Inspection on 25/01/06 for Ashton Court

This inspection was carried out on 25th January 2006.

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

Ashton Court 24/05/07

Ashton Court 24/07/06

Ashton Court 03/08/05

Ashton Court 17/01/05

Ashton Court 16/06/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Ashton Court 376 West Road Newcastle Upon Tyne Tyne & Wear NE4 9RJ Lead Inspector Elaine Malloy Unannounced Inspection 12:15 25 to 26 January 2006 th th 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 DS0000000392.V263502.R01.S.doc Version 5.0 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. DS0000000392.V263502.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ashton Court Address 376 West Road Newcastle Upon Tyne Tyne & Wear NE4 9RJ 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) 0191 275 0638 0191 2750638 Solehawk Limited Mrs Sue Horsley Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37) of places DS0000000392.V263502.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd August 2005 Brief Description of the Service: Ashton Court is a care home that provides personal care for up to 37 older people. The home is situated on the corner of the West Road and Two Ball Lonnen and is close to local amenities and public transport. There is an accessible garden and car parking space. Accommodation is over two floors and a passenger lift is provided. All bedrooms are currently single occupancy and there are larger rooms that can be used as doubles. The home has a large lounge that is divided into smaller areas and there is an adjoining dining room. DS0000000392.V263502.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over 2 visits totalling 5 hours. Standards were inspected through discussion with management, staff and residents, and examining records. The building was also inspected. Each area that the home was asked to improve at the last inspection was checked. What the service does well: What has improved since the last inspection? Action had been taken on some of the issues from the previous inspection. This had resulted in: Better recording of care plans for continence management. DS0000000392.V263502.R01.S.doc Version 5.0 Page 6 More frequent recording of day and night reports, linking to care plans. Replacing two windows with broken double-glazing seals. 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. DS0000000392.V263502.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection DS0000000392.V263502.R01.S.doc Version 5.0 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 the following standard(s): 3. All residents have their care needs assessed before admission. EVIDENCE: Evidence was seen that new residents have their care needs assessed before moving into the home. Care Management assessment is also obtained where applicable. The home uses an ‘Admission Checklist’ to ensure all necessary recording systems are completed. DS0000000392.V263502.R01.S.doc Version 5.0 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 the following standard(s): 7, 9 and 10. Residents’ needs are regularly assessed, care planned and reviewed. Toileting programmes need to be introduced to aid continence management. Residents are protected by the home’s medication recording system and staff have had training. There are practices to make sure resident privacy and dignity is maintained. EVIDENCE: Resident care records demonstrated thorough assessment of needs, up to date care plans and individual care reviews. At the last inspection a Requirement was made for care plans addressing continence management to be specifically recorded, and toileting programmes introduced. Care plans had improved, however individual toileting programmes were still to be put in place. Day and night reports were also to be recorded with greater frequency and link to care plans. These were now being recorded at least weekly with entries relating to current care plans. The home’s medication recording system was examined. Photographs were in place. Administration records were well recorded with no gaps to signatures DS0000000392.V263502.R01.S.doc Version 5.0 Page 10 and codes entered to state any reasons why medication was not given. The register for Controlled Drugs was also appropriately recorded. All care staff have completed medication training. Personal care and medical examination/treatment is carried out in private. Staff check and record how residents prefer to be addressed and their preference for gender of carer. The pay telephone was currently disconnected however residents can use the office telephone. Some residents have their own telephones in bedrooms. Mail is given unopened and staff/relatives support residents in dealing with correspondence. Systems are in place to make sure that residents wear their own clothes. All clothing is labelled and each resident has a named laundry basket. Individual bags to put tights/stockings/socks in for washing are to be purchased. No bedrooms are shared at present. Residents spoken with confirmed that staff treat them with respect and maintain privacy and dignity. DS0000000392.V263502.R01.S.doc Version 5.0 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 the following standard(s): 14 and 15. Residents are given choices and encouraged to make decisions in daily living. Variety and choice of meals is offered and residents said the food is very good. EVIDENCE: Residents are encouraged to manage their personal finances for as long as they have capacity to do so. Relatives and solicitors assist where needed. No one from the home/company has Appointeeship responsibility for any resident’s finances. Advocacy information is available. In practice many residents have relatives who advocate on their behalf. The extent of personal possessions that can be brought into the home is agreed before admission. Residents and relatives have access to personal records, and are involved in providing assessment information, care planning and reviews. Residents spoken with gave very positive comments on life in the home. They said they were happy here, there are flexible routines and described staff as lovely and kind. A 4-week seasonal menu was in place with good variety and choice of meals. Breakfast consists of grapefruit, prunes, cereals, porridge, toast and cooked items daily. Lunch is a soup starter followed by choice of main meal and dessert. Tea is also a choice of lighter meal, sandwiches and cakes. Snack suppers are served with milky drinks. Preference sheets are completed daily DS0000000392.V263502.R01.S.doc Version 5.0 Page 12 indicating each resident’s choice of meals. Menus are displayed on dining room tables. Residents spoken with said the food was very good and there was plenty provided. Nutritional assessment is completed and care plans are devised where needed. Resident weights are monitored. Supplement drinks are home made with fruit, cream, ice cream etc. Care and catering staff are knowledgeable about nutritional needs of older people and fortifying foods to meet the nutritional needs of older people. One resident currently requires some assistance with feeding. Two residents use plate-guards, one has adapted cutlery and ‘feeding’ cups are used at night to prevent spillage. DS0000000392.V263502.R01.S.doc Version 5.0 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 the following standard(s): 16 and 18. Residents understand how to make a complaint. There are procedures and staff training to protect residents from abuse. EVIDENCE: No complaints had been received in the period since the last inspection. Residents spoken with said they had no reason to make complaint but would speak to the Manager or staff if necessary. The home has policies and procedures for the protection of vulnerable adults, prevention of abuse and whistle blowing (informing on bad practice). Staff are provided with relevant training. There have been no allegations of abuse. DS0000000392.V263502.R01.S.doc Version 5.0 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 the following standard(s): 19, 21, 24, 25 and 26. A number of improvements are still needed to the building. The home is kept clean and there are measures to control infection. EVIDENCE: At the last inspection there was a number of outstanding Requirements concerning improvements to the building. Further Requirements were also made. These were checked during a tour of the home. The following issues had not been addressed: 1. The work on the upstairs shower room must be completed and made operational. 2. Repair to the bath panel in bathroom 4. 3. Suitable ventilation must be fitted in the designated smoking room 4. Lighting in bedrooms and bathrooms must be reviewed and where necessary brighter lighting provided. 5. Further decoration must be carried out in bedroom 22. DS0000000392.V263502.R01.S.doc Version 5.0 Page 15 During the tour the following issues were also noted: Mildew to tiles in shower room 2 Bedroom doors in need of repainting Odour from drains in bathroom 5 (unused). Resident bedrooms were nicely personalised with their belongings. The building was warm and clean. There are policies and procedures on infection control. Suitable hand washing facilities are provided in toilets, bathrooms, sluice, laundry and kitchen for staff hand washing. Disposable aprons and gloves are provided. The Manager is the link person for Infection Control and attends training/advice sessions. DS0000000392.V263502.R01.S.doc Version 5.0 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 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, 29 and 30. There are good staffing levels to meet the needs of the number of residents. The recruitment process for new staff has been improved. Staff are provided with a range of training relevant to their work with older people, including care qualifications. EVIDENCE: At the time of the inspection there was 24 residents. There is suitable care staffing levels of 4 carers in the morning, 3 carers in the afternoons and evening and 2 carers at night. A part time Activities co-ordinator is employed. Weekly catering, domestic and laundry staffing hours were satisfactory. At the last inspection a Recommendation was made for rotas to indicate staff left in charge of the home in the absence of the manager. This had been addressed. There is now a senior carer on each shift. There were no current vacancies. Two new carers had been appointed since the last inspection. Appropriate staff recruitment information was maintained. Arrangements are in place for staff to be subject to Criminal Records Bureau checks. New staff complete induction training. Details of all training courses and certificates are kept. Recent training included safe working practices – fire safety, food hygiene, moving and handling, and advanced first aid. Staff had also attended training on diabetes, continence, medication and palliative care. DS0000000392.V263502.R01.S.doc Version 5.0 Page 17 Care staff have either completed NVQ qualifications or are in the process of studying. DS0000000392.V263502.R01.S.doc Version 5.0 Page 18 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): 35, 37 and 38. Residents’ personal finances were properly recorded, however receipts for all external purchases should be obtained. The Registered Person, or their representative was still not conducting monthly visits to the home and reporting on findings. Health and safety checks are carried out and records are kept. Fire alarms need to be tested weekly. EVIDENCE: Resident personal finance records were examined. A file is maintained with individual sheets for each person’s transactions. Entries were suitably recorded with two signatures and numbered receipts. There was evidence of personal spending. Receipts should be obtained for all shop purchases. Spot checks of DS0000000392.V263502.R01.S.doc Version 5.0 Page 19 balances and cash were found to be correct. A cash float is available outside of office hours. At the last inspection a Requirement was made for The Registered Person, or their representative must visit the home at least monthly and prepare a written report on the conduct of the home. Only two reports were on file, from October and December 2005. Staff are provided with training in safe working practices and use of equipment. Records of fire safety checks, tests and instructions were examined. These were up to date with the exception of weekly fire alarm tests that were last recorded at the end of December 2005. Records of accidents are maintained and the Manager carries out monthly accident analysis. DS0000000392.V263502.R01.S.doc Version 5.0 Page 20 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 2 X X 2 2 3 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 2 X 2 2 DS0000000392.V263502.R01.S.doc Version 5.0 Page 21 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 2 Standard OP7 OP21 Regulation 15 23 Requirement (Outstanding Requirement) Toileting programmes must be introduced. (a) The work on the upstairs shower room must be completed and made operational (Outstanding Requirement) (b) Repair the bath panel in bathroom 4 (Outstanding Requirement) (c) Mildew to tiles in shower room 2 must be removed (d) Odour from drains in bathroom 5 must be eliminated. (a) Further decoration must be carried out in bedroom 22 (Outstanding Requirement) (b) Bedroom doors must be repainted Suitable ventilation must be fitted in the designated smoking room (Outstanding Requirement) (b) Lighting in bedrooms and bathrooms must be reviewed and where necessary brighter lighting provided. Fire alarms must be tested weekly and recorded. Timescale for action 26/02/06 26/04/06 3 OP24 23 26/04/06 4 OP25 23 26/04/06 5 OP38 23(4) 26/01/06 DS0000000392.V263502.R01.S.doc Version 5.0 Page 22 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 OP35 Good Practice Recommendations Receipts should be obtained for all purchases made on behalf of residents. DS0000000392.V263502.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 DS0000000392.V263502.R01.S.doc Version 5.0 Page 24 - 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!