Inspection on 09/02/07 for Abbeville RCH Ltd

This inspection was carried out on 9th February 2007.

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 RCH Ltd 06/02/09

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Abbeville RCH Ltd 58-60 Wellesley Road Great Yarmouth Norfolk NR30 1EX Lead Inspector Mr Pearson Clarke Key Unannounced 09th February 2007 09:50 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 RCH Ltd DS0000069356.V331191.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 RCH Ltd DS0000069356.V331191.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbeville RCH Ltd Address 58-60 Wellesley Road Great Yarmouth Norfolk NR30 1EX 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 844864 Abbeville RCH Limited Vacant Care Home 35 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (35) of places Abbeville RCH Ltd DS0000069356.V331191.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 02/11/07 Brief Description of the Service: Abbeville is situated in a residential area close to the local amenities of Great Yarmouth and within walking distance of the seafront. It is registered to accommodate 35 elderly people. The premises has increased in size with the Proprietors purchasing the property next door and converting this to include ten single ensuite rooms with a large lounge and extra outside patio space. The home consists of three storeys with a variety of communal areas. The home has thirty-one single and two double bedrooms all with en-suite facilities. Access to the upper floors is via two shaft lifts. To the rear of the home are two large enclosed patio areas with garden furniture, flowerbeds and shrubs and can be accessed by those using a wheelchair. There is a small car parking area at the front and also off street parking. The current fee range for the service is £281.00 to £410.00 per week. Abbeville RCH Ltd DS0000069356.V331191.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. During the site visit the inspectors spoke to a range of service users and staff on duty. A tour of the building was undertaken and time spent with the manager. Records were inspected and day to day interaction observed. What the service does well: What has improved since the last inspection? Abbeville RCH Ltd DS0000069356.V331191.R01.S.doc Version 5.2 Page 6 After a difficult period for the home involving a change of manager all concerned have worked hard to embrace the change and to continue to offer a good quality service. Bedrooms have continued to be redecorated as they fall vacant. 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 RCH Ltd DS0000069356.V331191.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 RCH Ltd DS0000069356.V331191.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): 3 Quality in this outcome area is (good). This judgement has been made using available evidence including a visit to this service. The service makes admissions based on an assessment of need and service users can have confidence that the home will meet their needs. EVIDENCE: During the site visit the inspectors looked at the paperwork associated with recent admissions to the service and spent time discussing the admission process with the service manager. The paperwork seen showed that in each case a needs led written assessment process had been carried out in addition to social work assessments. Discussion with the service manager indicated an understanding of the sort of needs which can be met and examples were given expressions of interest that were not proceeded with. As such the inspector believes that the service is making appropriate admissions to the home. Abbeville RCH Ltd DS0000069356.V331191.R01.S.doc Version 5.2 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. 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. Service users have an appropriate plan of care which guides staff in meeting their needs. Medication is soundly managed and residents have their privacy and dignity protected. EVIDENCE: During this site visit a sample of five care plans were tracked and service users were spoken to about their experience of care delivery. Service user plans were up to date and contained evidence of review. Service users sign to indicate acceptance of their plans and plans contain appropriate risk assessments. Care records detailed a sound approach to the promotion and protection of residents health care needs. Discussion with service users and management reinforced this picture. During the site visit the arrangements for the management of medication were inspected. Medication was securely stored and medication administration records were correctly recorded. Staff have received appropriate training and service users who self medicate have had a Abbeville RCH Ltd DS0000069356.V331191.R01.S.doc Version 5.2 Page 10 risk assessment compiled and have secure storage. Controlled drugs are securely stored with proper recording in place. Service users confirmed that their privacy and dignity is protected by staff. Abbeville RCH Ltd DS0000069356.V331191.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is ( good). This judgement has been made using available evidence including a visit to this service. Service users benefit from a relaxed and positive atmosphere, where they receive good care. Staff are valued and people have a satisfactory level of social stimulation. Recent changes to the menu have given people more choice in relation to their main meal. EVIDENCE: Prior to the site visit the inspector received written feedback from eight service users and five relatives. All of those who contributed were happy with the care given although some service users commented on a lack of choice at lunch time. During the inspection the inspectors spoke to seven service users both individually and collectively and time was spent observing the daily interactions. Service users spoken to on the day were very positive about the home and confirmed that the issue of lack of choice at lunch time had been addressed since people had commented on it and that they were happy with the food served. Residents said they felt relaxed and that staff and management were helpful and kind. The service has a designated activity organiser and the inspector saw residents taking part and enjoying a games Abbeville RCH Ltd DS0000069356.V331191.R01.S.doc Version 5.2 Page 12 session. People spoken to were happy with the provision in this area and felt able to exercise choice in relation to their lives. Although no visitors were talked to a number were observed in the home and the approach of staff was positive and welcoming. Abbeville RCH Ltd DS0000069356.V331191.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. Service users are protected by a satisfactory approach to complaints and adult protection. EVIDENCE: The service has a formal complaints process, however no complaints have been received since the last inspection. Service users told the inspectors that they would be confident to raise any concerns and that they would be addressed. The home has appropriate adult protection policies and staff receive training in this area. At the time of the site visit an incident had occurred in this area and the manager had followed the procedure in an appropriate manner. Abbeville RCH Ltd DS0000069356.V331191.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 and 26 Quality in this outcome area is (good). This judgement has been made using available evidence including a visit to this service. Services users benefit from a pleasant environment, which is warm, clean, comfortable and well maintained. EVIDENCE: During the visit to the home the inspectors toured all of the homes public areas and looked at a sample number of bedrooms. The service operates from two Victorian properties which have been combined into one home. All areas seen by the inspector were in good decorative order and the home was warm and comfortably furnished. The home was clean and there was no unwanted odour. Several service users commented on the lack of natural light in the lounge in the newest part of the home. Although the room has two sets of patio doors there is no other window, however there would appear to be the possibility of installing a window in the rear wall giving more light and a better Abbeville RCH Ltd DS0000069356.V331191.R01.S.doc Version 5.2 Page 15 aspect. In the inspectors opinion this would be worth consideration and as such a recommendation is made. In a number of areas the carpets were beginning to pose tripping hazards and some of the temporary repairs made were unravelling. The service manager confirmed that replacement carpets are to be fitted and during the inspectors time in the home the temporary repairs were made safe by the handyman. Given this and the providers good approach to maintaining the building ,no requirements are made. Abbeville RCH Ltd DS0000069356.V331191.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. Service users benefit from well trained staff who are well motivated. Staff are available in sufficient numbers to meet the needs of residents and the home has a safe recruitment system. EVIDENCE: Since the last inspection the providers have complied with the requirement made to increase staffing levels at the home. Based on the staffing rota submitted and taking into account the views of service users, staff and the manager, the inspectors judge the current staffing levels to be adequate to meet the needs of residents. Service users spoken to were very positive in their view of staff feeling that they get very good care. |||Observation on the day and discussion with staff on duty confirmed this picture. Staff are well trained and the home exceeds government targets for staff trained to NVQ level 2 or above. Inspection of the employment records relating to the last two members of staff employed showed an appropriate and robust process is in place with necessary checks carried out. Abbeville RCH Ltd DS0000069356.V331191.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): 31,33,35 and 38 Quality in this outcome area is ( good). This judgement has been made using available evidence including a visit to this service. Whilst the change of manager has affected the home service users continue to benefit from a well managed service. EVIDENCE: During the site visit the inspector sought the views of service users and staff as to the effect that the change of manager has had on the home. Whilst people acknowledged that the change had caused uncertainty and affected morale for a period of time things had now settled down and those spoken to felt that the new manager had found her feet and was doing a good job. Some staff supervision has happened however there is a need to increase the frequency to ensure that national standards are met. This was discussed on Abbeville RCH Ltd DS0000069356.V331191.R01.S.doc Version 5.2 Page 18 the day and the manager has plans to address this. Staff spoken to felt well supported and able to do their job. The manager has a good range of experience in the care industry although this is her first managers job. She is currently going through the process of registration. The manager receives a good level of regular support from the providers responsible individual including regular visits to the service. Since the last inspection of the service a ltd company has been formed and the provider is reminded of the resultant need to carry out formal regulation 26 reports. This would normally result in a requirement, however the inspector is confident that this will be addressed. Should this not happen then a requirement will be made. Those service users spoken to felt the home operates in their best interests and the service has a quality audit process which includes a survey of views of interested parties. Some personal monies are held on behalf of service users. These are securely held and records are kept. Sample records were checked by the inspector and no discrepancies were found. A selection of health and safety records were seen and were in order and while no significant health and safety issues were identified. It was noted that in a number of areas in corridors carpets were worn and beginning to pose a tripping hazard, however this was addressed during the time the inspector was in the home and the manager confirmed that the carpets were scheduled for replacement in the near future. Abbeville RCH Ltd DS0000069356.V331191.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 x x 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 x x x x x 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 x x 3 Abbeville RCH Ltd DS0000069356.V331191.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. 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. 1 Refer to Standard OP20 Good Practice Recommendations That consideration be given to ways in which natural light can be improved in the lounge in the newest area of the home. Abbeville RCH Ltd DS0000069356.V331191.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 RCH Ltd DS0000069356.V331191.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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