Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 05/04/06 for Ashby Court Nursing Home

Also see our care home review for Ashby Court Nursing Home for more information

This inspection was carried out on 5th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The service has a thorough assessment process that enables staff to establish the needs and preferences of residents. All residents tracked were able to relate to their involvement in assessment. Staff spoken with and observed demonstrated a good understanding of the needs of residents accommodated. Residents and relatives were positive about the home`s management approach and felt included and supported. Residents views are obtained by meetings and twice yearly surveys. The home has a culturally diverse staff group. Staff spoken with indicated that they felt valued and supported. The home is an approved centre for the adaptation of internationally recruited nurses. (Nursing and Midwifery Council) The home provides specialist care based on current research this includes the "Liverpool Care Pathways" and " Gold Standards Framework" this enables residents to have a " Good Death and is part of the Government`s End of Life Programme. Staff have received recent training and this was evidenced in records. The food provided is of an excellent standard; residents described it as hotel standard and available at flexible times. The chef has received awards for his cooking and for going the extra mile with providing buffets, parties and special cakes etc.

What has improved since the last inspection?

The home has commenced use of the " Gold Standards Framework" and staff have received training. This ensures that staff are able to offer appropriate care based on recent guidance, this ensures that care is managed appropriately at the time of death. BUPA have developed a new Basic Infection Control distance learning programme which was due to be rolled out to staff in the next few months, a copy of the programme was seen and is written in a format which is suitable for all levels of staff.

What the care home could do better:

Although improving, some areas of medication management still required further improvement, this included administration of medicines prescribed to an individual resident which was being administered to a group of residents, also improvements were required in relation to the record keeping of residents who were self medicating. Discussion with staff identified lack of knowledge in relation to " the Social Model of Disability"

CARE HOMES FOR OLDER PEOPLE Ashby Court Nursing Home Tamworth Road Ashby de la Zouch Leicestershire LE65 2PX Lead Inspector Mrs Gillian Adkin Unannounced Inspection 5th April 2006 09:30 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 Ashby Court Nursing Home DS0000001884.V285358.R01.S.doc Version 5.1 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. Ashby Court Nursing Home DS0000001884.V285358.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Ashby Court Nursing Home Address Tamworth Road Ashby de la Zouch Leicestershire LE65 2PX 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) 01530 560105 01530 560173 BUPA Care Homes (BNH) Limited Mrs Ruth Coales Care Home 60 Category(ies) of Old age, not falling within any other category registration, with number (60), Physical disability over 65 years of age of places (60), Terminally ill over 65 years of age (60) Ashby Court Nursing Home DS0000001884.V285358.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. V13707 To admit the person of category PD, named specifically in variation application V13707 dated 04 November 2004, who is under 65 years of age. V29138 To admit the person, named specifically in variation application V29138 dated 27 January 2006, who is under 65 years of age. 1st December 2005 2. Date of last inspection Brief Description of the Service: Ashby Court is a care home providing nursing care for up to 60 older people. The home is situated on the outskirts of Ashby in a residential area and is purpose built. It is easily accessed by public transport. The home provides residential and nursing care for sixty service users whose care needs fall within the categories of Older Persons and or Physical Disability over 65 years of age and terminal illness over 65 years of age. Accommodation is on two floors and can be accessed via a passenger lift. There is a choice of lounge/dining areas and all private rooms are with en suite facilities. The ground floor has spacious lounge and dining areas and the dining room opens out into the patio, which has been developed by the staff to include a herb and sensory garden. The home has fifty-four single bedrooms and three double bedrooms. All of the bedrooms are en-suite. The home employs registered nurses and care staff. Close to the home is a large shopping centre and a number of pubs and restaurants. The current range of fees charged by the home are: Residential = £595. Nursing = £695 dependant on care required. Ashby Court Nursing Home DS0000001884.V285358.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The service was inspected against the Regulations as in the Care Standards Act 2000. This was an unannounced inspection, which took place over one day and commenced at 09.30 am on 06/04/06.The inspection took 9.0 hours. The registered manager assisted the inspector. The focus of inspections is upon outcomes for residents living at the home and obtaining their views of the service provided. This process considers whether the home meets the National Minimum Standards and highlights areas, which might need further development. The method of inspection used is called “case tracking’ which involved selecting three service users’ and tracking the care they received by discussion with them and looking at associated records. During this inspection a tour of the rooms occupied by those case tracked and associated communal areas took place and the inspector viewed internal records, and care plans. The inspector spoke to service users’, nurses and a physiotherapist assistant from the Intermediate care team. Four care staff the chef; ancillary staff and a student nurse also took part in discussions with the inspector. Minimal relatives were available during this inspection for comments, however the inspector spoke with one relative over the telephone. There were 48 residents accommodated at the time of this inspection. Typical comments included: “Activities provided offer plenty of choice and are suitable for me, staff inform us of the days activities to see if we are interested” “Staff usually respond to requests for help in a timely way” “I see the physio and chiropodist regularly” “I have never had to complain since I have been here” “There is normally enough staff on duty” “Rooms are very comfortable and warm, my relative is very happy here” “The staff are very patient and very kind” “The meals are very good” “Staff always maintain my dignity, I have never been embarrassed” “The home is like a hotel” “ We are given choices about meals and there is some flexibility about timing” “ Residents are invited to meetings where they can raise any issues with the manager” “ My relatives complaint was dealt with satisfactorily and she felt able to go through the process independently” “ I was able to choose my room which suited me as its position is close to the toilets and lift etc” Ashby Court Nursing Home DS0000001884.V285358.R01.S.doc Version 5.1 Page 6 Typical staff comments included: “I am in the process of developing a food identity board so that food is recognisable for those with sensory difficulties. I am trialing a new plate for those with dexterity problems and to prevent staff mashing food into one as it has separated areas”. “As part of the activities programme I have been involved in baking cakes with the residents”. “Chef said that we hold birthday parties and buffets at christmas and easter etc. (says the parties are legendary and that relatives are invited to attend)we also provides funeral teas for familys where required” “We offer a cooked breakfast each day and residents and relatives are asked for ideas” “ We have had training in Control of substances hazardous to health” “ We have had training in medication” “There are no difficulties in understanding or being understood” “ The same training opportunities are afforded to us as other staff” “ We are supervised throughout our adaptation programme by a mentor RN” What the service does well: The service has a thorough assessment process that enables staff to establish the needs and preferences of residents. All residents tracked were able to relate to their involvement in assessment. Staff spoken with and observed demonstrated a good understanding of the needs of residents accommodated. Residents and relatives were positive about the home’s management approach and felt included and supported. Residents views are obtained by meetings and twice yearly surveys. The home has a culturally diverse staff group. Staff spoken with indicated that they felt valued and supported. The home is an approved centre for the adaptation of internationally recruited nurses. (Nursing and Midwifery Council) The home provides specialist care based on current research this includes the “Liverpool Care Pathways” and “ Gold Standards Framework” this enables Ashby Court Nursing Home DS0000001884.V285358.R01.S.doc Version 5.1 Page 7 residents to have a “ Good Death and is part of the Government’s End of Life Programme. Staff have received recent training and this was evidenced in records. The food provided is of an excellent standard; residents described it as hotel standard and available at flexible times. The chef has received awards for his cooking and for going the extra mile with providing buffets, parties and special cakes etc. What has improved since the last inspection? What they could do better: 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 DS0000001884.V285358.R01.S.doc Version 5.1 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 Ashby Court Nursing Home DS0000001884.V285358.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3.6 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to the service. The assessment process is good and involves residents/relatives and professionals. EVIDENCE: The inspector case tracked a newly admitted respite resident to establish how robust the process was and if the process met with the policy and procedure which was supplied.A resident confirmed his full involvement in the assessment which was undertaken by the manager. The inspector held a discussion with all three tracked residents about their experiences of pre admission assessment and their involvement in this. She also asked questions about what information was given to them before their admission to the home.Two out of three were aware of the service user guide and said they had enough information. The inspector case tracked a resident admitted under variation for rehabilitation to test the care plan and care privided.She also held a discusion Ashby Court Nursing Home DS0000001884.V285358.R01.S.doc Version 5.1 Page 10 with a member of the Intermediate Care team responsible for physiotherapy of the resident.Planned care was being delivered according to the assessment.A Discussion took place with a service user and the physotherapy assistant in relation to their progress and experiences of living in the home.It is recommended that was stated that the home had helped her to become more enabled since she had been admitted. The inspector read the admission and care planning policy prior to the above discusssion,One resident could not recall being involved in his care plan or any evaluations. Ashby Court Nursing Home DS0000001884.V285358.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7.8.9.10.11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Care planning processes overall are good and identify individual needs but do not always involve consultation with the resident.Outcomes for service users would be improved by more frequent evaluation of risk assessments. Medication mangement is adequate but administration of some medicines does not meet with BUPA policy and procedure and inaccurate documentation has the potential to place self medicating residents at risk. EVIDENCE: Discussion was observed between the manager and deputy regarding management of two residents with infections. The inspector examined three care plans,and associated daily records.Care plans seen were reflective of assessed needs and demonstrated ongoing assessment, and current good practise guidelines. A risk assessment in one care plan was not updated or reflective of the measures in place to reduce the identified risk.An improvement plan was received from the manager to detail how this would be improved. Ashby Court Nursing Home DS0000001884.V285358.R01.S.doc Version 5.1 Page 12 A group discussion took place with three trained staff and one trained care assistant plus a student nurse about management of medication and medication policy. Observation of medication records indicated that three residents tracked one of whom self medicated were overall managed well and signed for appropriately,however discussion with staff indicated that some liquid medicines that were prescribed for individuals were being used for more than one resident and that medicines given to another resident (who was self administering) were not fully accounted for on record sheets.Discussion took place between the manager, inspector and staff to clarify BUPA policy and good practise expectations regarding record keeping.Recommendations were made that staff responsible for administration of medicines re-read the policy. Discussion took place with a resident about self medication management and storage.The resident was fully aware of the homes system and risk assessment.The resident said he was “able to administer his own medication safely”. Observation of minutes of trained staff meeting evidenced that the home have been nominated as a home who will implement the Gold Standards Framework process which is part of the Governements initiative the End of Life Programme enabling people to have good death staff were questioned about the needs of residents tracked,responses received were appropriate and reflected information in the tracked care plans. Discussions took place with staff including those from minority ethic backgrounds and those from Eastern European Countries about diversity and the type of residents they may be required to care for.A member of staff stated that diversity was covered during induction and NVQ training. Ashby Court Nursing Home DS0000001884.V285358.R01.S.doc Version 5.1 Page 13 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 the following standard(s): Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to the service. Residents enjoy flexible routines,excellent quality meals and opportunities to be involved in menu planning. The activities provided are planned and varied. EVIDENCE: Discussion with the chef regarding management of cultural needs identified that there were no specific cultural needs presently in terms of meals or menus,although he stated that he has provided haggis for a Scottish resident and also cooks staff meals which include curries etc. These are also included on menus for those residents who enjoy them. Themed nights include Burns night,St Andrews night etc. Discussion with the chef identified that the home are currently trialing larger handled cups and high lipped plates which are individually portioned to aid those with sensory impairment or physical difficulties. Discussion with residents and observation of meeting minutes confirmed their involvement in menu planning. It was confirmed by the chef that relatives of residents are invited to hold post funeral teas at the home as part of the dying process and to allow the family to spend time arranging other aspects of the funeral. Ashby Court Nursing Home DS0000001884.V285358.R01.S.doc Version 5.1 Page 14 Minutes of residents meeting identified that the chef attends residents/relatives meetings and invites suggestions from them for meals and recipes etc. Discussion with a resident confirmed that there is flexibility in meal arrangements and routines.Discussion with the chef identified that a salad had been saved for a resident who did not want to eat at the planned time. Evidence was provided of an activities programme which has been put together by the registered manager and co-ordinator the programme includes both internal avtivities,excursions and entertainers.Evidence was seen of action taken by the manager to develop the programme. Evidence was seen of a training session attended by the activities organiser to improve her skills when planning activities.Further evidence was found of supervision and ongoing monitoring of the organiser by the registered manager . Evidence was seen on the notice board of a number of thank you letters from past relatives Ashby Court Nursing Home DS0000001884.V285358.R01.S.doc Version 5.1 Page 15 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 the following standard(s): Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to the service. Complaints management is good and managed in accordance with policy. An adult protection procedure is in place and staff are confident in responding to suspicion or allegation of abuse, residents complaints are taken seriously and they are protected from abuse. EVIDENCE: The Complaints book was inspected and there was evidence of two outstanding complaints. Further evidence was found of the successful conclusion of one complaint. The complaints procedure was displayed in the foyer and in service user guides in rooms. A discussion was held with a resident and their relative (phone call) to ascertain if they were happy with the management and outcome of their complaint, both stated, yes Observation took place of staff approach, manner, and body language with residents whilst working. The Inspector observed that staff were respectful and approached residents in an appropriate way. Staff training and recruitment records were analysed and evidence was found of a robust induction programme, which includes protection of vulnerable adults. Ashby Court Nursing Home DS0000001884.V285358.R01.S.doc Version 5.1 Page 16 Staff training records seen evidenced that approximately 50 of staff had received POVA training. Discussion with three residents indicated that although not fully aware of the formal complaints process they were able to advocate independently and stated they would speak with the manager or her deputy, both of whom were described as visible and approachable. Ashby Court Nursing Home DS0000001884.V285358.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19.21.22.24.26 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to the service. Service users live in safe, comfortable and homely surroundings with their possessions around them, Good provision is made regardng bathing and toileting facilities to meet individual needs. EVIDENCE: A tour of the home demonstrated that all areas were clean and hygienic and external areas, observed appeared to be well maintained. One toilet on the top floor was out of order, however further exploration and discussion with the registered manager indicated that this would not affect the outcome for any residents accommodated on this floor as all bedrooms are en-suite. A broken bath panel, which had been previously identified as requiring replacement on the top floor relaxation bathroom, had not been attended to. Plasterwork in bathroom 8.9.10 were in need of some attention as it was badly damaged by wheelchair footplates. The manager agreed to replace the bath panel immediately to reduce the risk to residents. Ashby Court Nursing Home DS0000001884.V285358.R01.S.doc Version 5.1 Page 18 Discussion took place with ancillary staff re :adequacy of numbers of domestic staff, training provided and equipment, staff stated that there was always adequate numbers of people employed to maintain a good standard of cleanliness in the home, although only two staff are employed at weekends a list of all rooms spring cleaned was shown to the inspector, staff said that all rooms are spring cleaned on a rotating cycle. Discussion with ancillary staff confirmed that they were using the recommended good practise guidelines for reducing infection for example micro fibre mops and cloths. A new trolley was seen which contained equipment, and cleaning materials. Staff described the system in operation for cleaning rooms and disposing of soiled mops and cloths etc, staff said they had received training in handling chemicals and were able to relate to use of Chemical products data sheets/information. The inspector discussed with 3 care staff their knowledge of infection control and the training they had received, discussion with them confirmed that they had received basic infection control training during induction and knew about the basic principles (universal precautions) Staff were unaware of the new distance learning programme which was due to be launched this month. The manager provided a workbook to the inspector for observation and use during discussion. The inspector observed ancillary staff dealing with clinical waste bins according to good practise recommendations (tied tops) yellow bags. Brief Discussion took place with the full-time maintenance person about how residents independently use lifts. Discussion with the residents tracked described how they had selected the rooms they occupied and related the position of rooms to their particular needs and specialist equipment required by them such as wheelchairs, specialist beds etc. Residents tracked described the individual pieces of furniture they had brought into the home with them. Residents room were clean, comfortable and homely and were laid out in positions which suited them, one resident said he had moved his bed to another position as it suited him better. A recent satisfaction survey was inspected and indicated that 85 of residents viewed their accommodation as excellent or very good. Maintenance records were not inspected on this occasion; these will be included during the next inspection period. Ashby Court Nursing Home DS0000001884.V285358.R01.S.doc Version 5.1 Page 19 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 at least once during a 12 month period. 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 the service. Good recruitment,induction,training and supervision processes ensure that adequate numbers of staff are employed who are suitable,well trained and safe to provide the care required by residents. EVIDENCE: Discussion with the registered manager about current staffing indicated that the staffing levels were the same as when fully occupied (at the time of this inspection the home was not full).The manager stated that there were three nurses on duty at all times and eleven care assistants in the morning and eight care assistants in the afternoon. A discussion with the manager and staff confirmed that staff were rotated between floors in order to establish continuity of care and sound overall knowledge of all residents needs. Adaptation nurses were involved in discussions with the inspector in relation to their roles and how they worked alongside and were supervised by existing qualified staff. Evidence was found in training records of the variety of skills that the staff group had,this was further evidenced by discussion with staff. Supervision records were inspected some of which highlighted the individual development goals of staff interviewed.All evidenced a thorough induction programme and probationary period. Ashby Court Nursing Home DS0000001884.V285358.R01.S.doc Version 5.1 Page 20 Discussion with residents tracked indicated that there was usually adequate staff on duty to meet their individual needs, one person tracked commented that staff sometimes have to alter the shower day if a member of staff is off sick,it was apparent through discussion however that this did not affect the overall outcome for this person. Staff training and supervision records inspected identified a wide variety of training which appeared to meet the diverse needs of those persons accomodated,it was evident however that a number of staff were not aware of the Social Model of Disability and barriers that disabled persons living in a care home might experience. Few staff were aware of the Mental Capacity Act and its relevance to the residents accomodated and their roles. As part of an improvement plan the manager agreed to address these training needs after this inspection. Three staff files were inspected all contained information as required in Schedule 2 of Regulation 19 (Care Standards Act 2000).The manager was required to provide evidence of a leave to remain document for a member of staff employed in the home.This document was forwarded to the Commission for Social Care Inspection for observation prior to this report being published. Ashby Court Nursing Home DS0000001884.V285358.R01.S.doc Version 5.1 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31.33.35.38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The manager provides good leadership and direction this ensures residents benefit from her ethos and positive approach. Residents live in a safe environment and are supported to maintain their own finances and air views this ensures the lifestyle experienced is positive and enabling. EVIDENCE: Policies and procedures were tested out with three residents tracked, one resident stated he had refused to sign a risk assessment for medication until his broken lock was fixed on his lockable drawer, another stated his family managed his personal finances, a third resident refused to discuss personal finances with the inspector. All three residents tracked were aware of the internal facilities for safe keeping of money and valuables. One resident was aware of the risks involved with Ashby Court Nursing Home DS0000001884.V285358.R01.S.doc Version 5.1 Page 22 keeping larger amounts of money in their possession and was willing to take the risk. Minutes of meetings were inspected the meetings involved both residents and relatives and all staff. Evidence was seen of all persons making suggestions and expressing views. Evidence was seen of follow up action taken by the manager in relation to improving activities after a residents meeting identified issues relating to the quality of the programme. A business and continuity plan dated 2005 was inspected detailing arrangements for management of emergency situations, trained staff were aware of this plan. A satisfaction survey was conducted in autumn 2005 and had just been published before this inspection, one resident tracked was able to show the inspector that he had received this information and had read it. The survey indicated that in the six months from spring 2005-autumn 2005, 53 of residents rated the home as either excellent or very good. Discussion with the manager and observation of internal records identified that the manager maintains professional registration and attends training as required to maintain this registration. The following areas were inspected during tour of the premises: Lounges. All were found to be clean and well decorated.Furniture seen was in good condition. All lounges were carpeted. Bathrooms : An upstairs bathroom still had a broken bath panel, which had not been repaired.The registered manager agreed to address this immediately as it was a potyential hazard for those who are able to independantly mobilise. Toilets: upstairs toilet 10 Was out of order. The manager was unaware and walls in this bathroom were scratched with wheelchair damage.This needs addressing as soon before the next inspection. Residents rooms.All three bedrooms were clean ,well decorated,maintained, and risk assessmenst were seen identifying environmental issues. Residents tracked confirmed rooms were appropriate to their individual needs. Dining room: was clean and well maintained.One resident described it as a “restaurant” one as a “cafeteria”. External areas (gardens) were well maintained and appeared safe for residents use. The home employs a full time maintenance person and BUPA maintains accurate maintenance records. Ashby Court Nursing Home DS0000001884.V285358.R01.S.doc Version 5.1 Page 23 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 X X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 3 3 X 3 X 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 3 3 3 X 3 3 X 3 Ashby Court Nursing Home DS0000001884.V285358.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 OP19 Good Practice Recommendations Plaster work which is damaged in the upstairs toilet (8.9.10) and the bath panel, which is broken in the relaxation bathroom, must be attended to as soon as practicable. Toilet (10) is out of action and must be repaired within the next two weeks. It is recommended that is recommended that staff are provided with training in relation to “The Social Model of Disability” It is recommended that further consideration is given to the administration of bulk medications and appropriate discussions are held with the General Practitioner and pharmacist in order to prevent inappropriate administration of liquid medication. All reasonable attempts should be made to involve residents and or /representatives I their care plan and any evaluation of it. DS0000001884.V285358.R01.S.doc Version 5.1 Page 25 2 3 4 OP21 OP30 OP9 5 OP7 Ashby Court Nursing Home Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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 DS0000001884.V285358.R01.S.doc Version 5.1 Page 26 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!