Inspection on 05/02/08 for Abbas Combe Nursing Home

This inspection was carried out on 5th February 2008.

CSCI found this care home to be providing an Good service.

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

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

CARE HOMES FOR OLDER PEOPLE Abbas Combe Nursing Home 94 Whyke Road Chichester West Sussex PO19 2JF Lead Inspector Sheila Gawley Key Unannounced Inspection 5th February 2008 09:30 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 Abbas Combe Nursing Home DS0000070405.V351768.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. Abbas Combe Nursing Home DS0000070405.V351768.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbas Combe Nursing Home Address 94 Whyke Road Chichester West Sussex PO19 2JF 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) 01243 789826 01243 775111 Lotus Care 2 Ltd Post Vacant Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (0) of places Abbas Combe Nursing Home DS0000070405.V351768.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home with nursing - (N) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category (OP). The maximum number of service users to be accommodated is 25. Date of last inspection N/A Brief Description of the Service: Abbas Combe is a care home with nursing situated on the A27 ring road to the south of Chichester and is approximately a twenty minutes walk to the town center with all its amenities. The home was originally a detached house, which has been altered and extended to provide accommodation for twenty-five people in the category Older Persons. The accommodation is offered on two floors, with passenger lift access to the first floor. Accomodation is offered in single rooms, many with en-suite facilities. There is a choice of communal day space including a sitting room and conservatory/dining room. The home is surrounded by attractive gardens, and a limited amount of parking space is available. The fees charged are £610- £655 Abbas Combe Nursing Home DS0000070405.V351768.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 stars. This means the people who use this service experience good quality outcomes. This site visit as part of the inspection was carried out on 05/02/08. This was the first inspection to a new registration of an existing home. The Registered Manager has recently resigned and the inspection was facilitated by the deputy Manager, the Registered Manager of a sister home in the organisation and the organisations group manager. Staff and residents spoken to stated that they were happy under the new organisational management of the home. Prior to the visit the service file was reviewed as were any comments or complaints received by the Commission for Social Car inspection. The Home had sent us their Annual Quality Assurance Assessment for the inspection, which gave us the information we needed on the home. Any records or documents required on the day were made available. Three residents completed surveys; many were spoken to on the day, as were two relatives and all expressed satisfaction with the service. What the service does well: Residents spoken to all stated that they are treated with kindness and respect. Meals are nutritious and varied. The changing needs of people who use the service are assessed and relevant action is taken. The home has an ongoing redecoration programme, several environmental improvements have occurred and plans are in place to complete this work throughout the home. Each resident has a comprehensive, up to date Service User Guide. Abbas Combe Nursing Home DS0000070405.V351768.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Abbas Combe Nursing Home DS0000070405.V351768.R01.S.doc Version 5.2 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 Abbas Combe Nursing Home DS0000070405.V351768.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3, Standard 6 is not applicable People who use this service experience good outcomes in this area, as there is a clear assessment and admission process. This judgement has been made using available evidence including a visit to this service EVIDENCE: There is an up to date and comprehensive Service User Guide and Statement of Purpose available to people who use the service and their residents or representatives to enable them to have information and make choices about the home. People who use the service have their needs assessed prior to admission. These assessments were seen in the care plans inspected. Abbas Combe Nursing Home DS0000070405.V351768.R01.S.doc Version 5.2 Page 9 There is a policy in place for emergency admissions to ensure their needs are assessed promptly on admission and information from health professionals and care managers is sought. Abbas Combe Nursing Home DS0000070405.V351768.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7-10 People who use this service experience good outcomes in this area because all needs are assessed and met, set out in a plan and residents are treated with respect. Medicines are handled appropriately. This judgement has been made using available evidence including a visit to this service. . EVIDENCE: All residents had a plan of care. Four people who use the service were case tracked. The care plans inspected contained information on health, personal and social need. The care plans were drawn up following an assessment of these needs. This included nutritional assessments, mobility, hygiene, continence, and pressure areas, and risk assessments. The risk assessments covered falls, nutrition, choking, wandering, skin assessment, nursing and personal care needs such as the number of carers to move the person or the Abbas Combe Nursing Home DS0000070405.V351768.R01.S.doc Version 5.2 Page 11 use of a slide sheet required. The care plans were up to date and had evidence of monthly review. Weight is monitored. Access to specialist health support is available as required including general practitioner, chiropodists, and outpatient appointments. There is a domiciliary dental and optician service. Staff were observed offering care in a respectful and encouraging manner and people who use the service spoken to stated that they are treated with respect. People who use the service and relatives spoken to stated that care is offered as assessed. Medicines are received, stored, administered and recorded appropriately. Medicine administration charts inspected were up to date. Abbas Combe Nursing Home DS0000070405.V351768.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12-15 People who use this service experience good outcomes in this area, because lifestyle in the home meets their expectations. Activities and events provided satisfy social, cultural and recreational needs. There is a variety of nutritional food on offer. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is an activities programme in place. This includes in house activities such as themed meals and some external entertainers. People who use the service spoken to stated that they were happy with daily life in the home. The general manager stated that this is an area that the proprietors are keen to develop further. People spoken to also stated that they could receive visitors as they choose. People spoken to stated that they have freedom in daily routines such as when to go to bed and where to take meals. Abbas Combe Nursing Home DS0000070405.V351768.R01.S.doc Version 5.2 Page 13 The chef was spoken to. There is varied menu in place and choice is offered to residents. The meal seen prepared and served today appeared nutritious and people who use the service said they enjoyed it. Two visitors were spoken to and they stated that the meals served always appear nutritious and appetising. Abbas Combe Nursing Home DS0000070405.V351768.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16-18 People who use this service experience good outcomes in this area, as there are policies and procedures in place for complaints and safeguarding adults. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a clear and accessible complaints procedure in place which residents spoken to stated that they were aware of, although all stated that they did not have reason to complain. Two visitors spoken to also stated that they did not have reason to complain but would know how to do so. There is the facility to record any complaints including actions and outcomes. Postal votes are arranged for people who use the service and there are details of advocacy services in the home, this is referred to in the Service User Guide and details are in a folder in the hall. There are policies and procedures in place regarding safeguarding adults and whistle blowing. Staff spoken to were clear about the procedures to follow in safeguarding adults allegations. Training records show that staff have training in safeguarding adults policies and procedures. Abbas Combe Nursing Home DS0000070405.V351768.R01.S.doc Version 5.2 Page 15 Abbas Combe Nursing Home DS0000070405.V351768.R01.S.doc Version 5.2 Page 16 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): 19,22,25,26 People who use this service experience good outcomes in this area because they live in a safe and well-maintained environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There have been many environmental improvements to the home such as new furniture and carpeting. Bedrooms were neat clean and personalised. The bedrooms are to be decorated as they become vacant and there are plans to create a new shower room. There are pleasant, well-decorated communal areas; a sitting room and a conservatory/dining room. A new boiler has been installed ensuring an efficient heating system and all taps except in the kitchen are thermostatically controlled. Radiators are covered. Abbas Combe Nursing Home DS0000070405.V351768.R01.S.doc Version 5.2 Page 17 There is a call bell system in place but the system was not working in one room, this was rectified when brought to the attention of staff. There is a passenger lift and the home has lifting aids and hoists. There is satisfactory sluice and laundry equipment but both rooms were untidy with basins lying about and items of clothing hanging from shelves. The shelves were made of unfinished plywood. The surfaces were not completely clean. The visiting manager and the groupl manager stated that this would be addressed with the purchase of a new shelving unit for the laundry and including these areas in the domestic staff schedule of cleaning. Abbas Combe Nursing Home DS0000070405.V351768.R01.S.doc Version 5.2 Page 18 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): 27-30 People who use this service experience good outcomes in this area because needs are met by a staff trained and qualified to do so. This judgement has been made using available evidence including a visit to this service EVIDENCE: There was sufficient staff on duty to meet the residents care needs as detailed in the care plans. Staff spoken with confirmed that they were happy with staffing levels and that this was good place to work. Residents spoken to stated they were happy with the number of staff at the home and found them to be kind and knowledgeable. They confirmed that they were well cared for. Training files were seen and staff confirmed that induction, mandatory and National Vocational Qualifications are provided. All mandatory training is given by an external training provider. Three staff files were checked they showed that the home had undertaken all the necessary checks to ensure protection of residents. Two references were in place and Criminal Records Bureau Clearance and POVA checks had been undertaken. Abbas Combe Nursing Home DS0000070405.V351768.R01.S.doc Version 5.2 Page 19 Abbas Combe Nursing Home DS0000070405.V351768.R01.S.doc Version 5.2 Page 20 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, 36,38 People who use this service experience good outcomes in this area because the home is run in the home is run in the best interests of the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Registered Manager post is vacant but the home has recruited and has offered the post to a Registered Nurse. The deputy manager is fulfilling the management function in the home. Staff spoken to feel that the home is well run and a nice place to work. Abbas Combe Nursing Home DS0000070405.V351768.R01.S.doc Version 5.2 Page 21 Quality assurance systems are in place to elicit opinion from the residents on how the home is run. This includes surveys and there are quarterly staff meetings. The home has facilities if requested to, hold money for people who use the service separately, securely and it would be recorded. Staff are supervised and records of this were seen in staff files. The health and safety of residents and staff are ensured by the provision of mandatory training and policies on health and safety. Evidence of utility and equipment testing and maintenance is held and was available for inspection. Abbas Combe Nursing Home DS0000070405.V351768.R01.S.doc Version 5.2 Page 22 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 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 3 17 3 18 3 3 X X 3 X X 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Abbas Combe Nursing Home DS0000070405.V351768.R01.S.doc Version 5.2 Page 23 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. Refer to Standard Good Practice Recommendations Abbas Combe Nursing Home DS0000070405.V351768.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Abbas Combe Nursing Home DS0000070405.V351768.R01.S.doc Version 5.2 Page 25 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!