Inspection on 25/06/09 for Ashbrook Court Care Home

This inspection was carried out on 25th June 2009.

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

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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ashbrook Court Care Home 17/11/09

Ashbrook Court Care Home 14/07/08

Ashbrook Court Care Home 18/06/07

Ashbrook Court Care Home 13/06/06

Similar services:

165 Putnoe Lane

Claremont House

Sun Court Nursing Home

Bramley Avenue (73)

15 Bramble Close

Dolphin Court

Fen Road

Wakes Hall

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: Ashbrook Court Care Home Sewardstone Road Waltham Abbey Essex E4 7RG     The quality rating for this care home is:   one star adequate 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: Michelle Love     Date: 2 5 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 34 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 34 Information about the care home Name of care home: Address: Ashbrook Court Care Home Sewardstone Road Waltham Abbey Essex E4 7RG 02085245530 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) : jennie.worthington@carebase.org.uk Carebase (Sewardstone) Limited care home 70 Number of places (if applicable): Under 65 Over 65 56 34 dementia physical disability Additional conditions: 57 34 Persons of either sex, aged 60 years and over, who require nursing care by reason of a physical disability (not to exceed 34 persons) Persons of either sex, aged 60 years and over, who require nursing care by reason of dementia (not to exceed 36 persons) Persons of either sex, aged 60 years and over, who require residential care only by reason of dementia (not to exceed 20 persons) The layout of the home will ensure that service users with dementia who have nursing needs will not have their bedrooms in the same areas of the home as those residents with dementia needs who do not require nursing The total number of service users accommodated in the home must not exceed 70 persons Three named persons, under the age of 60 years, who require care by reason of dementia Date of last inspection Care Homes for Older People Page 4 of 34 Brief description of the care home Ashbrook Court Care Home is a purpose built 70 bedded home situated on the outskirts of the Essex town of Waltham Abbey, in close proximity to the M25 London orbital motorway. It is registered for a total of 70 residents who need personal and nursing care. The beds are multi registered to allow for flexibility of admission to the home. The home accepts residents over the age of 60 years of both genders who require nursing care by reason of physical disability; nursing care by reason of dementia; and residential care by reason of dementia. All accommodation is in single occupancy en-suite rooms on two floors. The decoration and equipment throughout the home is of a high standard. It is homely in decorative style and many occupied rooms are personalised to the residents taste. There are a number of communal areas throughout the home, including a dining room on each floor. The range of fees given at the time of the site visit were people who are privately funded, #800.00 per week, people who are funded by Social Services, residential (dementia) #550.00 per week, nursing (dementia) #630.00 per week and people who solely require nursing care #600.00 per week. Ashbrook Courts Statement of Purpose and Service Users Guide/brochure can be obtained from the home upon request. Care Homes for Older People Page 5 of 34 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: one star adequate 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: This was an unannounced key inspection. The visit took place over one day by two inspectors and lasted a total of 10 hours with all key standards inspected. Progress against previous requirements and recommendations from the last key inspection were also inspected. Prior to this inspection the manager had submitted an Annual Quality Assurance Assessment (AQAA). This is a self assessment document, required by law, detailing what the home does well, what could be done better and what needs improving. It also gave us some numerical information about the service. Information given in this document has been incorporated into this report. Care Homes for Older People Page 6 of 34 As part of the process a number of records relating to people who live at the care home, care staff and the general running of the home were examined. A partial tour of the premises was undertaken throughout the day. People who live at the care home, their representatives and members of staff were spoken with and their comments are used throughout the main text of the report. We requested that surveys for residents, staff and healthcare professionals be forwarded to the home for distribution and for people to complete and return to us. However we were advised that these had not been received at the care home. We spoke to people throughout the time of the site visit and where comments have been recorded, these have been incorporated into the main text of the report. The manager was on annual leave at the time of the site visit. The interim manager, business manager and members of the staff team assisted us. Feedback of the inspection findings were given as a summary to both the interim manager and business manager of the organisation. The opportunity for discussion and/or clarification was given. As a result of concerns raised during this site visit, we issued a Serious Concern Letter pertaining to care planning/risk assessing processes and procedures and an Immediate Requirement Letter relating to some aspects of medication practices and procedures. What the care home does well: What has improved since the last inspection? What they could do better: Ensure that a plan of care detailing the persons care needs and how these are to be met by staff is compiled at the earliest opportunity from when the person is admitted to the care home. This will ensure that people living at the care home will be provided with good care outcomes. Ensure that the plan of care is reflective of their specific care needs, are up to date and provide clear guidance for staff as to how care should be provided and risk areas identified and proactively managed. Daily care records need to be improved so that they evidence staffs intervention and place less emphasis on the routines of the home. Current medication practices and procedures within the home need to be improved so as to ensure peoples safety and wellbeing. Further training opportunities for staff in relation to those conditions associated with the needs of older people needs to be provided. This will ensure that staff working at Care Homes for Older People Page 8 of 34 the care home will be confident and competent to meet the needs of people living at Ashbrook Court. Ensure that staffing levels are appropriate to meet the needs of existing residents, so as to ensure their safety and wellbeing. All staff to be supervised at regular intervals and records maintained. This will evidence the management teams ability to support staff and to ensure that where issues are raised, these are managed appropriately. 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 9 of 34 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 10 of 34 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 who come to live at the home can be confident that their needs will be assessed. Evidence: There remains a formal pre admission assessment format and procedure in place, so as to ensure that the management and staff team are able to meet the prospective persons needs. Records showed that in addition to the formal assessment procedure, supplementary information is provided from individuals placing authority and/or hospital. We were advised by the business manager of the organisation that it is the expectation that all placements to Ashbrook Court are planned and the prospective person and/or their representative are given the opportunity to visit the service, prior to their admission. This provides them with the opportunity to meet members of the staff team, to look around the premises and to meet other people who already live at Ashbrook Court. It is noted that on occasions a person is admitted to the care home in Care Homes for Older People Page 11 of 34 Evidence: an emergency and where this happens, attempts are made to acquire as much information as possible on the person from a number of different sources. The AQAA details that many enquiries received are by word of mouth. As part of this inspection, the care files for 3 people who were newly admitted to the care home were examined. Records showed that a pre admission assessment had been completed for each person, prior to their admission. In general terms information recorded was observed to be informative, however care must be taken to ensure there is clear evidence to demonstrate the rationale for admittance, based on the assessment of need. This refers to 2 pre admission assessments being detailed and informative, whilst the assessment for 1 person was seen to be basic. There was limited evidence to show that the above assessments had been conducted with the person and/or their representative. Of those people case tracked, none were able to confirm as to whether or not they had been involved in the above process or visited the care home as a result of their poor cognitive ability. However, from discussions with another person who has lived at Ashbrook Court for some time, they confirmed that their family visited the care home and that they had provided additional information to the person completing the initial assessment. They confirmed that their move into the care home had been smooth. A copy of the homes Statement of Purpose and Service Users Guide is readily available and is located within the main reception area of the home. The Service Users Guide is presented in both a written and pictorial format. The home does not provide intermediate care. Care Homes for Older People Page 12 of 34 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can expect to have a plan of care, however shortfalls identified mean that some people cannot be assured that their needs will always be met or that their health and wellbeing will be maintained or proactively managed. Evidence: A formal care planning system is in place to help staff identify the care needs of individual people and to specify how these are to be met by staff who work in the care home. As part of this site visit the care files for 6 people were examined (2 in full and 4 partially examined in relation to specific healthcare needs. These included the 3 files looked at as part of the pre admission assessment process). Records show that in addition to the formal assessment process, additional assessments are undertaken in relation to falls, pressure area care, moving and handling, nutrition and dependency. This inspection showed that further development in care planning and risk assessing, continues to be required to ensure the care needs of individual people are clearly recorded and staff have the most up to date information to ensure appropriate levels of care delivery are achieved and proactively managed. Care Homes for Older People Page 13 of 34 Evidence: On inspection of one persons care file, records showed that no plan of care was completed, 8 days after their admission to Ashbrook Court. Records showed that a Baseline assessment is completed for each person, covering a number of specific topics and this is used to inform the plan of care in addition to the pre admission assessment format, however this did not include specific information as to how the needs of the person were to be met and/or provide guidelines for staff. This was not an isolated case and on inspection of another persons care file, not all elements of their care plan had been completed until the 2nd and 5th day after their admission. Additionally records showed that not all the care needs of this person had been recorded within their care file, detailing their specific care needs and the staff support required e.g. the pre admission assessment recorded the person as experiencing pain to their back/abdomen and being prescribed pain relief medication. However no plan of care was devised in relation to pain management. We also noted that where changes to individuals care needs had taken place, the plan of care/risk assessment had not always been updated to reflect the changes. For example the care file for one person recorded them as requiring time to swallow their medication. Daily care records recorded that their condition had deteriorated over a short period and they were no longer able to swallow their medication. This was not updated on their plan of care and/or risk assessment. Another care file including the persons pre admission assessment recorded the person as exhibiting on occasions challenging behaviour. The daily care records for this person recorded them as being physically aggressive towards both staff and other people living at the care home and on occasions refusing to take their medication. On inspection of both their current care file and their archived file, no plan of care was devised for either area. A risk assessment was only devised for the persons challenging behaviour, however this was seen to be basic and not compiled at the time of incidents first occurring. Daily care records showed that the person continues to be aggressive and confrontational towards others. On the day of the site visit, they were observed to make several attempts to get out of the unit, to be verbally abusive towards others (staff and other people who live at the care home) and to threaten staff by raising their fist, however staff were observed to provide little interaction and/or interventions. Daily care records showed little evidence of staffs interventions, actions taken to de-escalate situations and the outcome of incidents. This is surprising as from discussions with staff and nursing staff, we were confident that people do know the care needs of this person pertaining to their challenging behaviour and the approaches to be used. Care records showed that incidents of challenging behaviour are recorded on a behavioural chart and within daily care records, however these did not always tally. Care Homes for Older People Page 14 of 34 Evidence: Daily care records were observed to be written each day and after each shift, however the quality of information recorded was seen to be variable. Records did not always record staffs interventions and records tended to focus on the routines of the home and not around the needs of the people living at the care home. The AQAA confirms this and details under the heading of what we could do better daily note entries need to be more person centred and less task lead. Some positive aspects of care planning were also observed. The care file for one person recorded them as being admitted to Ashbrook Court for palliative care. Records showed that as a result of their condition deteriorating a specific assessment had been introduced (Liverpool Care Pathway for the Dying Patient Plan). This is used to provide guidance for nursing staff/care staff, as to the delivery of care for people requiring palliative care. However, care must be taken to ensure that this document and the persons care plan are reflective of one another and do not provide staff with conflicting information. Prior to the key inspection concerns were raised by a local NHS Trust in relation to one persons pressure area care and the general recording of wound management. As a result of concerns raised, the organisation reviewed all documentation relating to peoples pressure area care within the home. As part of our inspection process we looked at the care files for 2 people who currently have a pressure sore. Records were observed to be detailed and informative, specifying a description of the wound area (including a photograph), on-going treatment, equipment in situ, evidence that an appropriate healthcare professional was involved and advice had been sought and that the wound was being regularly monitored and the care plan evaluated and updated. As discussed at the time of the site visit, care must be taken to ensure that consent has been agreed by the person to have their wound photographed at regular intervals. Care records showed that all people in the care home have access to a range of healthcare professionals and services as and when required. Nurses employed by the home primarily provide assistance and care to those people admitted for nursing care, while arrangements are in place for the community nurse/district nurse services etc to provide care and support to those people accommodated for residential care. We were advised that there continues to be a positive relationship with the visiting GP surgery and other healthcare professionals. During the site visit we observed that prior to the commencement of the afternoon shift, staff were given a hand over, whereby staff coming on duty were provided with information as to how the morning shift had been and if there were any specific issues relating to individual people living at the care home. People spoken with confirmed that they are treated with respect and dignity and that their care needs are met. One Care Homes for Older People Page 15 of 34 Evidence: person stated, its fine, the staff are very nice to me. Sometimes I have to wait to go to the toilet, if they are busy. Cant fault any of them, they smile, laugh and have a joke. Others stated, the staff are lovely, I have no problems and staff are wonderful and look after you well. Positive comments were also recorded within resident surveys about the quality of the service provided at Ashbrook Court in January 2009. Medication is stored securely within each of the treatment rooms on the ground and first floor. However while observing the administration of medication during the morning, we observed both medication trolleys being left unlocked and unattended by the qualified nurse, with blister packs of medication and bottles/packets of medication left on top of the trolley. This means that medicines are easily accessible to people living at the care home and potentially places them at risk. The temperatures of both medication storage rooms was observed to be monitored each day and within recommended guidelines. On inspection of fridge temperatures for medication which requires cold storage, some gaps were noted whereby this was not recorded and on occasions the temperature was above the recommended level. This means that this could result in some people receiving medication that is ineffective. We observed the morning medication round on both the ground and first floors. The medication round on the first floor did not commence until 09.20 a.m. and the medication round on the ground floor did not start until 09.35 a.m. We are concerned that the medication round on the first floor did not complete until 11.25 a.m. and the medication round on the ground floor did not finish until 12.35 p.m. The Medication Administration Record (MAR) recorded that morning medications should be administered close to 09.00 a.m. We also observed that the lunchtime medication round on the ground floor was administered at 13.55 p.m. and completed at 14.20 p.m. and on the first floor the medication round started at 14.20 p.m. and was completed at 15.00 p.m. This means that some people received their medication soon after their morning medication and there was an insufficient time lapse between medications administered, which could result in people being placed at risk. As a result of the above, an Immediate Requirement Notice was forwarded to the organisation detailing our findings. A response was promptly forwarded to us and this sets out the actions to be taken by the organisation to improve medication practices and procedures within the service. On inspection of MAR records, the majority of records sampled were seen to be satisfactory, however some medication discrepancies were identified. These relate to there was no record of some medicines having been given to the resident when they were due, as the entries on the MAR chart had been left blank and not signed or initialled by staff. Records also showed that as part of good practice procedures, some Care Homes for Older People Page 16 of 34 Evidence: handwritten MAR records were not signed to confirm that the medication received was accurately recorded. In addition, the date and quantity of medication received was not always recorded. Records also showed that one persons medication was not available and they missed 2 doses of their prescribed medication. We also found a stock discrepancy for one persons medication and instead of 10 tablets being available, only 9 tablets were in stock. This was discussed with the qualified nurse administering medication, however no rationale could be provided as to the discrepancy. An audit of controlled drug medication for 3 people was examined and records and actual medication available was observed to tally. The staff training matrix evidenced that staff who administer medication to people living at the care home have up to date medication training, however not all qualified nurses employed at the home have been regularly assessed as to their continued competency to administer medication. Care Homes for Older People Page 17 of 34 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can expect the activities programme to generally meet their social care needs. People can expect to receive a varied diet. Evidence: An activities co-ordinator is employed at Ashbrook Court Monday to Friday for 40 hours per week. We were advised that the activities co-ordinator has undertaken dementia training and completed a course specifically centred around activities for older people/people with dementia. Also they meet up with other activities co-ordinators from within the company to share ideas and experiences. There is an activities folder within the home from NAPA (National Association for Providers of Activities for Older People), however the activities co-ordinator has not yet had an opportunity to refer to this and/or read the information. Information relating to peoples social care needs are recorded within their plan of care and includes their personal preferences, likes and dislikes and past interests and hobbies. The AQAA details that people are enabled to have their own routines and lifestyles and activities at the care home are one aspect of their social life at Ashbrook Court. In general terms this concurred with our findings. An activities schedule for the week is displayed within each of the units and is devised Care Homes for Older People Page 18 of 34 Evidence: in both a written and pictorial format. Activities provided for people include both in house and community based activities such as bingo, strawberry picking, religious observance, reminiscence, sing-a-long, coffee morning, gardening, quiz, tea dance, board games, pamper mornings, arts and crafts, knitting and sewing. In addition to these other external trips are undertaken and external entertainers visit the care home. There is a 16 seater bus and a full time driver is employed for the sole purpose of transporting people on trips. One person spoken with confirmed that they had recently enjoyed a day out to Ely Cathedral and stated, it really made our afternoon. Other external trips included a trip to Waltham Abbey, High Beech and a walk in Epping Forest. The majority of activities are for people who are self motivated and mentally alert and there remains limited evidence to show that the social care needs of people with acute dementia and/or poor cognitive ability are met. On the day of the site visit, people were given the choice to sit in the garden, to listen to music, to dance and to play a ball game. An open visiting policy is in place whereby visitors to the home can visit at any reasonable time. There was evidence throughout the day of the site visit that people who live at Ashbrook Court are supported and enabled to maintain contact with friends and family. There is a rolling 4 week menu within the home providing people with a varied choice of meals each day. The dining experience for people was observed by us within 2 units and in general terms was seen to be positive. We observed that no menus depicting the meal choices available on the day of the site visit were visible. From our observations it was apparent that some people had difficulty remembering the meal options available and staff were observed to not remind people of the choices. When asked as to what was available people stated, I have no idea at all-there is a menu, but I never look at it and I havent got a clue mate-nobody tells me. This was highlighted at the last key inspection. In addition to the 2 main choices, alternatives to the menu were readily available. People are given the option of having their meal in the dining room, in the lounge or in the comfort of their own room. Dining tables were attractively laid with tablecloths, cutlery, placemats and serviettes. Although there was a choice of drinks available, not all people were given a choice and no condiments were placed on the tables. The latter was highlighted at the last inspection. One person spoken with confirmed that if there had been salt and pepper on the table, they would of used these. Meals provided to people were observed to be attractively presented and in sufficient quantity. Where people require assistance from staff to eat their meal, support was observed to meet individuals care needs. Where people require verbal encouragement to eat their meal this was provided and people were not hurried to eat their meal. However we observed a member of staff tearing up Care Homes for Older People Page 19 of 34 Evidence: some bacon for a resident with their fingers and we saw a member of staff blow on the food for one person on several occasions before offering to the person to eat. This is unacceptable practice with regard to peoples dignity and protection from the spread of infection. As stated at the previous key inspection to the home, we observed that people are brought into the dining room some considerable time prior to the meals being served and that some people find this wait too long and can become restless. People spoken with were positive about the quality of meals provided and comments included, yes its very nice, its lovely and yeah, its not bad I have no complaints, if I dont like it I leave it. People were also given the option to have wine with their meal and found this to be positive. Care Homes for Older People Page 20 of 34 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. People can expect their concerns to be listened to and dealt with appropriately and that they will be safeguarded by staffs knowledge and supporting policies and procedures. Evidence: There is a complaints policy and procedure in place and this is clearly displayed within the main reception area of the home. The business manager was advised that this should also include/make reference to the local Primary Care Trusts involved at Ashbrook Court. From inspection of the homes complaint records and confirmed by the AQAA, over the past 12 months, the home has received 11 complaints. Records showed that these have related to issues pertaining to laundry, cleanliness of the home, unexplained bruises for 2 people, lack of staff on the first floor units and medication found in a chair. Records showed that a record had been kept depicting the details of the complaint made, details of any investigation, action taken and outcomes. People spoken with confirmed that they know how to make a complaint and to who, however it is apparent that people are more confident about some members of staff dealing with their concerns and/or issues raised than others. Since the last key inspection, there have been 3 safeguarding issues raised of which we are fully aware. These relate to alleged poor care practices by agency staff/staff and concerns relating to one persons pressure area care. There was evidence to show Care Homes for Older People Page 21 of 34 Evidence: that the organisation had undertaken appropriate measures and the relevant external agencies notified. At the time of the site visit, the outcome of each safeguarding issue was unknown, however further meetings with the Local Authority were planned. Safeguarding policies and procedures are readily available and staff spoken with were able to demonstrate a basic understanding and awareness of safeguarding procedures. Staff spoken with confirmed that they had received safeguarding training. The training matrix provided to us showed that the majority of staff have received up to date safeguarding training. Care Homes for Older People Page 22 of 34 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. People can expect to live in a safe, comfortable and homely environment which meets their needs. Evidence: A partial tour of the premises was undertaken by us throughout the day. The home is divided into 3 separate units (residential, nursing and nursing for those people who have a formal diagnosis of dementia). Each person is provided with a single room which has en-suite facilities. Of those rooms inspected, all were observed to be individualised and personalised with many personal items on display. People spoken with confirmed that they like their room. Each unit has sufficient communal space (lounge and dining areas for peoples use) and the home was observed to be clean and tidy. Some odours of urine were noted during the morning, however by the afternoon these were not present. There are 3 courtyard garden areas, which are well maintained and accessible for peoples use. The AQAA details that since the last key inspection improvements to the home environment have included replacement flooring in some peoples rooms, refurbishment programme to replace some items of furniture has commenced and new tableware has been purchased for dining rooms. As stated at the previous key inspection to the home, there is some signage around the home however this needs to Care Homes for Older People Page 23 of 34 Evidence: be improved so as to aid orientation for people who have poor cognitive ability and/or dementia. The AQAA details that within the next 12 months to improve signage within the home so as to assist those people with dementia and to remove patterned carpets and replace them with plain carpets. In addition it is envisaged that new pictures and photographs will be purchased and rummage boxes will be devised and completed to provide sensory stimulation to people living in the care home. We were advised that as a result of the maintenance person being suspended and this being managed under the homes disciplinary processes, maintenance cover is currently being provided from a sister home of the organisation for urgent issues. A random sample of safety and maintenance certificates showed that equipment in the home has been serviced and remains in date until their next examination. The home has a fire safety risk assessment in place and all other fire safety records were seen to be in order. Care Homes for Older People Page 24 of 34 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People cannot be assured that there will always be sufficient staff on duty to meet their needs. However, people can be assured that staff are trained in core areas and protected by the homes recruitment policies and procedures which are implemented and followed. Evidence: At the time of the site visit there were 67 people living at Ashbrook Court. We were advised by the business manager that staffing levels are 1 RGN and 4 care staff (Nursing Unit), 2 care staff (Residential Unit) and 1 RGN and 5 care staff (Nursing/Dementia Unit) during the day and at night there are1 RGN and 5 waking night staff. In addition to the above there are catering and domestic staff and a full time administrator. The managers hours are supernumerary to the above. On inspection of 4 weeks staff rosters, these showed that staffing levels as detailed above have not always been maintained. We have not received Regulation 37 notifications advising us of the staffing shortfall and measures undertaken to deploy staff to the home. Rosters were observed to be clear and identified cover by bank and/or agency staff, however the full names of staff were not always recorded. We were advised by the business manager that currently there are only 3 full time qualified nurses employed at Ashbrook Court, with the remainder of qualified staff Care Homes for Older People Page 25 of 34 Evidence: being used from an external agency. We were also advised there are currently no care staff vacancies as there has been a recent successful recruitment drive. The AQAA details our staffing ratio is in line with CSCI (previous regulatory body) guidelines and is sufficient to meet the needs of our residents. It is unclear as to how the rationale for the above staffing levels has been calculated based on peoples dependency levels and other contributing factors e.g. layout of the premises, staff skills, variations throughout the day etc. The Care Quality Commission have no specific guidelines for care homes depicting staffing levels to be in place at a care home, however it is the responsibility of the organisation to ensure that there are sufficient staff on duty on any given shift for the needs and numbers of people within the home. The staff files for 3 people who had been newly employed since the last key inspection were examined. Records showed that all records as required by regulation had been sought. Evidence of induction was available for the staff members case tracked and this was seen to be comprehensive and in line with Skills for Care. Profiles and/or a letter for agency staff were requested to confirm evidence that all recruitment checks have been undertaken by the external agency and that agency staff working within the care home have been robustly recruited, however no evidence was available at the time of the site visit. Agency staff spoken with confirmed that they are given a tour of the premises, shown fire exits and introduced to staff and residents on the unit where they are to work however this is not always formally recorded. A copy of the staff training matrix was provided at the time of the site visit. This shows that all staff have up to date training in core subject areas e.g. manual handling, health and safety, fire safety awareness, safeguarding, food hygiene and infection control. Since the last key inspection some staff have received training pertaining to dementia awareness, death and dying, COSHH (Control of Substances Hazardous to Health), care planning, Mental Capacity Act and first aid. We advised the business manager that consideration must also be undertaken for staff training, specifically relating to those conditions associated with the needs of older people e.g. diabetes, nutritional awareness for older people , falls management, Parkinsons disease, sensory impairment, continence awareness and pressure area care. The training matrix showed that not all staff have received dementia awareness training or training to deal with people who are challenging and/or resistant to care, yet the home is registered to admit people who have a formal diagnosis of dementia. The AQAA details that 12 members of staff have NVQ Level 2 or above. Care Homes for Older People Page 26 of 34 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is generally well run however shortfalls identified could potentially affect positive outcomes for people who live there. Evidence: On the day of inspection the manager was on annual leave. We were advised by the business manager that the manager had been on leave from 2nd June 2009 and was not anticipated to return to Ashbrook Court until 2nd July 2009. Following discussions with the business manager, she confirmed that the organisation had failed to write to us to advise that the manager would be absent from the care home for a continuous period of 28 days. We were assured that measures were undertaken by the organisation to appoint an interim manager to manage the care home during this period. The interim manager is the manager for a sister home of the organisation and is supporting the home on a day to day basis. We were officially notified in writing following the inspection that the manager will not Care Homes for Older People Page 27 of 34 Evidence: be returning to Ashbrook Court and that the reported interim management arrangements will continue. In addition to this the business manager is to spend a minimum of 3 days a week at the home, assisting with implementing action plans to meet requirements identified by us, Essex Social Services and the organisation. An additional registered manager is on call in an advisory clinical role, additional administrative support has been provided and an additional RGN is on duty who is supernumerary. Feedback of the inspection findings were provided to the interim manager and the business manager and included areas of good practice and identified shortfalls. The business manager confirmed that where shortfalls were identified, some of these had already been picked up by the organisation and a plan of action was already in the process of being formalised and implemented so as to deliver the best outcomes for people living at Ashbrook Court. All sections of the AQAA were completed and the document returned to us when requested. Information recorded is satisfactory in some areas however in some cases there is little evidence to support the claims made within it and the AQAA does not provide us with a reliable picture of the service. The care home does not manage peoples monies on their behalf. It is the expectation that people will manage their own financial affairs or have a relative and/or appointee. We were advised that the organisation commissioned a quality assurance visit and report to be completed by an external consultancy agency in November and December 2008, which incorporated the Care Quality Commissions outcome groups. The report highlighted areas of good practice and areas which required further development. We also looked at the homes quality assurance surveys, whereby the views of residents and their representatives had been sought in January 2009. In general terms comments were mostly positive and confirm that people living at Ashbrook Court are happy with the care and support provided. Comments included, staff provide good care and service, good care is given to me and they have always been very kind and thoughtful. In addition to the quality assurance surveys, the organisation monitor the quality of the service through regular monthly visits by the business manager. We were advised by the business manager that it is the organisations policy and expectation that all staff will have 2 appraisals and 4 recorded supervisions annually. We were advised that annual appraisals should have been completed between January and April 2009, however she confirmed that these had not been undertaken. A random sample of staff supervision records were examined and these showed that although there is a standard format in place, the quality of the information recorded is poor and Care Homes for Older People Page 28 of 34 Evidence: in some instances one observation of practice is being recorded as a formal supervision. This was discussed with both the business manager and the interim manager at the time of the site visit and both confirmed that further development is required to ensure that supervision covers all aspects of practice, philosophy of care in the care home, work performance, identified training needs, clinical support (where appropriate) and is recorded in sufficient detail to evidence actual discussions between parties, outcomes and actions. Records also showed that the frequency of supervisions has not been in line with National Minimum Standards recommendations. Resident accident records were inspected and these showed that recording of accidents were well documented and audits are undertaken so as to monitor the number of accidents/incidents in the care home and to look at any common trends and/or themes. There is a health and safety policy and procedure in the home and all staff have up to date training. Care Homes for Older People Page 29 of 34 Are there any outstanding requirements from the last inspection? Yes R No £ 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 1 7 15(1) Care planning at the home 01/09/2009 must identify, and be effective in meeting all residents assessed needs and ensure that these are regularly updated/reviewed to reflect the most up to date information. Previous timescale of 1/10/2008 not met. So as to ensure that staff have the information they need to deliver good care. 2 7 13(4) Risk assessments must be devised for all areas of assessed risk. Previous timescale of 8/9/2008 not met. So that risks to residents can be minimised. 01/08/2009 3 9 13(2)12(1)(a) People must be protected 26/06/2009 from harm by having their medication administered safely and in accordance with the prescribers instructions. Previous timescale of 14/7/2008 not met. So as to ensure peoples safety and wellbeing. Care Homes for Older People Page 30 of 34 4 30 18(1)I and (i) Ensure that staff, receive appropriate training to the work they perform. This refers specifically to those conditions associated with the needs of older people. Previous timescale of 1/11/2008 not met. This will ensure that staff, have the competence, confidence and ability to meet resident?s care needs. 01/11/2009 5 36 18(2) Ensure that staff, receive regular supervision. Previous timescale of 14/7/2008 not met. So that staff feel supported and residents know that staff are appropriately managed. 01/09/2009 Care Homes for Older People Page 31 of 34 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 1 9 13 Ensure that the timing of the 28/06/2009 administration of medication throughout the day to people who live at the care home is appropriate. So as to ensure that medication is received in a timely manner and that peoples wellbeing is maintained. 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 9 13 Ensure that when medication is not administered to people, records clearly record this, the rationale why they are not and any action taken to address the above. This is to ensure a clear audit trail and to ensure peoples health and welfare. 06/07/2009 2 9 13 Ensure that medication is not left unattended and easily accessible to people who live at the care home. So as to ensure their safety and wellbeing. 26/06/2009 Care Homes for Older People Page 32 of 34 3 12 16 All people who live at the 01/09/2009 care home must be given the opportunity to engage in a varied programme of activities. This refers specifically to those people who have poor cognitive ability and/or dementia. So as to ensure that people are enabled to maximise their potential. 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 improving their service. No. Refer to Standard Good Practice Recommendations 1 9 Hand written MAR records should be double signed, so as to ensure that the information recorded is accurate. Ensure that a menu depicting the meal choices for the day are visible for people living at the care home and people are reminded by staff as to the choices available. 2 15 Care Homes for Older People Page 33 of 34 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. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. 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