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Inspection on 10/11/05 for Winnie Care (Ashbourne Lodge) Limited

Also see our care home review for Winnie Care (Ashbourne Lodge) Limited for more information

This inspection was carried out on 10th November 2005.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

What has improved since the last inspection?

What the care home could do better:

There were minor issues of maintenance and the need to renew some floor coverings, and this was accepted by the Proprietor. Advice given by the Fire Officer in respect of the provision of automatic door closures must be followed.

CARE HOMES FOR OLDER PEOPLE Winnie Care (Ashbourne Lodge) Limited Ashbourne Lodge Care Home The Green Billingham Stockton on Tees TS23 1EW Lead Inspector Christine Moon Announced Inspection 10th November 2005 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 Winnie Care (Ashbourne Lodge) Limited DS0000058608.V250919.R01.S.doc Version 5.0 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. Winnie Care (Ashbourne Lodge) Limited DS0000058608.V250919.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Winnie Care (Ashbourne Lodge) Limited Address Ashbourne Lodge Care Home The Green Billingham Stockton on Tees TS23 1EW 01642 553665 01642 558662 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) Winnie Care (Ashbourne Lodge) Ltd Mrs Catherine Mary Boult Care Home 55 Category(ies) of Dementia - over 65 years of age (17), Old age, registration, with number not falling within any other category (38) of places Winnie Care (Ashbourne Lodge) Limited DS0000058608.V250919.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Manager (Mrs Catherine Boult) should attain (by 2005) a qualification at Level 4 NVQ in Management and Care or equivalent. 30th June 2005 Date of last inspection Brief Description of the Service: Ashbourne Lodge is registered for the care of 55 older people, 38 of whom are elderly and frail, and 17 of whom are suffering from a dementia. It is a purpose built home, and all bedrooms have en suite facilities consisting of toilets and wash hand basins. The home is situated on Billingham Green, close to a small number of local shops, and is easily accessible by public transport. The building is set back from the road, and has secure gardens for the use of service users and their families. The home also owns a mini-bus and this is used for outings and shopping trips. Winnie Care (Ashbourne Lodge) Limited DS0000058608.V250919.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Inspection was Announced, and took place over six hours spent in the home. During this time, documentation and records were assessed, and discussion was held with the manager, staff and those living in the home. 5 Comment Cards were returned by service users and family members prior to the Inspection. Pre-Inspection documentation was received by the Commission for Social Care Inspection(CSCI). What the service does well: What has improved since the last inspection? The décor of the home is much improved and the home looks much brighter and more welcoming. A new I.T. system has been installed, which will ease management tasks. A programme is underway to fit door closures, in line with advice from the Fire Service. More attention is paid to dietary needs, and there is greater use of fresh fruit and vegetables in the preparation of meals. Winnie Care (Ashbourne Lodge) Limited DS0000058608.V250919.R01.S.doc Version 5.0 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. Winnie Care (Ashbourne Lodge) Limited DS0000058608.V250919.R01.S.doc Version 5.0 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 Winnie Care (Ashbourne Lodge) Limited DS0000058608.V250919.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 5 and 6 Assessment of need is carried out prior to any new admission to the home. Prospective service users and their families are free to visit the home to assess its suitability. The home does not provide intermediate care. EVIDENCE: Prior to any new admission to the home, the manager, along with a senior member of staff, carries out a detailed assessment of need. This usually takes place by either visiting the home of a service user, or a hospital ward in the case of a hospital discharge. The manager said that she is thorough in her approach to assessing need, as this will indicate whether or not the home is able to adequately meet care needs. Where this is felt not to be the case, an admission is not accepted. Winnie Care (Ashbourne Lodge) Limited DS0000058608.V250919.R01.S.doc Version 5.0 Page 9 Any prospective resident, and their family if appropriate, are invited to visit the home and spend time there, if they wish. These visits can include staying for meals. In addition, a Service User Guide is provided containing details about the provision of care and facilities within the home. The home does not provide intermediate care. Winnie Care (Ashbourne Lodge) Limited DS0000058608.V250919.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 Care Plans contain details of health, personal and social care needs. EVIDENCE: Care Plans examined were seen to be thorough and contained details of all aspects of daily living. It was clear that Care Plans are used by staff as ‘working documents’ to inform the care to be provided to those living in the home. Plans are audited by Principal Senior Carers on a regular basis, and evidence was seen within care files to confirm that this is taking place. Care staff within the home are expected to ‘take ownership’ of Care Plans, and as a result of this are aware of changes which may take place in the provision of care. Winnie Care (Ashbourne Lodge) Limited DS0000058608.V250919.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 15 Residents say that the home definitely matches their expectations. Food provided is appetising, well balanced and said to be ‘delicious’ by those living at the home. EVIDENCE: Residents spoken with said that the home definitely meets their expectations. In addition they said that staff work very hard to try to ensure as high a quality of life as possible. For example, the manager and staff put on concerts for their residents, and it was obvious that these are really enjoyed and appreciated. Recently a ‘Remembrance’ evening has been held and photographs of this event were seen displayed within the home. In addition, shopping trips in the mini-bus can be arranged, and staff are able to accompany residents on local walks in the vicinity of the home. The two Inspectors carrying out the Inspection enjoyed having lunch with service users. The food prepared was attractively presented, looked appetising and tasted delicious. Service users said ‘the food is always as good as this’, and ‘I have put on weight since I came to live here’. Alternative choices are available at all meals. Small tables are used for meals, which are eaten in pleasant dining areas. Winnie Care (Ashbourne Lodge) Limited DS0000058608.V250919.R01.S.doc Version 5.0 Page 12 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 Service users and families spoken with said that they were confident complaints would be listened to and acted upon. EVIDENCE: Those service users and relatives spoken with during the Inspection said that they were sure any issues or complaints they had would be listened to and acted upon. The home has a Complaints policy, and all complaints are entered into a book detailing the nature of the complaint and its resolution. Information was seen to be on display giving advice about the role of the Commission for Social Care Inspection (CSCI) in respect of complaints. Winnie Care (Ashbourne Lodge) Limited DS0000058608.V250919.R01.S.doc Version 5.0 Page 13 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 The home provides a safe and well-maintained environment, and is clean, pleasant and hygienic. EVIDENCE: At the time of the Inspection, Ashbourne Lodge was looking bright, well decorated and maintained. The corridors of the home, which have been repainted in light, pastel shades and the new carpet, have greatly improved the appearance of the home. Only minor adjustments were needed to the interior of the home. These included new flooring in an upstairs ‘smoking’ lounge, and in an upstairs dining room. In addition, the ceiling in bathroom 3 was in need of attention. Winnie Care (Ashbourne Lodge) Limited DS0000058608.V250919.R01.S.doc Version 5.0 Page 14 The proprietor of the home has recently purchased a Rotowash machine for cleaning carpets, and this has proved to be highly efficient in that it cleans using a cold-water process, without the need for chemicals. It is also very easy for staff to use. The home was seen to be very clean, pleasant and hygienic on the day of the Inspection. Winnie Care (Ashbourne Lodge) Limited DS0000058608.V250919.R01.S.doc Version 5.0 Page 15 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 and 29 Staff numbers and mix of skills is adequate to meet care need. The recruitment policy and procedures support the protection of service users. EVIDENCE: Staff rotas seen indicated that an adequate number of staff were on duty. Staff work to a rolling, four-week rota, which enables staff to know in advance when they will be working. In the event of staff sickness, shifts are covered by senior staff and the manager, in preference to the employment of agency staff. The home has a policy and procedure in respect of staff recruitment. Staff do not commence employment until two satisfactory references, and a CRB (Criminal Records Bureau) and Pova (Protection of Vulnerable Adults) check have been carried out and clearance received. Winnie Care (Ashbourne Lodge) Limited DS0000058608.V250919.R01.S.doc Version 5.0 Page 16 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, 35 and 38 The home is well managed and the Registered Manager is qualified and competent to be in charge. Service users’ financial interests are safeguarded. As far as is possible, the health, safety and welfare of service users is promoted and protected. EVIDENCE: The manager of the home leads by example, and will work alongside staff when the need arises. Since being appointed, she has worked very hard to ensure that the home meets the requirements of the Care Homes Regulations and has instigated improved systems of recording where needed. She is ready to listen to advice where appropriate. Staff feel well supported by management, and during the Inspection, staff morale appeared high. Winnie Care (Ashbourne Lodge) Limited DS0000058608.V250919.R01.S.doc Version 5.0 Page 17 Although, in theory, the manager of the home has completed her Registered Managers’ Award, as a result of circumstances beyond her control, some units are having to be reassessed, and work is currently in hand to ensure this takes place. Spot checks carried out on personal allowances belonging to service users were accurate. Recording was of amounts held was clear, and appropriately signed and dated. In respect of the health and safety of both service users and staff, hot water checks were satisfactory and not in excess of 43 degree C. In respect of bedroom doors wedged open, against the advice of the Fire Service, the manager said that self-closures are going to be fitted to all doors, starting with those where service users express a preference to have their doors left open. This must be followed through. The Proprietor of the home has recently introduced a new Software programme – Cool Blue, which will enable details of records and systems to be stored, updated and readily accessed. Winnie Care (Ashbourne Lodge) Limited DS0000058608.V250919.R01.S.doc Version 5.0 Page 18 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 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 X 10 X 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 x 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X 2 Winnie Care (Ashbourne Lodge) Limited DS0000058608.V250919.R01.S.doc Version 5.0 Page 19 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 OP38 Regulation 13(4)a(b) Requirement The advice of Cleveland Fire Brigade in respect of all bedrooms doors remaining either close, or fitted with an approved closure device, linked to the fire alarm, must be followed Timescale for action 31/12/05 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 OP19 Good Practice Recommendations The floor covering in the upstairs lounge and dining room, which are dedicated ‘smoking’, is very basic and could be improved Winnie Care (Ashbourne Lodge) Limited DS0000058608.V250919.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Winnie Care (Ashbourne Lodge) Limited DS0000058608.V250919.R01.S.doc Version 5.0 Page 21 - 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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