Inspection on 04/10/05 for Abbeleigh House

This inspection was carried out on 4th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Abbeleigh House 27/10/06

Abbeleigh House 19/06/05

Abbeleigh House 10/03/05

Abbeleigh House 20/07/04

Abbeleigh House 23/02/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Abbeleigh House 69 Squirrels Heath Road Harold Wood Romford Essex RM3 0LS Lead Inspector Harbinder Ghir Unannounced Inspection 4 October 2005 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 Abbeleigh House DS0000027827.V255818.R01.S.doc Version 5.0 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. Abbeleigh House DS0000027827.V255818.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Abbeleigh House Address 69 Squirrels Heath Road Harold Wood Romford Essex RM3 0LS 01708 345110 01708 342827 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) Masumin Limited Ms Jacqueline Sheila Harrison Care Home 35 Category(ies) of Dementia (35), Old age, not falling within any registration, with number other category (35) of places Abbeleigh House DS0000027827.V255818.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 35 beds to be used flexibly between both categories. Date of last inspection 19th July 2005 Brief Description of the Service: Abbeleigh House offers 24-hour residential care to 35 people over the age of 65 years. The home is also registered to provide dementia care. The accommodation is split between 2 floors, providing 13 single and 11 double bedrooms. All rooms are spacious, airy and bright. They all have TV points and a call system. The home has a passenger lift. There are two lounges, a dining room, and a visitors room. The rear garden is with disabled access to the grounds and there are car parking facilities to the rear of the property. The home is located on a busy residential road in Harold Wood in the London Borough of Havering and is close to local services and facilities in Romford Town Centre, which are easily accessible by car and by public transport as is the A127. Abbeleigh House DS0000027827.V255818.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission was represented by Harbinder Ghir, Regulatory Inspector who was in Abbeleigh House from 9.30 a.m. until 11.40 pm. This inspection was the second unannounced inspection carried out as part of the annual inspection plan. During that time some staff agreed to speak with the Inspector. The home and some records were inspected. Eight Requirements were set at the previous inspection and for one of these the timescale has not yet been reached, so has been restated in this report with a new timescale for compliance. Seven have been met. Seven Recommendations were set at the previous inspection and four have not been met, so have been restated in this report. Further information about unmet Requirements and Recommendations can be found in the relevant standard. Failure to comply by the revised timescale will lead to the Commission for Social Care Inspection considering enforcement action to secure compliance. This was the second statutory inspection for 2005/6, and across the two visits all core standards have been assessed. What the service does well: What has improved since the last inspection? All care plans and risk assessments are reviewed monthly and the dietary intake of all residents is monitored to ensure their nutritional intake is monitored. Abbeleigh House DS0000027827.V255818.R01.S.doc Version 5.0 Page 6 The daily case recording format has been changed which now reflects the care, that care staff are providing on a daily basis. The home completes routine environmental risk assessments both internally and externally. A supervision matrix has been devised by the home to ensure all staff are supervised at least 6 times a year. Supervision is beginning to take place. 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. Abbeleigh House DS0000027827.V255818.R01.S.doc Version 5.0 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 Abbeleigh House DS0000027827.V255818.R01.S.doc Version 5.0 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): 1,2,3,4,5 The homes Statement of Purpose and Service User Guide are good but need to be updated to comply with The Care Homes Regulations 2001. Trial visits are offered and pre -admission assessments are completed prior to admission to ensure identified needs can be met by the home. EVIDENCE: The Statement of Purpose was seen, which provided detailed information about the service, but needs to be updated to include information on how the home meets the needs of those residents diagnosed with dementia. The Service User Guide was in large print and in pictorial format. However, this document needs to be updated to include information required by The Care Homes Regulations 2001. A copy of the Service User Guide is given to all residents prior to admission and is readily available within the home. The last inspection report is readily available via the manager. All residents receive a written contract of terms and conditions, which was very comprehensive. The home has a good pre-admission assessment form. Pre-admission assessments are completed by the manager who assures potential residents their needs can be met by the home. The manager confirmed that trial visits to the home are encouraged and are an opportunity for potential residents and Abbeleigh House DS0000027827.V255818.R01.S.doc Version 5.0 Page 9 their family to identify how appropriate the home is for them in meeting their needs. Residents are encouraged to visit the home for the day and once admitted can trial the home for up to four weeks. The home does not provide intermediate care. Abbeleigh House DS0000027827.V255818.R01.S.doc Version 5.0 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): 9, 11 The systems for medication administration are good with clear and comprehensive arrangements being in place to ensure residents’ medication needs are met. Residents’ wishes in the event of death were established in care plans. EVIDENCE: Medication is managed well by the home. The home has an appropriate medication policy and procedure in place. All medication is appropriately stored and all staff who administer medication have undergone medication training. In the event of death the home appropriately manages residents’ wishes. The homes procedures in the event of death are very detailed and service user led. Three care plans seen contained information regarding individual resident wishes in the event of death. These had been recorded sensitively. Abbeleigh House DS0000027827.V255818.R01.S.doc Version 5.0 Page 11 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, 15 Social activities are organised but residents needed to better informed of what was being organised for them. The meals in the home are nutritious offering both choice, variety and catering for special diets. Residents were not aware of what the daily menu was. EVIDENCE: Recommendations made concerning additional social activities and daily menu’s have not been implemented. They have been restated as recommendations 1 and 2 in this report. Abbeleigh House DS0000027827.V255818.R01.S.doc Version 5.0 Page 12 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): 16, 18 The home’s complaints procedure must be updated to ensure the role of The Commission for Social Care Inspection is appropriately represented. Policies, procedures and staff training were provided that protected residents from abuse. EVIDENCE: The home has a comprehensive complaints policy. However, the complaints procedure needs to be updated to include, that The Commission for Social Care Inspection can be contacted at any stage of the complaint being made or investigated. Staff responded promptly and complaints were actioned appropriately. Policies and procedures regarding the abuse of vulnerable adults were provided. Records seen identified all staff received training on adult abuse and this was also incorporated into the induction programme. The manager had also obtained policies and procedures from placing Local Authorities. Abbeleigh House DS0000027827.V255818.R01.S.doc Version 5.0 Page 13 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): 24, 25 Residents benefited from living in warm, clean personal and communal accommodation, although their comfort would be enhanced by additional maintenance. EVIDENCE: Two recommendations were set at the previous inspection that bedside lighting is provided for all residents and all windows where required are fitted with window restrictors. These have not yet been actioned, so have been restated as recommendation 3 and 4. Requirements made at the last inspection have been complied with. Abbeleigh House DS0000027827.V255818.R01.S.doc Version 5.0 Page 14 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): 29 The home needs to better support its staff by providing them with job descriptions and terms and conditions. EVIDENCE: A requirement was set out at the previous inspection that all staff employed by the home are provided with a contract of terms and conditions. This has not yet been actioned, so has been restated as Requirement 3, with a new timescale. Abbeleigh House DS0000027827.V255818.R01.S.doc Version 5.0 Page 15 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, 32, 33, 35, 38 Residents’ benefit from an experienced manager who recognises their needs and manages the home well. The manager has a clear vision for the home, which she has effectively communicated to residents, relatives and staff. The systems for service user consultation need to be improved to ensure residents’ views are sought and acted on. Systems are in place to protect residents’ financial interests. The welfare of staff and service users are promoted by the homes policies and procedures at all times. EVIDENCE: The manager has many years experience of working with this service user group and has completed the Registered Managers Award. Staff spoken to at the home stated the home was well run and they were well supported by the manager. A resident spoken to informed that the manager is very Abbeleigh House DS0000027827.V255818.R01.S.doc Version 5.0 Page 16 approachable and manages the home well. Quality assurance questionnaires were sent out last year to residents and relatives. The results were published and included in the Service User Guide for last year. The document also stated that quality assurance surveys are completed twice a year. However, this year no surveys have taken place. Quality assurance and monitoring systems still need to be developed to include the views of stakeholder in the community, e.g doctors, community nurses etc. Reports regarding monthly visits in accordance with Regulation 26 visits are received by CSCI. These are comprehensive, giving a good picture of how the organisation assesses itself. Residents were encouraged to manage their own financial affairs or to have assistance from their families / representatives, although the home would hold small quantities of cash for residents if requested. A simplified system of holding and recording residents’ cash by the home was in place. The propertier was an appointee for one resident. All written transactions and receipts were maintained and kept up to date by the registered person. The home has a maintenance person who takes overall responsibility for ensuring relevant checks are carried out. It is clear from the records seen that all relevant legislation is complied with and reportable incidents are reported to the appropriate authorities. The home has a written policy regarding safe working practices. Fire signs and safety posters are evident throughout the home. All members of staff have health and safety training as part of the induction process. Abbeleigh House DS0000027827.V255818.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 X 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 X X 3 Abbeleigh House DS0000027827.V255818.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? Yes 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 OP1 Regulation 4(b)Sched ule1, 5(1) Requirement The Statement of Purpose must be updated to include information on how the service meets the needs of those residents diagnosed with dementia. The Service User Guide must be updated to include the information required by the Care Homes Regulations 2001. The complaints procedure must be updated to include that The Commission for Social Care Inspection can be contacted at any stage of the complaint being made or investigated The registered person must ensure that all staff employed by the home are provided with a contract of term and conditions which are to be signed by the employer and the employee. (Previous timescale of 30 August 2005 not met) Quality assurance and monitoring systems must be completed regularly which are used to monitor the performance of the home and overall quality DS0000027827.V255818.R01.S.doc Timescale for action 04/12/05 2 OP16 7 (a) (b) 04/12/05 3 OP29 Schedule 4 (e) 04/12/05 4 OP33 24(1)(a)( b),(2)(3) 04/12/05 Abbeleigh House Version 5.0 Page 19 of care. Quality assurance methods must also developed to seek the views of stakeholders. 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 OP12 Good Practice Recommendations It is recommended that more hours are designated to social activities and the weekly rota of activities is available to residents throughout the home. Recommendation restated from last inspection. It is recommended daily menus are readily available for residents and relatives to view within the home. Recommendation restated from last inspection. It is recommended appropriate bedside lighting is provided for all residents. Recommendation restated from last inspection. It is recommended that all windows where required are fitted with window restrictors. Recommendation restated from last inspection. 2 3 4 OP15 OP24 OP25 Abbeleigh House DS0000027827.V255818.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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 Abbeleigh House DS0000027827.V255818.R01.S.doc Version 5.0 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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