Inspection on 19/05/05 for Ashby Court Nursing Home

This inspection was carried out on 19th May 2005.

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

Ashby Court Nursing Home 24/05/07

Ashby Court Nursing Home 08/06/06

Ashby Court Nursing Home 07/11/05

Ashby Court Nursing Home 08/12/04

Ashby Court Nursing Home 19/07/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Ashby Court Nursing Home Ashby Avenue Hartsholme Lincoln LN6 0ED Lead Inspector Wendy Taylor Unannounced 19th May 2005 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 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. Ashby Court Nursing Home C53 C04 S2529 Ashby Court V220050 190505 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Ashby Court Nursing Home Address Ashby Avenue Hartsholme Lincoln LN6 0ED 01522 695458 01522 696252 N/A Lace Housing Limited Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Cathy Trevor Care Home 41 Category(ies) of Old Age (OP) - 41 registration, with number of places Ashby Court Nursing Home C53 C04 S2529 Ashby Court V220050 190505 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: The home is registered to provide personal care with nursing for service users of both sexes whose primary needs fall within the following category:Old Age, not falling within any other category (OP) (41) Date of last inspection 8 December 2004 Brief Description of the Service: Ashby Court is registered to provide nursing care and personal care to persons over the age of 65years. The property is purpose built and was originally designed for warden controlled accommodation. It is situated in a residential area close to Hartsholme Park, local facilities of shops and post office are approximately 270 metres away. The city centre of Lincoln is approximately 34 miles away. There is also a day centre attached to the home and service users are able to access the facilities if they choose, these include, a library, shop and hairdressing salon.The home is owned by L.A.C.E housing association which is a non-profit making organisation providing housing and care services for older people.Accommodation is provided in mainly single flats, which comprise of a sitting room, bedroom, kitchenette, shower and toilet. Two double flats are also available. Accommodation is available on two floors, first floor rooms are accessed via a shaft lift. There are also two communal lounges and a dining room. Ashby Court Nursing Home C53 C04 S2529 Ashby Court V220050 190505 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place in May 2005. There were no outstanding requirements from the previous inspection and actions had been taken in regard to most of the recommendations. A tour of the building took place and residents and staff files were looked at. Policies, procedures and general records were also seen. Seven residents, two relatives and three members of staff were spoken to. Observations of the care provided and general interaction between staff and residents took place throughout the inspection. Residents said that staff are very good to them although there are more specific comments recorded in the body of this report. What the service does well: What has improved since the last inspection? What they could do better: The residents would benefit from increased opportunity to go on outings of their choice, with the home recording the opportunities offered and whether the residents accepted the offer. The home could also demonstrate that they take resident’s views into account when monitoring and reviewing staffing levels. Ashby Court Nursing Home C53 C04 S2529 Ashby Court V220050 190505 stage 4.doc Version 1.30 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ashby Court Nursing Home C53 C04 S2529 Ashby Court V220050 190505 stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Ashby Court Nursing Home C53 C04 S2529 Ashby Court V220050 190505 stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,34, Residents are only admitted after a full care needs assessment has been carried out. They and their relatives/representatives benefit from access to a wide range of information about the home. EVIDENCE: The home has a comprehensive statement of purpose and service user guide that were available on the day of inspection. The service user guide contained clear admission criteria and a description of the process. Individual resident’s files contained clear admission assessments and there was evidence that the residents and /or their representatives are involved in the process. Terms and conditions were also seen on individual files. Ashby Court Nursing Home C53 C04 S2529 Ashby Court V220050 190505 stage 4.doc Version 1.30 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 - 10 Resident’s benefit from clear and consistent care planning, which allows the home to show that health needs are fully met. The home promotes choice and independence for residents EVIDENCE: Five residents files were looked at. The files were well laid out and consistent in format. Care plans were in accordance with the needs assessments and there was evidence of monthly reviews. Care plans and review sheets were signed by residents and/or their relatives. Information sheets were available about specific treatments or equipment such as nebulisers. Care plans also include records of professional visits such as GP or District nurses, weight charts and body maps, which are consistently completed. Key workers are clearly identified in care files and there was evidence that residents are given the opportunity to choose their own key worker if they wish. Risk assessments were available on files e.g. use of equipment, use of kettles, use of electric wheelchairs. Accident reports were kept on individual files and records demonstrate that procedures are followed. There has been one admission to a local Accident and Emergency Department and again records were satisfactory. All resident’s records were stored securely. Ashby Court Nursing Home C53 C04 S2529 Ashby Court V220050 190505 stage 4.doc Version 1.30 Page 10 There is a comprehensive medication policy, and self-medication assessments were seen on individual files. The assessments were signed by the individual resident and lockable storage areas are available to them. All other medication records and storage were satisfactory. One resident said that night staff could be more respectful in their approach to her for example she feels rushed when being supported with personal needs. The manager is aware of this issue and is working towards resolving it (see ‘Staffing’ section of this report for further information). Ashby Court Nursing Home C53 C04 S2529 Ashby Court V220050 190505 stage 4.doc Version 1.30 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 - 15 The home provides a programme of social and leisure activities that is developed in consultation with the residents. Residents would benefit from the opportunity to have more outings of their choice. Dietary needs are met and records enable monitoring of intake. Resident’s benefit from a wide choice of food. EVIDENCE: Staff were observed to welcome visitors throughout the inspection. Residents have access to an on-site day service, hairdressers and a shop. Several residents said that they don’t get out of the home enough, but they do have a range of in house entertainment and activity which they are consulted about. The manager said that outings have been arranged but often residents will change their minds about going on the day. One resident said that she chooses not to join in activities. Daily routines were recorded in individual files. There was evidence that residents are supported to use their voting rights and that they have resident’s meetings at least every 6 to 8 weeks. Minutes were seen and demonstrated that residents are encouraged to express their views and make clear choices. The Responsible Individual attends resident and relatives meetings once a year. Ashby Court Nursing Home C53 C04 S2529 Ashby Court V220050 190505 stage 4.doc Version 1.30 Page 12 All residents spoken to say that they have a choice of meals from a menu, and alternatives are available if those choices are not suitable. They said that snacks are available throughout the day if they ask for them. They said that the food was well cooked and that the portions were good. Individual dietary requirements are recorded and kept in the kitchen area and a record of what individuals have eaten is kept in individual files. Ashby Court Nursing Home C53 C04 S2529 Ashby Court V220050 190505 stage 4.doc Version 1.30 Page 13 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 - 18 Resident’s benefit from robust complaints and adult protection procedures. They also benefit from the staff team’s knowledge and awareness of the policies and procedures. EVIDENCE: The home has a complaints and an adult protection policy. The complaints policy still refers to National Care Standards Commission. There has been one complaint received by the home since the last inspection, which was responded to in accordance with the policy, and appropriate action was taken. There have been no reports of adult protection issues and staff demonstrated a good working knowledge of the protection procedures. There was evidence that staff receive training in this area. Residents and relatives said that they would feel happy to raise any concerns or issues with the staff or the manager. Ashby Court Nursing Home C53 C04 S2529 Ashby Court V220050 190505 stage 4.doc Version 1.30 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,22,23,24,25,26 The home provides a comfortable and homely environment. Resident’s benefit from the availability of specialist equipment and risk assessments to ensure suitability and safer practice. The home maintains a good standard of cleanliness and encourages residents to personalise their bedrooms. EVIDENCE: The home was clean, tidy and generally well maintained. There were bare patches on some walls where telephones had been removed. The manager said that this work is planned within the redecoration schedule for the home. A new door entry system has recently been installed. Communal areas were seen to be comfortably furnished. Residents said that they liked their own rooms and found them comfortable, and they were able to personalise them. There is a range of specialist hoists and bathing equipment available, which had been serviced in March 2005. One hoist was awaiting repair on the day of the inspection. Individual care plans contain risk assessments for the use of equipment. Ashby Court Nursing Home C53 C04 S2529 Ashby Court V220050 190505 stage 4.doc Version 1.30 Page 15 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 - 30 Residents are protected by robust recruitment practices. They benefit from a staff team who are knowledgeable about their daily needs and who receive appropriate training and support. The home needs to take account of resident’s views in relation to staffing levels. EVIDENCE: Staff files contain CRB checks, identification, references and application forms. Staff said that they have training in moving and handling, fire safety, adult protection, and they have access to NVQ level 2 and 3 courses. Records confirmed this and showed that training also includes catheter care, palliative care, diabetes care, infection control and care planning. Staff also said that they received regular supervision, which again was confirmed by records. Staff demonstrated a clear understanding of their roles and responsibilities and said that they are allocated work areas at the beginning of each shift. They demonstrated a good understanding of residents needs. They said that they receive good support from the manager of the home and that she is approachable. They said there is a good atmosphere among the team and colleagues are very supportive. Residents said that staff were often very busy but they are able to meet their needs, they said that staff rush around but they do their jobs well. Staff said that they can be very busy in the mornings especially, but this depends on the needs of the residents. Duty rotas demonstrate that there are six staff per day Ashby Court Nursing Home C53 C04 S2529 Ashby Court V220050 190505 stage 4.doc Version 1.30 Page 16 shift and four staff at night. Staff were observed to be taking time to talk to residents whilst carrying out tasks, and they were interacting in a respectful manner. They were seen to maintain individual privacy and dignity when attending to personal care needs. Ashby Court Nursing Home C53 C04 S2529 Ashby Court V220050 190505 stage 4.doc Version 1.30 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 - 38 Records are generally well maintained and show that the resident’s health, safety and welfare needs are promoted. Some records need to be kept up to date. The home ensures that the residents have the opportunity to voice their views and opinions. EVIDENCE: There are a range of policies and procedures available in the home such as fire safety, Control of Substances Hazardous to Health, Infection Control, Adult Protection and Health and Safety. Fire risk assessments were available and there was evidence of regular fire alarm checks, fire drills and emergency lighting checks. The gas safety certificate, boiler service records, chlorination records and water temperature checks were also seen, although water temperature checks had not been recorded for the past two months. The home has thermostatically controlled taps. The home has an annual property inspection. Ashby Court Nursing Home C53 C04 S2529 Ashby Court V220050 190505 stage 4.doc Version 1.30 Page 18 Where it is agreed that the home will support a resident with their personal money, an agreement/care plan is completed and signed by the resident or their representative, evidence of this was seen on resident’s files. The home has a policy relating to resident’s finances. The home conducts resident and relatives satisfaction surveys. The next one is to be carried out in June 2005. Ashby Court Nursing Home C53 C04 S2529 Ashby Court V220050 190505 stage 4.doc Version 1.30 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 x 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 x x 3 3 3 3 3 3 Ashby Court Nursing Home C53 C04 S2529 Ashby Court V220050 190505 stage 4.doc Version 1.30 Page 20 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard 12 37 16 Good Practice Recommendations It is recommended that the home record when outings have been offered to residents and whether or not the residents have chosen to go.. It is recommended that the home maintains records of regular water temperature checks. It is recommended that the home change its reference within their complaints policy from National Care Standards Commission to Commission for Social Care Inspection. Ashby Court Nursing Home C53 C04 S2529 Ashby Court V220050 190505 stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection Unity House, The Point Weaver Road Off Whisby Road Lincoln, LN6 3QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ashby Court Nursing Home C53 C04 S2529 Ashby Court V220050 190505 stage 4.doc Version 1.30 Page 22 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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