Inspection on 04/12/06 for Winnie Care (Ashbourne Lodge) Limited

This inspection was carried out on 4th December 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 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)... 10/11/05

Winnie Care (Ashbourne Lodge)... 30/06/05

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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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 Neil McKenzie Key Unannounced Inspection 11:30 4 and 8th December 2006 th 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.V321905.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. Winnie Care (Ashbourne Lodge) Limited DS0000058608.V321905.R01.S.doc Version 5.2 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.V321905.R01.S.doc Version 5.2 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. 10th November 2005 Date of last inspection 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. The minimum cost for a bed was £345.00 and the maximum cost for a bed £380.00 per week. There were additional costs for hairdressing, chiropody and personal items. Winnie Care (Ashbourne Lodge) Limited DS0000058608.V321905.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection. The inspection lasted for 7 hours and this included 2 visits to the home. The first visit involved two inspectors. The reason for the inspection was to see how good a job the home does in meeting the National Minimum Standards for Care Homes. During the visits the inspector spoke to 4 residents, 4 staff and 3 relatives to find out what their views were about living and working at Ashbourne Lodge. The inspector also spent time speaking to the manager of the home, her line manager, the operations manager, and the owner of the home. The inspector spent some more time watching how staff and residents are with each other. A tour of the home took place and records looked at included staff recruitment and training, resident care plans and how the home handles money and medication. There was also questionnaire’s sent to the home and these were looked at to help decide how good a job the home does in meeting the National Minimum Standards. What the service does well: Residents who use the service spoke highly of the staff team. One resident spoken to during the inspection said, ‘ every one is very nice, I can go to anyone here’. Another resident stated, ‘I like the home’. The home is also good at making sure residents have a contract that clearly states the terms and conditions that they can expect from the home. These contracts are updated on a regular basis. The home provides a pleasant and welcoming environment. One relative spoken to during the inspection commented, ‘ you are made to feel very welcome’ Winnie Care (Ashbourne Lodge) Limited DS0000058608.V321905.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Winnie Care (Ashbourne Lodge) Limited DS0000058608.V321905.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Winnie Care (Ashbourne Lodge) Limited DS0000058608.V321905.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (good). This judgement has been made using available evidence including a visit to this service. Residents who use the home are given information to make an informed choice of the home in which they are to receive care. Each resident living in the home receives a statement of terms and conditions/contract. Assessment of needs is carried out to ensure that the home can meet the needs of the individual person. EVIDENCE: A statement of purpose/service user guide was available for inspection that contained all the required information. This statement is also available on tape for residents who have difficulties in reading. A visiting relative spoken to during the inspection described how they were sent information on this and other homes by a social worker and visited the homes before deciding on the best home to meet the needs of their relative. Winnie Care (Ashbourne Lodge) Limited DS0000058608.V321905.R01.S.doc Version 5.2 Page 9 The relative stated, ‘When we came here for a visit we knew it was the place for her’. Each resident living in the home had a signed statement of terms and conditions/contract and these were available on file in the home. Residents who had been living in the home for some time had these contracts updated. Resident files demonstrated that a pre-admission assessment of people who use the service is carried out by a social worker before the resident is admitted to the home. Winnie Care (Ashbourne Lodge) Limited DS0000058608.V321905.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (poor). This judgement has been made using available evidence including a visit to this service. Assessment of needs carried out to ensure the home can meet the needs of an individual resident must be supported by care plans that are up to date, include relevant risk assessments, are regularly reviewed, have informed daily records to ensure care needs are met. The home must also ensure that all medicines are administered and hand written amendments are double-checked. Residents feel they are treated respect and sensitivity. EVIDENCE: Four care plans were examined during the inspection. A number of care plans contained basic assessment of needs, however, there were a lack of specific care plans in respect of highlighted problems. For example, issue of falls highlighted in one pre-admission assessment was not highlighted in the care plan with regard to risk and safe guards. Winnie Care (Ashbourne Lodge) Limited DS0000058608.V321905.R01.S.doc Version 5.2 Page 11 Another assessment of need referred to ‘confusion’ and monitoring of mental health but the care plan had no elaboration on the risks associated with this and or evaluation of needs identified. A number of care plans had incomplete weight charts and demonstrated little evidence of evaluating changing needs of residents. For example, a recent fall had no reference to this in the care plan and daily record. There was also no evidence of a planned review with regard to the incident and or risk assessment to reduce the likelihood of the incident happening again. The accident book showed numerous entries for falls and apparent injuries at the time. At the time of the inspection the Regional Lead Pharmacist completed a separate random inspection. In summary, the lead pharmacist found the home to have sound medicines management systems in place as evidenced by appropriate, clean and tidy storage and mostly accurate records. It also demonstrated good practice in its handling and recording of controlled drugs. There was, however, an urgent need to ensure that all handwritten entries on MAR sheets are signed by the author and initialled by a witness. Individual residents’ medication record sheets did not contain photographs of the person to help ensure that residents receive the correct medication. The residents’ who spoke to the inspector stated that staff treated them with respect and dignity. For example, one resident stated, ‘‘ every one is very nice, I can go to anyone here’. Another resident stated, ‘I like the home’. Winnie Care (Ashbourne Lodge) Limited DS0000058608.V321905.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (adequate). This judgement has been made using available evidence including a visit to this service. The residents should benefit from more planned social activities to provide variety and interest for people staying in the home. Residents maintain contact with families and friends from open visiting. On the whole the home provides a wholesome, varied menu that ensures dietary needs of residents are met. EVIDENCE: There was a planned Christmas concert involving staff, residents and relatives to be held later in the month at a local community centre. However, at the time of the inspection there was no social activity planned for residents in the home on a day-to-day basis. One resident stated, ‘well that’s the problem isn’t it, there is nothing to do’. Another resident commented, ‘ the last two years there’s been nothing to do. We could go out all over, we don’t hardly have bingo or anything anymore’. Relatives spoken to at the time of the inspection felt they were made welcome to visit by the home. One relative stated ‘ very welcome, everything dealt with quickly’. Another relative commented, ‘always made to feel welcome’. Winnie Care (Ashbourne Lodge) Limited DS0000058608.V321905.R01.S.doc Version 5.2 Page 13 The home offers a six-week menu with alternative choice offered at mealtime. Menus examined were wholesome and showed variety. Fridges and freezers inspected demonstrated variety of food storage. Residents spoken to at lunchtime during the inspection said they liked the food that was provided. One resident said, ‘ The food is good and if you don’t want what’s on the menu they will get something else for you’. Winnie Care (Ashbourne Lodge) Limited DS0000058608.V321905.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (good). This judgement has been made using available evidence including a visit to this service. The home provides arrangements to ensure that residents are enabled and supported to make any complaint they consider necessary. The home plans to introduce appropriate training in respect of adult protection to ensure an appropriate response to any allegation. EVIDENCE: At the time of the inspection an ‘in house certificated course’ on adult protection was being planned by the home. A course that should ensure staff responds appropriately to any allegation. The home has demonstrated that previous allegations of abuse have been appropriately investigated, involving other professionals, with an agreed outcome. The home has a complaints procedure and a summary of this is displayed in the home. Relatives spoken to said that they felt able to approach the Manager and staff and make any complaint necessary. Winnie Care (Ashbourne Lodge) Limited DS0000058608.V321905.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (good). This judgement has been made using available evidence including a visit to this service. The home offers a pleasant and comfortable environment EVIDENCE: A tour of the premises found the home to be warm, welcoming and friendly. A number of bedrooms were personalised with pictures and belongings of residents. At the time of the inspection there was evidence of refurbishment with a shower room being upgraded following an identified leak. Two separate sink taps gushed out very hot water when initially switched on and this needs to be made good to avoid accidental scolding. The staff room should benefit from a new carpet and décor. Winnie Care (Ashbourne Lodge) Limited DS0000058608.V321905.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (good). This judgement has been made using available evidence including a visit to this service. The home is staffed to levels agreed by previous registration authority and residents are protected by the homes recruitment practices. Staffs have the skills, experience and are appropriately trained to meet the needs of the residents using the service. EVIDENCE: On the day of the inspection there were 50 residents staying at the home. 17 were staying on the dementia unit, 23 in the upstairs unit and 14 in the downstairs unit. Staff rotas examined showed that there were sufficient staffs on duty during the day and night. In addition to the staff rota a housekeeper and 4 domestics, 2 laundry workers, 2 cooks and 2 assistants, a gardener and part time handy person support residents. The recruitment and selection records of four members of staff were examined. Winnie Care (Ashbourne Lodge) Limited DS0000058608.V321905.R01.S.doc Version 5.2 Page 17 On the whole good practice was evidenced in respect of recruitment, such as the carrying out and receipt of appropriate POVA/Criminal Record Bureau checks for staff prior to commencement of employment. Appropriate references, job descriptions and job specifications and the start date of employment were also available on each file. Four staff files and Training and Development plans were examined. Discussion also took place with the manager and the operations manager who confirmed that staff had completed all of the required mandatory training including fire, first aid, health and safety and food hygiene. At the time of the inspection 54 of staff had completed a National Vocational Qualification level 2 in Care. The Operations manager is also in the process of introducing staff training portfolio to ensure each staff member receives ongoing training specific to resident needs. For example, training for staff to have a better understanding of dementia. Winnie Care (Ashbourne Lodge) Limited DS0000058608.V321905.R01.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (adequate). This judgement has been made using available evidence including a visit to this service. The manager of the home was appointed 6 months ago and is currently being inducted into her new role. Staffs require more regular supervision. Resident financial interests are recorded and documented. The home should be run in the best interests of residents by ensuring regular meetings are held to illicit their views of the home. EVIDENCE: The new manager has worked in the home for 8 years and therefore has a good understanding of resident needs. The new manager has a National Vocational Award Level 3 in Care and started the Registered Managers award recently. Winnie Care (Ashbourne Lodge) Limited DS0000058608.V321905.R01.S.doc Version 5.2 Page 19 The manager is also due to apply to the Care Commission to be approved a Registered Manager. The previous manager has been promoted to Operations Manager but remains based in the home to support the new manager of the Home. Sample of staff files indicate that staff require more formal supervision, at least 6 times a year, to support them in developing their work practices. A random sample of 3 resident’s personal allowances and records were examined and there were no discrepancies with the balance stated on the transaction sheet and the actual amount contained in the individual money envelope. The transaction should be made more robust by ensuring that 2 members of staff sign financial transactions. The home has in the past completed an annual survey to illicit the views of residents and relatives on how the home could be made better from their point of view. The manager stated that there were plans to have another annual survey that could then inform the home as what could be better. The manager said she spoke to individual residents to check how things are but this audit is not documented. Details of health and safety were made available through the pre-inspection questionnaire and tour of the premises. These records were recorded as up to date with relevant certificates, for example gas safety, made available on request. Winnie Care (Ashbourne Lodge) Limited DS0000058608.V321905.R01.S.doc Version 5.2 Page 20 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 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 1 X 3 Winnie Care (Ashbourne Lodge) Limited DS0000058608.V321905.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 14 (2) 15 (1) Requirement Timescale for action 08/12/06 2 OP9 13 (2) 3 OP13 16 (n) 4 OP19 23 (2) The registered person must ensure that a care plan is generated from a needs assessment, is drawn up, reviewed and updated to reflect changing needs of residents. The registered person must 13/12/06 ensure sufficient supplies of medicines are always in stock so that all medicines are administered as prescribed to all service users. The registered person must 08/12/06 consult residents about the programme of activities arranged by or on behalf of the home. The registered person must 08/12/06 ensure the potential hazard to scolding caused by hot water initially gushing out of sinks is made safe. Winnie Care (Ashbourne Lodge) Limited DS0000058608.V321905.R01.S.doc Version 5.2 Page 22 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 2 Refer to Standard OP9 OP36 Good Practice Recommendations All handwritten medication administration records and handwritten amendments should be double-checked as evidenced by two staff signatures. Staff should receive formal supervision on all aspects of practice at least 6 times a year Winnie Care (Ashbourne Lodge) Limited DS0000058608.V321905.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX 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 Winnie Care (Ashbourne Lodge) Limited DS0000058608.V321905.R01.S.doc Version 5.2 Page 24 - 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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