CARE HOMES FOR OLDER PEOPLE
Abberdale House 165-169 Hinckley Road Leicester Leicestershire LE3 0TF Lead Inspector
Kim Cowley Unannounced Inspection 30th November 2005 11:00 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 Abberdale House DS0000053123.V268598.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. Abberdale House DS0000053123.V268598.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Abberdale House Address 165-169 Hinckley Road Leicester Leicestershire LE3 0TF 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) 0116 2915660 0116 2915660 None Shankar Leicester Ltd Marie French Care Home 24 Category(ies) of Dementia - over 65 years of age (24), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (24), Old age, not falling within any other category (24) Abberdale House DS0000053123.V268598.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 12th September 2005 Brief Description of the Service: Abberdale House accommodates 24 older people, some of whom have dementia or mental health needs. The home is on three floors and has a passenger lift. It is situated on the Hinckley Road about a mile from the centre of Leicester. The home has three lounges, a small smoking room, and a large dining room. At the rear of the home is a secluded garden with seating areas. Abberdale House DS0000053123.V268598.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on a weekday. When undertaking inspections the Commission for Social Care Inspection (CSCI), focuses on the outcomes for residents living in a home. In order to do this, the inspector ‘case tracked’ three residents living at Abberdale House. This means the inspector checked their care records and met with them. In addition the inspector met a further two residents, and spoke to the Owner, the Manager, and two of the care staff team. Further care and other records were examined. One requirement was made. What the service does well:
Abberdale House specialises in the care of residents with mild dementia and mental health needs. The premises are secure and homely and the atmosphere is friendly and welcoming. There is an established staff team, some of whom have worked at the home for many years. All residents interviewed praised the staff and the following comments were made, ‘The staff are very good’, ‘The staff look after us well’, and ‘The staff are lovely.’ The Manager and the Owner run the home as a team. Both work full-time and share an office where residents and relatives are welcome to call in at any time. The Manager and Owner talk to residents every day and to relatives when they visit. The Manager said ‘We try and run the home for the residents and let them make choices about bedtimes, getting up times, food and activities. If a resident is confused we find out from their families what sort of routines are best for them.’ Those residents interviewed said they were happy at Abberdale House and looking forward to Christmas activities including a trip to see the lights, carols in Abbey Park, and visiting entertainers. One resident said ‘It’s lovely here. Everything’s nice and the food is good.’ Another commented ‘There’s nothing to complain about here.’ Abberdale House DS0000053123.V268598.R01.S.doc Version 5.0 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. Abberdale House DS0000053123.V268598.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 Abberdale House DS0000053123.V268598.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): EVIDENCE: These Standards were inspected at the last inspection on 12.09.05. Abberdale House DS0000053123.V268598.R01.S.doc Version 5.0 Page 9 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 Medication is safely managed and administered. EVIDENCE: Medication is given out by senior carers who have been trained in-house and by the home’s contract pharmacist. Medication records were examined and found to be in good order. There are written procedures for staff to follow when administering medication. The contract pharmacist inspected the medication systems on 20.06.05 and found them to be satisfactory. No residents self-medicate at present. Residents with a psychiatrist have their medication reviewed routinely every three months. Staff monitor other residents to see if their medication is effective and consult GPs if there are any concerns. One resident commented ‘The staff do my tablets for me and tell me when to take them.’ Abberdale House DS0000053123.V268598.R01.S.doc Version 5.0 Page 10 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): EVIDENCE: These Standards were inspected at the last inspection on 12.09.05. Abberdale House DS0000053123.V268598.R01.S.doc Version 5.0 Page 11 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): EVIDENCE: These Standards were inspected at the last inspection on 12.09.05. Abberdale House DS0000053123.V268598.R01.S.doc Version 5.0 Page 12 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): EVIDENCE: These Standards were inspected at the last inspection on 12.09.05. Abberdale House DS0000053123.V268598.R01.S.doc Version 5.0 Page 13 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): 28, 29 Not all staff have the necessary documentation in place to enable them to work in a care home. EVIDENCE: The staff team consists of the Manager, the Owner, four seniors (one on each shift), nine carers, the housekeeper, two domestics (on work experience), and a laundry assistant. Staffing levels meet minimum standards. All residents interviewed praised the staff and the following comments were made: ‘The staff are very good.’ ‘The staff look after us well.’ ‘The staff are lovely.’ Staff were observed interacting with residents in a warm and professional manner. Staff files were inspected and found to be in need of improvement for the following reasons: • • some staff had only one written reference on file (they must have two) one member of staff had testimonials rather than references, these are not acceptable and proper references must be obtained
DS0000053123.V268598.R01.S.doc Version 5.0 Page 14 Abberdale House • • • not all induction records have been completed so it could not be ascertained whether all staff have been properly trained not all staff files have photos of the members of staff in question – these must be in place for identification purposes not all staff files contained declarations of health for the members of staff in question – these must be obtained Staff files must be audited and missing documentation put in place in order to meet Regulation 19/Schedule 2. This will contribute to the safety of residents in the home. The majority of staff have satisfactory CRB/POVA clearance. One member of staff was still waiting for their application to be processed. The Manager said this member of staff would be working under supervision until then. Abberdale House DS0000053123.V268598.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, 33, 35 The Manager, who runs the home in conjunction with the Owner, is well qualified and experienced. Residents are encouraged to make choices about their lifestyles. Residents’ financial interests are safeguarded. EVIDENCE: The Manager and the Owner run the home as a team. Both work full-time and share an office where residents and relatives are welcome to call in at any time. The Manager is an experienced carer who has worked at Abberdale House for seven years. This year she completed her NVQ Level 4/Registered Managers Award. The Owner looks after the business side of the home. Either the Manager or the Owner is on call at all times. The home has a friendly atmosphere and staff encourage residents to make choices about their lives. The Manager and Owner talk to residents every day and to relatives when they visit. The Manager said ‘We try and run the home
Abberdale House DS0000053123.V268598.R01.S.doc Version 5.0 Page 16 for the residents and let them make choices about bedtimes, getting up times, food and activities. If a resident is confused we find out from their families what sort of routines are best for them.’ The home looks after small amounts of money for some residents who are not able to look after it themselves. Appropriate records are kept. Other residents have their money looked after by their relatives or solicitors. Social workers are involved if there are any concerns about how a residents’ money is being managed. Abberdale House DS0000053123.V268598.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 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 X 28 3 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X X Abberdale House DS0000053123.V268598.R01.S.doc Version 5.0 Page 18 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 OP29 Regulation 19 Requirement Timescale for action Staff files must be audited and 30/01/06 missing documentation put in place in order to meet Regulation 19/Schedule 2. 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 Abberdale House DS0000053123.V268598.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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