Inspection on 12/05/05 for Ashley Court

This inspection was carried out on 12th May 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Ashley Court 07/06/07

Ashley Court 04/07/06

Ashley Court 13/10/05

Ashley Court 14/10/04

Ashley Court 15/06/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Ashley Court 251 Penn Road Penn Wolverhampton WV4 5SF Lead Inspector Bhag Jassal Unannounced 12 May 2005 09:00 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. Ashley Court E56 000058006 Ashley Court V225367 UI 120505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Ashley Court Address 251 Penn Road, Penn, Wolverhampton, WV4 5SF 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) 01902 335584 Ashley Court Care Ltd Vacant Care Home 18 Category(ies) of Old Age (18) registration, with number Physical Disability PD(E) (5) of places Dementia DE(E) (6) Ashley Court E56 000058006 Ashley Court V225367 UI 120505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1) Service Users with a physical disability may only be admitted to rooms 5, 7, 9, 12 and 15. 2) An application to register a manager must be received by the Commission wihtin 3 months of the date of this registration. 3) No more than 5 service users may be admitted having a physical disability (PD). 4) No more than 6 service users may be admitted having mild dementia (DE). 5) Bedroom 1, once vacated by the current service user is to be converted into a `multipurpose` room. At this time the Commission must be informed and a new certificate will be issued reducing the registered beds from 18 to 17. 6) Adequate staffing levels must be maintained to reflect the increase in registered numbers and the change in categories of clients accommodated. Date of last inspection 14/10/2004 Brief Description of the Service: Ashley Court Care Home is a care home providing personal care and accommodation for eighteen older people. The home is located on the Penn Road, one and a half miles from Wolverhampton city centre. It is close to the local shops and amenities. The home is a large semi-detached property that was adapted as a residential care home in 1981; and further improvements have been made over the years. The accommodation consists of single occupancy rooms with en-suite facilities, communal sitting areas and dining room. There are gardens and a patio area at the rear of the building. Ashley Court E56 000058006 Ashley Court V225367 UI 120505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and started at 9.00 am and lasted 10 hours. All 18 places were occupied with one service user being admitted to a local hospital. The inspection included discussions with service users, staff and relatives/friends. The daily routines were observed and service users and staff records, policies and procedures were examined. Inspection of premises both inside and outside and facilities were also undertaken. What the service does well: What has improved since the last inspection? Ashley Court E56 000058006 Ashley Court V225367 UI 120505 Stage 4.doc Version 1.30 Page 6 The Registered Provider has made good effors in implementing all the recommendations contained in the recent respective inspection reports of the Fire Safety Officer and Environmental Health Officer. The garden and patio areas have been kept tidy and neat and broken fences have been replaced. New fly screen has been fitted to the kitchen window. The service users’ bedrooms have been adequately furnished and equipped. Fire safety and equipment and electrical systems have been appropriately maintained. The staff have received safe working practice topics training and handling of medication by the senior carers to improve their care practices. The Registered Provider has engaged an occupational therapist to conduct a risk assessment of the premises and facilities. The Registered Provider is continually working on improving record keeping formats and systems. 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 Ashley Court E56 000058006 Ashley Court V225367 UI 120505 Stage 4.doc Version 1.30 Page 7 contacting your local CSCI office. Ashley Court E56 000058006 Ashley Court V225367 UI 120505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Ashley Court E56 000058006 Ashley Court V225367 UI 120505 Stage 4.doc Version 1.30 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 standard(s) 1, 3 and 5 The Registered Provider has produced a Statement of Purpose and a Service Users’ Guide, which is being made available to all the service users including the prospective residents. The service users are assessed before moving into the home. They are provided with opportunity to visit the home to assess the quality, facilities and the suitability of the home before their relatives move in. EVIDENCE: The Registered Provider stated that the Statement of Purpose for the home and the Service Users’ Guide have been finalised and copies of these documents are being made available to all the service users, and in suitable format, including in large print. A sample of three service users’ care plans and files were seen at the inspection. All contained evidence that the service users received the benefit of a comprehensive assessment prior to admission. The Registered Provider also carries out assessments and these details are documented in care plans, which are drawn up by senior staff with the help from the service users and Ashley Court E56 000058006 Ashley Court V225367 UI 120505 Stage 4.doc Version 1.30 Page 10 their relatives. There was evidence to show that all service users have been provided with contracts. The home has a good admissions procedure, which is made available to all prospective service users and their relatives/ representatives. Ashley Court E56 000058006 Ashley Court V225367 UI 120505 Stage 4.doc Version 1.30 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 standard(s) 7, 8, 9 and 10 The staff within the home are aware of the needs of each service user, and meet their needs in a professional manner. There is a clear and consistent care planning system in place, which provides staff with the information they require to meet service users’ health and personal care needs. Lack of accredited training in safe handling of medication by care staff potentially could place service users at risk. EVIDENCE: There was evidence to show that all service users’ care plans are formulated on the basis of their assessed needs and short- term and long – term goals are set and the actions to be taken by the care staff to implement these goals are identified. The care plans are reviewed on a monthly basis. The home maintains records of all health checks carried out by the doctors, opticians, dentists, district nurses and chiropodists. The home also ensures that nutritional screening is undertaken, including weight gain or loss records are maintained and appropriate action is taken if required. Ashley Court E56 000058006 Ashley Court V225367 UI 120505 Stage 4.doc Version 1.30 Page 12 Case tracking demonstrated an effective review process together with the home’s ability to meet the changing needs as they occur. The service users’ health is closely monitored and appropriate medical care services are sought. It was observed on the day of inspection that no personal care interventions were taken in communal areas. In addition, consultation with the health and social care professionals are carried out within the service users’ bedrooms. The Inspector spoke at length with eight service users and all of them commented positively about their care and they felt that they have everything that they need. Four service users stated that “the carers are very good and kind” and “they look after us very well”. Four other service users commented that “ the carers are always there to help us”. The service users have access to a payphone, which they can use in private. Staff observed during the inspection spoke respectfully to service users. Service users’ relatives who were present at the home stated that they could see their relatives in private if they wish. Individuals receiving care during the day of inspection were taken to their bedrooms. The Registered Provider stated that accredited medication training for care staff is still to be provided, and they are to be enrolled at a local college shortly. However, the senior carers have completed this training. Ashley Court E56 000058006 Ashley Court V225367 UI 120505 Stage 4.doc Version 1.30 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 standard(s) 12, 13 and 15 Ashley Court provides a good quality of care and promotes lifestyles for the service users in residence. The service users maintain contacts where they wish with family, friends and the local community. Meals at Ashley Court are of a good homely type offering both choice and variety and catering for special needs. EVIDENCE: The home has a varied plan of activities for all service users to take part in. Records of these activities enjoyed by the service users are being maintained. All the service users reported that they are in touch regularly with their friends and family members and spoke about their visitors and how they enjoyed their company in the home. The visitors’ book showed considerable activity. Two relatives of one of the service user stated that they visit the home at various times of the day as they wish. All the relatives and friends who spoke to the Inspector said they are given a warm friendly welcome by all the staff whenever they visit. The service users also keep contacts with the local community facilities i.e. church services, local shops, pubs, and park. Ashley Court E56 000058006 Ashley Court V225367 UI 120505 Stage 4.doc Version 1.30 Page 14 There was evidence to show that the home provided a varied, wholesome and nutritious diet. The meals provided during lunchtime on the day of inspection were well received by the service users. The Registered Provider stated the menu is changed on a regular basis and in consultation with the service users. Several service users told the Inspector “the food was very nice”. Three relatives of service users also stated that the food was very good offering a good variety and choice. Ashley Court E56 000058006 Ashley Court V225367 UI 120505 Stage 4.doc Version 1.30 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 standard(s) 16 and 18 Concerns and complaints are dealt with promptly and professionally. The service users are protected from abuse by the home’s policies and procedures. The arrangements for protection of service users from abuse are satisfactory. EVIDENCE: The home has a Complaints Procedure, which is referred to for information in the Service Users’ Guide. There is a system of recording complaints and it was noted that there were two complaints during the last twelve months. One of these complaints was substantiated and the other was not substantiated. The service users spoken to by the Inspector stated that their views are always listened to by the Provider and the staff The home has a policy and procedures in place with regard to the protection of service users from abuse. The Registered Provider stated that the staff have been made aware of the adult abuse and protection issues. The staff also have received induction training on these issues. All existing and new members of staff have been CRB checked. Ashley Court E56 000058006 Ashley Court V225367 UI 120505 Stage 4.doc Version 1.30 Page 16 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, 21, 22, 24 and 25 The general standard of the environment is good providing service users with a homely place to live. The high standard of cleanliness reflects the ongoing cleaning schedule, which maintains this standard throughout the home. EVIDENCE: The home is well decorated, furnished and equipped. It is accessible, safe and well maintained. The home has ample space for dining and lounge areas. Both of these areas have been redecorated and new flooring has been provided in the dining room. All the recommendations contained in the Fire Safety Officer’s inspection reports dated 5 October and 8 November 2004 have been implemented. A dishwasher is still to be provided in the kitchen and the extractor fan in the kitchen is to be repaired/replaced. The home has undertaken a risk assessment of the premises and the facilities by a suitably qualified occupational therapist. However, a suitable loop system may be required in the home for the benefit of the service users. Staff call system must also be installed in bedroom 5 and bedrooms 5 and 6 to be Ashley Court E56 000058006 Ashley Court V225367 UI 120505 Stage 4.doc Version 1.30 Page 17 redecorated, and new carpet to be fitted in bedroom 6. Hot water temperature in the hot water outlets in the service users’ bedrooms must be maintained at the required temperature level of below 43 degrees C at all times. Suitable tables in several of the service users bedrooms still to be provided and locks and self closures on doors to be kept in working order at all times. Ashley Court E56 000058006 Ashley Court V225367 UI 120505 Stage 4.doc Version 1.30 Page 18 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, 29 and 30 The home is adequately staffed at all times which ensures the quality of care provided, and the ability of the home to meet the needs of the service users. The home continues to support staff to complete training. The home has satisfactory staff recruitment policy and procedures. EVIDENCE: The information provided by the home and the available staff rotas showed that the home is adequately staffed. However, the vacant post of a care manager for the home still to be filled ( please refer to NMS 31), and the vacant post of the deputy manager (36 hours) and a cleaner (15 hours) to be filled as a matter of priority. The Registered Provider stated that several of carers are to commence their NVQ level 2 training shortly. Several members of staff have undertaken safe working practice topics training courses and those who have not as yet received this training must do so as a matter of priority, including training in dementia and adult protection from abuse. Discussion with the Registered Provider and examination of the most recent staff files demonstrated that thorough recruitment procedures had been followed in line with the home’s recruitment policy. Two written references and enhanced CRB checks are being undertaken before new staff actually commences their duty. The Registered Provider is aware that any member of Ashley Court E56 000058006 Ashley Court V225367 UI 120505 Stage 4.doc Version 1.30 Page 19 staff with criminal records would not be employed in accordance with the Department of Health Guidance in July 2004. The home has introduced the TOPSS (now Skills and Care) Induction and Foundation training for all new members of staff. Training records format/a training plan was discussed with the Registered Provider and it was agreed that all individual members of staff would have training profiles. However, the home needs to consider providing specialist training i.e. mental health needs, disability awareness and adult protection from abuse. Ashley Court E56 000058006 Ashley Court V225367 UI 120505 Stage 4.doc Version 1.30 Page 20 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) 31, 33, 35, 36 and 38 The home is managed satisfactorily, but the vacant post of the care manager must be filled as a matter of priority. The staff are clear of their roles and responsibilities. Good systems of communication are in place to seek the views of the service users and their families and friends. The service users’ monies are appropriately handled by the Registered Provider. Staff are regularly supervised to enable them carry out their work professionally. Health, safety and welfare of the service users and staff are promoted by safe working systems put in place by the Registered Provider and staff. EVIDENCE: It was noted that the home the home has been without a Registered Manager since March 2004 and this has been a concern for the CSCI. It was also noted that the Registered Provider has taken action to advertise this vacant post and she has been unable to recruit/appoint any suitably qualified candidate. The Ashley Court E56 000058006 Ashley Court V225367 UI 120505 Stage 4.doc Version 1.30 Page 21 Registered Provider stated that post is being re-advertised with the view to get someone in post as soon as possible. The Registered Provider stated that the home as yet have not implemented any Quality Assurance system, however, she will implement the Quality Assurance plan by the end of July 2005. Monies held at the home on behalf the service users are handled in line with the home’s policy of handling service users’ money. A sample of three service users’ money was checked and found to be satisfactory at the inspection visit. All members of staff are appropriately being supervised on a regular basis. Records of supervision were examined during the inspection. Accidents and fire prevention records and procedures were examined, which were appropriately maintained. Matters pertaining to fire safety and environmental health were found to be satisfactory and all the issues have been appropriately addressed. The Registered Provider stated that the staff still undertaking their safe working practice topics training courses and this is an ongoing training programme. All new staff would also receive this training as a matter of priority. Ashley Court E56 000058006 Ashley Court V225367 UI 120505 Stage 4.doc Version 1.30 Page 22 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 x 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 2 3 3 2 x 2 2 x STAFFING Standard No Score 27 2 28 x 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 x 3 1 x 2 x 3 3 x 2 Ashley Court E56 000058006 Ashley Court V225367 UI 120505 Stage 4.doc Version 1.30 Page 23 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13 Requirement Timescale for action 15/10/05 2. OP19 23 3. OP22 16 and 23 4. OP24 16 and 23 The Registered Providermust ensure that all care staff that administer medication receive accredited medication handling training in accordance with NMS 9.7. 30/09/05 The Registered Provider must bedrooms 5 and 6 are approriately redecorated; the extractor fan is repaired/replaced in the kitchen and a dishwasher is also provided in the kitchen. Selfclosures to the bedroom doors must be regularly checked and ensure that these close to their rebate. The Registered Provider must 30/09/05 assess the home for the installation of a suitable loop system to determine the benefit for the service users; and staff call system must also be installed in bedroom 5. The Registered Provider must 30/09/05 ensure that new carpet is fitted in bedroom 6; and suitable tables to sit at must be provided in several service users bedrooms, and locks on bedroom doors are maintained in working Version 1.30 Ashley Court E56 000058006 Ashley Court V225367 UI 120505 Stage 4.doc Page 24 order at all times. 5. OP25 13 The Registered provider must ensure that the hot water temperature in ALL hot water outlets is maintained at the required level of close to 43 degrees C at all times. The Registered Provider must take appropriate action to ensure to fill the vacant post of deputy manager (36 hours per week), and a cleaner (16 hours per week) as a matter of priority. The Registered Provider must ensure that a suitably qualified, competent and experienced manager is appointed to run the home. The Registered Provider must develop and implement a comprehensive Quality Assurance system in which the views of the service users, their relatives, other professionals abbbnd staff are sought through a series of questionnaires and monitoring formats/systems. The Registered Provider must ensure that all staff receive the safe working practice topics training as a matter of priority and all new staff receive TOPSS Inductio and Foundation training. 30/09/05 6. OP27 18 30/09/05 7. Op31 9 30/09/05 8. OP33 24 30/09/05 9. OP38 17 30/09/05 10. 11. 12. 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. Ashley Court E56 000058006 Ashley Court V225367 UI 120505 Stage 4.doc Version 1.30 Page 25 Refer to Standard Good Practice Recommendations 2. 3. Ashley Court E56 000058006 Ashley Court V225367 UI 120505 Stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection 2nd Floor, St Davids Court Union St Wolverhampton WV1 3JE 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 Ashley Court E56 000058006 Ashley Court V225367 UI 120505 Stage 4.doc Version 1.30 Page 27 - 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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