Inspection on 06/12/06 for Abbeville Lodge

This inspection was carried out on 6th December 2006.

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 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

Abbeville Lodge 29/08/07

Similar services:

Claremont House

Chesham House

Oak Ridge

Argyll House

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Bilney Hall

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

CARE HOMES FOR OLDER PEOPLE Abbeville Lodge Acle New Road Great Yarmouth Norfolk NR30 1SE Lead Inspector Mr Pearson Clarke Key Unannounced 6th December 2006 09:10 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 Abbeville Lodge DS0000068044.V323875.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. Abbeville Lodge DS0000068044.V323875.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbeville Lodge Address Acle New Road Great Yarmouth Norfolk NR30 1SE 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) 01493 857300 Abbeville RCH Limited Mrs Rita Rose Care Home 20 Category(ies) of Dementia (3), Mental Disorder, excluding registration, with number learning disability or dementia - over 65 years of of places age (1), Old age, not falling within any other category (18), Physical disability (2) Abbeville Lodge DS0000068044.V323875.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Three care staff to be on duty during the waking day. Care staff must receive dementia training to care for service users with a diagnosis of dementia. Date of last inspection Brief Description of the Service: Abbeville Lodge stands within the seaside town of Great Yarmouth. The service operates from an adapted building where all of the accommodation is on the ground floor. The home was previously known as Bridge house, but changed its name with a change of ownership in the summer of 2006. fees for the service range between £271 to £350 a week. The home was originally established in 1993 and is a single storey building with all bedrooms off the main corridor. The home has extensive gardens that consist of one enclosed garden with a patio and seating area, and a further open lawned area. There is ample car parking at the front of the premises. Abbeville Lodge DS0000068044.V323875.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Care services are judged against outcome groups which assess how well a provider delivers outcomes for people using the service. The key inspection of this service has been carried out by using information from previous inspections, information from the providers ,the residents and their relatives, as well as others who work in or visit the home. This has included a recent unannounced visit to the home and this report gives a brief overview of the service and current judgements for each outcome. What the service does well: What has improved since the last inspection? The home now has strong and effective management. There have been wide ranging improvements to the environment. These include extensive cleaning, redecoration, new carpets and new curtains. New beds and mattresses, new bedding, overhaul of bath hoists and repairs to the emergency lighting. Abbeville Lodge DS0000068044.V323875.R01.S.doc Version 5.2 Page 6 Staffing levels have been improved and a training plan put in place. A robust recruitment procedure has been established. A quality audit has taken place and any relevant outstanding requirements arising from the last inspection under previous ownership have been addressed. 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. Abbeville Lodge DS0000068044.V323875.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 Abbeville Lodge DS0000068044.V323875.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): 1,2,3 and 6 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service has been subject to much recent change, with new ownership, new management and a change of name. Since assuming ownership the new management identified concerns regarding a number of service users who appeared to be outside of the services category of registration. As such the Commission were aware that they were seeking professional reassessment in order to establish as to whether their care needs could be safely met in the home. As a result of the site visit, which involved discussion with the manager and inspection of care records, the inspector is happy that this process has been carried out in a sound manner. As such it has been decided to continue to offer care to a number of named service users who are settled in the service and whose needs can currently be met. This situation will be kept under review Abbeville Lodge DS0000068044.V323875.R01.S.doc Version 5.2 Page 9 and all new admissions will be people who fall within the main category of registration, which is older people. The new owner is an existing provider and as such has imported the admission and assessment process from their other service. These allow for a thorough assessment of needs to underpin admission to the service. The process of admission was described to the inspector and this involves visits to the home where possible and an assessment carried out by the service in the residents current setting. Since assuming ownership the management has re-issued contracts and service user guides to all service users and copies of the former were seen on service user files. Abbeville Lodge DS0000068044.V323875.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): 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since assuming ownership of service one of the major priorities has been to establish a sound system of care planning in the home. This task has been very problematic as the inherited records were chaotic and of a very poor quality. As a result the service has had to start from scratch and the resultant records are still in the process of development as more information becomes available. The inspector accepts that for these reasons the plans seen at the visit did have omissions, particularly in relation to life history, social and emotional needs and indications that service users are involved in the process. However the plans seen were sound in relation to direct care delivery, containing good information relating to medical needs, risk assessments and a process of review. With new admissions the service needs to ensure that the omissions identified are addressed and to continue to develop existing plans. Abbeville Lodge DS0000068044.V323875.R01.S.doc Version 5.2 Page 11 This is acknowledged by the service management and it is the inspectors judgement that this will now happen as more time becomes available. As with care plans the services existing medication has been overhauled and improved. As such the home now has secure storage and proper recording in this area. The local primary care trust has recently carried out a medication audit which indicated that a sound process was in place. Two service users self medicate and both have a risk assessment in place and secure storage in their rooms. The inspector sampled drug records which were accurately and fully completed. Some of the lunch time medication round was observed and the practice seen was appropriate. Service users interviewed on the day were very happy with the care received and felt that there was a good level of respect for their privacy and dignity. Abbeville Lodge DS0000068044.V323875.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): 12,13,14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Discussion with service users and staff employed in the home indicated that there has been a huge improvement in food provision at the home. The service cook contrasted the quality and amount of food stocked and ordered under the new regime with what went before. Service users talked to felt the home has improved and that they were very well cared for in an environment where they felt able to exercise choice and control over their lives. A number of social activities have been planned , and the service now has a small mini bus, however this is an area which would benefit from future development. Abbeville Lodge DS0000068044.V323875.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The provider has introduced an appropriate complaints process and this has been made available to service users through the service user guide and is also displayed in the home. The provider has received no complaints since assuming ownership. Service users spoken to by the inspector had no complaints, but were confident that should they need to do so then their concerns would be addressed. The home has a whistle blowing procedure and policies in relation to the protection of vulnerable people. The manager will support these procedures with training for all staff which has been booked to take place in January 2007. Abbeville Lodge DS0000068044.V323875.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,25 and 26Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the site visit the inspector undertook a tour of the premises, spoke to service users and staff and management about the environment. It was clear from this that significant improvement has happened in this area in a relatively short period of time. The inspector looked at a quality audit record which highlighted a long list of improvements made. These addressed health and safety issues, general cleanliness, decoration and furnishings. Included in the above was the replacement of all bedding and mattresses and some unsuitable beds. A number of carpet replacements and industrial cleaning of those remaining. Repair to bath hoists has taken place as has repair to the emergency lighting. A number of rooms have been redecorated and this programme will be rolled out to the whole building. All areas seen were clean Abbeville Lodge DS0000068044.V323875.R01.S.doc Version 5.2 Page 15 and fresh and the home felt comfortably warm. Water temperatures are regulated at each hand basin, but not currently on each bath. This was discussed at inspection and it is clear that this will be addressed as part of the major extension of the service which is planned. In the interim staff are instructed to use thermometers to measure water temperature before service users are bathed. As this issue will be addressed no requirements are made , however should the planned work not proceed then the provider must regulate bathwater temperatures. Abbeville Lodge DS0000068044.V323875.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: As in other areas much work has taken place in relation to staffing. The manager has carried out a training audit based on an induction process carried out with all the staff employed at the change of ownership. As a result a training plan is in place and priority training has already taken place. The service exceeds government targets for NVQ qualified care staff. Staffing levels have been increased and the service is well staffed in the inspectors opinion. Discussion with staff and service users during the site visit reinforced the view that staff are able to meet the needs of service users and residents were fulsome in the praise for the staff. During the visit the inspector observed staff working in an kindly and patient manner with service users. The provider has updated all staff criminal record bureau checks and introduced a robust employment system. Abbeville Lodge DS0000068044.V323875.R01.S.doc Version 5.2 Page 17 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): 31,32,33,35,37 and 38 Quality in this outcome area is adequate . This judgement has been made using available evidence including a visit to this service. EVIDENCE: Written feedback received prior to the site visit indicated that the new service management is viewed in a very positive light. This view was reinforced by discussion and observation during the site visit. Staff spoken felt well managed and that the manager had high standards and was providing leadership. Service users confirmed this view and the inspector spoke to visitors to the service who were quick to commend the new regime, having seen a huge improvement in all areas of the home. The service manager is very experienced and appropriately qualified. Given the scale of the inherited challenge it was impressive that so much has been achieved in a relatively Abbeville Lodge DS0000068044.V323875.R01.S.doc Version 5.2 Page 18 short period of time. It was noted however that the services system for managing service users finances was not as robust as it should be. Sample records were inspected by the inspector and in one case the records did not tally with the monies held. It seems likely that this is a failure to record a transaction, however it is essential that the service has a robust fully auditable system and as such a requirement is made. This was discussed on the day and the manager undertook to fully review the system as a priority as soon as the inspection finished. It was also noted that the provider is not complying with regulation 26 in respect of the reporting arrangements and this is subject to a requirement. The home has a good quality system based on audit and records of this were seen. The approach to health and safety is sound with records supporting this. Abbeville Lodge DS0000068044.V323875.R01.S.doc Version 5.2 Page 19 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 3 x x x 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 3 x 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 3 3 x 2 x 2 3 Abbeville Lodge DS0000068044.V323875.R01.S.doc Version 5.2 Page 20 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 OP35 Regulation 17(2) schedule 4 9(a) (b) 26 Requirement Timescale for action 31/01/07 2 OP37 That the management review its system for the management of service user finances to ensure that it is based on clear auditable records and secure storage. That the provider comply with 06/12/06 the visiting and reporting expectations as outlined in regulation 26 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 That the service continue to develop its care planning process to ensure that the social and emotional needs of service users are fully addressed. Abbeville Lodge DS0000068044.V323875.R01.S.doc Version 5.2 Page 21 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Abbeville Lodge DS0000068044.V323875.R01.S.doc Version 5.2 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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