Inspection on 08/11/07 for Abbey Road [53]

This is the latest available inspection report for this service, carried out on 8th November 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Abbey Road [53] 02/11/05

Abbey Road [53] 27/06/05

Abbey Road [53] 28/09/04

Abbey Road [53] 08/06/04

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Cherry Tree House

Ashwood House (Leyton)

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

CARE HOMES FOR OLDER PEOPLE Abbey Road [53] 53 Abbey Road Newbury Park Ilford Essex IG2 7LZ Lead Inspector Julie Legg Unannounced Inspection 10:00 8 November 2007 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Abbey Road [53] DS0000025946.V354209.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Abbey Road [53] DS0000025946.V354209.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbey Road [53] Address 53 Abbey Road Newbury Park Ilford Essex IG2 7LZ 0208 518 6757 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) novao@servitehouses.org.uk Servite Houses Limited Nova Ann O`Sullivan Mrs Nova O`Sullivan Care Home 18 Category(ies) of Dementia - over 65 years of age (18), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (18) Abbey Road [53] DS0000025946.V354209.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd February 2007 Brief Description of the Service: 53 Abbey Road is an 18-place care home with nursing for older people, who have dementia or mental health issues. The home is operated by Servite Houses Ltd, a national charity that provides similar homes across England. The home has a contract with the local Primary Care Trust; therefore the home only accepts referrals from the Trust. The home is purpose built and is situated in a residential area of Newbury Park, close to tube and bus routes. The accommodation is spread over two floors, with nine single, en-suite, bedrooms, bathrooms and toilets on each floor. There is a passenger lift and all parts of the building have full disabled access. There is a lounge/dining area on each floor, with an additional lounge on the ground floor, through which a well maintained garden is accessed. Nursing and personal care are provided on a 24-hour basis and specialist health needs are met by visiting professionals. The Statement of Purpose and the Service User Guide are issued to every prospective resident and both of these documents are displayed in the entrance hall of the home. A copy of the most recent inspection report is also available. A resident or relative/representative could ask for his or her own copy, which the manager would make available. All of the beds within Abbey Road are blocked purchased by the local Primary Care Trust. Abbey Road [53] DS0000025946.V354209.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place over one day. The manager was present for the duration of the inspection and was available for feedback at the end of the inspection. Discussions took place with the manager, nurse, care staff, the chef and domestic. Care staff were asked about the care residents receive and were also observed carrying out their duties. The chef was asked about the meals she provided to the residents and their likes and dislikes. Staff were also asked about their recruitment, induction programme and ongoing training. Further information about Abbey Road was also gathered from residents, relatives and the Primary Care Trust who commission the beds. A tour of the home was undertaken and all of the rooms were seen to be clean and free from any offensive odours. Residents’ files were also examined and case tracked; including risk assessments and care plans, together with the examination of staff files and other home records. These records included medication charts, financial transactions, and staff rotas and staff recruitment procedures. Additional information relevant to this inspection has been gained from the Annual Quality Assurance Assessment, Regulation 37 notifications and Regulation 26 reports. We had a discussion on the broad spectrum of equality & diversity issues and the manager was able to demonstrate a good understanding of the varied needs around religion, sexuality, culture, disability and gender. The inspector had a discussion with the manager, residents and staff as to how the people living at the home wished to be referred to in this report. The manager stated that the home use the term ‘resident’. This is reflected accordingly throughout this report. The inspector would like to thank the residents, the manager and staff for their input during this inspection. What the service does well: The home has a very experienced manager and dedicated staff team that are committed to the residents and the quality of care they receive. The manager and staff work with the residents to enable them to retain a level of independence and to exercise choice and control over their lives. Most of the Abbey Road [53] DS0000025946.V354209.R01.S.doc Version 5.2 Page 6 residents require a high level of support in meeting some of their needs and every effort is made to work closely with other professionals to ensure their needs are met. It was evident that the home is run in the best interests of the residents. Every effort is made to ensure that their views and of significent others are taken into account on any decisions in relation to the running of the home. Relatives that were spoken to were very complimentary of Abbey Road. “I am extremely happy with the care that my relative receives, Nova (manager and the staff do a grand job”. A resident stated, “I love living here, it’s wonderful”. A commissioning health professional stated, “We are very happy with the care being provided at Abbey Road”. What has improved since the last inspection? What they could do better: There were no Requirements and one Recommendation identified from this inspection. The Recommendation is for the manager to discuss with staff and residents, appropriate covering (curtains/blinds) for the front door and window. Please contact the provider for advice of actions taken in response to this Abbey Road [53] DS0000025946.V354209.R01.S.doc Version 5.2 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Abbey Road [53] DS0000025946.V354209.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 Abbey Road [53] DS0000025946.V354209.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,4 and5 People who use this service experience good quality outcomes in this are. We have made this judgement using a range of evidence including a visit to this service. Prospective residents and their relatives have detailed information on the home, which assists them to make an informed choice about moving into the home. A detailed pre-admission assessment is undertaken of all prospective residents, this will ensure that their identified needs can be appropriately met by the home. Prospective residents and their relatives are able to visit the home prior to their admission. EVIDENCE: The Statement of Purpose clearly sets out the objectives and philosophy of the service and clearly states what the home can provide. The Service User guide is informative and written in plain English, a copy of this document has been Abbey Road [53] DS0000025946.V354209.R01.S.doc Version 5.2 Page 10 given to all of the residents. The file of the most recent admission was looked at. The manager had undertaken an in-depth assessment, which included sections on; personal care, covering areas such as ability to wash, step into a bath and putting on shoes. Other sections covered: communication, mobility, personal safety, risks and medical history including physical and mental health. Other areas covered in the assessment included; diet, weight, dental and foot care, religious, cultural and social activities. Further information was also obtained from health professionals and family, prior to the resident’s admission to the home. Residents and relatives are able to visit the home prior to a resident moving in. The inspector spoke to six relatives, all of whom stated their parents or partners were unable to visit the home prior to their admission due to their frailty. However all of the relatives had visited the home prior to their relative’s admission. One relative stated, “they made me feel very welcome, nothing was too much trouble”. Another relative stated, “when I walked in I could hear residents and staff chatting and laughing and Nova (manager) had already been to see my relative and knew such a lot about them”. The home does not provide intermediate care. Abbey Road [53] DS0000025946.V354209.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 People who use this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service The health and personal care needs of each resident are set out in individual care plans and risk assessments. These comprehensive and person centred plans provide staff with detailed information, which ensures that residents’ care needs are being met on a daily basis. There are clear medication policies and procedures for staff to follow and medication records are being completed correctly, this safeguards the residents with regard to the administration of their medication. Residents are treated with respect and the arrangements for their personal care ensures that their right to privacy is upheld. EVIDENCE: Abbey Road [53] DS0000025946.V354209.R01.S.doc Version 5.2 Page 12 The manager and staff have ensured that all of the residents have been involved in all decisions about their lives. The care planning system is clear and concise. Each resident has their own care plan; the inspector examined three of these plans. These care plans were completed with the involvement of the resident and relatives (if appropriate) and each of these care plans is broken down into morning, afternoon, evening and night care. The care plans are very detailed, comprehensive and person- centred, identifying the resident’s personal, social, health, cultural and religious needs, as well as likes and dislikes, happy and painful memories, strengths and limitations and how these needs and wishes should be met. They also identify essential things or routines that are important to the resident. As stated earlier the care plans are personcentred and had details such as ‘Z will inform staff when she wishes to have a bath’. ‘X does not like wearing socks or jumpers’. ‘Y likes her breakfast before she goes to bed’. Daily records indicated that care plans were being followed and recordings related to the care plans; ‘Just after midnight Y had her breakfast in the lounge; she was assisted to write a letter and then went back to bed. Y told the inspector “I like to have my breakfast before going to bed”. There was evidence that residents’ care plans are being evaluated on a monthly basis or when a change in need is identified. Residents, relatives, the nurse and key worker are involved in this evaluation. All areas of the care plan are discussed and fully documented. One resident stated, “I have read my care plan and agree with it”. A score of 4 has been given in recognition of the work that has been undertaken in ensuring that the care plans are meaningful and person centred. There was evidence that body maps are being completed following an accident or incident. The recordings of fluid and food intake and pressure wound charts were all completed satisfactorily. The tissue viability nurse has been involved with some of the residents and she is satisfied with the actions of the staff. All residents are weighed regularly and if any weight loss is noted over two consecutive weighings then the resident is referred to their GP or dietician. Residents’ files also have written evidence that they are seen by other health professionals including psychiatrists, opticians, dentists, chiropodists, tissue viability nurse, GP and hospital out-patient appointments. One resident told the inspector “I have recently had new glasses”. Some of the residents are taken to health appointments and other residents receive their health care within the home. Risk assessments were examined; those seen were detailed and covered areas such as, personal safety/protection, diet/fluid intake, skin pressure area care, nutritional intake, use of hoist and wheelchairs. Residents where possible, relatives and health professionals have been consulted in the formulating of Abbey Road [53] DS0000025946.V354209.R01.S.doc Version 5.2 Page 13 these risk assessments. There was evidence that risk assessments are being reviewed and regularly updated. Medication policies and procedures were examined and found to be up to date. The manager advised the inspector that the home has recently changed Pharmacist, as they were able to provide a more comprehensive service and have also provided training to the staff. Only nursing staff can administer medication. Three residents’ Medication Administration Records (MAR) charts were examined and all had been completed appropriately and medication given correlated with the MAR charts. The manager undertakes regular medication audits and audits would also be part of the Regulation 26 visit. As stated earlier the Primary Care Trust commissions all of the beds and they have stated that, “we are very satisfied with the care that is being provided at Abbey Road and we have a very good working relationship with the manager” The inspector spoke to a number of residents and relatives who all said that staff were very respectful and thoughtful when attending to personal care. One relative stated, “the staff are wonderful, they are so gentle with her”. A resident stated, “Nothing is too much trouble, they knock on my door and treat me very respectful”. Staff were observed interacting with the residents, their relationship was easy going but in a professional manner. Staff were seen to ask residents what they wanted and offered different objects, to assist residents to be able to indicate what they wanted. They understood the need to promote dignity through practices such as, the way they addressed residents and knocking on bedroom and bathroom doors before entering. Residents’ privacy and dignity are covered during the staff’s induction programme. Abbey Road [53] DS0000025946.V354209.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 People who use this service receive excellent quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The residents are able to participate in a varied programme of activities, which suits individual needs, preferences and capacities. Visiting times are flexible and people are made to feel welcome when visiting the home. This ensures that residents are able to maintain contact with their family and friends as they wish. Residents are able to exercise choice and control over their lives. The meals in the home are well presented and nutritionally balanced. They offer both choice and variety to the residents. EVIDENCE: Residents were asked their views and care plans were examined. The signingin book shows that there are visitors to the home every day. Visitors are Abbey Road [53] DS0000025946.V354209.R01.S.doc Version 5.2 Page 15 encouraged to join in activities such as monthly entertainment and other special occassions. The care plans contain information about preferred activities including spiritual and cultural activities. One resident attends the local church, another receives visits from the local priest, another resident who use to be in a choir, enjoys singing hymns and listening to church music. One of the residents is Jewish but chooses not to follow her religion, however staff talk to her about Jewish events. The manager has sourced a company that produces a multi-faith calendar and a handbook of faiths that are appropriate to the residents of Abbey Road. Key workers having commenced working with residents and their families to compile individual activity books so that activities are based around residents’ individual needs. Pictorial ‘life story’ books have also been compiled these covers areas such as, life tree, parents, schooling, relationships, marriage, married life, holidays, children, as time goes by, work, interests, likes and dislikes, fond memories. These books have been completed sympathetically and gives care staff a real insight into the resident’s life history, as well as a tool that will assist staff and relatives to communicate with people living with dementia. One activity that takes place is a multi-choice quiz, one of the residents does not like being in a room with other people but she is still able to join in as she is given the quiz to do in her own room. The staff have spent time exploring residents’ wishes and one resident now goes to the pub once a month and another resident goes on a monthly shop with her key worker, they either go to Romford or Ilford. Another resident enjoys listening to Capital radio and another resident enjoys a glass of beer. At least once a month Abbey Road have a themed evening. Themed events have been St Patrick’s Day, Easter Sunday where the residents decorated chocolate eggs, had an Easter egg hunt and quiz, a summer barbeque, harvest lunch and the most recent event was Halloween and some of the residents made Halloween biscuits and others made witches hats. On the day of the inspection some of the residents were making cakes, others were colouring and sticking glitter on pictures of poppies. These pictures were then placed on the large notice board with other reminders of Remberance Sunday (four days after the inspection). One of the residents said, “It makes me feel sad but I like to watch the service and remember”. Other daily activities within the home include; armchair exercises, ball games, arts & crafts, manicures and hand massages as well as 1:1 reading, a variety of music and sing-a-longs and coordination games i.e. connect 4. The staff are also encouraged to spend time talking to residents on a one to one basis. A score of 4 has been given in recognition of the work that has been undertaken by the manager and staff in enabling residents to participate in such varied activities, which suits individual needs, preferences and capacities. Abbey Road [53] DS0000025946.V354209.R01.S.doc Version 5.2 Page 16 Visiting times are flexible and visitors confirmed that they could visit at any time. All of the relatives spoken to said that they were made to feel very welcome and they were always offered a cup of tea or coffee. Relatives confirmed that they could see the resident either in one of the lounges or in their own bedroom. One relative stated, “I really enjoy coming to visit, everyone is so friendly”, another relative stated, “There is such a lovely atmosphere, I look forward to coming”. Residents’ care plans indicate their preferred name, their choice as to where they take their meals, whether they choose to have a both or shower and their wishes regarding illness or their death. Residents are encouraged to bring in their own personal possessions with them when coming to live at the home and this was evident when the inspector visited residents’ bedrooms. Items such as radios, televisions, photographs, pictures and ornaments enabled the room to feel more homely. Meals are mostly served in the dining rooms, though residents can take their meals in their bedroom if they so wish. The chef has worked at the home for 11 years and is very aware of residents’ likes and dislikes. The meals seen on the day of the inspection looked appetising and nutritionally balanced. All of the cakes, pies and pastries are home cooked and all of the vegetables are fresh. There was a choice at lunchtime of chicken & mushroom pie or toad in the hole, boiled potatoes, broccoli, and grilled tomatoes, for dessert there was bananas and custard. At teatime there was a choice of soup and sandwiches or sausage rolls and homemade cakes, however one resident had requested sausages and chips. Another resident had eaten very little at lunchtime and early afternoon the chef bought her a small sandwich, which she ate. Both residents and relatives were extremely complimentary of the food and one relative stated, “I am here most lunchtimes and the food is marvellous”. One resident said, “The food is wonderful and if there is anything I don’t like then the chef will cook me something different”. Some of the residents require assistance with eating their meals and staff were seen to carry out this task appropriately, talking to residents and not rushing them. One of the residents does not like eating with others and she sits on a table on her own. Abbey Road [53] DS0000025946.V354209.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use this service receive good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The manager and staff make every effort to sort out any complaints or concerns. Residents and their relatives can be confident that their complaints will be listened to and acted upon. There are policies and procedures on adult protection and staff have received training in safeguarding adults to ensure that there is an appropriate response to any allegations of abuse. EVIDENCE: The home has a clear complaints procedure and a copy of this procedure has been made available to all of the residents and to their relatives. There have been no complaints recorded since the last inspection (February 2007). However the manager welcomes concerns and complaints about the service and we are confident that the manager would take any concerns/complaints seriously and would deal with them appropriately. There are regular resident and relative meetings and the manager also has an open door policy. On the day of the inspection two relatives came to talk to her. Three residents were asked, ‘If you were unhappy about anything in the Abbey Road [53] DS0000025946.V354209.R01.S.doc Version 5.2 Page 18 home, who would you talk to?’ all three of them said, “I would tell Nova (manager)”. Three relatives, who were visiting the home at the time of the inspection stated, “I haven’t had to make a complaint but I would speak to Nova”. Other relatives that were contacted by telephone all said they would talk to Nova (manager) and felt confident that they would be listened to. The home has policies and procedures for the safekeeping and expenditure of residents’ money and all monies are held securely within the home. The responsible individual when carrying out Regulation 26 visits will also monitor residents’ finances. Residents are supported to make purchases and receipts for all expenditures and records of money held. The home has comprehensive ‘safeguarding adults’ policies and procedures; these include the local authority (London Borough of Redbridge) policy and procedure and the organisations’ policies and procedures. The manager was clear in what incidents needed to be referred to the Local Authority as part of the local ‘safeguarding adults’ procedure. There have been no reported ‘safeguarding adults’ issues since the last inspection. Staff members were clear on what constituted abuse and their responsibility in reporting any potential or actual abuse. Staff files indicated that all members of staff have attended ‘safeguarding adults’ training and this was a subject that was also dealt with during staff meetings. Abbey Road [53] DS0000025946.V354209.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20, 23,24,25 and 26 People who use 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. The home is very homely and provides the residents with a clean, safe and comfortable environment. Residents’ bedrooms suit their needs and are decorated and furnished in a way that suits their lifestyles EVIDENCE: A tour of the home was undertaken including residents’ bedrooms. The home is situated in a residential area of Newbury Park and community facilities are accessible. The home is decorated and furnished in a homely fashion and all areas of the home were well maintained, clean and free from any unpleasant odours. The home has an infection control policy and would seek advice from external specialists if and when required. Abbey Road [53] DS0000025946.V354209.R01.S.doc Version 5.2 Page 20 A visit was made to both the kitchen and laundry room, both were maintained to a very high standard. Food within the refrigerators and freezers was stored and labelled appropriately and refrigerator and freezer tempretures are regularly recorded. The living area of the home consists of two lounge/dining rooms (one on each floor) with an additional lounge on the ground floor, from which the garden can be accessed. The home is currently undergoing a refurbishment and redecoration programme. All of the corridors, lounges/dining rooms and bathrooms have been redecorated. The residents have decided that they do not want heavy curtains at the windows of the down stairs lounge, as they feel the room is lighter and they get a better view of the garden (this room is not overlooked by any other property). However the manager needs to be mindful with the winter approaching and perhaps blinds might be an alternative. On the day of the inspection the outside of the home was being painted. As the ability of people living with dementia to communicate with words decreases, the use of non-verbal cues and the environment are important in enabling them to cope with daily life and orientation. Though the residents were involved in choosing the colours, the manager also consulted the Alzheimer’s Society book ‘The dementia care environment’ to ensure that the colours were appropriate; toilet doors have been painted in different colours (to assist with identification), pictorial signage is also in place and the bathroom has been painted in a ‘warm’ blue, to help people relax. The manager applied for and was successful in obtaining £15,000 from the Government’s ‘capital grant’ fund and this money will be spent in improving the quality of life for the residents of Abbey Road. The upstairs bathroom is to be upgraded with a ‘Parker’ bath and retiled, new dining room furniture, curtains and tableware and easy chairs will also be purchased. The corridors are to undergo further transformation with scenic panels to be placed along the walls that residents can touch and feel, these panels will be themed and run alongside a river. This could be beneficial to some residents in finding their way along the corridor ‘following the river’. All bedrooms have en-suite toilets and are furnished with their own furniture and possessions, such as, televisions, radios, ornaments and photographs. The front of the building is quite exposed (the front door and large window have plain glass), which means people who are walking past can see into the home, this could be particularly disconcerting at night (residents and staff safety). It is a Recommendation that the manager consults with residents and staff as to what type of covers they would like at the windows. This is Recommendation 1. Abbey Road [53] DS0000025946.V354209.R01.S.doc Version 5.2 Page 21 The garden is well maintained and accessible and the residents make full use of this facility in the summer. The home is cleaned on a daily basis and throughout the inspection all areas of the home, the standard of cleanliness was very good. There are adequate control systems in place to ensure that the home is free from any offensive odour. Abbey Road [53] DS0000025946.V354209.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 People who use this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home’s staffing levels are satisfactory and there are sufficient staff on duty, all of whom have the appropriate skills and training to meet the individual needs of the residents. The home has a clear and robust recruitment policy and procedure and appropriate checks are undertaken, which ensures the protection of the residents. EVIDENCE: Staff rotas were examined and the rota correlated with the number of staff on duty, during the day there are four care workers and a qualified nurse on duty. On the day of the inspection there was a sufficient number of staff on duty to meet the needs of the residents. There are currently fourteen residents living at the home and the staffing levels are: one nurse and four carers (two on each floor) on each day shift and one nurse and two waking night staff during the night. Permanent staff covers the majority of the shifts, however the residents know the bank and agency staff. This is clearly to the benefit of the residents since it provides continuity of care, which is extremely important to people who are living with dementia. In discussion with the manager and staff, at all levels, it was apparent that staff morale is high and they are enthusiastic and positive about wanting to improve the quality of life for the residents. Abbey Road [53] DS0000025946.V354209.R01.S.doc Version 5.2 Page 23 The registered providers have a robust recruitment and selection procedure in accordance with the requirements of legislation, equal opportunities and antidiscriminatory practice, which ensures the protection of residents. Two members of staff have been recruited since the last inspection and these files were examined and all showed that all the relevant recruitment procedures had been adhered to. All files had a completed application form, two written references, satisfactory Criminal Records Bureau checks, copy of birth certificate and passport were also on file. Two people are involved with interviewing prospective staff and on staff files there was the questions and answers from the interview (answers are scored against a criteria). The organisation employs a workforce from diverse cultures and backgrounds, some of which are different from the people living in the home. However, staff have undertaken training in ‘equality and diversity’. This ensures that the spiritual, dietary, cultural, sexual and any other diverse needs of residents at Abbey Road is understood by staff and appropriately met. Staff are able to demonstrate a thorough understanding of the particular needs if individual residents and can therefore deliver meaning full person centred care. All newly appointed staff undertake an induction programme, which is in line with Skills for Care. Topics covered during the induction are, moving & handling, first aid, understanding the principals of care, recognising and responding to abuse, equality & diversity, communicating effectively and maintaining safety at work. From talking to staff, inspecting training records and observation, it was evident that staff have the opportunities to undertake a variety of training courses and that such training is put into practice within the home to the benefit of the residents. All of the staff have undertaken training specific to caring for people living with dementia and other mental health needs. This has included understanding communication, a three-day course on living with dementia, and mental health in later life and one-day courses in ‘providing activities for older people’. The effectiveness of this training was evident in the attitude and practices of staff when interacting and caring for the residents. All of the care staff have a training plan which records ‘what training has been done’, ‘what training you need to enable you to do your work’ and ‘what training do you need for your personal development’. Records showed that staff have undertaken further training in essential areas, such as fire safety, health & safety, first aid, moving & handling, safeguarding adults, infection control and food & hygiene. More than 50 of the staff have attained their NVQ 2, one carer has her NVQ 3. A score of 4 has been given in recognition of residents being supported by a very competent, effective and qualified staff team. Abbey Road [53] DS0000025946.V354209.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36 and 38 People who use this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home is managed by a qualified and experienced manager who also has very sound management practices, this means service users’ health and welfare are promoted and protected. Service users can be confident that their views underpin the self-monitoring, review and development of the service. EVIDENCE: The manager is a registered nurse and has the relevant clinical and management qualifications and has been the manager of Abbey Road for the Abbey Road [53] DS0000025946.V354209.R01.S.doc Version 5.2 Page 25 past eleven years. She is committed to providing and improving good quality care at Abbey Road. To achieve this she works closely with residents, relatives, health and social care professionals. She has many years of experience in providing and managing nursing care services and continues her own personal development by attending further training, she has recently attended training on Dementia, safeguarding adults, recruitment & selection and medication awareness. She has a sound knowledge of both strategic and financial planning and how the operational plan for the home fits in with these. She has responsibility for the financial budget of the home and is aware of her budgetary limitations. As stated earlier the manager applied for and was successful in obtaining £15,000 from the Government’s ‘capital grant’ fund and this money will be spent in improving the quality of life for the residents of Abbey Road. In discussion with the manager it is clear that she receives effective and regular support from the organisation and that there are clear lines of accountability. Discussions with the manager showed she was able to describe a clear vision of the home based on the organisation values. It was evident that she was able to communicate a clear sense of direction and demonstrate a sound understanding and application of good practices, particularly in relation to continuous improvement of the service. The manager has carried out ‘spot checks out of ‘normal hours’ and this is supported by regular supervision of all the staff and other quality monitoring systems, such as, residents’ and relatives meetings, feedback from quality assurance surveys. From this information the home has a development plan that reflects the aims and outcomes for the residents. Independent auditors have carried out an audit and this is an extract from their report ‘The high scores and the numerous positive comments indicate a very high level of satisfaction among the residents and relatives of Abbey Road’. There is a Quality Assurance (QA) group within the home, which consists of staff, residents and relatives. The group are looking at the home’s policies and are currently looking at the organisation’s policy on ‘answering the telephone’. Previous suggestions that have been put forward have been acted upon i.e. Staff training on ‘blind awareness’ and a change in the layout of the staff rotas. The home has responsibility for the personal allowances of some of the residents and secure facilities are provided for their safekeeping, with accurate records being maintained During the course of the inspection the manager was observed leading from the front, by directly engaging with the residents, relatives and staff. Comments from residents, relatives, staff were extremely complimentary, saying that she is very helpful, supportive and manages the home in the best interest of the residents. One resident stated “Nova is excellent, nothing is too much trouble for her”, a relative commented, “She is a first class manager and runs an excellent home”, a member of staff commented, “She is very supportive, I wouldn’t have got through my NVQ 2 without Abbey Road [53] DS0000025946.V354209.R01.S.doc Version 5.2 Page 26 her encouragement and help”. There was evidence on staff files that they are receiving regular supervision and yearly appraisals, regular staff meetings are also taking place. Staff also confirmed that these were taking place. The manager was able to demonstrate her knowledge and commitment to equality and diversity issues, which are given a priority in caring for the residents. It was also evident that the manager followed the policies and procedures of the home and organisation. As previously stated record keeping remains of a consistently high standard with records being kept securely locked in accordance with the Data protection Act. All of the working practices within the home are safe, within a risk management system. The manager proactively monitors the home’s health & safety performance and consults other specialist agencies when necessary. Risk assessments were in place for fire, first aid, infection control and moving & handling. Staff have the benefit of a structured induction, which is in line with the Learning Skills Council and subjects such as, infection control, moving & handling, safe use of hoists are covered. A wide range of records were looked and these were found to be detailed, up to date and accurate. Refrigerator and freezer temperatures are taken and recorded daily and food that had been opened was stored, covered and dated. Fire drills are taking place regularly; fire extinguishers received their annual check and a fire risk assessment has been completed. The gas certificate is dated 29/06/07 and the five year electrical certificate is date 29/05/07. Regular audits are undertaken of personnel file, medication records, care plans and health & safety records to check for compliance to the National Minimum Standards. Regulation 26 visits are undertaken by the organisation and copies of these reports are available to the Commission, as are Regulation 37 notifications that advise the Commission of any significent events within the home. A score of 4 has been given in recognition of the manager’s leadership and the benefit that the residents receive in living in a home that is well run and in their best interests. Abbey Road [53] DS0000025946.V354209.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X 3 3 3 3 STAFFING Standard No Score 27 4 28 4 29 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 4 4 X 4 Abbey Road [53] DS0000025946.V354209.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP19 Good Practice Recommendations For the manager to discuss with staff and residents, appropriate covering (curtains/blinds) for the front door and window. Abbey Road [53] DS0000025946.V354209.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Abbey Road [53] DS0000025946.V354209.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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