Inspection on 22/02/06 for Ash Court Care Centre

This inspection was carried out on 22nd February 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

Ash Court Care Centre 20/07/07

Ash Court Care Centre 09/11/06

Ash Court Care Centre 11/01/05

Ash Court Care Centre 02/08/04

Similar services:

Ashlong House

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

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

CARE HOMES FOR OLDER PEOPLE Ash Court Nursing Home Ash Court Ascham Street London NW5 2PD Lead Inspector Ms Pippa Treadwell-Smith Unannounced Inspection 22nd February 2006 11:00 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 Ash Court Nursing Home DS0000010320.V250408.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ash Court Nursing Home DS0000010320.V250408.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Ash Court Nursing Home Address Ash Court Ascham Street London NW5 2PD 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) 020 7419 7474 020 7419 7676 florence.clarke@foresthc.com Ash Court Community Limited Ms Florence Justina Clarke Care Home 62 Category(ies) of Old age, not falling within any other category registration, with number (61), Physical disability (1) of places Ash Court Nursing Home DS0000010320.V250408.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. for the provision of general nursing care for up to 62 users aged 60 years and over. a) out of which 16 beds can also be used for people requiring personal care only. b) up to 3 of the 62 service users can also be aged 55 years and over. c) up to one named service user (as per Ash Court application of 21st February 2005) aged 53 years and over, can be accommodated for the provision of nursing care. Room 44 to be used only for Patients, who do not need to use a wheelchair or who do not need assistance to be nursed in bed. The Staffing Notice For the provision of general nursing care for one young Physically disabled, named person, aged 55 provided that there are sufficient resources and skilled qualified nursing staff to meet all Ms Q’S assessed health care needs at Ash Court Nursing Home. 10th August 2005 2. 3. 4. Date of last inspection Brief Description of the Service: Ash Court is a purpose built care home with nursing. It is privately owned and managed. It can accommodate 62 people from the age of 60 years in 58 single and 2 double rooms. Sixteen of those places can be used for service users requiring personal care only. The home is sited in a courtyard in a residential area. Access to the home is through a gated driveway. There is sufficient care parking space for 10 cars at the front of the property. The nearest underground station is Kentish Town and the home is on the C11, 134 and 204 bus routes. Entry into the complex is through a security gate. The front entrance is covered by a large conservatory, which is used by service users. Although a garden is not available service users have access to limited but well-presented outside space. The home is spread over three levels. Each floor is self-contained, with bedrooms, assisted bathrooms and seating-cumdining areas. Each floor is staffed independently. There is a main kitchen and laundry room, which serves the whole home. All the bedrooms have an ensuite toilet and hand basin. Each room has a variable height profile bed. There are cantilever tables and footstools available. Room sizes, corridor widths and doorframes are large enough to allow access to wheelchair users or zimmer frames. A nurse call system is installed throughout the building. There is a shaft lift that gives access to the upper floors. Ash Court Nursing Home DS0000010320.V250408.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the second inspection for the inspection year 2005/2006. It took place during the day and lasted about four hours. The manager, deputy and service users assisted in the inspection. A variety of records were looked at including medication administration records, training records and service user’s financial records. What the service does well: 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. Ash Court Nursing Home DS0000010320.V250408.R01.S.doc Version 5.1 Page 6 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 Ash Court Nursing Home DS0000010320.V250408.R01.S.doc Version 5.1 Page 7 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): EVIDENCE: Ash Court Nursing Home DS0000010320.V250408.R01.S.doc Version 5.1 Page 8 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): Standard 9 The systems for the administration of medication are good with clear and comprehensive arrangements in place to ensure that service users needs are met. EVIDENCE: The home has a policy for the administration of medication. It provides good practice guidance on all aspects of medication handling including handling drug errors. This policy was being followed. The manager confirmed that no service users are self-administering their medication due to their complex health conditions. There are arrangements in place for risk assessments and individual storage if service users are assessed as being competent to self-administer their medication. A sample of medication administration records (MARS) was checked on all three floors of the home. The recording of administration is good. Sample signatures are available at the front of each MARS folder and there is a photograph of each service user attached to the MARS chart. There are no gaps in recording, the use of food supplements and topical preparations are Ash Court Nursing Home DS0000010320.V250408.R01.S.doc Version 5.1 Page 9 being recorded consistently. The inspector did identify that the prescription recorded on the MARS chart by the dispensing pharmacist was not always clear enough. On occasions the pharmacist has recorded “Follow the directions given by your doctor”. Staff are aware that this is insufficient and are in discussion with the pharmacist. Also when a new medication is prescribed, staff are recording it on the MARS sheet but not always signing and dating the entry. On each floor medication is stored in locked clinical rooms. The clinical rooms have air conditioning units. Medication fridges are available and the temperatures are monitored. Where breaches of the recommended temperature occur, these are investigated. This monitoring has identified a problem with one fridge with a high reading and interim arrangements are in place to store the contents of this fridge elsewhere. Each medication cupboard has a separate controlled drugs cupboard. The medication policy has guidance on the storing and recording of controlled drugs. The CD cupboards are alarmed so when they are opened an alarm is sounded on the floor. Medication is administered by registered nurses, or by adaptation nurses under supervision. The CSCI Pharmacy Inspectors are recommending that as care staff are responsible for most of the day-to-day care of service users; that it would be good practice to ensure that they are familiar with the side effects of medication so that they can notify any change in health condition. It is recommended that the medication profile include the side effects and purpose of each medication. Ash Court Nursing Home DS0000010320.V250408.R01.S.doc Version 5.1 Page 10 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): EVIDENCE: Ash Court Nursing Home DS0000010320.V250408.R01.S.doc Version 5.1 Page 11 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): Standard 18 The service users living in Ash Court are protected and kept safe by the home’s policies, procedures and training. EVIDENCE: The home has a policy and procedure on adult protection, which is linked to local authority guidance. Staff received training on adult protection and it is also discussed as part of ongoing supervision. The home has been the subject of an adult protection investigation and the allegations were not upheld. The investigation showed that a good standard of care was being provided. Ash Court Nursing Home DS0000010320.V250408.R01.S.doc Version 5.1 Page 12 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): EVIDENCE: Ash Court Nursing Home DS0000010320.V250408.R01.S.doc Version 5.1 Page 13 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): Standard 28 The care needs of the service users are being met by staff with the appropriate knowledge, skills and training. EVIDENCE: A training plan is available, which shows what training has been booked for the coming year. The home offers placements to both adaptation students and student nurses. A programme is in place for care staff to enrol on NVQ training. All senior care staff have achieved NVQ level 2. For these staff that do not choose to do NVQ training, then comparative shortened training is available. An example of this is 13 staff are attending NVQ in infection control. All staff receive training, which is commensurate with their role in the home. There is clear evidence of qualified staff keeping themselves updated with regards to P.R.E.P. Ash Court Nursing Home DS0000010320.V250408.R01.S.doc Version 5.1 Page 14 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): Standard 31 & 35 The registered manager is qualified and experience to manage the home effectively. There are systems in place to ensure that service users personal finances are well managed. EVIDENCE: The manager has successfully completed the fit person process for registration. She has a relevant nursing qualification and completed courses 998, 934 and a BSC in Nutrition. She is registered to start the Registered Manager’s Award in March 2006. The home has a policy relating to handling service users monies. Financial records are computerised and these can be printed off for service users and relatives. Monies are kept securely in the administrators’ office. Receipts are obtained as well as signatures for all transactions. Service users have access to their monies held in safe keeping at the weekend. Ash Court Nursing Home DS0000010320.V250408.R01.S.doc Version 5.1 Page 15 Ash Court Nursing Home DS0000010320.V250408.R01.S.doc Version 5.1 Page 16 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 X 28 3 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X X Ash Court Nursing Home DS0000010320.V250408.R01.S.doc Version 5.1 Page 17 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. 1 Refer to Standard OP9 Good Practice Recommendations It is recommended that the home expand the drug profiles to enable care staff to familiarise themselves with the use of the drugs and their side effects. Ash Court Nursing Home DS0000010320.V250408.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection Camden Local Office Centro 4 20-23 Mandela Street London NW1 0DU 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 Ash Court Nursing Home DS0000010320.V250408.R01.S.doc Version 5.1 Page 19 - 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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