Inspection on 02/06/09 for Ashley Court

This is the latest available inspection report for this service, carried out on 2nd June 2009.

CQC found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ashley Court 04/07/06

Ashley Court 13/10/05

Ashley Court 12/05/05

Ashley Court 14/10/04

Ashley Court 15/06/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

Extracts from inspection reports are licensed from CQC, this page was updated on 12/10/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Ashley Court Ashley Court 251 Penn Road Penn Wolverhampton West Midlands WV4 5SF     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Bhag Jassal     Date: 0 2 0 6 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 33 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 33 Information about the care home Name of care home: Address: Ashley Court 251 Penn Road Ashley Court Penn Wolverhampton West Midlands WV4 5SF 01902335584 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Ashley Court Care Ltd care home 21 Number of places (if applicable): Under 65 Over 65 9 21 dementia old age, not falling within any other category Additional conditions: 0 0 The home can accommodate service users aged 60 years on admission whose needs can be met as specified in the Statement of Purpose. The home can provide care and accommodate for 21 service users in the category (OP), of these 9 places can be for service users with dementia care needs DE(E). Date of last inspection Brief description of the care home Ashley Court care home provides personal care and accommodation for up to 21 older people and 9 of these people may also have Dementia care needs. The home is located on the Penn Road, one and half miles from Wolverhampton city centre. It is close to the local shops and amenities. The home is a large semi - detached property that was adapted as a residential care home in 1981; and further extension and improvements have been made over the years. Care Homes for Older People Page 4 of 33 Brief description of the care home The accommodation consists of 21 single occupancy rooms with en - suite facilities, communal sitting areas and dining room. There are gardens and a patio area at the rear of the building. There is ample car parking space at the front of the building. The present Responsible Individual/Registered Manager Mrs Narinder Kaur Bachra (on behalf of Ashley Court Care Ltd) has been operating this service since February 2004. Ashley Court Care Ltd makes their services known to prospective service users in The Statement of Purpose and Service Users Guide. The inspection report is mentioned in the statement of purpose and how a copy can be obtained. The care home rates are reviewed annually and people who use the service are notified one month in advance. The only additional charges to people who use the service are for hairdressing and chiropody. This is clearly laid out in the terms and conditions. Fees for Ashley Court as of 1st April 2008 are: £357.00 to £408.00. All service users pay monthly. Care Homes for Older People Page 5 of 33 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is 2 Star. This means the people who use the service experience good quality outcomes. This report is on a Key Inspection, part of which includes an unannounced visit undertaken on 2nd June 2009. The unannounced visit started at 09:00 and lasted 7 hours and 55 minutes. The home had all 21 places occopied. The judgements made within this report are based upon information supplied by the home, from interviews with staff, people who use the service and their relatives. During the course of inspection the assessment information and care plans were case tracked for four people who use the service. Medication administration was checked. Care Homes for Older People Page 6 of 33 Staff records were seen to check staff rotas, recruitment procedures and training. Various documents were seen in order to check compliance with health and safety legislation. A tour of premises was also undertaken, and care practices and interaction between staff and people who use the service were observed. Discussions took place with several members of staff on duty, and several people using the service and two visiting relatives were spoken to throughout the day of inspection. The Registered Manager - Mrs Narinder Bachra was present throughout this Inspection. On this occasion all the key Standards of the National Minimum Standards were assessed - that is those areas of service delivery that are considered essential to the running of a care home, that ensure the best outcomes for people living there. Regulation 37 Notifications, concerns and complaints about the home and an Annual Quality Assurance Assessment (AQAA), which had been completed by the Registered Manager and submitted to the Care Quality Commission (CQC) prior to this inspection. The AQAA is a self - assessment and a dataset that is filled in once a year by all Registered Providers. It informs us about how Registered Providers are meeting outcomes for people using their service and is an opportunity for Registered Providers to share with us areas that they believe they are doing well. It is a legal requirement that the AQAA is completed. Ashley Court returned their completed AQAA to CQC within the given timescale. Information within this document demonstrates that the Registered Manager recognises the strengths and weaknesses within the service and are able to plan for improvement. The AQAA provided information to supplement the inspection. We also received completed Surveys from five people who use the service, two relatives, seven members of staff and a health care professional. We wish to thank the Registered Manager, the staff, people who use the service and their relatives for their assistance and co - operation on the day of inspection. What the care home does well: What has improved since the last inspection? Care Homes for Older People Page 8 of 33 People commented that: Lots of recent improvements to decor and fittings etc. I am pleased that its look much better. The facilities and the care provided by management and staff is far better now than previously. The home has an experienced Registered Manager in post and she is managing the care home well. Conversations with staff, people using the service and their visiting relatives, indicated that the Registered Manager is service user focused, leads and supports an enhanced staff team providing them with improved training and supervision. This style and approach to management aims to pursue future improvements in all aspects of service. One person who lives at the home stated that This place is a lot more peaceful and better organised now. The home has made some good improvements in their record keeping and care planning. Care Plans seen for people who use the service were informative and gave good indication of how care is to be delivered for each of them. Medication practices have improved and more senior staff have received training in safe handling of medication. The AQAA completed by the Registered Manager states We have met the requirement in our last inspection report in ensuring that correct water temperature is maintained in the bathroom. Audit systems have been put in place, and the bathroom has been completely refurbished. We have put in place a new mechanism to track our policies and procedures and ensure that they are regularly updated and revised with reference to changes in legislation. We also sought good practice advice or guidelines from authoritative bodies, such as the Department of Health, National Institute for Clinical Excellence (NICE) and Care Quality Commission (CQC) etc. and ensured staff receive the appropriate training to reflect these changes. What they could do better: Those members of staff who as yet have not received training in fire safety updates and safe handling of medication must do so as a matter of priority. This training would enable staff to improve further their care practices, knowledge and skills. The AQAA submitted prior to this visit by the Registered Manager stated that We will continue with the annual reviews of policies, documents, maintenance of equipment and update where necessary. To make improvements to our pre - admission and trial visits. This will be done by having a designated staff mamber to look after the prospective service user throughout the period of the visit. Subsequently, this staff member will become the keyworker, this allows familiarity and continuity for the service user which is important particularly Care Homes for Older People Page 9 of 33 for those with dementia. To continue forging links with community organisations and explore and introduce new acitivities. This will be done by appointing a co - ordinator whose role will be to establish robust community links and that community engagement issues are added in care plans. As dependency of our service users increases over time, we are to ensure that we review and audit our facilities and equipment to ensure they are fully sufficient to meet the changes and needs of our service users. This will be done by an internal audit and also thereafter acquiring the services of an independent Occupational Therapist. The homes AQAA also contains improvement plans specific to each of the seven outcome areas and this is a most welcome arrangement If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 10 of 33 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 11 of 33 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can be confident that the home supports them as people have all the information they need before they move into the home. Evidence: Ashley Court care home provides detailed and clear information, in the form of a Service Users Guide, to people who will be using the service and their families to enable them to make decisions about whether or not to live at the home. Admissions are not made to the care home until a full assessment has been undertaken. The home is then able to confirm that they can meet the needs of the individual through the service they deliver as detailed in the Statement of Purpose. For people who are self funding and without a care management assessment, they always receive assessment by the Registered Manager. Four files and care plans of people who use the service were inspected, which Care Homes for Older People Page 12 of 33 Evidence: contained pre - admission assessments of their needs, both from assessments by the homes senior staff and other relevant professionals. The AQAA completed by the Registered Manager states We work very hard on ensuring that all new service users receive a comprehensive needs assessment prior to admission. We try hard to make sure that the process is not a difficult one for prospective service users as we fully understand how a new service user may be feeling when they are looking at moving into care. We make sure that the assessment is carried out only by trained and experienced staff with skill and sensitivity, and strictly according to our admissions policy and using our own assessment form. All aspects of an admission is carefully thought and all necessary preparations made to make the move as positive and constructive as possible for the new service user. Observations and discussions with people using the service, their visiting relatives, Registered Manager, and staff on duty indicated that the home continues to meet the needs of older people in a satisfactory and sensitive manner. It was noted from the staff training records that almost all members of staff have undertaken their training in Dementia care and adult protection and safeguarding issues. The home does not provide a service for those assessed and referred solely for intermediate care, who require help to maximise their independence and return home. Care Homes for Older People Page 13 of 33 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service have individual plans of care, which ensures that their personal, healthcare and social needs can be met. Medication is administered and stored in a manner that safeguards everyone using the service. People who use the service are treated with respect and dignity and their right to privacy is understood and upheld. Evidence: People who use the service undergo an assessment of their needs prior to admission to the care home. A Care Plan is produced, which is based on the assessment of needs. The home operates a good key worker system, which helps to ensure that the recommendations arising from the care plan reviews are implemented. Four Care Plans of people using the service were case tracked and examined in detail. There was evidence to show that the short term goals and long term goals, aims and objectives were clearly identified and appropriate interventions required to meet the individual needs of people who use the service were also identified. Care Homes for Older People Page 14 of 33 Evidence: Discussion with people who use the service showed that the home has a good ethos of involving them in all aspects of their life. The care plans that were read were clearly written and included an element of risk assessment. Information from the initial assessments had been written into plans of care. The care plans are reviewed on a monthly basis by senior staff. Care Plans demonstrated that the staff actively promoted the rights of people who use the service of access to the health services both within the home and the community. Appointments are planned or arrangements are made for professionals to visit frail people using the service. Whenever possible continuity of care for the service users declining state of health is assured. District Nurses are called upon to assist with clinical help, equipment and advice where necessary. The Registered Manager promotes the key worker system so that relationships between staff and individuals are enhanced. Visitors are able to meet people using the service in their bedrooms, in the lounge or in the visitors room on the ground floor. It was observed that people who use the service were being treated with respect and staff were working both professionally and sensitively in meeting individual needs. We spoke at length with several people using the service and all of them commented positively about their care and felt they have everything that they need. Four people who use the service stated that The carers are very good and kind and they look after us very well. Two other people who use the service said The carers are always there to help us. A relative of a service user who returned a completed Survey states I feel at ease knowing there is someone at hand 24 hours if my dad should need attention. The meals are very good, and my dad seems to be content. Another relative states that My mother is being cared for to a good standard. Generally people who use the service appeared to be content and comfortable. They were complimentary regarding the quality of their lives and care they were receiving at Ashley Court care home. There are appropriate policies and procedures in place for the administration of medication. It was noted that the care plans contained a list of current medication. The Registered Manager stated that reviews are carried out on a regular basis of all the care plans to ensure that medication details are up to date. Appropriate records are kept of all medicines received, administered and leaving the home. Random sample of medication and administration sheets were seen at the inspection and there were no discrepancies. All the medicines are stored in the medication room kept under lock and Care Homes for Older People Page 15 of 33 Evidence: key. Daily checks are taken of the temperature of the medicines in the refrigerator and the medication room. There are no controlled drugs used by anyone using the service at the care home. If in the future there is someone prescribed with controlled drugs then these will be appropriately stored securely and safely in a lockable metal cupboard in the medication room under lock and key. Medication rounds were observed during the inspection. Senior staff were seen to administer and record when medicines had been given. The Registered Manager stated that all senior staff responsible for administering medication were appropriately trained in safe handling of medication. However, the Registered Manager stated that those members of staff who have not yet received training in the safe handling of medication will receive this mode of training shortly. The homes plans for further improvement in the next 12 months are: The introduction of the Department of Health End of Life Care Planning Programme into the home will be supported over the next 12 - 24 months by a programme of palliative care training for our staff, which will be conducted in partnership with our local hospice. This will be evidenced in training plans, End of Life Care Planning paperwork, concepts incorporated into care plans and the homes improvement action plan. The home intends to make improvements to its care services for terminally ill and dying service users and their families, particularly in meeting the spirtual needs of our multi - ethnic client group and in improved advance care planning. Care Homes for Older People Page 16 of 33 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are able to exercise choice with regard to social and leisure activities at the home. Activities provided meet the needs of the people using the service. Relatives and friends are encouraged and assisted to maintain contact with the people using the service. The food at the home is of good quality and choices are always available. Evidence: The home provides an activities programme in accordance with everyone using the service, their choices, preferences and capacities in relation to social, leisure and cultural interests. People using the service, who were able to give opinion, were very complimentary about the activities provided, and particularly the external entertainers. People who use the service are enabled to enjoy a full and stimulating life style with a variety of options to choose from. A record of activities participated in is kept and photographs of major events displayed in the home. People using the service were seen sitting in the lounges chatting to staff and visiting relatives and in other communal areas within the home. Three people who use the service stated that they preferred to sometimes sit quietly in their bedrooms and the Care Homes for Older People Page 17 of 33 Evidence: staff respected this. After lunch time a number of people who use the service were engaged in playing different games. The AQAA completed by the Registered Manager states that The home provides a wide range of daily activities which are carefully designed to suit the needs and wishes of our service users. The range of activities are outlined in our Statement of Purpose so that prospective service users can see what the home have to offer. Activities are regularly reviewed to ensure that they meet the preferences and capabilities our our service users. Reviews, including feedbacks from service users are gathered through regular quality assurance questionnaires. The homes plans for improvement in the next 12 months includes: This home understands how important it is to help service users continue participation in activities they engaged in prior to entering the home or re - establishing activities if they change localities. The home already supports these kind of activities as a key element in our care planning but we wish to do more to enable them to achieve their goals, follow their interests and be integrated into the community life and leisure activities. Training has been booked in June 2009 for staff to undertake a personal exercise and nutrition course. This will better equip the staff to understand the link between exercise and nutrition and how these improves the quality of life for our service users. In order to make this improvement the home plan to appoint a co - ordinator whose role will be to establish robust community links and to ensure that community engagement issues are addressed in every care plan. Several people using the service spoken to stated that they were in regular contact with their family members and friends, and spoke about their visitors involvement and interest in their care matters. The visitors book kept in the home showed a considerable activity. People who use the service also keep contacts with the local community, for example, church services, pubs, shops and park. Five people who use the service told the us that they are happy with the care and social activities offered by the care home. They further added The home provides a good service and the staff are very caring and they are pleasant. The home also provides a variety of indoor activities, including festive and birthday parties. The Registered Manager stated that the people who use the service were positively encouraged and helped to exercise their choices, and control over their lives and daily living, subject to risk assessments in terms of safety, security and capacity to make Care Homes for Older People Page 18 of 33 Evidence: certain decisions. The Registered Manager also stated that a close liaison is maintained with the relatives and representatives, where the people using the service are not able to make certain decisions. The relatives of people using the service and their representatives are informed of the availability of Advocacy Service based at the local Age Concern. The information about the Advocacy Service is included in the homes Statement of Purpose and Service Users Guide. Several people who use the service told us The home is very good and its peace and quiet here. The food was very nice well cooked and tasty. However, one service user, who completed a Survey received by us states May be more choices at Teatime, as we have one at Dinner time and do not always want what is on offer. So would welcome a more variation in food is offered. Nevertheless the consensus of people using the service was the range, quality and choice of food provided was very good and the home catered for those people using the service, who have individual preferences and medical needs. The Registered Manager stated that the menu is changed regularly in consultation with the people who use the service. This is usually done in accordance with seasonal changes as well. The kitchen is well equipped and kept clean and tidy. The catering staff are trained in food safety and hygiene matters. Care Homes for Older People Page 19 of 33 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home safeguards people from abuse and takes appropriate action to follow up any allegation. This ensures that any complaints made are listened to and acted upon. The home has an Adult Protection and safeguarding policy and procedure in place to protect people who use the service from all forms of abuse. Evidence: The home has a good Complaints Procedure in place, which is referred to in the homes Service Users Guide and in the Statement of Purpose. There is a system of recording concerns and complaints. During the last 12 months the Care Quality Commission (CQC) has not received any complaints about the care home or any adult protection and safeguarding referral. The people, who use the service, when asked, were certain of how to formally make a complaint but they said they would quite happily talk to one of the staff or the manager. The AQAA completed by the Registered Manager at the end of April 2009 states that Ashley Court are committed to ensuring that ongoing training is high on our agenda and provide learning and training in all areas particularly when new legislations have been introduced. In order to ensure the safety and protection of our service users, the staff have received the following training:- Dignity in Care, Person Centred Dementia Care Homes for Older People Page 20 of 33 Evidence: Care, Mental Capacity Act 2005, Deprivation of Liberty Safeguards, and POVA and Safeguarding Vulnerable Adults. The home has good policies and procedures in place regarding restraint, dealing with aggressive behaviour and prevention of abuse, which includes whistle - blowing policy. The Registered Manager stated that adult protection and safeguarding issues are discussed during induction training and supervision meetings. Several people who use the service stated they are satisfied with the service provision, feel safe and well supported by staff that have their protection and safety as a priority. Care Homes for Older People Page 21 of 33 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The standard of the environment is good providing a homely, clean and secure place to live. Evidence: The home offers a comfortable and well - maintained environment to all people who use the service. The home has ample communal space - two lounges and a dining room on the ground floor. The home has a rolling programme of redecoration to maintain good standards. The garden and patio areas are well - maintained. The home has provided suitable aids and adaptations in the home to meet the general and specific needs of all the people using the service. There are adequate numbers of bathrooms and showers and WCs in the home. It was noted that the bedrooms are personalised by most of the people using the service. The home have met the requirement from our last key inspection report in maintaining the correct water temperature in the bathroom on the first floor. This bathroom has been completely refurbished and also has a thermostatic mixer valve fitted. Hot water temperature tests are conducted once a week. Over the last year the home have instigated a rolling programme of premises improvements, including modernising all of the lounges so that they are more in Care Homes for Older People Page 22 of 33 Evidence: keeping with the style required by the people who use the service. The home have made the following improvements since our last inspection: Complete refurbishment of a bathroom, replaced shower curtains with fitted shower enclosures. Replacement of all dining chairs. Replaced carpets in a number of bedrooms, stairs and corridors on the first floor. New cooker and dishwasher have been provided in the kitchen. A large washing machine has been purchased for the laundry room. New flooring has been provided in the small lounge and visitors room. The Registered Manager stated that Infection Control inspection was undertaken, which scored very highly by Wolverhampton City Council. The home use the Essential Steps action plan, and received 100 success rate in their MRSA screening. During the day of inspection, the home was found to be clean, tidy and free from any unpleasant odour. However, we noted the following issues, which needs to be addressed as a matter of priority for the safety and comfort of people who use the service: That the broken and loose slabs at the new patio area near the rear garden needs to be replaced and made safe. The slightly overgrown grass at the rear garden should be appropriately maintained; a suitable ramp should be provided for easy wheelchair access to the main entrance door; and bedroom 2 on the ground floor is in need of redecoration and also the carpet is in need of thorough cleaning or replacement. This is to ensure the safety and comfort of people who use the service. The home has good policies and procedures in place regarding infection control and COSHH. However, it was noted from the staff training records that almost all members of staff have undertaken training in infection control and those couple of members of staff who as yet have not received this mode of training will do so shortly and as a matter of priority. It was noted that all new members of staff received induction training and they are made aware of the dangers of cross - infection. The homes AQAA completed by the Registered Manager states that their plans for improvement in the next 12 months includes: To continue with the ongoing rolling programme of maintenance and refurbishment and decoration throughout the home as and when required. To keep our staff up - to - date with training and any issues related to infection control. Care Homes for Older People Page 23 of 33 Evidence: To provide large HD flat screen TVs in communal areas, which will improve the quality of viewing television programmes and watching videos and DVDs for our service users. Care Homes for Older People Page 24 of 33 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Ashley Court care home is staffed by well - trained and experienced staff to meet the needs of people who use the service. There are robust recruitment procedures in place to protect people who use the service. There is a good training programme in place that ensures staff are competent to do their jobs. New members of receive structured induction training. Evidence: Information provided by the home and available staff rotas for the month of May and first week of June 2009 indicated that the home has sufficient care staff to meet the needs of the 21 people using the service at present. There is one senior carer and two carers on duty throughout the day. Two carers are on wakeful night duty and a senior member of staff on - call in case of emergency. There are currently adequate numbers of ancillary staff on duty to cover catering, domestic and laundry duties at the care home. The Registered Managers hours are supernumerary. The staff training records showed that 95 of staff have completed their NVQ Level 2 qualification and three members of staff have also completed their NVQ Level 3 training. The remaining members of staff who as yet have not received this mode of training will also be nominated to undertake the training shortly. The home does not employ Agency staff. The staff team is a well - balanced group in terms of age, Care Homes for Older People Page 25 of 33 Evidence: experience, gender and ethnicity. Four staff files were examined in detail in order to check compliance with the recruitment requirements. All four files contained copies of two written references, and a full employment history. There was evidence on staff files that all four had been subject to satisfactory Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) checks prior to being appointed. There was evidence on files that staff have received the statements of their terms and conditions of employment. There is a staff training and development programme in place. In addition to the mandatory training (see NMS OP38) staff also would benefit from training in Mental Capacity Act 2005, equality and diversity, Fire Safety updates and safehandling of medication. Staff confirmed that training is provided and there are many opportunities to improve themselves for the benefit of the care of people using the service. All new staff received their induction training in accordance with the Skills for Care standards and specifications. The Homes AQAA completed by the Registered Manager states that We have met the last requirement in ensuring that all our staff are up - to - date in adult protection training. We ensure that in addition to safer working practice mandatory training, we also access and provide learning opportunities for all staff in other key areas i.e. food and nutrition, diabetes awareness, falls prevention, exercise and fitness, team leading, Deprivation of Liberty safeguards, Dignity in Care and Person centre dementia care. Ashley Court have updated its recruitment policy and process. Our aspiration is to ensure that our recruitment reflects our interest to only attract and select the best possible staff who are right for the job concerned. People who use the service commented that they feel safe with staff caring for them and they felt that the home employs people that are capable of carrying out their care duties. A service user states in a Survey returned to us I am happy here, staff are good and I have met my friend M.... Several members of staff have returned completed Surveys to us and all of them have made positive comments about the management of the home and their own committment to meeting the care needs of people who use the service. For example, a member of staff states I feel that Ashley Court covers all aspects very well. The Care Homes for Older People Page 26 of 33 Evidence: quality of care and hygiene are excellent. All members of staff are pleasant and easy to get on with. I feel that Ashley Court do everything that they can to help everyone. Another member of staff states The home caters for each individual, regarding meals, any faith, personal care, and entertainment for all residents. keeping all employees updated on any courses and training. Care Homes for Older People Page 27 of 33 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service can be assured that the home is run in their interests. Financial interests of people using the service are safeguarded. The home promotes the health, safety and welfare of people who use the service. Evidence: The Registered Manager - Narinder Bachra was registered with CSCI (now CQC) in February 2004. Ms Bachra has completed her Registered Managers Award (RMA) and NVQ Level 4 qualifications. She appears to be managing the home well. There are clear lines of accountability within the home. The home has a formal staff supervision system in place, and Ms Bachra is implementing the system of supervision of staff and meetings both with staff and people using the service. Observations made and discussions with people who use the service and their relatives and staff have indicated that the Registered Manager is very approachable and she operates an open door policy. People who use the service, who could express Care Homes for Older People Page 28 of 33 Evidence: themselves stated that they are happy to approach the manager and staff with any problems they might have and were confident that they would respond to them appropriately. Equality and diversity for people who use the service were seen to be promoted throughout the home within the assessments, care plans and activities. Equality for staff is promoted through the opportunities for training at all levels. It was noted that the home has a Quality Assurance monitoring system in place. Quality Assurance takes place throughout the service in both a formal and informal manner. Meetings and day - to - day contacts all provide records to show that satisfaction is at the heart of the service for people who use the service. Surveys were carried out for the years 2008 and 2009. A report on the result of the feedback from people who use the service and their relatives had been prepared. The comments received were generally very positive. In addition, stakeholders survey was also carried out and the feedback was also positive. Financial records and administrative procedures relating to the handling of the monies of people who use the service were looked at and were found to be well ordered and maintained. The home actively encourages people using the service, where able, to manage their own money. The home keeps records to show that Fire Safety, health and safety of people who use the service is promoted and protected. The staff training records showed that a majority of staff have received their mandatory training in safe working practice topics, e.g. moving and handling, food hygiene, first aid and health and safety. The Registered Provider stated that all those members of staff who as yet have not received this mode of training will do so shortly. They will also receive training in safe handling of medication, fire safety updates and NVQ Level 2. People who use the service spoken with were very complimentary about the Registered Manager and staff in the home. Many of them knew who they were by name and looked at ease in their presence. Care Homes for Older People Page 29 of 33 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 30 of 33 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 19 23 The Registered Manager 31/07/2009 must take appropriate action to ensure that the broken and loose slabs at the new patio area near the rear garden are replaced and made safe. This is to ensure the patio and garden areas are safe for people using the service. 2 19 23 The Registered Manager 31/07/2009 must take appropriate action to ensure the essential repairs and maintenance work (such as those identified in this report) are addressed promptly. This is to ensure people who use the service are living in a comfortable and safe environment. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of Care Homes for Older People Page 31 of 33 improving their service. No. Refer to Standard Good Practice Recommendations Care Homes for Older People Page 32 of 33 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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