Inspection on 18/05/06 for Ashley Court Care Home

This inspection was carried out on 18th May 2006.

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 18/11/05

Ashley Court Care Home 16/06/05

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 Mrs Kathy Jones Unannounced Inspection 18th May 2006 12:00 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 Ashley Court Care Home DS0000050486.V292408.R02.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. Ashley Court Care Home DS0000050486.V292408.R02.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Ashley Court Care Home Address Reservoir Road Kettering Northants NN16 9QT 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) 01536 482777 01536 415654 ashleycourt@regalcarehomes.com Regal Care Homes Ltd Mrs Beatrice Emma Kelly Care Home 38 Category(ies) of Dementia - over 65 years of age (38) registration, with number of places Ashley Court Care Home DS0000050486.V292408.R02.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 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. By agreement there are 2 (two) female service users who have needs within the category of DE (E) and PD (E) By agreement 1 (one) male service user is accommodated with needs within the category of MD (E) 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. 18th November 2005 Date of last inspection 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. The home is situated in a residential area on the outskirts of Kettering town centre. It is set within its own grounds and has 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 toilet facilities. A passenger lift provides access to the first floor. There are two bathrooms on the ground floor and three on the first floor. Communal facilities consist of two lounge/dining rooms on the ground floor and a lounge and a dining room on the first floor. There is a small room on the ground floor available for private meetings. On the first floor there is a room, which has almost been completed for use as a sensory room. The following fees were provided by the registered manager as being current at the time of the inspection on 6 April 2006: • Privately funded residents in room shared by two people - £400 • Privately funded residents in a single room - £450- £500 Fees for residents funded by Local Authorities vary and are paid according to their agreed rate. The fees include personal care, accommodation and meals. Chiropody and hairdressing services can be arranged and are charged separately. Other costs would include clothing and toiletries. Ashley Court Care Home DS0000050486.V292408.R02.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. All standards identified as ‘key’ standards and highlighted through the report were inspected. These standards are those considered by the Commission to have a particular impact on outcomes for residents. This was achieved through review of existing evidence, pre-inspection planning, an unannounced inspection visit to the home and drawing together all of the evidence gathered. The review of evidence and pre-inspection planning was carried out over the period of one day and involved reviewing the reports of the inspections carried out in June and November 2005, the findings of a complaint received, notifications of events reported by the home, telephone calls received and a pre-inspection questionnaire submitted by the registered manager. Results of six questionnaires from residents completed with the help of relatives, nine from relatives and two from health professionals were analysed. The information gathered assisted with planning the particular areas to be inspected during the visit. The unannounced inspection visit covered a period lunch time until early evening on a weekday. This was carried out through talking to residents, staff, a relative and the registered manager. Conversations with residents’ were limited due to their dementia. Observations were made of residents’ general well being, daily routines and interactions between staff and residents. A sample of residents care records were reviewed to check how residents’ care and health needs were being assessed and how their care is planned and supported. Staff training was discussed with staff and records sample checked. Two files for recently recruited staff were reviewed to check the adequacy of the recruitment process. A sample of residents’ bedrooms were viewed with the registered manager during the inspection. Feedback on the inspection findings was given to the registered manager throughout the inspection visit. What the service does well: Prospective residents and relatives have information about the home prior to making a decision to move in. An assessment is carried out before someone moves into the home to make sure that their needs are able to be met. Ashley Court Care Home DS0000050486.V292408.R02.S.doc Version 5.1 Page 6 Care plans are detailed and provide staff with information about the actions they need to take to meet residents’ personal care needs, health needs and preferences. The plans are particularly important for residents’ with dementia who may not be able to express preferences easily. Details such as whether the resident likes to wear make up and the type of clothing and jewellery they wish to wear is included. The plans are reviewed and updated regularly often with the involvement of a relative. Relatives say they are consulted and kept informed about the care provided. Relatives and health professionals are satisfied with the overall care provided for residents’ and health care services are accessed on behalf of residents. Visiting arrangements are flexible and comments from relatives such as “welcomed with open arms” confirm that visitors are encouraged and made welcome in the home. Residents’ are happy with the food, they have breakfast, a two course lunch, tea which is often a hot snack and supper which consists of things like crumpets, sandwiches or cheese and crackers. Observations during the inspection confirmed that staff speak to and treat residents’ with respect. The home was clean and comfortable and there were no unpleasant odours. Residents all have single bedrooms with en-suite toilets. They are able to personalise their bedrooms and are encouraged to bring familiar items into the home with them. They are offered keys to their bedrooms, which are generally locked when not in use. However staff assist those residents who are not able to manage a key to access their rooms as and when they wished. The recruitment procedure for new staff is good with references and criminal record bureau checks being taken up before they start work. A high percentage of staff have a basic qualification in care and all receive additional training in safe working practices and specific training for the residents at Ashley Court such as dementia care training. What has improved since the last inspection? Since the last inspection new carpets and curtains have been fitted in the ground floor lounge, some areas have been re-decorated and some furniture replaced. New non-slip vinyl flooring has been fitted in the upstairs dining room and the finishing touches are being put to a sensory room on the first floor, which will be used by residents’ with advanced dementia. There is also now a hairdressing room on the ground floor. The monitoring of standards of care by the company has improved since the last inspection. Systems appear to be more thorough with areas for Ashley Court Care Home DS0000050486.V292408.R02.S.doc Version 5.1 Page 7 development identified and acted on. An annual development plan has identified key areas for improvement including continuing development of the quality assurance processes. 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 DS0000050486.V292408.R02.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 Ashley Court Care Home DS0000050486.V292408.R02.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): 1,2,3,std 6 is not applicable, the home does not provide intermediate care. Quality in this outcome area is good. This judgement has been made using all the available evidence including a visit to the service. The admission process provides assurances that the needs of Residents entering the home can be met. EVIDENCE: Information is provided to prospective residents’ and their families about Ashley Court and the services it provides. This information is in the form of a statement of purpose and a service user guide. These documents have recently been updated. Questionnaires received from residents’ completed with the assistance of relatives confirm that sufficient information was provided to enable them to make a decision about moving into the home. As part of this inspection the conditions of registration have been reviewed. As a result of this it is considered not to be necessary to have a registration condition relating to uneven floors in two of the bedrooms. However advice Ashley Court Care Home DS0000050486.V292408.R02.S.doc Version 5.1 Page 10 has been given to ensure this information together with the actions taken to minimise risk are clearly stated within the home’s statement of purpose. Contracts are in place for privately funded residents’ and copies of terms and conditions of residence for those people funded by a local authority. This was confirmed in residents’ questionnaires. Review of a newly admitted residents’ care file confirmed that an assessment of need is carried out prior to residents being admitted to the home and an assessment is also obtained from the local authority where applicable. Care needs identified during the assessment process formed the basis for the resident’s plan of care. Ashley Court Care Home DS0000050486.V292408.R02.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 Quality in this outcome area is good. This judgement has been made using all the available evidence including a visit to the service. The overall care provided to residents is good. EVIDENCE: Relatives and health professionals who responded to questionnaires were satisfied with the overall care provided. They also confirmed that they are consulted and kept informed about changing health and care needs. Four residents responses confirm that they always receive the care and support they need while two said they usually do. Care plans are in place for all residents’, which provide a good level of information about their personal care needs, health needs and preferences. Information in most cases is specific to the individual and as changes occur or new information comes to light the care plan is updated. Details such as whether the resident with dementia likes to wear make up and the type of clothing and jewellery they wish to wear is included. Ashley Court Care Home DS0000050486.V292408.R02.S.doc Version 5.1 Page 12 Care plans are accessible to staff however they are all located on the ground floor making it more difficult for staff caring for residents’ on the first floor to use the care plans as working tools. The care plan for one resident identified that due to the stage of dementia the resident sometimes reverted to their first language, which was not English. Relatives had provided translations of key words such as pain and toilet to assist staff in understanding. Unfortunately these were not readily available to staff and were found on top of the resident’s wardrobe. Records showed that health care services are accessed for residents’. Comments received from health professionals were in the main positive however one highlighted some communication difficulties and the fact that there is not always someone available that has an understanding of the care needs and history of residents’ with dementia. Staff on duty at the time of the inspection were able to demonstrate a good understanding of residents’ care needs however the registered manager confirmed that she would look at the quality of information being passed to health professionals. A sample check of the medication system confirmed that there is a clear system in place for the management and recording of medication administered. Residents’ prescribed medication was available and signed as administered in accordance with the prescription. Staff receive training in the administration of medication. Medication is securely stored and stock levels are not excessive. The majority of medication is supplied in a blister pack format, which aids stock control and auditing. The registered manager advised that the procedure for medication supplied, for example in a bottle, is that any left over at the end of the month will be carried forward in the records. A sample check identified that this had not occurred this month making it difficult to identify errors or misuse. Observations during the inspection confirmed that staff speak to and treat residents’ with respect. Their privacy and dignity is respected in that personal care is provided in the privacy of people’s rooms and staff were ensuring that residents’ were appropriately dressed. Ashley Court Care Home DS0000050486.V292408.R02.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): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using all the available evidence including a visit to the service. Visitors are encouraged and made welcome in the home, residents’ are happy with the food and have a lifestyle, which meets most of their needs and expectations. EVIDENCE: Questionnaires sent to residents’ and completed with the help of relatives asked if there are activities arranged that they can take part in. One replied always, three usually. Two replied sometimes, however one acknowledged they were out of the home regularly. Review of activity records for two residents’ on the first floor and discussion with staff indicated that there is no set programme of activities and it is dependent on the choices of staff on the day. Records for residents with dementia on the first floor indicated very few opportunities for activity or stimulation with no record in some cases for several days. The registered manager later pointed out an activity list, which was displayed in the home, and considered it may be, that activities were not always recorded, however Ashley Court Care Home DS0000050486.V292408.R02.S.doc Version 5.1 Page 14 acknowledged the need to look at how the programme is implemented in practice. A group of residents on the ground floor were enjoying conversations and some light hearted ‘banter’. Upstairs one resident spent time folding serviettes and had earlier been looking at a book of the English Royal family. A visitor had brought in a bag of items such as coloured balls, a soft toy and a jigsaw puzzle, which were used effectively as aids to communication with a resident during the visit. The manager advised that there are similar objects to stimulate residents, which are not part of the formal activity programme however these were not evident during the inspection. It is positive that the company have identified in their annual development plan the need “to provide a more stimulating environment geared specifically at enhancing the quality of life for clients suffering from dementia”. Preferences in relation to times for getting up and going to bed were recorded in individual care plans. Residents spoken to were unable to recall the actual times of getting up and going to bed however the registered manager confirmed that she carries out spot checks to ensure that staff are adhering to residents’ preferences. Residents’ have the opportunity to receive visitors in private and they confirm that they are welcomed into the home and made to feel comfortable. One relative said that they are “welcomed with open arms, always offered refreshments and a warm smile”. Another points out that the fact that staff are kind and caring makes it easier to handle that their relative is in residential care. Residents are able to personalise their bedrooms and are encouraged to bring familiar items with them. Residents’ are offered keys to their bedrooms, which are generally locked when not in use. Staff were observed to assist those residents who are not able to manage a key to access their rooms as and when they wished. Care plans and observations confirmed that consideration is given to the importance of residents’ being able to retain as much control as possible over their lives. For example for some ladies although due to their dementia they may no longer be able to manage their financial affairs the need to have a handbag with them is acknowledged. There is a four week menu plan in place, which is reviewed and revised periodically. Meals provided are breakfast, a two course lunch, tea and supper. The lunch on the day of inspection was chicken portions with stuffing, potatoes, brussel sprouts and mixed vegetables. Dessert was lemon mousse. Residents confirmed during the inspection and through comments in the questionnaires that they are happy with the food provided. Ashley Court Care Home DS0000050486.V292408.R02.S.doc Version 5.1 Page 15 Care records showed that changes in weight are identified and the registered manager confirmed the involvement of the dietician where weight loss is identified. Ashley Court Care Home DS0000050486.V292408.R02.S.doc Version 5.1 Page 16 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): 16, 18 Quality in this outcome area is good. This judgement has been made using all the available evidence including a visit to the service. Complaints are taken seriously with the findings of investigations being acted on where necessary to improve the standard of care provided for residents’. EVIDENCE: The Commission for Social Care inspection (CSCI) has received one complaint since the inspection carried out in November 2005. The complaint related to poor induction of new staff resulting in residents’ needs not being fully met, lack of monitoring and oversight of the laundry, inadequate staffing levels and staff working excessive hours. The complaint was forwarded to the responsible individual for Regal Care Homes Ltd for investigation. The complaint was thoroughly investigated and action taken to improve the staff induction programme ensuring that it is focussed on meeting residents needs and monitoring of the staff rota. The registered manager records any complaints or concerns regardless of the source and documents any action taken. The record shows that complaints are taken seriously and where necessary action is taken to resolve the problem. The home has a complaints procedure, which the majority of residents’ and relatives confirmed they are aware of. Information about how to make a Ashley Court Care Home DS0000050486.V292408.R02.S.doc Version 5.1 Page 17 complaint is contained in the homes statement of purpose and also displayed in the hallway of the home. Recent training has been provided for staff in protecting vulnerable adults from abuse. Discussion with staff confirmed that they have no concerns about how residents are treated and are aware of their responsibilities to report any concerns. Senior staff are aware of who to contact if a concern is reported to them. Ashley Court Care Home DS0000050486.V292408.R02.S.doc Version 5.1 Page 18 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, 20, 24, 26 Quality in this outcome area is good. This judgement has been made using all the available evidence including a visit to the service. The home was clean, comfortable and in good decorative order providing a pleasant environment for Residents. EVIDENCE: A limited tour of the premises was conducted; the residents bedrooms viewed were pleasantly decorated, furnished to a good standard and contained small personal possessions, such as photographs, pictures and ornaments. There are bedrooms on the ground and first floor, they are all single rooms and have ensuite facilities. A passenger lift provides access to the first floor. Ashley Court Care Home DS0000050486.V292408.R02.S.doc Version 5.1 Page 19 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 clean, pleasant and comfortably furnished. There is an enclosed garden area with seating which provides a pleasant area and safe area for residents to sit in the warm weather. There is a repair and renewals programme in place. Since the last inspection new carpets and curtains have been fitted in the ground floor lounge, some areas have been re-decorated and some furniture replaced. New non-slip vinyl flooring has been fitted in the upstairs dining room and the finishing touches are being put to a sensory room on the first floor, which will be used by residents’ with advanced dementia. There is also now a hairdressing room on the ground floor. Additional work has been identified and approved as part of the in the annual development plan for 2006/2007. Areas for attention identified during the inspection, which are not included on the annual development plan, were the carpet in the upstairs lounge, which is worn, and the ground floor corridor carpets, which have stretched during cleaning and now have ridges, which are a potential tripping hazard. The registered manager confirmed that these areas would be discussed with the responsible individual on her visit next week. New signage is ready to put up when the re-decoration of corridors is complete which will aid residents in orientating themselves around the home The home was clean and free from offensive odours. Staff training in infection control was carried out in September 2005 and more is in the process of being arranged. The home has suitable laundry facilities and the laundry appeared well organised with no backlog of laundry evident. The assistance of relatives is sought in labelling clothing to ensure that residents’ clothing is properly identified and returned to the correct person. Ashley Court Care Home DS0000050486.V292408.R02.S.doc Version 5.1 Page 20 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 all the available evidence including a visit to the service. Recruitment procedures are thorough and the commitment to staff training and development provides staff with the necessary knowledge and skills to meet the needs of residents. EVIDENCE: Discussion with staff and feedback from relatives and residents’ confirms that there are enough staff to meet residents’ needs. A comment was made about the manager having to cover shifts including night shifts however the registered manager confirmed that new staff have been recruited and the problem has been resolved. Discussion with staff and records confirm that there is an ongoing programme of staff training relevant to meeting the needs of residents’. As identified in the complaints section action was taken following a complaint to improve induction training for new staff to ensure that new staff were aware of residents individual needs and the care they required. A pre-inspection questionnaire submitted by the registered manager identifies that 72 percent of staff have achieved a National Vocational Qualification at level 2. This exceeds the National Minimum Standards target of 50 staff being trained to a National Vocational Qualification level 2. Ashley Court Care Home DS0000050486.V292408.R02.S.doc Version 5.1 Page 21 Additional training provided since the last inspection includes first aid, movement and handling, food hygiene, protection of vulnerable adults/abuse and dementia, which are all important in meeting the specific needs of residents’. Training from the Parkinson’s disease nurse has been arranged for the end of May 2006 and pressure area care training is being planned. Records reviewed for two recently recruited staff confirms that there is a thorough recruitment process in place, which includes obtaining references and a satisfactory criminal record bureau clearance prior to someone starting work in the home. Ashley Court Care Home DS0000050486.V292408.R02.S.doc Version 5.1 Page 22 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 all the available evidence including a visit to the service. The management and organisation of the home is good promoting the health, safety and welfare of the people living in the home. EVIDENCE: There is an experienced registered manager in post who has achieved the National Vocational Qualification Level 4 in Management and the Registered Managers Award. The registered manager has undertaken some dementia care training however continues to update her knowledge and is currently waiting for a place to become available on a more in depth dementia training course. Ashley Court Care Home DS0000050486.V292408.R02.S.doc Version 5.1 Page 23 Quality assurance systems are in place and an annual development plan has been developed. The plan includes developing and implementing a more in depth quality assurance policy. Various elements of a programme are already in place; relatives’ and residents’ views are sought through meetings, care plan reviews and a quality survey of relatives where letters/questionnaires are sent out every three months. Responses are now being returned directly to head office who will collate the information and forward to managers in the form of a report. Areas of the premises, which require re-decoration and refurbishment, are generally identified through regular reviews of the premises. The responsible individual carries out unannounced visits to the home each month to review standards of care. Copies of the reports of the visits identify that residents’ care records are reviewed in depth during these visits. A newly appointed training officer will be assisting with these visits focussing on standards of care and staff training needs. A sample check of monies held on behalf of residents found that money was securely stored and balances were correct. The registered manager confirmed that regular checks of the premises are undertaken to identify any health and safety issues. The pre-inspection questionnaire confirms that regular servicing and maintenance checks on the premises and equipment are carried out. For example servicing of the central heating system, lift and fire equipment. A maintenance man is employed to deal with day to day work that is required. Records confirm that staff receive appropriate training in safe working practices. Ashley Court Care Home DS0000050486.V292408.R02.S.doc Version 5.1 Page 24 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 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X X 3 X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Ashley Court Care Home DS0000050486.V292408.R02.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? No 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. Refer to Standard Good Practice Recommendations Ashley Court Care Home DS0000050486.V292408.R02.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Northampton Office 1st Floor, Newland House Campbell Square Northampton 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. 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