Inspection on 16/03/06 for Abbeyfield 10 Eastfield Park

This inspection was carried out on 16th March 2006.

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

The inspector 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

Abbeyfield 10 Eastfield Park 29/01/09

Abbeyfield 10 Eastfield Park 30/01/07

Abbeyfield 10 Eastfield Park 09/08/05

Abbeyfield 10 Eastfield Park 17/03/05

Abbeyfield 10 Eastfield Park 14/07/04

Abbeyfield 10 Eastfield Park 23/02/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE 10 Eastfield Park Weston Super Mare North Somerset BS23 2PE Lead Inspector John Hurley Unannounced Inspection 09:00 16 March 2006 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 10 Eastfield Park DS0000008110.V280897.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 10 Eastfield Park DS0000008110.V280897.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 10 Eastfield Park Address Weston Super Mare North Somerset BS23 2PE 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) 01934 622144 01934 644532 s.furzeman@aol.com The Abbeyfield (WSM) Society Mrs Patricia Joan Boley Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places 10 Eastfield Park DS0000008110.V280897.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. May accommodate up to 20 persons aged 65 years and over requiring personal care only That Mrs Patricia Boley completes the Register Managers Award by December 2006 9th August 2005 Date of last inspection Brief Description of the Service: 10 Eastfield Park is a care home owned by The Abbeyfield (Weston-superMare) Society and offers 24-hour personal care and accommodation for up to 20 frail elderly people. The home is situated at the end of a quiet cul-de-sac in Weston-super-Mare and is in close proximity to a small private park. Regular transport is provided daily to take residents into the town and sea front, if they wish.Accommodation is available in single or one double room, many of which have ensuite facilities. Residents may bring in small items of furniture if they wish, after discussion with the manager. The home is on two floors linked by a lift.The home has extensive front gardens for residents to enjoy and garden furniture is provided. 10 Eastfield Park DS0000008110.V280897.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out as part of the planned annual programme of inspection. The inspection was unannounced and carried out by John Hurley, Regulation Inspector, over four hours. The focus of the inspection was to look at standards not inspected at the previous inspection. The previous inspection was announced and took place on ninth of August 2005. That inspection covered the majority of the core standards and so this report may appear brief but should be read in conjunction with the previous inspection report. During the course of the inspection the Registered Manager, service users, relatives and staff members were spoken with. Care practice was also observed, records examined and a tour of the premises was made. What the service does well: The home has a group of staff who have worked at the home for a long time providing continuity of care. They ensure the well-being and comfort of the residents’ and treat them with great respect and kindness. Residents spoke of the “lively atmosphere” and “happy home. Meals are continue to be varied, well balanced and nicely presented offering choice and variety. The service user informed the inspector that the staff team manage the daily activities and provide opportunities for them to maintain links with the local community. All the residents spoken with were pleased with the choice and variety available. The home continues to provide high quality care with competent staff in a welldecorated, pleasant and homely environment. 10 Eastfield Park DS0000008110.V280897.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 10 Eastfield Park DS0000008110.V280897.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection 10 Eastfield Park DS0000008110.V280897.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,4,6 The service users have contracts. There appears to be high levels of satisfaction of service provided by the home. The service users and their relatives confirmed that they felt the home could meet their needs. EVIDENCE: The inspector sampled the service users contracts. They found that there were good details relating to the trial period and charges for the room. The contracts also state that the service user will receive full board and what this means ie lighting, heating, meals and laundry services etc. The contract also states what is not included such as personal clothing and newspapers. In order to further enhance the contracts it would be helpful if they stated the individuals room to which the charges are made against. The inspector spoke with service users in a group and individually. They all confirmed that they felt their needs were being met and enjoyed living in the home. The visiting relatives who the inspector spoke with confirmed that they 10 Eastfield Park DS0000008110.V280897.R01.S.doc Version 5.1 Page 9 were pleased with the services provided and considered that the home offers good care. The registered manager informed the inspector that the home does not offer intermediate care. 10 Eastfield Park DS0000008110.V280897.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,9,10 Service users benefit from care plans that are well formulated and give clear information to enable staff to meet residents’ health and social care needs. Medication policies and procedures do not currently meet the required standards. Bereavement issues are acknowledged in the service user documentation. EVIDENCE: The inspector sampled some of the care plans that are maintained for each service user. These include details of individuals’ needs, daily routines and preferences. Care plans were thorough and included detailed directions to staff of the level and type of assistance to be provided to each person. A moving and handling assessment had been completed for each service user. Care plans had been regularly reviewed and updated as required. Residents spoken to confirmed the staff were well aware of their needs and did everything to those needs. The inspector discussed medication issues with the registered manager and looked at the administration records, cross referencing against the service user individual file where appropriate. 10 Eastfield Park DS0000008110.V280897.R01.S.doc Version 5.1 Page 11 Some service user self medicate and have signed declarations that they will take responsibility for their medication. This needs to be risk assessed and reviewed on an ongoing basis. There are occasions when the home has to dispense controlled drugs. The home has separate and suitable storage arrangements for these medications but the recording systems do not meet with the required standard and a separate controlled drugs book needs to be obtained. The registered manager confirmed that homely remedies (over the counter pharmacy preparations) are available to service users if required. The home needs to evidence that the individual’s doctor is in agreement with this practice. It would also be helpful if there was a full recorded rationale relating to the administration of medication via the PRN route. The registered manager evidenced that they had acknowledged medication issues prior to the inspection and senior staff were due to attend training in safe medication practices later that month. A Commission for Social Care Inspection pharmacist will make a further visit to the home to give further guidance on these issues. The service user records detail how the individual wishes to be treated at the time of their death. Relatives confirmed that they were confident that the home would work with them in the best interests of their relatives, considering the staff to be compassionate and knowledgeable. 10 Eastfield Park DS0000008110.V280897.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,14,15 The routines of the home are unhurried and appear to suit the individuals needs. Service users excise their rights and make choices aided by staff through positive encouragement. The food meets with the approval of the service user group. EVIDENCE: Daily routines are flexible to meet the needs of service users. Service users are able to participate in a range of activities. A weekly program of activities is displayed in the dining room. Service users spoken with were satisfied with the activities provided. Several service users told the inspector that they knew what activities were taking place, some they liked others they did not. Given that the home provides two communal areas those who choose not to participate do not have too. Some service user access the local community independently, appropriate risk assessments are in place. It was noted that a door wedge was used by one service user to prop open the front door so that they did not have to ring the bell to gain entry on their return to the home. 10 Eastfield Park DS0000008110.V280897.R01.S.doc Version 5.1 Page 13 The registered manager acknowledged the inspectors observation that it may be more appropriate to give the individual a key to the front. The relatives spoken to confirmed that they are welcome in the home at any reasonable time. The service users informed the inspector that they could meet people important to them in their own rooms, communal rooms or in the dinning room. The staff impressed as having built up positive relationships with people important to the service users and were observed discussing issues in a knowledgeable non-judgemental fashion. The lunchtime meal was briefly observed. The service users commented that the food was good and in sufficient quantities. A service user explained that if they did not like what was on offer an alternative would be provided. They also said that this rarely happened as they, (the staff) knew what I like. Service users confirmed that they could eat their meals in their own rooms if the wished, but most enjoyed this social activity in the dinning room. 10 Eastfield Park DS0000008110.V280897.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): This group of standards were not inspected EVIDENCE: 10 Eastfield Park DS0000008110.V280897.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,23,24 The areas of the home inspected were safe and well maintained. The home continues to provide a good standard of accommodation, which has retained a degree of domestic character. Risk assessments are in place relating to the environment. EVIDENCE: The inspector briefly toured the premises and noted that the service users rooms are comfortable and well maintained. There is a range of different shape rooms, which have been furnished to the occupant’s individual taste. A service told the inspector that they had brought in some of their own photos and keepsakes. They said that they liked their room and felt it was furnished to their liking. They commented that if they wanted staff would help them keep their rooms tidy. Many service users commented that they appreciated the radiators, as it was a good place to dry small items. The home has grab rails situated at relevant points. A passenger lift is easily accessible to assist resident mobility and aid independence within the home. A 10 Eastfield Park DS0000008110.V280897.R01.S.doc Version 5.1 Page 16 stair lift is also available for access to one level of the home. All resident rooms are provided with locks that are accessible to staff in an emergency. The home was clean and free from offensive odours throughout. The laundry facilities were well organised with impermeable and washable flooring and walls to maintain cleanliness and prevent the spread of infection. Staff demonstrated a good understanding of Infection control procedures and practices and maintained a clean and hygienic environment. Appropriate risk assessments are in place and the radiators, which required further considerations regarding risks have been re assessed. The registered manager informed the inspector that although one radiator in a communal hallway is turned down, it is regularly turned up again. There is no evidence in the accident book, or other sources, that this radiator is problematic and poises any significant risk, this appears to support the risk assessment. The inspector would however suggest that whilst the radiator in the bathroom does not appear to present a scolding hazard it may be helpful to consider fitting a thermostatic valve to reduce the surface temperature to a more acceptable level. 10 Eastfield Park DS0000008110.V280897.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28 Staff are well trained and deployed in numbers sufficient to meet the needs of the service user group. The employment procedures should ensure that safety of the service user group. EVIDENCE: The rotas viewed indicate that there is sufficient staff on duty to meet the service users needs. Service users spoken to said that the staff were kind and caring and always there to help. The inspector observed that staff were spending time with residents, call bells were answered quickly and those who required more reassurance were attended to promptly. The care staff were supported by ancillary staff who prepared meals and undertook domestic duties. The inspector sampled the staff files and looked at the last two staff members to take up employment at the home. There was sufficient evidence on file to illustrate that the home verifies identity and takes up references following a formal interview. The files that were shown to the inspector contained copies of original documents. Not all copies of the references taken were available. Evidence of induction programmes was seen and staff i confirmed that they continue to be supervised in their practice. All staff have received first aid and fire safety training. Staff spoken to said that there was lots of training and records seen showed attendance at a variety of relevant training sessions. 10 Eastfield Park DS0000008110.V280897.R01.S.doc Version 5.1 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,37,38 The home is well managed and provides needs lead service. There are appropriate systems in place to obtain the views of service users. Records relating to service users are stored securely. All staff should wear aprons in the kitchen area. The organisation needs to ensure that a valid electrical hardwiring certificate covers the homes electrical circuits. EVIDENCE: The home is being run in an open and transparent fashion. The registered manager engaged in the inspection process well and gave ever assistance to the inspector in carrying out the inspection. Although a number of issues relating to medication have been identified during the inspection, as noted earlier the registered manager had already identified these issues and taken steps to address the problems. Quality assurance measures are in place to ensure the monitoring of standards and that the residents have a say in the running of the home. 10 Eastfield Park DS0000008110.V280897.R01.S.doc Version 5.1 Page 19 Records relating to service users are stored securely. The home displays appropriate Employers Liability Insurance. Examination of records and discussion with staff indicate safe working practices are being observed on the home. The hot water temperature is regularly recorded demonstrating that the hot water is constantly monitored. Fire safety equipment has been serviced and tested as required. Staff have been provided with regular fire safety training. Equipment servicing records have been appropriately maintained. The fire risk assessment had been reviewed. Staff confirmed that they are provided with health and safety training, on commencing employment at the home. The kitchen area was briefly observed. All foodstuffs were appropriately stored and fridge and freezer temperatures regularly recorded. The area was clean and hygienic. Although no food was being served or prepared it was noted that staff do not always where aprons in the kitchen area, this could undermine infection control measures. The registered manager was not able to show the inspector the homes electrical hardwiring certificate at the time of the inspection 10 Eastfield Park DS0000008110.V280897.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x 3 x 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 1 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 x 3 x x x 3 3 x x STAFFING Standard No Score 27 3 28 3 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x x x x x 3 2 10 Eastfield Park DS0000008110.V280897.R01.S.doc Version 5.1 Page 21 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 Requirement The registered manager must ensure that service users who take responsibility for their own medication do so in a risk management framework The registered manager must ensure that there is a clear and recorded rationale for the administration of medication via the PRN route The registered manager ensures that the procedures for the receipt, recording, storage, handling administration and disposal of medicines meet the current requirements. Timescale for action 21/04/06 2 OP9 13 21/04/06 3 OP9 13 21/04/06 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 OP38 Good Practice Recommendations The registered manager should consider ensuring that the electrical hard wiring certificate is available for inspection. DS0000008110.V280897.R01.S.doc Version 5.1 Page 22 10 Eastfield Park 2 OP10 The registered manager should consider giving front door keys to those who assess the community independently. 10 Eastfield Park DS0000008110.V280897.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 10 Eastfield Park DS0000008110.V280897.R01.S.doc Version 5.1 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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