rooms to bring them up to a good standard. 27 rooms have an en-suite toilet. The extension also includes two new assisted bathrooms and two new sluices. Most of the existing building has been redecorated and bedrooms have been re-carpeted. The overall standard of accommodation has been improved for all residents. The manager said that the corridors in the original building will be redecorated when the maintenance person is back at work and new carpets have already been delivered and will be fitted when the decorating is completed. Atherton Lodge Nursing Home DS0000018711.V304489.R01.S.doc Version 5.2 Page 17 Exterior areas have also been improved. The entrance area and car park have been tarmaced and there is a safe outdoor areas for the residents of the Charles Roberts unit. All areas were clean and there were no unpleasant odours. Atherton Lodge Nursing Home DS0000018711.V304489.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There were not enough staff to fully meet the needs of residents, many of whom have a high level of need. EVIDENCE: The home employs nine nurses, 28 care staff and twelve ancillary staff. On the morning of 18th August 2006 there were seven carers, two nurses and the manager on duty. Three staff were going off duty at lunch time. In the evening the rota showed two nurses and three care staff on duty. The manager said that the home is ‘ridiculously busy’ since the increase in number of residents. Other members of staff said that they were feeling very ‘stretched’ and ‘stressed’. A relative had telephoned the Commission for Social Care Inspection as she was concerned that there was only one member of staff on duty on the dementia care unit when she visited. One of the nurses expressed concerns about the new unit as she felt that she didn’t have time to spend in there to get to know the residents. Atherton Lodge Nursing Home DS0000018711.V304489.R01.S.doc Version 5.2 Page 19 An immediate requirement was made that the home must comply with Regulation 18 of the Care Homes Regulations 2001 to ensure that there are always staff provided in such numbers as are appropriate for the health and welfare of the residents. It was the opinion of the inspector that the concerns regarding the care of residents, referred to earlier in this report, were due to insufficient number of care staff on duty. The home manager addressed this requirement and confirmed, on 21st August, that ten care staff will be on duty in the morning, six in the afternoon and five at night. Any shortfalls will be covered by offering overtime to the home’s own staff first and then to agency staff. At all times there is also one or two registered nurses on duty and the night nurses have agreed to commence their shift earlier. The manager highlighted a difficulty in recruiting new staff. She felt that some candidates had come for interview when they were not really interested in a job. She intends to address this with the Job Centre. Two others had left without giving any notice. At the meeting on 24th August 2006 the home owner said that she intended to advertise the care staff vacancies in the local press. Twelve care staff have a national vocational qualification in care and three more are working towards this. Others will have the opportunity to start NVQ in the near future. Six staff are working towards NVQ level 3. 12 care staff have a First Aid certificate. All staff had dementia care training before new unit opened. The home has four cleaners and there at least two on duty each day. Personnel files for four of the most recently recruited staff were looked at and showed that good recruitment practices had been followed. All staff have an enhanced Criminal Records Bureau disclosure. Atherton Lodge Nursing Home DS0000018711.V304489.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a stable and experienced management team but the upheaval of recent months has interrupted the usual smooth running of the home and the health and welfare of residents and staff are not promoted and protected. EVIDENCE: The manager has been in post for 11 years and the deputy for 15 years. Management responsibilities are shared between these two staff members. The home owner also visits regularly and is involved in the day to day running of the home. Unfortunately the manager has had two significant periods of time off work in recent months following two bereavements and monitoring has not been maintained to the same standard as usual. For example, the accident audit was carried out monthly until May 2006 but not since. Atherton Lodge Nursing Home DS0000018711.V304489.R01.S.doc Version 5.2 Page 21 Management responsibilities need to be reviewed following the increase in numbers of residents and the opening of a separate dementia care unit. There is no administration support within the home and the home would benefit from having a manager on duty during weekdays who is supernumary to the staff rota in order to carry out all of the management and administration duties required in a home of this size. Relatives said that they received a letter explaining to them about the alterations that were being carried out and were kept informed of progress. During this and other visits to Atherton Lodge it has been apparent that visitors always feel able to come into the office and speak with the manager. The manager said that, following the visit on 18th August 2006, staff have been consulted in planning the new staff rota. Staff in the home are not involved with the financial affairs of any residents, however small amounts of personal spending money may be kept in the home’s safe. The nurse in charge has access to this and good records are kept. Residents can pay £5 per month to cover the cost of toiletries provided by the home but they can also choose to opt out of this and provide their own toiletries. The pre-inspection questionnaire completed by the manager provided details of the servicing and maintenance of equipment and services. The fire officer visited in July 2006 and fire training is booked for all staff on 29th September 2006. A monthly fire drill is carried out. There is a fire procedure on display in various parts of the home that is dated 1993. It was not clear whether the instructions are aimed at residents, visitors or staff and should be reviewed. Atherton Lodge Nursing Home DS0000018711.V304489.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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 2 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 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Atherton Lodge Nursing Home DS0000018711.V304489.R01.S.doc Version 5.2 Page 23 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 OP8 Regulation 13(4)(c) Requirement Residents must always be adequately protected from the risk of injury from bedrails. Timescale of 30/12/05 not met. At all times staff must be provided in such numbers as are appropriate for the health and welfare of residents. Ensure that medicines are always handled safely and recorded in full. Provide a programme of social activities for residents. Timescale for action 30/09/06 2 OP27 18(1)(a) 18/08/06 3 OP9 13(2) 18/08/06 4 OP12 16(2)(n) 30/09/06 Atherton Lodge Nursing Home DS0000018711.V304489.R01.S.doc Version 5.2 Page 24 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 OP8 Good Practice Recommendations Review residents’ pressure sore risk assessments and ensure that appropriate pressure relieving equipment is being provided. Review the arrangements for residents of the Charles Roberts unit and residents who are cared for in bed to receive their meals. Ensure that the registered manager has the time, resources and support to carry out management duties. Review the fire procedure that is displayed in the corridors. 2 OP15 3 4 OP31 OP38 Atherton Lodge Nursing Home DS0000018711.V304489.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT 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 Atherton Lodge Nursing Home DS0000018711.V304489.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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