Care Home: Ashbury Court

What has improved since the last inspection? Substantial works have been undertaken to address the home environment that had been neglected for some time. This has been achieved through redecoration and the replacement of worn fittings and fixtures. The environment now meets the expectations of the people who live in the home. Care plans are available to staff on a daily basis. They now give clear guidance for staff so that they know what action to take to meet service users` needs and minimise any potential risks to them. Service users now have access to a dentist if they choose to maintain their oral health. The staff team have received training in how to meet the needs of people with learning disabilities who live in the home. What the care home could do better: In the AQAA the home did not identify the areas of the service where improvements could be made both in the short and long term. There was also little evidence to show how the home had improved in the last year in some key areas. It is the responsibility of the service to continually self monitor and to evidence that it provides a good quality of service for the people that use it. The records of medication administration in the home are not completed according to guidance from the Royal Pharmaceutical Society. The current system in place for medication audits and assessing the competency of staff requires to be revisited to ensure that clear and accurate records are maintained so that the potential for medication errors is minimised.Ashbury CourtDS0000070940.V375120.R01.S.docVersion 5.2Page 7 Key inspection report CARE HOMES FOR OLDER PEOPLE Ashbury Court 43 Sea Road Westgate-on-Sea Kent CT8 8QW Lead Inspector Nicki Dawson Unannounced Inspection 8th May 2009 09:30 DS0000070940.V375120.R01.S.do c Version 5.2 Page 1 This report is a review of the 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. 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. Ashbury Court DS0000070940.V375120.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Ashbury Court DS0000070940.V375120.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashbury Court Address 43 Sea Road Westgate-on-Sea Kent CT8 8QW 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) 01843 834493 Select Healthcare (2006) Ltd Mrs Diane Margaret Rimai Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (0) of places Ashbury Court DS0000070940.V375120.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care Home only (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: 2. Old age, not falling within any other category (OP) The maximum number of service users to be accommodated is 37. Date of last inspection 9th June 2008 Brief Description of the Service: Ashbury Court provides accommodation and support for up to 37 older people. It is a large semi detached home in the town of Westgate-on-Sea. The home is close to the sea front and many of rooms have a sea view. It is within easy travelling distance of local amenities such as a railway station, bus stops, leisure and sports centres, shops, churches, colleges and local cinema. Ashbury Court is owned by Select Healthcare. The company owns and manages a number of residential and nursing homes around the country, including seven residential care homes in Kent. Since the last inspection, the person in day to day charge of the home has been successful in registering with us as the home manager. The fees for support from the home vary according to the individual needs of the service user. The registered home manager stated that the average fee levels at this time are between £350 to £595 per week. Ashbury Court DS0000070940.V375120.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. The inspection was unannounced, which means that the service users, staff and home manager did not know that the inspector was calling at the home. The inspection started at 9.30am and took 7 ½ hours. Discussion took place with service users, staff, the registered home manager and a visiting health care professional and relative; to gain their views and knowledge of the level of care, provided by the service. A tour was made of the shared areas of the home and a selection of service users’ bedrooms. A number of records to do with service users’ care and safety were looked at. Prior to the inspection an annual quality assurance assessment (AQAA) was sent to the service. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. Survey questionnaires (“Have Your Say About...”) were sent by the commission to the home before the inspection visit to give out to service users, staff and health and social care professionals . These comment cards are useful in gaining the views of the people who live and work in the home about the quality of care that is provided by the service. Two questionnaires were returned from staff. Staff commented that the staff team works well together and that although a number of activities are provided for service users service users would benefit from going out more. What the service does well: The management team of the home has a clear sense of direction. There is clear evidence that the home have taken steps to make the lives better for the people who live and work at the home. Care plans are based on the individual needs of the people who live in the home. They contain very detailed information about people’s choices and abilities such as whether the person wants someone to open their mail for them, and whether the person is able to say if they are in pain. This clear information helps make sure that people that live in the home receive care in the way that they prefer. Ashbury Court DS0000070940.V375120.R01.S.doc Version 5.2 Page 6 The home follows the company’s policies and procedures to ensure that all the relevant checks are carried out before a new member of staff starts to work at the home. This makes sure that service users are looked after by people who are fit to do so. A large percentage of staff have achieved NVQ level 2 which is a qualification recognised as useful for people who work in a residential care setting. What has improved since the last inspection? What they could do better: In the AQAA the home did not identify the areas of the service where improvements could be made both in the short and long term. There was also little evidence to show how the home had improved in the last year in some key areas. It is the responsibility of the service to continually self monitor and to evidence that it provides a good quality of service for the people that use it. The records of medication administration in the home are not completed according to guidance from the Royal Pharmaceutical Society. The current system in place for medication audits and assessing the competency of staff requires to be revisited to ensure that clear and accurate records are maintained so that the potential for medication errors is minimised. Ashbury Court DS0000070940.V375120.R01.S.doc Version 5.2 Page 7 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. Ashbury Court DS0000070940.V375120.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ashbury Court DS0000070940.V375120.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 People using the 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 considering moving to the home would benefit from some additional information so that they have all the information that they need to help them decide whether or not to it is the right place for them to live. Peoples’ needs are fully assessed before they move into the home so that they can be sure that they will receive the right type of care. EVIDENCE: The aims and objectives of the home are clearly set out in the home’s ‘Statement of Purpose. The Service User Guide contains details of the services and facilities that are available to the people living in the home. This document contains useful practical information such as how to recognise staff Ashbury Court DS0000070940.V375120.R01.S.doc Version 5.2 Page 10 by their uniforms and the current prices for hairdressing at the home. Service users would benefit from information about the sizes of bedroom available at the home, the fee ranges, where to obtain a copy of the most recent inspection report and how to contact the local social services and health care authority being added to the documents. Before new service users are admitted to the home a full needs assessment should be carried out to decide whether or not the home is a suitable place for the person to live. Assessments were seen for two service users, including one who had recently moved to the home. They gave good information on which to base an assessment as to whether the home can meet this persons needs. The registered manager said that in addition, if a service user is admitted to hospital for a period of time, she visits this person to reassess if the home is still able to meet their care needs. This is good practice. If the person is funded by the local social services, then a copy of the social services assessment is obtained from social services. The main aim of the home is to care for the needs of older people. At the last inspection it was found that the home had admitted a number of residents with the additional need of a learning disability. Most of the staff team have received training in how to care for people with a learning disability. Before the inspection the registered manager informed us in the AQAA that they had been working with the local intermediate care team to support service users to return to their own homes. During the inspection the registered manager said this type of care had not been provided recently and therefore, this standard was not inspected at this time. Ashbury Court DS0000070940.V375120.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7 - 10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users care plans give clear guidance to staff as to how to meet their assessed needs. There was a delay in writing a plan of care for one service user which means that this persons individual needs may not have been met temporarily. Service users benefit from being supported to access health care services. Although there is no evidence that the recording of medicines in the home has put any service user at risk, people who administer medication would benefit from further guidance and assessment in this area to increase their competence. Service users are treated with dignity and respect and their privacy is maintained. EVIDENCE: Ashbury Court DS0000070940.V375120.R01.S.doc Version 5.2 Page 12 Each service user should have an individual plan of care that clearly sets out their health, personal and social care needs, together with the staff support that is required to meet these assessed needs. Four service users’ care plans were looked at. The service has made a number of changes to care plans that benefit service users. Firstly, care plans are now written in a person centred way. This approach puts the service user in the driving seat by finding out what they want to happen in their life. For example, when writing about personal care needs, plans specifically state which part of the care the service user is able to do for themselves and which parts the service user needs staff support with. Secondly, all care plans now contain useful guidance for staff as to how meet service users’ assessed needs and how to minimise the effect of any potential risks. Thirdly, service users’ now sign their own care plans to show that they had been involved in their development and review. Lastly, care plans are now used as a daily guide for staff. Staff said that they are easy to understand and they are kept where staff can refer to them on a daily basis, rather than use the office. The exception to this good practice is that a care plan had not been completed for a service user who has been living at the home for two weeks. Whilst there is basic information about this person and an assessment of potential risks, staff do not have any guidance as to how to meet this person’s needs. During the writing of this report, the registered manager confirmed that a care plan is now in place for this person. Evidence was seen that each service users’ healthcare needs, including specialist health and dietary requirements are clearly recorded in care plans. A visiting health care professional said that the home is active in seeking their advice if they have any concerns about an individual service user’s health care needs. Since the last inspection, the registered home manager has consulted with service users so that they have access to a dentist of their choice. The home uses a pre-dispensed system for administration of medicines. This system is used to reduce the risk of service users receiving incorrect doses or incorrect medication. The person that is giving out the medicine records on a pre printed form (MAR) the medicine has been given or, if it hasn’t been given, the reason why. The registered manager stated in the AQAA received before the inspection that medication is audited monthly. However, on examination of this record it was found that there were some gaps in recording medicine so that it was not clear if the service user had received their medication. Where the name, dosage and frequency of a medicine is written by hand on the MAR sheet, the deputy manager said that this information is checked by two people Ashbury Court DS0000070940.V375120.R01.S.doc Version 5.2 Page 13 so that the potential for error is reduced. However, there was no evidence to show that two people check this information as there was only one signature on the MAR record. It is required that two signatures are now recorded. It is also required that for any medicine that is not pre-dispensed, the date when the medicine is first used is recorded so that an audit trail can be kept of all medicines used in the home. At the last inspection complete records were not kept of all controlled drugs in the home. A comprehensive record is now kept to safeguard service users. The person delegated to be responsible for medicines in the home is currently on a three month training course in medication administration. This should further their knowledge in this area. The registered manager said that to minimise the potential for any medication error being made, an audit of medication will be undertaken weekly rather than monthly. During the visit staff respected service users’ privacy by knocking on bedroom doors before entering. During lunch, staff were observed chatting informally with service users and service users clearly enjoyed this individual attention. Ashbury Court DS0000070940.V375120.R01.S.doc Version 5.2 Page 14 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12 - 15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users are able to choose their life style and to keep in touch with family and friends. Service users enjoy mealtimes and receive a healthy and varied diet. EVIDENCE: At the last inspection the registered manager said that a part-time activities coordinator would be staring shortly to offer a more individual programme of activities. An activities organiser has not been employed and instead activities are offered by the care staff team and outside visitors. A timetable of activities available for service users is on display in the lounge. This includes bingo, arts and crafts, gardening, watching a movie and chair exercises. The registered manager said that members of local churches visit for any service Ashbury Court DS0000070940.V375120.R01.S.doc Version 5.2 Page 15 users that wish. Some service users are booked to go to a local tea dance. The registered manager said that the home celebrates special events such as St. Georges Day, Easter and Red Nose Day with special events, food and crafts. Photographs were seen of staff dressing in red to celebrate Red Nose Day. A visiting relative said that they are able to visit at any reasonable time and are always made welcome. The things that are important to services users are recorded in their care plans. For example, individual choices if they wish to have an afternoon sleep, or if they wish to have the light off and door shut when they are asleep. One service user said that they are able to come and go as they please and are able to choose how they wish to spend their day. The inspector joined some service users for lunch. During the meal a member of staff joined another group of service users at their table. Some service users had chosen to have their meal in their own room. The meal looked appetising and that it was enjoyed could be seen from the empty plates on the tables. The cook explained that a four weekly menu is being used and that choices are available at every meal. A nutritional assessment is carried out for all service users and the registered manager is planning staff training in this area to increase the knowledge of the care staff team. Ashbury Court DS0000070940.V375120.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users are confident that any compliant they make will be listened to. For service users to be assured that any complaint is resolved to their satisfaction, a record of the complaint and the outcome must be kept at the home. Staff feel confident to speak out and take action to protect service users, if they have any concerns about their care. EVIDENCE: The commission has not received any complaints about the service in the last year. The home informed us in the AQAA that they have received one complaint. The registered manager confirmed that the complaint has been resolved to the satisfaction of the complainant. However, evidence of this was not available at the inspection since the complaint record has been sent to the head office of the company. Details of how service users or their relatives can make a compliant about the service are displayed prominently in the home and Ashbury Court DS0000070940.V375120.R01.S.doc Version 5.2 Page 17 contained in the Service User Guide. Staff demonstrated that they knew how to follow the homes’ complaints procedure if a service user made a complaint. Staff said that if they saw any form of abuse taking place in the home, that they are confident to report the incident to a more senior person on duty. Most staff have received training in how to safeguard vulnerable people from abuse. Ashbury Court DS0000070940.V375120.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 - 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users benefit from living in a safe, clean and comfortable home. EVIDENCE: At the last inspection a judgement was made that the home environment did not meet service user expectations of being clean and well-maintained. During the last year the home has taken a number of actions to make the environment better for the people that live at Ashbury Court. Ashbury Court DS0000070940.V375120.R01.S.doc Version 5.2 Page 19 A redecoration programme has nearly been completed so that most areas of the home are freshly painted and this makes the home look bright. Service users’ bedroom furniture that was worn has now been replaced. The kitchen and hairdressing room which previously presented an infection control hazard has been refurbished. New windows have been fitted to the smoking room so that service users can now enjoy the sea view. The area outside to one service user’s room has been cleared of boxes so that they are able to look out of their window. The courtyard area is now rubbish free, which meets the expectations of people that live in the home. At the last inspection it was noted that radiators had been guarded to minimise the risk of scalding if a service user falls. The registered manager said that after an assessment, all windows above the ground floor have been restricted to minimise the potential risk of service users falling. Call bells are now in reach of all people who need to use them to call for assistance. The home was required after the last inspection to make sure that sufficient numbers of baths and showers are available to service users. An additional bath chair has been purchased that some service users are able to use, so that there are is now one assisted shower and two assisted baths. At the last inspection service users were not able to use the baths in their bedrooms since the water had been turned off. Evidence was seen that the water temperature has now been regulated to a safe temperature for service users to bathe. However, there are currently no service users who benefit from using the baths in their rooms. This is because service users all require a hoist to safely bathe and no hoists have been fitted to service users’ ensuite baths. It was observed that service users have aids to help them mobilise around the home. Care plans include information about equipment that service users require such as airflow mattresses and pressure relieving cushions. Work has now been completed with regards to putting up handrails in the corridors of the home, to help service users who need assistance. It was observed from a tour of the home that service users are able to personalise their rooms according to their individual choices and tastes. The home has one double room and it is recorded in the service users care plans that these two people made an active choice to share. There is a shaft lift for service users to gain to get to the first and second floor. At the last inspection the home was not clean in all areas. On the day of this inspection the home was clean in all areas that were looked at. New flooring and new toilets have been fitted so that it is easier to maintain the cleanliness of the home. No unpleasant odours were detected when walking around the home. Action has also been taken to minimise the spread of any infection in the home by installing sluice facilities. Ashbury Court DS0000070940.V375120.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27 - 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users benefit from receiving care from a qualified and competent staff team. Service users are protected by the homes recruitment practices. EVIDENCE: The staff rota evidenced that there are four of five care staff on duty in the morning; four care staff in the afternoon; and two or three waking night staff. The registered manager joins the care staff team as one of this number in the morning. One member of staff commented that there is ‘always’ enough staff on duty to meet service users’ needs and another commented that there ‘usually’ is enough staff on duty. Each day a cook and assistant cook prepare meals for service users and a person is available to launder their clothes. A maintenance person is now employed to keep the equipment in the home in good working order. Comments received were complimentary about the staff team. One person said, “Before there would be some bad talk in front of residents. There is none now. The staff team has changed and it has changed for the better”. Ashbury Court DS0000070940.V375120.R01.S.doc Version 5.2 Page 21 70 of staff are trained to National Vocational Qualification (NVQ) level 2 or above. The home has exceeded the National Minimum Standard in this area which is to have 50 of care staff qualified to this level. This award is useful because it helps staff develop good care practices and their skills in working with people who live in a residential care home. Before new members of staff are employed at the home a number of checks need to be carried out to make sure that all members of staff working at the home are suitable to care for vulnerable service users. Files were seen for two members of staff employed at the home since the last inspection. All the relevant checks and documentation including Criminal Record Bureau enhanced disclosures, two references, contract of employment and application form were included showing that the recruitment process followed protects the service users. There is a checklist on the front of each file showing the information that should be included. This is a valuable way of making sure that all staff files contain the information that is needed. The registered manager is responsible for making sure that care staff have the skills they need to support the people who live in the home. Evidence was seen that all new care staff receive the appropriate introductory training, which gives them the basic competencies they need to be able to work without direct supervision. In addition to the introductory training, care workers undertake a number of training courses that develop their skills in caring for the people that live in the home. The registered manager has recorded each care staff’s training in their individual records. At the last inspection no member of staff was up to date with their mandatory training. The registered manager confirmed that now all staff are trained in the areas necessary for their roles. She said that she intends to complete a staff training matrix which makes it easier to identify the training that each member of staff needs to achieve. Ashbury Court DS0000070940.V375120.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31-33, 35-36 and 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users benefit from the management approach of the home, which is individual and open. The home is not doing all that it can to ensure that it is being run in service users best interests. The health, safety and welfare of service users is promoted. EVIDENCE: Ashbury Court DS0000070940.V375120.R01.S.doc Version 5.2 Page 23 The registered manager is responsible for the day to day running of the home. She has been employed at the home for one and a half years. There is a lot of evidence in this report that the registered manager has made the lives of people living in the home better. For example, staff say that they are clearer about their roles and responsibilities; care plans are person centred; the environment is now well maintained after being neglected for a number of years. She has both of the formal qualifications specified by the National Minimum Standards which are recognised by the commission to be useful because they help to make sure that people who manage residential care services have the competencies that are necessary to do so. From observing the registered manager chatting with service users, it is evident that she knows the individual needs of the people that live in the home. Staff said that the management team are easy to approach. “Di is passionate about the residents”, commented one staff member. A visitor to the home said, “Di is firm. She tells people what they want to know but in a nice way”. Before the inspection, the registered manager sent us an annual quality assurance assessment (AQAA). This is a self-assessment that focuses on how well outcomes are being met for people using the service. The assessment was not thoroughly completed. The home failed to identify what they could do better in the key areas of health, daily living, complaints and protection, the environment, staffing and management. They also failed to identify what their plans for improvement are for the next year in the majority of key areas. The registered manager is reminded that the AQAA is a legal document and is used as evidence of the home’s ability to provide quality outcomes for people living at Ashbury Court. For the home to run in the best interests of the service users it is important to have a system in place which regularly obtains the views of service users and visitors about the standard of care that they receive from the home. Returned questionnaires for service users and relatives were seen for last year. The registered manager did not write a report about the feedback from these questionnaires detailing any changes necessary to improve the service. New questionnaires are being sent out and the registered manager said that such a report would be written after these questionnaires have been returned. Evidence was seen that the home is regularly visited by an appointed person, who undertakes detailed checks about the quality of the service. The registered manager said in the AQAA that an audit of medication is carried out. There is no evidence that this audit is effective in ensuring that there is an effective recording system in place for the safe administration of medicines in the home. Where monies are kept on behalf of people who live in the home, evidence was seen that they are well organised to ensure that monies are spent in the best interests of each individual service user. Ashbury Court DS0000070940.V375120.R01.S.doc Version 5.2 Page 24 Staff said that they regularly attend staff meetings, which help better communication between the staff team. Staff also commented that they have regular formal supervision and a yearly appraisal. This gives staff the opportunity to discuss care practice and to identify and develop their skills for caring for the people who live in the home. The registered manager made a declaration in the AQAA that all items of equipment in use in the home remain in good working order. Records to ensure fire safety in the home were looked at and showed that action had been taken to minimise the potential risk of a fire occurring in the home. Although the registered manager said that staff have undertaken regular fire drills, there was no evidence to show that staff have done so and therefore know what to do in the event of a fire. The registered manager acknowledged this and said that the home is introducing a new health and safety system with clearer recording processes. As mentioned previously, individual staff files indicate that staff are now up to date with training necessary for their roles. The registered manager said that she will develop a staff training so that any training needs can be clearly identified in the future. Ashbury Court DS0000070940.V375120.R01.S.doc Version 5.2 Page 25 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 2 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 3 X 3 Ashbury Court DS0000070940.V375120.R01.S.doc Version 5.2 Page 26 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. 1. Standard OP9 Regulation 13 (2) Timescale for action The registered person shall make 09/06/09 arrangements for:Two people to check and sign all handwritten entries on the Medication Administration Record to ensure that they are accurate. This is so that people receive their medications as prescribed by their GP. To record the date when all medicines that are not in blister packs, are first administered. This will make sure that there is a clear audit trail of all medicines entering and leaving the home. Requirement RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Ashbury Court DS0000070940.V375120.R01.S.doc Version 5.2 Page 27 No. Refer to Standard Good Practice Recommendations Ashbury Court DS0000070940.V375120.R01.S.doc Version 5.2 Page 28 Care Quality Commission Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: 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. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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