Care Home: Ashbrook Court Care Home

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What the care home does well Prospective people wishing to live at Ashbrook Court are assessed prior to admission so that the management and staff team are able to meet the individual`s needs. Visitors to the home are made to feel welcome and are offered refreshments. Several members of staff have been employed at the care home for some considerable time, providing stability and continuity of care to the people who live there. There is a quality assurance system in place so as to seek the views of residents and their representatives and staff about the services and facilities provided at the home. Medication is mainly stored and administered in accordance with legal requirements and the directions of the prescribers. The home`s medication records provide an audit of medication kept in the home and printed protocols are kept with the medicines records to assist staff where prescribing directions require further decision, for example, "when required". People who use the service are able to raise concerns and feel confident to do this. Where safeguarding alerts are raised and initiated, there is evidence to show that the management and staff team of the home are proactive so as to ensure positive outcomes for people and that they are protected from possible harm and/or abuse. The quality of meals provided at the home for residents is good and people`s comments in relation to meals provided were positive and are recorded within the main text of the report. There is a safe and robust system in place to ensure that recruitment procedures within the home ensure people`s safety and wellbeing. People live in a home which is comfortable, safe and homely for their needs. The home was observed to be clean, tidy and odour free at the time of the site visit. What has improved since the last inspection? The organisation have appointed a permanent manager for Ashbrook Court. The manager has at this inspection demonstrated an enthusiasm, awareness and understanding of areas that are working well and where improvements are still required to ensure positive outcomes for people who live at the home. The manager is formally registered with the Care Quality Commission having submitted an application and undergone a `Fit Person` Interview in May 2010. Improvements have been made by the management team of the home to address previous shortfalls and deficits pertaining to the home`s care planning and risk assessing processes. A new care planning format has been adopted and newly implemented, the care files have been streamlined with much historical information now archived and formats/forms which were seen as a disadvantage and not used by staff have been withdrawn. In addition staff working at the home have received care planning training. Some aspects of medication practices and procedures have improved. This refers specifically to medication not left unattended and easily accessible to people who live at the home and people now have their medication administered in accordance with the prescriber`s instructions. An independent consultancy and training team specialising in developing dementia care services for older people has been utilised at Ashbrook Court for the past 10 months for advice and support. The ultimate aim of the project is to provide the home with an opportunity to implement a holistic approach to improving the culture of care for people with Dementia. This has assisted staff in looking at how people with Dementia can be better supported in all aspects of their lives, to provide a more `person centred` approach and to enhance people`s opportunity to receive meaningful social care activities. More training opportunities in both core and specialist subject areas have been provided for staff so as to ensure they are able to carry out their role effectively. Staff are now receiving regular formal supervision. What the care home could do better: Further development of the home`s care planning and risk assessing processes is required, so as to ensure that these clearly identify individual`s care needs and staff have the most up to date information about the individual. Medicines administered by healthcare professionals from outside the home require monitoring to ensure they are stored and handled correctly. The cold storage of medicines requires increased monitoring to ensure correct conditions of temperature and security are maintained. Documented accountability is required for all changes to medicine records. Medication must not be handled directly by the person administering the medication and where a resident is refusing to take their medication and/or exercising their right not to take it at a specified time, the member of staff administering medication must respect the person`s choice. Ensure the dining experience for all people at the home is positive and people`s choices and wishes are taken into account. Key inspection report Care homes for older people Name: Address: Ashbrook Court Care Home Sewardstone Road Waltham Abbey Essex E4 7RG     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Michelle Love     Date: 0 7 0 6 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 34 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 34 Information about the care home Name of care home: Address: Ashbrook Court Care Home Sewardstone Road Waltham Abbey Essex E4 7RG 02085245530 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): jennie.worthington@carebase.org.uk www.ashbrookcourtcarehome.co.uk Carebase (Sewardstone) Limited Name of registered manager (if applicable) Mrs Glenda Myfanwy Barker Type of registration: Number of places registered: care home 70 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia physical disability Additional conditions: The maximum number of service users who can be accommodated is: 70 The registered person may provide the following category of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Dementia - Code DE Physical disability - Code PD Date of last inspection Brief description of the care home Ashbrook Court Care Home is a purpose built 70 bedded home situated on the outskirts of the Essex town of Waltham Abbey, in close proximity to the M25 London orbital motorway. It is registered for a total of 70 residents who need personal and nursing care. The beds are multi registered to allow for flexibility of admission to the home. The home accepts residents over the age of 60 years of both genders who require nursing care by reason of physical disability; nursing care by reason of Care Homes for Older People Page 4 of 34 Over 65 0 0 70 70 1 7 1 1 2 0 0 9 Brief description of the care home dementia; and residential care by reason of dementia. All accommodation is in single occupancy en-suite rooms on two floors. The decoration and equipment throughout the home is of a high standard. It is homely in decorative style and many occupied rooms are personalised to the residents taste. There are a number of communal areas throughout the home, including a dining room on each floor. The range of fees given at the time of the site visit were people who are privately funded, £800.00 per week, people who are funded by Social Services, residential (dementia) £550.00 per week, nursing (dementia) £630.00 per week and people who solely require nursing care £600.00 per week. Ashbrook Courts Statement of Purpose and Service Users Guide/brochure can be obtained from the home upon request. Care Homes for Older People Page 5 of 34 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This was an unannounced key inspection. The visit took place over one day by one inspector and lasted a total of 9.5 hours, with all key standards inspected. Additionally progress against previous requirements and recommendations from the last key inspection were also inspected. A specialist pharmacist inspector examined medication practices and procedures. As part of the process a number of records relating to people who live at the home, care staff and the general running of the home were examined. Additionally a partial tour of the premises was undertaken, residents and members of care staff were spoken with and their comments are used throughout the main text of the report. The manager, care manager, administrator, business manager and other members of the staff team assisted us on the day of the site visit. Feedback on the inspection findings were given to the management team and the opportunity for discussion and/or Care Homes for Older People Page 6 of 34 clarification was given. As a result of concerns relating to the homes medication practices and procedures and care planning and risk assessing processes at the key inspection of June 2009, a focused random inspection was undertaken on 17th November 2009. Some improvements were noted in each area. Further improvements were required to be made by the organisation so as to ensure positive outcomes for people. Requirements made at the random inspection were inspected as part of this inspection and our findings are recorded within the main text of the report. Care Homes for Older People Page 7 of 34 What the care home does well: What has improved since the last inspection? The organisation have appointed a permanent manager for Ashbrook Court. The manager has at this inspection demonstrated an enthusiasm, awareness and understanding of areas that are working well and where improvements are still required to ensure positive outcomes for people who live at the home. The manager is formally registered with the Care Quality Commission having submitted an application and undergone a Fit Person Interview in May 2010. Improvements have been made by the management team of the home to address previous shortfalls and deficits pertaining to the homes care planning and risk assessing processes. A new care planning format has been adopted and newly implemented, the care files have been streamlined with much historical information now archived and formats/forms which were seen as a disadvantage and not used by staff have been withdrawn. In addition staff working at the home have received care planning training. Some aspects of medication practices and procedures have improved. This refers Care Homes for Older People Page 8 of 34 specifically to medication not left unattended and easily accessible to people who live at the home and people now have their medication administered in accordance with the prescribers instructions. An independent consultancy and training team specialising in developing dementia care services for older people has been utilised at Ashbrook Court for the past 10 months for advice and support. The ultimate aim of the project is to provide the home with an opportunity to implement a holistic approach to improving the culture of care for people with Dementia. This has assisted staff in looking at how people with Dementia can be better supported in all aspects of their lives, to provide a more person centred approach and to enhance peoples opportunity to receive meaningful social care activities. More training opportunities in both core and specialist subject areas have been provided for staff so as to ensure they are able to carry out their role effectively. Staff are now receiving regular formal supervision. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 34 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 34 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who come to live at the home can be confident they will be assessed prior to admission and their needs will be met. Evidence: The home has a Statement of Purpose and Service Users Guide, both of which were reviewed in May 2010. Both of these documents provide the prospective person and/or their representative with the necessary information to enable them to decide if the home would be able to meet their assessed needs. Included within each document are photographs of the home environment and where appropriate and upon request both documents can be provided in larger print, in Braille or in an alternative language. There is a formal pre admission assessment format and procedure in place, so as to ensure that the staff and management team are able to meet the prospective persons needs. Admissions are not made to the home until a full needs assessment has been Care Homes for Older People Page 11 of 34 Evidence: undertaken. In addition where appropriate, supplementary information is provided by the persons Placing Authority or Primary Care Trust. The manager confirmed that usual practice is for the prospective person and/or their representative to be given the opportunity to visit Ashbrook Court prior to admission so as to look around the premises, to have a meal, to meet people who already live in the home and to meet staff. It is the expectation of the organisation that all placements to Ashbrook Court are planned however where a person is admitted to the care home in an emergency, steps are taken to acquire as much information as possible about the person. As part of this site visit the care files for two people newly admitted to Ashbrook Court were examined. Records showed that a pre admission assessment was completed for each person. There was evidence to show that the information recorded as part of the pre admission assessment process forms the basis of the persons individualised plan of care. Information recorded for one person was seen to be lacking in detail and it was unclear as to how the management team had determined the persons needs could be met based on the information gathered at the initial pre admission assessment stage. Consideration should be given to ensure there is clear evidence available to demonstrate that the prospective person has been actively involved in the admission process and that their views have been incorporated where possible as this was unclear from inspection of their pre admission assessment and both people were unable to clarify to us if they had been involved in the assessment process. We spoke with a relative of a resident who has been living at Ashbrook Court for some time. They told us they had visited the home prior to their member of familys admission and that the admission process had been smooth and their relative had been made to feel very welcome. Care Homes for Older People Page 12 of 34 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live at the home can expect to have the majority of their care needs identified so as to ensure positive outcomes for people. Evidence: There is a formal care planning system in place to help staff identify the care needs of individual people and to specify how these are to be met by staff who work in the home. In addition to the care plan, formal assessments are completed in relation to manual handling, nutrition, pressure area care and falls. Of those people case tracked, each person was observed to have a plan of care and these were devised from information undertaken as part of the pre admission assessment and as stated previously, from other associated information provided by external stakeholders. As part of the inspection process we looked at 3 peoples care files (2 in full and 1 in relation to a specific healthcare need). We were advised by the care manager that following the key inspection in June 2009 and the random inspection in November 2009, improvements have been made to the Care Homes for Older People Page 13 of 34 Evidence: homes care planning processes. This has included streamlining the information kept on each persons care file and implementing a new care planning system. Records showed that since 2009 improvements have been made to the care planning system so as to ensure they provide clearer information about the individual persons care needs, provide appropriate guidance to care staff as to how the persons care needs are to be met, ensure that identified risks to the individual person are recorded and proactively managed and there is a clear audit trail of care and interventions provided by care staff and other healthcare professionals and agencies as required. Each care plan looked at was written in plain language and was easy to understand and a detailed life history was completed for each person. Records also showed that efforts have been made by staff to make the care records more person centred and to include peoples wishes and personal preferences where possible. This was particularly noticeable within their personal hygiene element of their care plan documentation. Information recorded included the number of staff required to provide assistance, clothing preferences and the specific areas where they required staff support. Where further improvements to care planning are required, specific examples were discussed with members of the management team. The care file for one person made reference to them having a significant sensory impairment however there was no care plan or risk assessment devised as to how their sensory impairment impacts on their ability to undertake everyday tasks and the challenges posed. The same persons care file recorded them as having a history of falls and being at risk. A care plan relating to falls was in place however it was unclear as to why this was written 7 days after their admission to the home and not sooner based on their previous medical history and the outcome of the formal falls assessment. The care manager was unable to provide a rationale. We looked at two peoples care files in relation to their mental wellbeing and challenging behaviour. Records showed for one person that their mental health could be unpredictable on occasions and that they had previously attempted to harm others. The care plan relating to their mental wellbeing was observed to be basic and it was unclear from the records examined as to how this was to be proactively managed. In addition there was no information recorded as to how their mental health needs were being monitored and the steps to be taken should this deteriorate to an unacceptable level. No risk assessment was in place detailing the steps to be taken by staff to reduce the risk of harm to the person or others. However formal behavioural monitoring records recorded several occasions whereby the person had been physically challenging towards staff. Although records detailed the challenging behaviour exhibited they did not provide details of the outcome of the incident. We looked at another persons care file in relation to their challenging behaviour. We Care Homes for Older People Page 14 of 34 Evidence: looked at daily care records and these confirmed occasions whereby they could become verbally and physically challenging towards others, however records lacked detail and clarity as to staffs interventions and outcomes. This refers specifically to generic comments recorded by staff which included all hell was let loose and [name of person] spend half of day in bed and when they woke they were very aggressive punching staff. Had a good day though. No care plan was formulated detailing the specific nature of the persons challenging behaviours, known triggers or evidence to show that guidelines were in place detailing the persons care needs and the action to be taken by care staff to ensure their needs are met and other people protected. On inspection of one persons daily care records, these told us they are prescribed PRN (as and when required) medication to assist in the management of their challening behaviours. A PRN protocol was in place although further clarification is required so there are clear guidelines for staff to follow when administering these medicines e.g. the specific circumstances when this medication is to be administered. Daily care records evidenced inadequate and unclear explanations as to why the medication was administered. Examples of our findings were discussed with the management team of the home at the time of the site visit. Records showed that people living at Ashbrook Court continue to have access to a range of healthcare professionals and services as and when required, both at the care home and within the local community. These include attendance at hospital appointments, optician, dentist, District Nurse Services, Community Psychiatric Nurse, GP, Dietician, Practice Nurse etc. Three members of staff spoken with were able to demonstrate a good understanding and awareness of peoples basic care needs and throughout the day of the inspection, there were many positive interactions between these staff and people who live at the home. Where support and assistance was provided by staff in relation to individuals personal care, this was conducted with respect, sensitivity and in a timely manner. We spoke with 4 people who live at Ashbrook Court and who are able to tell us what it is like to live there. Comments were positive and included the staff are lovely, the care and support provided is very good, nothing is too much trouble, I am happy with the care provided and I am happy here. One relative spoken with told us they feel their relative receives a good level of support, care and attention by staff and in their opinion their relative is happy living at Ashbrook Court. There were other interactions by two qualified members of staff which did not provide positive outcomes for people living in the home. These were discussed with the management team of the home at the time of the site visit and are recorded in more Care Homes for Older People Page 15 of 34 Evidence: detail further on within the main text of the report. The manager confirmed her disappointment from our observations and gave us a verbal assurance that the issues highlighted were isolated and not indicative of the culture of the service. The manager told us that an independent consultancy and training team specialising in developing dementia care services for older people has been utilised at Ashbrook Court for the past 10 months for advice and support. The ultimate aim of the project is to provide the home with an opportunity to implement a holistic approach to improving the culture of care for people with dementia who live at Ashbrook Court. We were told that in April 2010 an audit consisting of 6.5 hours of observation over one day by the independent consultancy team was carried out. A comprehensive report and action plan was provided from the findings of the audit with many improvements noted. Practices and procedures for the safe storage, handling and recording of medication were examined as part of this inspection. The first day of the 4-weekly repeat prescribing cycle started on the day of this inspection and therefore most of the medicine administration record (MAR) charts and medication supplied had only been started that day. There were therefore few records to audit, however, some issues were noted, as follows. Insulin was being administered by district nurses to a resident in the homes dementia unit on the ground floor. Once the insulin was in-use its usage is limited to 28 days as indicated on the container, however, there was no record of the date the vial of insulin was started and therefore no indication of when the 28 days are lapsed. At the dosage of 10 units each morning being administered and the strength of the insulin at 100 units per ml, each 10ml vial contained 100 days treatment. This posed the risk of the insulin being used for 72 days beyond its in-use expiry date or longer if the resident was unavailable such as being admitted to hospital. Approximately 3mls remained in the vial currently in use, which suggests that the vial had been in use for approximately 40 days beyond its in-use expiry. In addition the insulin was stored on the open top of a wardrobe in the residents room together with syringes and needles for administration. Although this may not have been in reach of the resident it may be within reach of other residents or visitors to the dementia unit or may fall from the free-standing wardrobe if it was jolted. The home has a responsibility to ensure that medicines kept in the home and administered by outside healthcare professionals are stored correctly and usage is monitored. Any discrepancies by outside healthcare professionals should be reported to the local Primary Care Trust (PCT). This is reinforced by the homes medication policies & procedures reference 11.1. Care Homes for Older People Page 16 of 34 Evidence: Changes to the MAR charts made by the homes staff require the signed initials and date of entry to provide for accountability and audit, however, this was not always followed despite the homes medication policies & procedures requiring this in reference 27.3 bullet point 8, although this documented procedure omitted the need to date the entry. Changes not meeting this requirement were found on the MAR chart for a male resident in the dementia unit where the dosage direction for Aricept 5mg tablets had the words or two crossed out leaving the dosage as one, and an entry for a female resident on the upper floor where the dosage direction for senna tablets had the words one or crossed out leaving the dosage as two. Levothyroxine prescribed for a resident in the dementia unit was recorded as run out awaiting new script. Although we were informed that delays had occurred with the doctors surgery sending the prescription further steps should have been taken to ensure continuity of treatment. Although the medicines fridges in the medicines storage rooms on both the lower and upper floors were lockable they were found to be unlocked and the key not available on request. The fridge on the lower floor had a current temperature of 10C which is beyond the required range of 2 to 8C, however, the daily records indicated the temperature as 7C for that day. Both fridges had maximum/minimum thermometers which were not being fully utilised. It would therefore be good practice to record the maximum and minimum temperatures each day in addition to the current temperature to ensure the required temperature range is being maintained at all times. Non-medicated topical medicines such as creams and ointments were recorded on the MAR charts as applied by care staff. For accountability a record should be completed by the care staff at the point of usage when applying these treatments. This could include a duplicate copy of the MAR chart and both the duplicate and original MAR charts archived together. The homes medication policies & procedures were readily available for the guidance of staff on the ground floor, however, the document was not available when requested to the nurse in charge on the upper floor. We observed the morning administration of medication to people on the ground floor as the administration of medication on the first floor had been completed at the time of our arrival. At the previous random inspection to the service in November 2009 we observed medication to be left unattended and easily accessible to people who live at the home and others on several occasions. At this site visit the medication trolley was locked and no medication was left unattended therefore the requirement made at the Care Homes for Older People Page 17 of 34 Evidence: last inspection is considered met. The administration of medication on the ground floor was completed by an acting senior carer on the Residential Dementia Unit and by a qualified member of staff on the Nursing Unit. We watched medicines being given to some people during the morning. The acting senior carer administering medication was observed to interact well with people who live at the home when giving them their medication and this was observed to be undertaken in a safe manner. However we saw the qualified member of staff handle medication by dispensing medication from a blister pack into their hand and then to place in a medication pot on more than one occasion. This increases the risk of contamination and cross infection and remains an outstanding requirement. The qualified member of staff was also observed to attempt to administer medication to one person. During the interaction the qualified member of staff was observed to repeatedly ask the person to open their eyes. The person responded by saying alright alright while keeping their eyes closed and it became clear that they did not want to participate or take their medication at that time. The member of staff continued this for a period of 15 minutes before then respecting the persons choice and moving on to another task having still been unable at that time to get them to take their medication. Care Homes for Older People Page 18 of 34 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are opportunities for people to have their recreational and social care needs met. Further improvements are needed to ensure that all people who live at the home have a positive dining experience. Evidence: An activities co-ordinator is employed at Ashbrook Court Monday to Friday for 40 hours per week. From discussion with the manager and as part of staffs role, it is an expectation that all care staff will also initiate and undertake activities with people who live at the home. As previously stated the organisation have over the past 10 months utilised an independent consultancy and training team specialising in developing dementia care services for older people. The manager told us they have introduced a system whereby in addition to a varied programme of activities provided by the homes activities co-ordinator, a short burst of activities is provided by care staff for individual people or in small groups for those people who have severe dementia and/or poor cognitive ability. The type of activities provided is linked wherever possible to the persons past life history. Care Homes for Older People Page 19 of 34 Evidence: A copy of the activity programme was observed to be displayed in each of the lounge areas. The manager was advised to consider devising this in a more appropriate format so as to enable people who have a poor cognitive ability and/or sensory impairment to make an informed choice e.g. larger print and pictorial. While we recognise there are pictures detailed on the border of the activities programme, few pictures relate to the activities scheduled and this may lead to some people finding this confusing and unhelpful. Activities include sing-a-longs, watching films, art and craft projects, religious observance, knitting circle, gardening, manicures, hairdressing, external entertainers and trips out within the local community. People have access to a mini-bus 1 to 2 days a week and the opportunity to register with Dial-a-Ride or the Taxi Card Service. On the day of the site visit we observed activities for people on the dementia unit on the ground floor. The activities programme detailed that sing-a-long would be undertaken between 11.00 and 12.00 midday but this did not happen and instead one member of staff made a fruit salad with 2 people and then undertook a manicure with a another person. Each person was observed to enjoy the 1 to 1 activity provided and two other people were observed to read a newspaper. An open visiting policy is in place whereby visitors to the home can visit at any reasonable time. There was evidence throughout the day of the site visit that people who live at Ashbrook Court are supported and enabled to maintain contact with friends and family and to form relationships. Two relatives spoken with confirmed they are made to feel welcome by staff when they visit the home and can visit at any time without giving prior notice. The dining experience was observed within both units on the first floor. On one unit dining tables were attractively laid with tablecloths, cutlery, placemats, vase of flowers, condiments and serviettes. A blackboard was on the wall and this recorded the lunchtime menu choices available. We asked 4 people as to the meal choices available and found that 2 out of 4 people were able to tell us they had chosen. The lunchtime experience on this unit was observed to be positive and people were reminded of the meal choices available. People were able to choose where they had their meal, either in the dining room, while sat at a comfortable chair and a small table placed in front of them or in the comfort and privacy of their room. People were offered a choice of drinks. Where people require assistance and support by staff to eat their meal, this was provided with sensitivity and due care. We spoke with 3 people who live at the home about the quality of meals provided. Comments were positive and included oh the meals are lovely, theyre very good, I have no complaints whatsoever and the food is fine, if you dont like it you can always have an omelette or a sandwich. Care Homes for Older People Page 20 of 34 Evidence: The above was in contrast to the dining experience for people on the other unit on the first floor. No menu was displayed and when meals were provided, no-one was told of the meal choice placed in front of them. Each person was provided with a drink but not given a choice, with each person given orange juice. One person was observed to have a plated meal placed in front of them by a member of staff. The resident responded by repeatedly saying I havent had any breakfast, Im not eating until Ive had my lunch, Im not wanting anything till I have my breakfast, where is my breakfast and Dont you know what breakfast is, you dont know what it is, chuck it on the wall, its no good to me. A member of staff was observed to tell another member of staff that they would go to the main kitchen and ask the chef for a bowl of cereal. While they were gone it was of concern that a qualified member of staff sat next to the resident and made several attempts to spoon food into the persons mouth, resulting with the resident turning their face away and becoming more distressed. No attempts were made by the qualified member of staff to reduce the persons anxiety or to explain to them that their request for breakfast was being actioned. After a period of 10-15 minutes a bowl of cereal was provided, after which the resident was heard to say take dinner away I want my breakfast first. The resident was observed to settle and to enjoy eating their cereal. Verbal interactions by staff with people during the meal time were observed to be limited and where some people had stopped eating they were not given prompt assistance or support to continue to eat their meal. The dining experience for people on this unit needs to be improved so as to ensure positive outcomes. Care Homes for Older People Page 21 of 34 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are able to express their concerns and are protected from abuse. Evidence: The home has a complaints procedure that explains to people how to raise issues and the timescales by which they can expect a response. This was clearly displayed in the entrance to the home and also detailed within the Statement of Purpose and Service Users Guide. Since the last key inspection to the service in June 2009 there have been 8 complaints. These related to concerns about missing personal items, staff shortages and alleged poor care practices. In some instances we were made aware of these by the complainant and in line with our methodology and approach to managing concerns and complaints, requested the registered provider look into each matter under their complaints procedure. Where requested records of each investigation were forwarded to us prior to this inspection, these showed that each one had been investigated fully, responded to and actions identified and completed. In addition the complaints log at the home provided the same information about those complaints not forwarded to us and we were satisfied that appropriate actions had been undertaken by the management team of the home. While looking at one persons care file and their daily care records we noted that their family had made a verbal complaint to staff about Care Homes for Older People Page 22 of 34 Evidence: their member of familys lack of personal hygiene and expressed concerns that some personal belongings had gone missing. On inspection of the complaints log there was no evidence to show this had been recorded or actioned by the management team. When discussed with both the manager and care manager we were advised that neither had been informed by staff of the issues. People who live at the home are aware of how to raise concerns and said they would discuss this with their member of family, a member of care staff or manager. People spoken with also indicated they were confident to raise issues and felt their concerns and/or worries would be listened to and dealt with. One relative told us I have confidence in the manager to address any concerns. We also looked at the homes records of compliments. These included I would like to take this opportunity to thank you and your staff for all the love and care you have shown to our relative, I am writing to you on behalf of myself and other family members, to thank you for the care our relative received at Ashbrook Court and I am happy to express my satisfaction concerning the standard of care and attention which was bestowed upon my relative, by you and your team, since their admission to your establishment. My opinion is that for the duration of their stay, they received exemplary attention by you all and their life, however limited, was enhanced accordingly. There are appropriate safeguarding policies and procedures in place. Since the last key inspection in 2009 there have been 3 safeguarding referrals. We were made aware of these by the manager and are satisfied that appropriate measures were taken to refer these to the local safeguarding team. Staff spoken with demonstrated a basic understanding and awareness of safeguarding procedures and stated that should an issue arise, information would be passed to the senior in charge of the shift, care manager and/or the manager. On inspection of the staff training matrix this showed that staff working at the home have got up to date SOVA (Safeguarding of Vulnerable Adults) training. Care Homes for Older People Page 23 of 34 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a safe, well maintained and comfortable environment which meets their needs. Evidence: A partial tour of the premises was undertaken throughout the day. At the time of the site visit there were 61 people living at Ashbrook Court within 3 unitised living spaces. This refers specifically to an 18 bedded nursing unit for people with physical disabilities on the ground floor, a 16 bedded residential unit for people with dementia and a 36 bedded unit for people with dementia and who are also assessed as requiring nursing care on the first floor. There are sufficient communal space and this refers specifically to a number of communal lounge/dining areas on the ground and first floors. Two units within the home have their own kitchenette area. There are sufficient bathing and communal toileting facilities available on each floor which enable immediate access and these are fitted with appropriate aids and adaptations. Each person is provided with a single room which has en-suite facilities. A random sample of residents bedrooms on the ground and first floors were inspected and all were observed to be personalised and individualised to peoples personal preferences. People spoken with told us they are happy with their personal space. On the day of the site visit all areas of the home were observed to be clean, tidy and odour free. There are 3 secure courtyard garden Care Homes for Older People Page 24 of 34 Evidence: areas which are well maintained and accessible for peoples use. On the day of the site visit several people were observed to enjoy sitting in the garden. Improvements to the home environment have been made to each of the dementia units. On a tour of the dementia units there was now evidence of appropriate signage in place to better support recognition and orientation for people living with dementia. In addition new pictures, photographs and other sensory items have been purchased so as to provide sensory stimulation to people living at Ashbrook Court. During a tour of the premises during the morning three health and safety issues were observed. These related to the electrical lead of a Hoover and floor polisher extending across the corridors on the ground and first floor, potentially causing a tripping hazard to people who live at the home and others. In addition the cleaners trolley was left in a corridor on the ground floor while the cleaner was undertaking another task. On the trolley we observed a number of COSHH (Control of Substances Hazardous to Health) items which could cause a potential health and safety risk to people. The manager was observed to deal with two of the issues promptly. A random sample of safety and maintenance certificates showed that equipment in the home has been serviced and remains in date until their next examination. The organisation has recently reviewed the homes fire safety risk assessment and a visit by the fire safety officer from Essex County Fire and Rescue Service recorded a satisfactory standard of fire safety was being achieved and maintained at Ashbrook Court. All other fire safety records were seen to be in order with regular weekly and monthly testing of fire equipment and systems being undertaken. Care Homes for Older People Page 25 of 34 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at Ashbrook Court can expect to be cared for by sufficient numbers of competent and safely recruited staff who can meet their needs. Evidence: The manager told us there were 61 people living at Ashbrook Court and current staffing levels are 1 RGN and 3-4 care staff between 08.00 and 20.00 (Ground Floor Nursing Unit), 3 care staff (including senior in charge) between 08.00 and 20.00 (Ground Floor Residential Unit) and 1 RGN and 6 care staff between 08.00 and 20.00 (First Floor Nursing Dementia Unit) and between 20.00 and 08.00 1 RGN and 6 care staff each day. The manager told us that they are looking to review the staffing levels on the First Floor Dementia Unit to 2 RGN and 5 care staff. The above shows that since the last key inspection to the service in June 2009, the staffing levels have been reviewed and increased as a result of peoples dependency levels. In addition to the above, ancillary staff are employed and these include a chef, kitchen assistant, housekeeper and domestic staff. The managers hours are supernumerary to the above and they are employed for 40 hours per week Monday to Friday. The care managers hours are divided between providing clinical support as part of a shift and having supernumerary shifts. Care Homes for Older People Page 26 of 34 Evidence: On inspection of 4 weeks staff rosters, records showed that the above figures have been maintained. We checked the staff roster on the day of the site visit and this reflected accurately the staff on duty. The staff rosters show that no agency staff have been used at the home for some considerable time however there is a pool of bank staff to cover shifts on an as and when needed basis. Deployment of staff on the day of the site visit was observed to be appropriate for the needs and numbers of people in the home. Observation at this site visit showed that staff were working effectively as a team, are available throughout the day for people in the home whether they are in the communal lounge areas or choose to spend time in their room. Three staff files were viewed for those people newly employed at Ashbrook Court within the past 12 months. The purpose of this was to check the recruitment process in the home. Records showed there is a reasonable recruitment procedure and process in place and the majority of documentation as required by regulation is received prior to the employee starting work. The only discrepancy noted was that there was only one reference on file for one person. Each member of staff was noted to have received the homes in house orientation induction and Skills for Care was being progressed. We requested a copy of the staff training matrix and advised the management team that this would be examined following the site visit. Records showed that there is a high percentage of staff with up to date training in core subject areas e.g. fire awareness, manual handling, health and safety, safeguarding, food hygiene, basic first aid and infection control. The training matrix also provided evidence of those conditions associated with the needs of older people and that some staff have received training relating to bereavement, communication, Dementia awareness and Dementia Care Matters, nutrition and malnutrition, Mental Capacity act and Parkinsons Disease. National Vocational Qualification (NVQ) records provided to us by the manager show that 6 people have attained NVQ Level 2 and 4 people have achieved NVQ Level 3. Care Homes for Older People Page 27 of 34 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a home that is well managed. Evidence: The manager has been employed at Ashbrook Court since August 2009. The manager has over 37 years experience within both the NHS (National Health Service) and private sector. In addition to working as a nurse she has previously managed a care home for people with acquired brain injury, physical disability and learning disabilities. The manager is an RGN has a Diploma in Nursing and a Honours Degree in Nursing combined with an ENB Higher Award in Clinical Practice, has completed NVQ Level 4 in Management and Leadership, attained the Certificate in Dementia Care and is currently undertaking a Diploma in Dementia Care which is due to complete in December 2010. Since the last key inspection to the service in June 2009 the manager has been formally registered with us as of May 2010 and following a Fit Person Interview. The manager was able to demonstrate a clear understanding of the ethos, aims and Care Homes for Older People Page 28 of 34 Evidence: objectives of the service that she wishes to provide at Valentine House. The manager confirmed this as ensuring that people who live at the home receive good quality care, that is person centred and which meets their individual care needs. The manager told us that since her appointment as manager she has worked hard to enable and facilitate staff to work in a more preson centred way and to champion Dementia Care as a specialism at Ashbrook Court. The care manager spoke of a very positive relationship with the manager and together felt they worked cohesively as a team. From discussions with both the manager and the care manager, they told us that they feel there have been many improvements in all areas within the home made over the past 8-9 months, so as to ensure positive outcomes for people but recognise the findings from the inspection require addressing. Both care staff and people who live at the home were very complimentary about the manager stating they found her to be approachable and understanding. It was evident at the site visit that she has a good rapport and relationship with people who live there and people were observed to enjoy the positive interactions. It was evident at the site visit that the management team of the home are committed to making improvements and to ensure the care home is run in the best interests of the people who live there. The atmosphere within the home on the day of inspection was observed to be much improved and staff observed to be relaxed. The organisation have several ways of monitoring the quality of the service provided at Ashbrook Court. These include monthly Regulation 26 visits, medication audits, health and safety audits and a Key Outcome Audit that is comprehensive, detailed and based on outcome groups as detailed within the National Minimum Standards and Care Homes Regulations for Older People. The manager confirmed that a recent audit was completed by the organisation and this concluded that the home was achieving a good level of compliance in all areas to meet not only the Care Homes Regulations for Older People but meeting the organisations aims and objectives. We requested records of Regulation 26 visits and noted these have been undertaken regularly. While these record actions required as a result of the outcome of the visit they do not include details as to who is responsible for ensuring these are completed. Minutes of resident/relatives and staff meetings were available for review and showed that the manager was actively encouraging people to comment on the home, care provided and to discuss care practice issues. We were told by the manager that in February 2010 a quality assurance survey was carried out where the views of people who live at the home, their relatives and staff were sought about the quality of the service provided at Ashbrook Court. At the time of the site visit the results of the survey were being collated. The manager told us that it is her hope that this will be undertaken twice yearly. We were made aware that Care Homes for Older People Page 29 of 34 Evidence: Ashbrook Court achieved on the 5th June 2010 Employer of the Year award. We looked at a random sample of 3 staff members supervision records. These showed that staff are receiving regular formal supervision in line with the National Minimum Standards for Older People and this includes periodic observations of practice. Improvements have been made to the recording of supervision so as to ensure the information recorded is more detailed. Consideration should be given to ensuring there is a clear audit trail depicting actions agreed at the supervision, confirmation as to who is responsible for completion of the action and evidence of an outcome as this will provide a clear audit trail of the discussions and actions required. Corporate health and safety policies and procedures were observed to be in place within the home. Care Homes for Older People Page 30 of 34 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 7 15(1) Care planning at the home must identify and be effective in meeting all residents assessed needs. Previous timescale of 1/10/2008 to 11/1/2010 not fully met. So as to ensure that staff have the information they need to deliver good care. 01/08/2010 2 7 13(4) Risk assessments must be devised for all areas of assessed risk. Previous timescale of 8/9/2008 to 11/1/2010 not fully met. So that risks to residents can be minimised. 01/08/2010 3 9 13 Medication must not be handled directly by the person administering the medication. Previous timescale of 21/12/2009 not met. As this could potentially alter the properties of the medication. 14/06/2010 Care Homes for Older People Page 31 of 34 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 9 13 Medicines administered by healthcare professionals from outside the home require monitoring. So as to ensure they are stored and handled correctly. 14/06/2010 2 14 12 Consideration needs to be given to improving the dining experience for people in the home. So as to ensure positive outcomes. 12/07/2010 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 3 Ensure the pre admission assessment is detailed and comprehensive and that the information recorded enables the management team of the home to determine if the persons needs can be fully met. To have secondary records to document carers 2 9 Care Homes for Older People Page 32 of 34 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations administering items for which they are trained. 3 9 The specific circumstances where PRN medication are to be administered should be clearly recorded within the persons care file and/or on a PRN protocol. To monitor the cold storage of medicines to ensure security and temperature control is correctly maintained. 4 9 Care Homes for Older People Page 33 of 34 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. 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