Inspection on 30/06/05 for Winnie Care (Ashbourne Lodge) Limited

This inspection was carried out on 30th June 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Winnie Care (Ashbourne Lodge)... 09/12/08

Winnie Care (Ashbourne Lodge)... 25/01/08

Winnie Care (Ashbourne Lodge)... 04/12/06

Winnie Care (Ashbourne Lodge)... 10/11/05

Winnie Care (Ashbourne Lodge)... 24/11/04

Winnie Care (Ashbourne Lodge)... 24/08/04

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Turret Villa Retirement Home

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Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

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 Unannounced 30 June 2005 10:00 am 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 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 B51-B01 S58608 Ashbourne Lodge V236053 300605 Stage 4.doc Version 1.40 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 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 DE(E) Dementia - over 65 (32) registration, with number OP Old age (23) of places Winnie Care (Ashbourne Lodge) Limited B51-B01 S58608 Ashbourne Lodge V236053 300605 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th November 2004 Brief Description of the Service: Ashbourne Lodge is a 55 bed, two storey purpose built care home. It provides care for 23 older frail people and 32 elderly mentally frail people. All bedrooms are single with en suite facilities and service users are able to personalise their rooms according to wishes and tastes. The home is situated on Billingham Green, close to local shops and public transport. The building is set back from the road and at the rear is a secure garden for the use of service users and their families. The home also has a mini-bus which is used for outings and shopping trips. Winnie Care (Ashbourne Lodge) Limited B51-B01 S58608 Ashbourne Lodge V236053 300605 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an Unannounced Inspection, conducted over 5 hours spent within the home. The Inspector concentrated on talking with residents, spending time experiencing how they spend their day and speaking with staff. In addition, time was spent viewing the environment of the home. Residents spoken with said that they were ‘very happy’, and ‘best thing I ever did’, and said staff were ‘lovely people’ who ‘do their best for us’. A second Inspection will take place later in the year. What the service does well: What has improved since the last inspection? What they could do better: More attention must be paid to the responsibilities of the Organisation under Health & Safety (see ‘Health and Safety in Care Homes’, published by the Health & Safety Executive) to ensure that the environment of the home is free from hazards at all times. Winnie Care (Ashbourne Lodge) Limited B51-B01 S58608 Ashbourne Lodge V236053 300605 Stage 4.doc Version 1.40 Page 6 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 B51-B01 S58608 Ashbourne Lodge V236053 300605 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Winnie Care (Ashbourne Lodge) Limited B51-B01 S58608 Ashbourne Lodge V236053 300605 Stage 4.doc Version 1.40 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 standard(s) EVIDENCE: Not assessed at this Inspection Winnie Care (Ashbourne Lodge) Limited B51-B01 S58608 Ashbourne Lodge V236053 300605 Stage 4.doc Version 1.40 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9 and 10 Health, personal and social needs are set out in individual care plans, and staff at Ashbourne Lodge work with other involved professionals to ensure needs are fully met. Where appropriate, service users are able to retain responsibility for their own medication and are protected by the home’s policies and procedures for the administration of medication. Service users are treated with respect, and privacy is promoted, within the home. EVIDENCE: Three Care Plans were viewed at this Inspection and were seen to contain care needs in respect of aspects of daily living. In addition, a background history and ‘likes and dislikes’ are recorded. Evidence was seen that the Principal Senior carer audits Care Plans, and flags up where entries are either not up to day, or are in need of amendment. In order to try to ensure that all health care needs are fully met, care staff within the home work closely with other involved professionals, such as district nurses and community psychiatric nurses. If appropriate and following a risk assessment, service users are able to take responsibility for their own medication, if this is their wish. Winnie Care (Ashbourne Lodge) Limited B51-B01 S58608 Ashbourne Lodge V236053 300605 Stage 4.doc Version 1.40 Page 10 Those service users spoken with at the time of the Inspection said that they are definitely treated with respect by care staff. Residents said that staff are ‘smashing’, and they ‘treat us well’. All spoken with said that they feel they are ‘well looked after’. As all rooms have en suite facilities, personal care support is provided in individual bedrooms. Staff spoken with said that when staff assist with bathing, they ensure that doors are secure in order to maintain privacy, and try to maximise independence of personal care, as far as is possible. Winnie Care (Ashbourne Lodge) Limited B51-B01 S58608 Ashbourne Lodge V236053 300605 Stage 4.doc Version 1.40 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 standard(s) 12,13,and 14 Service users feel that their social, cultural and recreational interests are met, and that they are given choice how to spend their time. Visits both to and from family and friends are positively encouraged. EVIDENCE: Those residents spoken with said that life at Ashbourne Lodge does meet their social needs – activities are available if they wish to join in. All spoken with were very complimentary about the ‘Stars in their Eyes’ show, which members of staff had recently performed for them. ‘Sing Songs’ are also a favourite, along with old-time movies. Regular contact with family and friends is positively encouraged at Ashbourne Lodge, and the home has an ‘open’ policy in respect of families visiting. Some residents said that they are still able to make visits to family and friends, and value this. The home has transport, and this enables local shopping trips to take place, which both maintains contact with the local community and promotes and maintains independence of choice. The home’s transport is also used for trips further afield, such as the Metro Centre. Winnie Care (Ashbourne Lodge) Limited B51-B01 S58608 Ashbourne Lodge V236053 300605 Stage 4.doc Version 1.40 Page 12 Discussion with both residents and staff confirmed that service users are supported to make choices about their daily lives. For example, residents said that they are asked ‘when would you like to get up’ and are able to eat meals in their own rooms, if this is their choice. Observation during the Inspection indicated that service users were relaxed, and were seen to move freely around the home. Winnie Care (Ashbourne Lodge) Limited B51-B01 S58608 Ashbourne Lodge V236053 300605 Stage 4.doc Version 1.40 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 Training is in place to ensure that staff are aware of the protection of vulnerable adults. EVIDENCE: The manager said that the importance of the protection of vulnerable adults is emphasised during all Induction Training. In addition, the home has a training video which is used in staff training sessions. Staff spoken with were aware of the home’s Whistle Blowing policy, and said that they would not hesitate to speak to either their Principal Senior or the Manager of the home if they had concerns about residents. Winnie Care (Ashbourne Lodge) Limited B51-B01 S58608 Ashbourne Lodge V236053 300605 Stage 4.doc Version 1.40 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,23,24,25 and 26 Ashbourne Lodge is well-maintained, and service users have access to safe and comfortable facilities within the home. There are adequate toilets and washing facilities and specialist equipment is available to maximise independence. Bedrooms are comfortable and suitable for the needs of those who live in the home, and the home is clean and hygienic. EVIDENCE: The environment of the home was seen to have improved since the last Inspection. The corridors have been newly decorated, and the carpets replaced. This has had the effect of making the corridors much more attractive, and appear lighter. New carpeting was also seen in the downstairs dining room. Winnie Care (Ashbourne Lodge) Limited B51-B01 S58608 Ashbourne Lodge V236053 300605 Stage 4.doc Version 1.40 Page 15 Communal space consists of sitting rooms on both the ground and upper floor. These were seen to be comfortable and airy, and have views towards Billingham Green. Dedicated smoking rooms are available, both upstairs and down. The dining room on the ground floor also serves as a recreation area when required. Seating outdoors, at the front of the home, has also been provided for use of residents when weather permits. En suite facilities within bedrooms consist of toilets and wash hand basins. There are an adequate number of bath and shower rooms, on both floors of the home, in addition to assisted baths for those who have higher levels of physical need. Those bedrooms viewed were seen to be suitable for purpose, clean and comfortable. Some service users have ‘personalised’ their rooms, which has created a more ‘homely’ feel. On the day of the Inspection the home was seen to be clean, comfortable and hygienic. No unpleasant odour was detected. One member of family commented that there is ‘no smell’. Winnie Care (Ashbourne Lodge) Limited B51-B01 S58608 Ashbourne Lodge V236053 300605 Stage 4.doc Version 1.40 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 30 Staff at Ashbourne Lodge are trained and competent to do their jobs. EVIDENCE: Staff spoken with at the Inspection were positive about the competency of the care staff team, and their ability to work together in the best interests of those who live at the home. This was confirmed in discussion with residents, who said that staff were ‘lovely people’ who ‘do their best for us’, and ‘look after us well’. National Vocational Training (NVQ) is underway. A number of staff have completed NVQ at Level 2 and are waiting to undertake NVQ Level 3. Additional training provided by an external training agency has taken place in respect of the Safe Handling of Medication, Infection Control and Dementia Awareness. Those members of staff spoken with were keen to progress their training, and would like the opportunity to develop further. Winnie Care (Ashbourne Lodge) Limited B51-B01 S58608 Ashbourne Lodge V236053 300605 Stage 4.doc Version 1.40 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,36 and 38 The management and leadership of the home reflects an ethos which is based on ‘person-centred’ care, and the home is run in the best interests of those who live there. Staff are appropriately supervised. More attention must be paid to ensuring that all aspects relating to the health and safety of residents are regularly reviewed, and adjustments made where needed. EVIDENCE: Staff and residents spoken with at this Inspection were complimentary about the Registered Manager. Staff said that they feel she is both approachable and supportive, and centres on the needs of the residents, trying to promote the best possible quality of life within the home. Winnie Care (Ashbourne Lodge) Limited B51-B01 S58608 Ashbourne Lodge V236053 300605 Stage 4.doc Version 1.40 Page 18 Those staff spoken with also had a high awareness of the need to work in a ‘person centred’ way, acknowledging that Ashbourne Lodge is the home of those living there. In addition to meeting physical care needs, the manager and staff try to add extra quality by ensuring social activities are available. The manager and staff recently presented ‘Stars in their Eyes’ for residents, and this was an obvious success – residents saying that it had been a ‘marvellous’ show. Evidence exists that the manager and staff also look for additional, every day opportunities to promote independence and as ordinary a life as possible. Where residents wish to and are able, transport can be provided to visit shops in order that service users can make their own choices of clothes and any other necessities. Accompanied short walks around the locality of the home are also offered, when weather permits. Supervision of staff is undertaken by Principal Seniors, who also audit Care Plans and other documentation. There are issues arising from this Inspection in respect of the health and safety of service users. During the Inspection, it was found that the hot water being delivered into one wash hand basin was 50 degrees C. In addition, it was also seen that the last recorded check on water temperatures took place on 14.3.2005. It is the responsibility of the Organisation to ensure that hot water is delivered at a temperature as close as possible to 43 degrees Centigrade, and to check and record temperatures on a regular basis, to reduce the risk of scalding injuries. In addition, it was seen that some bedroom doors are still chocked open. The policy of Cleveland Fire Authority on this issue is that of zero tolerance, this practice must cease and all bedroom doors must either be kept shut, or be fitted with suitable self-closing devices linked to the fire alarm system. Winnie Care (Ashbourne Lodge) Limited B51-B01 S58608 Ashbourne Lodge V236053 300605 Stage 4.doc Version 1.40 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION 3 3 3 x 3 3 3 3 STAFFING Standard No Score 27 x 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 3 3 3 x x 3 x 3 Winnie Care (Ashbourne Lodge) Limited B51-B01 S58608 Ashbourne Lodge V236053 300605 Stage 4.doc Version 1.40 Page 20 No Are there any outstanding requirements from the last inspection? 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 38 Regulation 13(4)(a)( b)(c) 13(4)(a)( b)(c) 13(4)(a)( b)(c) Requirement Timescale for action Immediate 2. 3. 38 38 Hot water outlets must be checked on a regular basis, and water discharged as close as possible to 43 degree centigrade. Hot water temperatures must be Immediate recorded and adjustments made where necessary The advice of Cleveland Fire Immediate Brigade in respect of all bedroom doors remaining either closed, or fitted with an approved closure device, linked to the fire alarm, must be followed 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 Good Practice Recommendations Winnie Care (Ashbourne Lodge) Limited B51-B01 S58608 Ashbourne Lodge V236053 300605 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection Unit B, 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 B51-B01 S58608 Ashbourne Lodge V236053 300605 Stage 4.doc Version 1.40 Page 22 - 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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