Inspection on 17/11/05 for 1-6 Ashby Court

This inspection was carried out on 17th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

1-6 Ashby Court 06/08/07

1-6 Ashby Court 31/05/06

1-6 Ashby Court 25/04/05

1-6 Ashby Court 24/09/04

1-6 Ashby Court 16/06/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 1-6 Ashby Court Spilsby Lincolnshire PE23 5DR Lead Inspector Kima Sutherland-Dee Unannounced Inspection 17th November 2005 09:30 1-6 Ashby Court DS0000002596.V266658.R01.S.doc Version 5.0 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 1-6 Ashby Court DS0000002596.V266658.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. 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. 1-6 Ashby Court DS0000002596.V266658.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 1-6 Ashby Court Address Spilsby Lincolnshire PE23 5DR 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) 01790 753432 01754 811004 Boulevard Care Miss Nicola-Jane Golightly Care Home 11 Category(ies) of Learning disability (11) registration, with number of places 1-6 Ashby Court DS0000002596.V266658.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th April 2005 Brief Description of the Service: Ashby court is a row of 6 terraced houses, owned by the Boulevard care group. The houses are 2 bedroom and they are very close to the centre of the small market town of Spilsby. The service can accomodate and support residents under 65 years old with the primary need of learning disability. The homes are aimed towards residents who can live semi independently although at least 2 members of staff are on duty with 2 staff sleeping in on the premises. Each house is decorated and furninshed and they are different depending on the preferences and abilities of the 2 residents sharing each home. 1-6 Ashby Court DS0000002596.V266658.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector spent the morning at the homes talking to the new acting manager, and 4 residents as well as reviewing a sample of the documents and touring 3 of the homes. What the service does well: What has improved since the last inspection? What they could do better: The medication dispensing system needs to change to prevent secondary dispensing. 1-6 Ashby Court DS0000002596.V266658.R01.S.doc Version 5.0 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. 1-6 Ashby Court DS0000002596.V266658.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 1-6 Ashby Court DS0000002596.V266658.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 The home offers prospective residents the information they need to make a decision and the staff are able to communicate with them about life in the home during their visits prior to moving. EVIDENCE: The organisation has produced a statement of purpose and a service users guide and these are available to prospective residents The new resident has settled in well and they say they like living at the home. Their care plan and assessment detail their needs and how these will be met. 1-6 Ashby Court DS0000002596.V266658.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Although the care plans are useful and detailed it is recommended that the home add each persons preferred daily routine. Residents are confident that their records are securely kept. EVIDENCE: The care plans are detailed and they recorded a good history and individual’s goals and wishes. Each person at the home has a different routine and therefore it would be useful for their key workers to record each residents normal ‘getting up and going to bed ‘times so that changes can be noted and supported. The resident’s meet regularly with their key workers and these are recorded. The records are kept securely in the office and the residents knew that they could have access to their own records. The residents told the inspector about what they had been doing and events they had attended and some of their goals. 1-6 Ashby Court DS0000002596.V266658.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,16 The home does provide appropriate leisure opportunities and it must now ensure that it can provide individual daytime activities to replace the day service. The residents do have enough food to provide a balanced diet and their choices are respected. EVIDENCE: The care organisation are shutting their day service at the beginning of December 2005 and plans are being put in Place for residents to be involved in more home based activities and learning. Two of the residents asked said this was positive. The inspector spoke with the day service manager and another resident and was informed that programmes were being developed for each resident and that they were in consultation with other agencies who may be able to come to the homes to offer some learning opportunities and so that the residents already working towards certificates may complete these. The inspector was informed that one of the resident had been involved in the football team and a number were involved in competition swimming through the day services. It is therefore important that the home develops programmes that build in physical exercise and social interaction. The home care staff will be providing the staffing for the new activities. Four residents at 1-6 Ashby Court DS0000002596.V266658.R01.S.doc Version 5.0 Page 11 the home did not attend the day services and therefore they will continue their normal routines. During a tour of the homes it was seen that some of the fridges were better stocked that others. A discussion with the acting manager took place and food is provided through weekly shops and also by the care organisation. All of the residents are able to go to the staff and request new items and a stock check is done once a week. Individual menus are recorded in each home and all the residents are able to prepare their own food with varying degrees of support. The previous problem of ant infestation in one home has been dealt with. The residents told the inspector that the staff spend time with them and they are supported to achieve their goals. This was confirmed by the care plans and by talking to the acting manager. 1-6 Ashby Court DS0000002596.V266658.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 The home receives and stores the medication appropriately but they need to change the administration system. EVIDENCE: The home dispenses medication from the original containers into individual medicine wallets. The inspector discussed the need to change this system with the manager. It was agreed that the tablets would be dispensed directly from the prescribed container to the resident. The home still needs to develop protocols for P.R.N (prescribed as required) medication so that staff are clear about why they are giving these, how long for and any side effects. The home does have medication policies and 2 staff have recently attended an administration of medication course. 1-6 Ashby Court DS0000002596.V266658.R01.S.doc Version 5.0 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 The staff are able to respond effectively to suspicions of abuse and the documents are in place to manage this. EVIDENCE: Staff have attended a training course in Adult Protection on the 5.8.2005 and the home has the policies in place for dealing with these situations. Care plans do contain information about the level of support that is required for each resident to maintain their personal hygiene, and the staff know each resident well enough to recognise self-neglect. Action has been taken since the last inspection concerning two residents and improvements have been made. 1-6 Ashby Court DS0000002596.V266658.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 The homes are individual and generally clean depending on the standards and wishes of the residents. EVIDENCE: The inspector visited three of the homes and they all had new kitchen floors and new kitchen equipment. The kitchen units in one of the homes were very worn. There was new furniture in one of the lounges and the staff have supported two residents to maintain their home. It was seen that the staff do knock on each residents door before entering and the residents said this had improved. 1-6 Ashby Court DS0000002596.V266658.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards will be assessed at the next inspection. EVIDENCE: 1-6 Ashby Court DS0000002596.V266658.R01.S.doc Version 5.0 Page 16 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,42 The acting manager is able to run the home and support the staff team. The health and safety of the residents are promoted and protected. EVIDENCE: The care organisation have recruited an acting manager from another of their homes. This manager was confident in their role and able to lead the team well, and is working towards their N.V.Q 4 manager’s award. The senior managers who visit regularly support them in their role. Staff are receiving regular supervision. Risk assessments are included in the care plans for both individual activities and for the environment. The homes are maintained and insured by the care organisation and equipment is serviced. A notice was seen in the bathrooms to take the temperature of the water with the provided thermometer and all staff are aware of this. 1-6 Ashby Court DS0000002596.V266658.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 X 3 X X Standard No 22 23 Score X 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X 2 X X 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X X X LIFESTYLES Standard No Score 11 3 12 3 13 X 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X X X X X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 1-6 Ashby Court Score X X 2 X Standard No 37 38 39 40 41 42 43 Score 3 X X X X 3 X DS0000002596.V266658.R01.S.doc Version 5.0 Page 18 yes 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. Standard Regulation Requirement Timescale for action 30/12/05 2 YA20 13(2) The registered person must change the medication administration system to prevent secondary dispensing. The home must also develop protocols for staff dispensing P.R.N medication. P.R.N requirement carries over form the May inspection. 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 YA7 Good Practice Recommendations It is recommended that the care plans detail each person’s normal and preferred daily routine. 1-6 Ashby Court DS0000002596.V266658.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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 1-6 Ashby Court DS0000002596.V266658.R01.S.doc Version 5.0 Page 20 - 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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