Inspection on 21/03/07 for Ashberry Court

This inspection was carried out on 21st March 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Ashberry Court 30/10/07

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Ashberry Court 39 Lewes Road Eastbourne East Sussex BN21 2BU Lead Inspector Mrs Ann Block Key Unannounced Inspection 21st March 2007 08:30 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 Ashberry Court DS0000067506.V333294.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. Ashberry Court DS0000067506.V333294.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashberry Court Address 39 Lewes Road Eastbourne East Sussex BN21 2BU 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) 01323 722335 01323 722335 ashberry@broadgate-healthcare.co.uk Mr Ramachandran Jalatheepan Mr Varunatheepan Ramachandran Mr David Short Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places Ashberry Court DS0000067506.V333294.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The maximum number of service users to be accommodated is twenty-two (22). Service users accommodated must be older people aged sixty-five (65) years or over on admission. That one named service user with a dementia type illness to be accommodated. That one named service user aged sixty-five (65) years on admission to be accommodated. N/A Date of last inspection Brief Description of the Service: Ashberry Court is a large converted house with a later extension in an area of similar properties. The house was adapted for use for 22 older people who are accommodated on 4 floors. Access to rooms in the extension is by passenger lift, other areas of the home are accessed by stairs or stair lifts. Fourteen rooms have an en-suite toilet and washbasin, the remaining rooms have a washbasin. Two bedrooms are large and can be shared on request. Residents have use of two lounges and two dining rooms. There is access to a rear garden. The home is sited on a main route into Eastbourne and whilst there are no shops close by, the town centre is approximately 1 mile away and can easily be accessed by bus. There is limited parking on site but on street parking is available locally. The home is staffed on a 24 hour basis with waking night staff, a manager and deputy manager, catering and domestic staff, care staff and a maintenance person. At the time of the inspection fees ranged from £325.00 to £500.00 per week. Residents pay for their own hairdressing, chiropody, personal telephone and TV, personal clothing and toiletries, and dentistry. Ashberry Court DS0000067506.V333294.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Ashberry Court has been run as a care home for older people for a number of years but changed ownership in August 2006, hence the service is considered a new service and was inspected on that basis. It is to be noted that there has been consistency in management and staffing of the home through the change of ownership with the current manager having been in post for some 8 years. A key inspection carried out by Ann Block which included an unannounced visit to the home on Wednesday 21st March 2007. The day was spent at Ashberry Court talking to residents, visitors, staff and the manager and observing general life in the home. At the time of the inspection there were 16 residents living at the home. A sample of records was seen. Feedback was given to the manager during the inspection. Residents, staff and visitors gave their full cooperation to the process of gathering evidence for service provision. Judgements made from conversation, observation and records indicate that the home is well managed giving residents a good quality of life. All spoken with were very complimentary about the home. Comments included: ‘Everything here is good’ ‘The management and staff have been first class in meeting the needs of its residents and families’ ‘I came here to recuperate after a serious illness, I could not have been shown more care, kindness and consideration’ ‘The manager has shown true professionalism in the care of others, he has shown true leadership and perfect organisational skills.’ What the service does well: Residents appreciate the management of the home which they say makes for a well run home and good place to live. Residents say they are well looked after by staff who are competent, well trained, kind and caring. They know that any requests for care or support will be responded to promptly. Ashberry Court DS0000067506.V333294.R01.S.doc Version 5.2 Page 6 Residents physical and mental health needs are well met with access to health professionals both in house and externally. Visitors are welcomed to the home and value being a part of their relatives lives if they choose. Residents have food that they enjoy, which is home cooked and nutritious and where their dietary needs are met. Residents value the provision to be themselves, to be private if they wish or to have places to have a chat with other residents or watch TV. Residents know there are people who they can talk to about any concerns, who will listen and who will take action to improve the situation. Staff and residents know they are valued as individuals and will have their potential recognised and developed. Staff appreciate the staff team, the training they receive and the positive attitude of the manager. Sound record keeping and research into current trends in the care of older people support good standards of care. What has improved since the last inspection? What they could do better: To ensure continued safety an electrical supply certificate must be obtained. To evidence that residents or persons acting on their behalf have agreed to any restriction to practice, the process of this decision making and agreement should be documented. To support overall good medication practice for residents, minor improvements to storage and dating should be carried out. Ashberry Court DS0000067506.V333294.R01.S.doc Version 5.2 Page 7 To provide a more even temperature through the home consideration should be given to upgrading the central heating pump. Processes of dealing with residents’ finances would have more accountability if transactions were witnessed by a second person. To ensure suitable staff continue to be employed the system for verifying previous work with vulnerable people needs enhancement. 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. Ashberry Court DS0000067506.V333294.R01.S.doc Version 5.2 Page 8 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 Ashberry Court DS0000067506.V333294.R01.S.doc Version 5.2 Page 9 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): 1,2,3,4,5 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ choice to move into Ashberry Court benefits from good admission and assessment practices. EVIDENCE: A combined statement of purpose and service users guide is available and has been updated to reflect the new ownership. The document gives good detail about the home, staff and services provided. Copies of inspection reports are also available. Residents considered they had good information about the home although few had used the service users guide as a reference, relying more on their own or others judgment. Some had visited the home before they moved in others had families, professionals or friends view the accommodation on their behalf. Those who had visited the home themselves Ashberry Court DS0000067506.V333294.R01.S.doc Version 5.2 Page 10 said they were made to feel welcome, met some of the staff and had a cup of tea with other residents. Prospective residents are fully assessed before admission with as much information as possible obtained from the resident, relatives and professionals. Great care is taken to ensure that, at the point of admission, the assessment process indicates that the home is suitable and can meet the resident’s needs. As a safeguard to both the resident and the service, each stay starts with a trial period. During this time the resident and staff at the home can decide whether the home is right for the resident. Where a later change in circumstances means the home is no longer suitable, support will be given in cooperation with families and professionals to find a more appropriate service. The manager and staff are open to offering opportunities to residents who may have complex needs and were recently commended by a care manager for the work carried out to support a particular resident. Each resident has a statement of terms and conditions which sets out their rights and responsibilities, what is provided in the weekly fee, how the fee is to be paid and by whom. Respite care can be provided if a room is available and the service can meet the resident’s needs. There is no specific accommodation for short term care, the resident is free join in with daily life in the home. Ashberry Court DS0000067506.V333294.R01.S.doc Version 5.2 Page 11 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): 7,8,9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ care and health needs are well met and evidenced. EVIDENCE: Each resident has a plan of care. They are advised they have the right of access to all their records and that details about their care needs will be recorded. Most residents spoken with had little interest in documentation about their care, they were more interested in how it was provided and felt that staff were very good at knowing what was needed and doing it. One resident said quite firmly when asked why there were few calls bells being heard: ‘Because staff know what they need to do and do it, that’s why!’ Staff spoken with knew each resident well and adjusted their approach to match the resident. This is assisted by a good keyworking system and was Ashberry Court DS0000067506.V333294.R01.S.doc Version 5.2 Page 12 particularly noticeable when staff were dealing with those residents with more complex needs. Whilst residents weren’t overly concerned about documentation, the manager has high expectations that staff will be diligent in recording care and support properly. The home uses a comprehensive care plan computer package which has sections to cover a range of physical, social, emotional, spiritual and health needs. Staff spoke of how they would record events and were confident in using the system using a terminal in the staff room with secure access. Daily diary notes seen evidenced that staff followed through where there were any concerns such as a fall. Printouts are made which are updated with superseded copies replaced promptly. Printouts are kept in individual resident files in the office and in the files used by staff. Care is taken to ensure absolute consistency and accuracy at all times. Care and support needs are regularly revised both formally and on a day to day basis. Residents, relatives and professionals are invited to take part in the review process. Any outcomes from reviews are used to update the care system Care plans include risk assessments which detail how a risk will be reduced or removed. General practice includes a risk assessment being carried out where an incident or observation indicates a risk. Risk assessments were seen to cover issues of restraint or restriction of rights but in one case hadn’t been fully documented. Individual mental and physical health needs are identified and recorded, including reference to support from other specialist services. Residents spoke of their own health issues and how these were met. Reference was made to the district nurse visiting regularly and of visits to the chiropodist and optician. Any action needed from such visits are recorded and followed through by staff. Records of weight are held and any loss or gain will be assessed to identify whether action needs to be taken. Specific dietary needs arising from health assessments will be passed on to the cook. Medication is stored securely in a drug trolley and wall mounted metal cupboard, but currently not in the most appropriate location. Medication storage has provision to store current, stock and controlled medication. Some minor adjustments to improve the system were needed. Records of medication and observation of practice indicated that medication is given as directed by the prescriber. Medication for a minority of residents indicated a need for review by the general practitioner, the manager said there were problems getting the general practitioners to do this. Only those staff who have received medication training are permitted to administer medication. Residents made frequent references to the excellent qualities of staff. There was evidence throughout the site visit that privacy and dignity was well Ashberry Court DS0000067506.V333294.R01.S.doc Version 5.2 Page 13 maintained and residents agreed this was standard practice. Staff felt that each person must be treated as an individual and respected this individuality with patience and understanding. Lockable doors where needed provide additional privacy. There are phones which can be used in private with some residents having their own phone line. Ashberry Court DS0000067506.V333294.R01.S.doc Version 5.2 Page 14 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): 12,13,14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have a relaxed comfortable lifestyle and the pleasure of home cooked meals and snacks. EVIDENCE: Ashberry Court is a place where residents can live a life as much as possible to their own choosing and where they can welcome friends and family. A quality of the home which residents and staff said appealed to them was the atmosphere of the home which they felt was warm, friendly and inviting. Whilst there are the expected routines of a well managed service and residents understand this, as far as practicable residents can make their own choices about their day. Residents said they could get up and go to bed when they choose. One resident said this was very important to him, he liked to be in bed about 6 or 7 o’clock and up at 5.30. He was then able to have a reasonably early breakfast which again was his choice. Another resident said Ashberry Court DS0000067506.V333294.R01.S.doc Version 5.2 Page 15 they liked to take their time in the morning and usually had breakfast about 8 or 8.30. When staff time is available, usually during the quieter afternoon period, staff will offer activities such as a quiz.. There is a schedule of activities for the week but it was reported that few residents expressed any interest in ‘activities’ and staff found it difficult to find things which really interested residents or identify what they would like to do. Residents are also able to occupy themselves with their own hobbies such as reading, knitting, watching TV, listening to music or just having a chat. Some residents have their own daily paper. Two residents felt like would to be able to get out more. When possible staff will take a residents out for a walk and encouragement is given for one to one interaction whenever time is available. Visitors are welcomed to the home and various visits took place during the day with many others recorded in the visitors book. There is no specific visitors room but there are plenty of places where people can chat in private including residents own bedrooms. Family can involve themselves in the practical and social care of their relative if the resident chooses. One family said they felt reassured as they were always contacted if there were any issues with their relative. Residents are encouraged to personalise their rooms with their own possessions if they wish. Two cooks cover most of the catering with one holding lead responsibility. Care staff prepare supper and interim drinks. Menus are changed according to season and residents choice, alternatives are available. As far as possible fresh produce is used. Residents and staff spoke well of the standard of cooking. Lunch sampled by the inspector was excellent with quality confirmed by residents also eating it. One resident said: ‘The food here is always good, you can’t fault it.’ Drinks, both hot and cold, were offered through the day. Specific dietary needs and personal preferences are made known to the cooks and provided. The majority of residents eat in the dining rooms but meals can be taken in individual rooms if preferred. One resident said he had all his meals in his room by choice and was relieved he was able to do so as he would have disliked having to eat communally. Ashberry Court DS0000067506.V333294.R01.S.doc Version 5.2 Page 16 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): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to make comments about the service and be listened to. Residents are protected from the risks of abuse. EVIDENCE: The home has a complaint procedure which is accessible to residents and visitors and gives timescales for response with contact details. Verbal responses from residents said they have had no need to make a complaint. Residents said they can talk to the manager or staff about any concerns and they are listened to. In this way minor issues are dealt with promptly before they become a complaint. A relative said that in the beginning they had made one or two comments to the manager and these had been promptly and satisfactorily addressed. The manager believes that complaints are part of providing a quality service and not to be seen as negative reflection on the home. Staff have received training in adult protection issues which is due to be updated, the manager carries out adult protection training in house. Staff have a good understanding of how abuse may present itself and make sure residents are safe from any such abuse. They are aware that any such abuse would have to be reported. Ashberry Court DS0000067506.V333294.R01.S.doc Version 5.2 Page 17 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): 19,20,21,22,23,24,25 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have a homely, well maintained and comfortable environment in which to live. EVIDENCE: Ashberry Court is a large older building which was converted and extended for use as a home for older people. There are 22 bedrooms which includes 14 en suite rooms and two rooms which can been shared on request, one of these being a flatlet on the top floor. The home is often described as a bit of a ‘rabbit warren’ as there are varying routes and levels and short runs of corridor. Rooms in the extension can be accessed by a passenger lift, access in the older part of the house is by stair lifts or stairs. Ashberry Court DS0000067506.V333294.R01.S.doc Version 5.2 Page 18 The home recently changed ownership. The new owners are aware of the areas which need refurbishment such as the carpet on the ground floor. Money is spent on refurbishment when it is available and the manager felt that genuinely the new owners were keen to promote good standards of environment. A number of rooms have already been redecorated and overall the home presented well. Rooms are normally redecorated when vacant. Two domestic staff are employed to carry out weekday cleaning with standards at the time of the visit good. A maintenance person is employed, residents and staff spoke of his good nature and willingness. Staff can record defects in a maintenance communication book which also records when action was taken. A fire risk assessment has been carried out and is due to be updated. As far as the inspector is aware there are no outstanding requirements from the Environmental Health Officer. Standards of cleanliness and storage in the kitchen were very good. Residents have use of two lounges and two dining rooms. One lounge and dining room is sited on the ground floor with the others at semi basement level. There are plenty of easy chairs and occasional tables can be made available if a resident wishes. Side access and ramped access from the upper basement level provides access to the rear garden. There are currently two bathrooms with in-bath hoists and a small shower room. In addition to en suite facilities toilets are sited around the home. Staff have their own toilet and small staff room. Necessary adaptations are made which include grab rails, hoists and signage. Both bath hoists can be taken out of the bath if a resident prefers an ‘open’ bath. A new call system was put in the home approximately five years ago. The system links to the computer allowing monitoring of the times call take to be answered. It was noticeable that there were few calls during the visit and all were answered promptly. Bedrooms vary in size and shape. All have space to fit a single bed, hanging and drawer space and an easy chair. Residents are encouraged to personalise their rooms by bringing in personal effects and, by agreement, items of furniture. Each bedroom has a radiator with adjustable thermostat. It was noted that the lower half of the home was warmer than the upper parts. A more powerful pump on the heating system was being considered and on the day of the visit this would seem to be good suggestion. Residents spoken to said they were warm enough in their rooms, where additional heat was required secondary Ashberry Court DS0000067506.V333294.R01.S.doc Version 5.2 Page 19 radiators were in place. Radiators in high risk areas are provided with safe surface covers to prevent the risks of burns. Hot water from baths and washbasins used by residents have safety valves to reduce the risks of scalds, temperatures from these outlets are regularly monitored. There is a laundry at basement level with a heavy duty washing machine and tumble drier. Care staff carry out the washing during the day with night staff doing the ironing. Staff are aware of the principles of control of cross infection and are advised where special precautions are needed. Ashberry Court DS0000067506.V333294.R01.S.doc Version 5.2 Page 20 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): 27,28,29 & 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users are cared for by properly recruited and well motivated staff. EVIDENCE: Residents consider that there are sufficient staff to meet their needs. At the time of the site visit only 16 residents were accommodated rather than the 22 registered for, giving more than adequate staff time. Whilst residents have use of a call system, they said they rarely needed to use it as staff knew individual routines and came promptly if they did call. Many staff have worked at the service for some years and felt the team worked well together. Residents benefit from this setting and the atmosphere was relaxed and open. Staff spend time talking to residents and showed a genuine interest and respect for residents wellbeing. Residents said that staff were ‘kind’, ‘friendly’ and ‘always ready to help’. The roster records the names of staff working on shift and shows where shift vacancies occur and how these have been covered, in addition a separate record is kept of hours actually worked. Staff felt the days when they worked Ashberry Court DS0000067506.V333294.R01.S.doc Version 5.2 Page 21 long shifts didn’t affect the quality of work with residents. There is some use of agency staff and other staff are employed to work on a casual basis. As mentioned, in addition to care staff, catering , domestic and maintenance staff are employed. Recruitment is taking place for weekend domestic staff. Three carers are usually on duty during day and evening hours, although this can be flexible dependant on residents’ needs; one wakeful and one sleep in staff are on duty at night. The manager ensures that legal responsibilities in the employment of young people are followed. Staff follow an induction process. For staff without NVQ qualifications the new skills for care common induction standards which link to NVQ training has recently been implemented. Those with NVQ qualifications follow a shorter induction format which relates specifically to Ashberry Court. This was being explained to a newly recruited member of staff during the site visit as part of her induction. New staff work off rota for a period and shadow more experienced members of staff. Each person is given a staff handbook and General Social Care Council Code of Conduct. The manager understands that sound recruitment is key to providing residents with suitable staff. Recruitment records seen evidenced that overall good recruitment practice was carried out with good documentation, POVA and criminal records bureau systems and evidence of physical and mental fitness. Equal opportunities were met. The system to ensure the reason for leaving work with vulnerable people is confirmed in writing needs to be improved, particularly where the workplace isn’t provided as a referee. The manager is keen that staff are given opportunities to show their potential. An agency was recently used to recruit from overseas and a carer was in the later stages of getting a visa before coming to the home to start work. The home has a training programme, which aims to enable members of staff to update their levels of competence, gain new skills and confirm good practice. Training includes manual handling, health and safety, infection control, fire, adult protection, first aid and medication administration. Catering staff are trained in food hygiene, plans are for other staff to have hygiene awareness training. Where training includes use of a video this is always accompanied by questions on the topic and overseen by the manager. Staff spoke of training courses they had undertaken and felt they had a good grounding to provide care. Training matrices are held which record training already undertaken and planned/booked training for the forthcoming year. Copies of staff training certificates evidence training achieved. The staff handbook includes the statement that staff are required to attend training as part of their employment. Ashberry Court DS0000067506.V333294.R01.S.doc Version 5.2 Page 22 The manager said that seven staff have obtained an NVQ level 2 or above in care with four currently working towards it from a care staff team totalling thirteen. Ashberry Court DS0000067506.V333294.R01.S.doc Version 5.2 Page 23 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): 31,32,33,34,35,36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a needs led and safe service, which is run in their best interests by a manager and staff who are committed to providing a good quality of life for older people. EVIDENCE: The manager is competent to run the home, has been in place for some eight years and has had many years experience in the care sector, including managerial posts. He holds an NVQ level 5 in operational management, the CRCCYP certificate relating to child care and is in the final stages of the NVQ level 4 in care award. Residents consider the manager is accessible and Ashberry Court DS0000067506.V333294.R01.S.doc Version 5.2 Page 24 approachable. All spoken to felt that the manager was committed to providing a good standard of service and had the needs of older people at heart. He is excellent in the manner in which he researches and implements good practice in care. Residents made numerous references to his qualities as a manager, one calling him a ‘great guy’. The home has a quality assurance system in place and individuals are able to express their views. Surveys are given to residents, relatives and professionals and feedback incorporated into developments of the service. Letters of commendation for the service were seen, including one which praised the management of the home in particular. A care manager had written a very positive letter commending the home for the care of a particularly difficult resident. Resident and staff meetings are held on a regular basis. The manager recognises that both residents and staff need to express their opinion of the service and that they have the right to have their views taken into account in any developments of the service. Residents are also able to talk directly to the manager and spoke of how friendly and easy he was to talk to. Written policies and procedures are available to provide guidance for staff, with a list of policies forming part of the staff handbook. The home has a system for the maintenance and storage of information relating to residents and staff, including accidents and incidents, which preserves confidentiality, meets data protection guidelines and is accessible on a need to know basis. Notification of accidents and adverse events is provided to the commission as required by regulation. General record keeping is very good and well ordered. The manager is part way through ensuring all staff have a recent photograph on file. The home assists a few residents with day to day management of their monies. Records are held of transactions with receipts held detailing any expenditure on the residents behalf. To provide better accountability it is recommended that finances are not dealt with solely by one person. An up to date insurance certificate is displayed in the home. Staff supervision is currently shared between the manager and deputy. Staff thought supervision sessions were very good and said that they also had opportunities during the course of work to talk through any issues with the manager as there was an ‘open door’ policy. From observation and discussion with residents and staff, there is a good awareness of health and safety. Staff spoke of fire drills attended and when fire alarms were tested, records are held to evidence fire safety practices. Staff are trained in moving and handling. A resident said that although she Ashberry Court DS0000067506.V333294.R01.S.doc Version 5.2 Page 25 didn’t like having to use a hoist she felt safe when being hoisted by staff and confirmed that there were always two staff present at the time. Routine maintenance of supplies and equipment is carried out. The manager said that the main electric fuse boxes were changed about a year ago and annual portable appliance testing is carried out. No electrical supply safety certificate could be found, a Gas Landlords safety certificate had been obtained. Although the proprietors have no previous experience in owning a care home the manager said they take an interest in the overall running of the home with a visit under regulation 26 carried out and recorded monthly. Ashberry Court DS0000067506.V333294.R01.S.doc Version 5.2 Page 26 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 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 2 3 2 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 3 2 3 3 3 3 Ashberry Court DS0000067506.V333294.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? N/A 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 OP23 (2) Regulation 38.3 Requirement An electrical supply safety certificate must be obtained from a recognised registered electrical contactor. Timescale for action 31/05/07 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 OP7 Good Practice Recommendations Where a risk leads to a decision that form of restriction of rights is needed, this should be documented through the risk assessment process including any agreement from professionals. Minor improvements to medication practice are needed including: • • Ensuring the date of opening of drops is recorded on the package Storing medication administration record files securely DS0000067506.V333294.R01.S.doc Version 5.2 Page 28 2 OP9 Ashberry Court • 3 4 OP25 OP29 Clearer identification of medication waiting for collection by the pharmacist Consideration should be given to upgrading the pump for the central heating to provide a more consistent level of heat through the house. The system to ensure the reason for leaving work with vulnerable people is confirmed in writing needs to be improved, especially where the employer is not given as a referee. To provide better accountability it is recommended that residents finances are not dealt with solely by one person. 5 OP34 Ashberry Court DS0000067506.V333294.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Ashberry Court DS0000067506.V333294.R01.S.doc Version 5.2 Page 30 - 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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