Inspection on 16/06/05 for Ashley Court Care Home

This inspection was carried out on 16th June 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

Ashley Court Care Home 08/08/07

Ashley Court Care Home 18/05/06

Ashley Court Care Home 18/11/05

Ashley Court Care Home 19/10/04

Ashley Court Care Home 24/05/04

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

CARE HOMES FOR OLDER PEOPLE Ashley Court Care Home Reservoir Road Kettering Northants NN16 9QT Lead Inspector Kathy Jones Unannounced 16 June 2005 @ 08:00 A.M. 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 Care Home C51 C08 S50486 Ashley Court V231104 Stage 4 160605.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Ashley Court Care Home Address Reservoir Road Kettering Northants NN16 9QT 01536 482777 01536 415654 ashleycourt@regalcarehomes.com Regal Care Homes Ltd 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 T Kelly Care Home Only (PC) 38 Category(ies) of Dementia - over 65 (DE(E)) 38 registration, with number of places Ashley Court Care Home C51 C08 S50486 Ashley Court V231104 Stage 4 160605.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. No person in the category DE(E) can be admitted into the home when there are 38 people within the DE(E) category already in residence. 2. By agreement there are 2 (two) female service users who have needs within the category of DE(E) and PD(E). 3. By agreement 1 (one) male service user is accommodated with needs within the category of MD(E) 4. The bedrooms with uneven floors are only used by service users who, following a risk assessment, are assessed as having full mobility with the use of mobility aids. Date of last inspection 19 October 2004 Brief Description of the Service: Ashley Court is a care home providing personal care and accommodation for 38 older people over the age of 65 years with dementia. Ashley Court is owned by Regal Care Homes Ltd. Ashley Court is situated in a residential area on the outskirts of Kettering town centre. The home is set within its own grounds with an enclosed garden area. There are parking facilities at the rear of the building. Accommodation is on two floors and all bedrooms are single with en suite facilities. There are two communal lounges/dining rooms on the ground floor and a lounge and a dining room on the first floor. There is a small room on each floor which is available for private meetings. There is a passenger lift providing access to the first floor. Ashley Court Care Home C51 C08 S50486 Ashley Court V231104 Stage 4 160605.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried during the evening of a weekday. The inspection involved a review of a sample of records relating to the assessment and planning of care needs for two Residents. Observations of the evening routine and the care provided to Residents were made. Although this was an evening inspection the Director of Care was visiting the home to carry out a regular unannounced visit and was in the process of reviewing care plans and discussing the care of Residents with the Registered Manager. The Inspector discussed the care provided with Residents, Staff, Registered Manager and the Director of Care during the inspection; no areas of concern were identified through these discussions. All Residents in the home have been diagnosed as having dementia and therefore some were unable to answer complex questions however all Residents were observed to be relaxed in the company of Staff. Eleven comment cards were received from Residents prior to this inspection and nine from relatives/visitors. The Manager advised that the eleven Residents who responded were able to complete the cards with the assistance of Staff or a relative. Five Resident chose not to give their names. Comments received were all very positive about the care provided. A pre-inspection questionnaire was submitted, which provided the Inspector with some additional information to inform the inspection. What the service does well: Positive relationships have been developed with Residents, Relatives and Visitors to the home. In addition to responding to the questions asked in the comment cards five relatives/visitors took the trouble to include additional comments praising the Staff and the care provided. There was a relaxed and flexible routine in the home on the evening of the inspection; Residents were assisted to their rooms and to bed as and when they were ready. Residents were observed to wander freely and were conversing with Staff and other Residents during the evening. The home has a Residents committee and the majority of Residents are happy with the level of decision making that they have in the home. Ashley Court Care Home C51 C08 S50486 Ashley Court V231104 Stage 4 160605.doc Version 1.30 Page 6 Staff were available to support and assist Residents where required and Residents were comfortable and relaxed with Staff. Staff were seen to have a calm and caring approach towards Residents. Residents care needs are kept under review with good systems in place for monitoring the health and well being of Residents. 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. Ashley Court Care Home C51 C08 S50486 Ashley Court V231104 Stage 4 160605.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 Ashley Court Care Home C51 C08 S50486 Ashley Court V231104 Stage 4 160605.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) 3, The home does not provide intermediate care therefore standard 6 is not applicable. The admission process provides assurances that the needs of Residents entering the home can be met. EVIDENCE: The file for one of the most recently admitted Residents was reviewed which confirmed that assessments of prospective Residents needs are carried out prior to admission. A copy of the assessment completed by the Care Manager on behalf of Social Services had been received and was held on file. Written confirmation had been provided to the Resident that following assessment the home were able to meet their needs. Ashley Court Care Home C51 C08 S50486 Ashley Court V231104 Stage 4 160605.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, 8, 9,10 Residents care needs are kept under review with good systems in place for monitoring and updating the care plans. EVIDENCE: Care plans are in place, which although brief guide staff as to the actions they need to take to meet Residents care needs. A sample check of information gathered during the assessment process for a Resident about individual preferences and existing routines showed that these had been incorporated into the care plan. The Manager acknowledged the need to continue to review and improve on the level of detail in the care plans regarding individual needs and preferences to ensure that Staff are fully aware of the care to be provided. The Director of Care was carrying out a regular visit to the home at the time of the inspection and had reviewed a sample of care plans, which she confirmed she does on each visit. Ashley Court Care Home C51 C08 S50486 Ashley Court V231104 Stage 4 160605.doc Version 1.30 Page 10 Daily records for a recently admitted Resident were sample checked, these records showed that relevant information was being recorded about eating and sleeping patterns and general well being. Records show that health care services are accessed appropriately for Residents. Comment cards received from nine relatives/visitors confirmed that they are kept informed about important matters, consulted about care and were satisfied about the care provided. One additional comment said that their relative is clean, well cared for and nourished. Residents were observed to be clean and well groomed. Comment cards received from Residents confirmed that they feel well cared for, that Staff treat them well and that their privacy is respected. Four Residents spoken to during the inspection confirmed that they were happy with the care. Staff were observed to take their time with Residents and to be calm and respectful of their dignity and in their general manner towards them. There was an incident of missing medication since the last inspection. A new improved system for checking controlled drugs has now been introduced and overall the system for managing Residents medication includes more safeguards. Ashley Court Care Home C51 C08 S50486 Ashley Court V231104 Stage 4 160605.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, 13, 14 The home provides suitable activities, encourages contact with friends and families and provides Residents with choice and control over their lives. EVIDENCE: Comment cards received from eleven Residents all confirmed that they were happy with the activities provided in the home. One Resident indicated that they didn’t wish to join in the formal activities and preferred to sit in the garden or read the paper. The Inspector observed residents to wander freely around the home. This flexible approach was confirmed by a relative. Records seen indicated that Residents had a choice regarding the times that they get up and go to bed. This was confirmed by observations during the inspection where Residents were indicating when they wished to be assisted to their rooms and to bed. Staff welcome visitors into the home and they are able to visit in private. This was confirmed through observations during the inspection. Ashley Court Care Home C51 C08 S50486 Ashley Court V231104 Stage 4 160605.doc Version 1.30 Page 12 Ten Residents confirmed that they were sufficiently involved in the decision making in the home with two saying that they were part of a Residents committee. One Resident felt that they would like to be more involved. Food provision was not fully reviewed during the inspection however fluids and fresh fruit were seen to be freely available and an evening snack was provided. Ashley Court Care Home C51 C08 S50486 Ashley Court V231104 Stage 4 160605.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 There is a complaints procedure,which the majority of people are aware of and issues raised are acted on. EVIDENCE: The home has a complaints procedure. Eight comment cards received from relatives/visitors confirmed that they are aware of the procedure and one wasn’t aware. Nine Residents stated that they knew who to talk to if they were unhappy with the care provided. The Commission for Social Care Inspection has received two complaints since the last inspection in October 2004. Both complaints were investigated and satisfactorily resolved with the management making changes where required. No further follow up was required. Discussions with a member of Staff confirmed a good understanding of Protection of Vulnerable Adults procedures and the importance of reporting any concerns about the care or treatment of Residents. Ashley Court Care Home C51 C08 S50486 Ashley Court V231104 Stage 4 160605.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 The environment is pleasant, homely and comfortable and meets residents needs. EVIDENCE: A full tour of the premises was not carried out during the inspection. It was confined to communal areas of the home, which were seen as the Inspector was talking to Residents and Staff. There are two communal lounge/dining rooms on the ground floor and a small lounge and small dining room on the first floor. These areas were noted to be comfortably furnished with Residents moving freely between chairs and chatting. The home was generally clean and tidy and noted to be comfortably furnished. Some of the paintwork was starting to look quite scuffed however the Manager confirmed that these areas are to be re-decorated. During the inspection the Manager and the Director of Care were discussing the need to replace the Ashley Court Care Home C51 C08 S50486 Ashley Court V231104 Stage 4 160605.doc Version 1.30 Page 15 carpet in one of the lounges, which was beginning to look stained. It has been confirmed that this is going to be done. A relative commented that the home would benefit from having a hairdressing room, which could when not in use be used for visits from a General Practitioner or District Nurse. The Manager advised that she was in the process of obtaining quotes for a ground floor room to be equipped as a hairdressing room. Currently a downstairs bathroom is used. Ashley Court Care Home C51 C08 S50486 Ashley Court V231104 Stage 4 160605.doc Version 1.30 Page 16 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) 28 Staff are encouraged to gain qualifications relevant to meeting the needs of Residents. EVIDENCE: The pre-inspection questionnaire submitted at the end of March 2005 by the Registered Manager stated that three members of Staff had gained a National Vocational Qualification; four Staff had submitted the work and a further five are nearing completion of the course. The expectation of the National Minimum Standards is that at least 50 of Staff have gained a minimum of National Vocational Qualification at level 2 by 2005. The home is on target to achieve if not exceed this target. Discussion with a new member of Staff confirmed that Staff training is encouraged. The National Vocational training undertaken Staff is all relevant to working with and meeting the needs of Older People. Ashley Court Care Home C51 C08 S50486 Ashley Court V231104 Stage 4 160605.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) 38 The Manager is aware of health and safety issues and takes appropriate action. EVIDENCE: The Pre-inspection questionnaire provides dates that relevant safety checks were carried out which include checks on fire safety equipment, central heating system and servicing of the lift. There was no record of when an electrical wiring check last took place however following the inspection the Manager has confirmed that this has been addressed. Discussion with the Manager regarding safety and maintenance checks confirmed that appropriate action is taken in respect of any recommendations in order to reduce the risk to Residents. Discussion with a fairly new member of Staff confirmed that new Staff receive appropriate training such as fire safety, first aid, health and safety and movement and handling. Ashley Court Care Home C51 C08 S50486 Ashley Court V231104 Stage 4 160605.doc Version 1.30 Page 18 Ashley Court Care Home C51 C08 S50486 Ashley Court V231104 Stage 4 160605.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 x x 3 x 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 x COMPLAINTS AND PROTECTION 3 x x x x x x x STAFFING Standard No Score 27 x 28 2 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x x x x x x x 3 Ashley Court Care Home C51 C08 S50486 Ashley Court V231104 Stage 4 160605.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 None made 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 7 Good Practice Recommendations The level of detail regarding individual needs and preferences within care plans should continue to be reviewed. Ashley Court Care Home C51 C08 S50486 Ashley Court V231104 Stage 4 160605.doc Version 1.30 Page 21 Commission for Social Care Inspection Northamptonshire Area Office Newland House, First Floor Campbell Square Northants, NN1 3EB 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 Care Home C51 C08 S50486 Ashley Court V231104 Stage 4 160605.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. 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