Inspection on 16/06/05 for Abbey Care Rest Home

This inspection was carried out on 16th June 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 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

Abbey Care Rest Home 08/09/09

Abbey Care Rest Home 27/11/07

Abbey Care Rest Home 09/01/07

Abbey Care Rest Home 20/06/06

Abbey Care Rest Home 25/08/05

Abbey Care Rest Home 18/01/05

Abbey Care Rest Home 28/09/04

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

CARE HOMES FOR OLDER PEOPLE Abbey Care Rest Home 14 Hampton Road Blackpool Lancashire FY4 1JB Lead Inspector Jackie Riley Unannounced 16 June 2005 09:30am th 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 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. Abbey Care Rest Home F57 F09 S60139 Abbey Care V211417 160605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Abbey Care Rest Home Address 14 Hampton Road Blackpool Lancashire FY4 1JB 01253 341458 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Mukadam Dr Mukadam Care home only 11 Category(ies) of DE Dementia (9) registration, with number MD Mental Disorder (2) of places Abbey Care Rest Home F57 F09 S60139 Abbey Care V211417 160605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Two Mental Disorder excluding Learning Disability or Dementia (MD) are to be maintained until the two service users no longer reside at the care home. There is a requirement for a registered manager to be in post at all times, until such a time the registered provider has gained the knowledge, skills and qualification to undertake the management of the home on a day to day basis. Date of last inspection 18th January 2005 Brief Description of the Service: Abbeycare is a registered facility, providing care for ten adults who suffer dementia and one adult suffering from mental illness. The care home is situated in a residential area of Blackpool, close to amenities including shops and the transport network. The home is spacious, with service user rooms on the ground floor and first floor. There are two double bedrooms and seven single rooms. There are no en-suite facilities. There is a stair lift for access to the first floor. There is a choice of two lounges with toilets in close proximity. Access to the home is facilitated by a ramp. There is no rear garden area however the front garden is accessible for service users and regularly used during the summer months. Abbey Care Rest Home F57 F09 S60139 Abbey Care V211417 160605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection therefore the registered person, staff and residents were not aware of the visit. The visit was undertaken during a three hour period of the day. The registered provider assisted the inspector to carry out the inspection process. One staff member on duty was interviewed. There were no visitors available throughout the inspection process. Two residents were spoken to as part of the inspection process and communicated their views. Records of medication, care plans staffing rotas and one staff recruitment file was examined. No complaints have been investigated by CSCI in the last twelve months. What the service does well: What has improved since the last inspection? The management and administration of medication has improved since the previous inspection. Advise and guidance provided by the Pharmacy inspector has been acted upon. Records and recording systems have been further developed and comply with regulations. Abbey Care Rest Home F57 F09 S60139 Abbey Care V211417 160605 Stage 4.doc Version 1.30 Page 6 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. Abbey Care Rest Home F57 F09 S60139 Abbey Care V211417 160605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Abbey Care Rest Home F57 F09 S60139 Abbey Care V211417 160605 Stage 4.doc Version 1.30 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 standard(s) 3, & 2 People are admitted to the home, only when social workers or other professionals have carried out assessments. This ensures a person’s needs can be met by the home. A contract should be given to each resident, which will ensure the terms and conditions of the home are fully known. Residents and relatives or advocates are provided with information relating to the service s of the home, which enables them to make an informed choice prior to admission EVIDENCE: The admission procedure is planned and ensures resident’s needs are properly assessed and planned for. One residents spoken to said, “I liked this home from the moment I came”. Individual professional assessments were complete and contained information relating to the needs of that person. Staff spoken to are fully informed of the needs of people living in the home. The contracts between the home and the resident or advocate are necessary to ensure all parties are protected. This registered provider was undertaking this task at the time of inspection. Abbey Care Rest Home F57 F09 S60139 Abbey Care V211417 160605 Stage 4.doc Version 1.30 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 standard(s) 7, 8, & 9 The recording’s of health care needs were consistent and up to date which ensured residents needs are fully met. Medication management has been greatly improved upon to ensure the safety of residents in the home. EVIDENCE: Individual records are kept for each resident with a plan of care setting out the action necessary by care staff to ensure all aspects of health, personal and social care needs of the residents were met. Risk assessments are included in all care plans, including all aspects of their daily lives and individual preferences. Reviews are taking place and identify any changes necessary. Daily records were clear and provided good recording of events for individual residents and action taken to resolve issues. The care plan for one resident showed how care needs had changed and the action taken by the home to resolve the problem. One staff member spoken to demonstrated her knowledge of residents needs, and said “ residents are given good care and attention”. District nurses and other professionals visit the home regularly. Medication practices observed were safe and good records had been maintained. Abbey Care Rest Home F57 F09 S60139 Abbey Care V211417 160605 Stage 4.doc Version 1.30 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 standard(s) 12, 13, & 15 Social activities are limited and should be further developed to meet the specialist needs of residents living at the home. Some residents go out daily, thereby maintaining community involvement. Meals prepared are balanced and provide a daily variation and interest for people living in the home, thereby ensuring the residents nutritional needs are met. EVIDENCE: There is no formal activity programme in place. The home would benefit from researching forms of activity specifically designed for people suffering from dementia. There was no evidence of an activity programme in place and two of the residents confirmed there are only occasions when suitable activities were planned. Residents have various limits on their ability to make choices, however staff were seen to help and gently guide them in all areas of their daily lives. Staff commented “residents like to do there own thing, one or two go out every day”. The food and menus seen are varied and daily choice is available. Mealtime arrangements are flexible enough to accommodate individual preferences. Staff members prepare and provide all meals. All staff responsible for food preparation should have current food hygiene certificates in place, in order to ensure they meet Environmental Health regulations. Abbey Care Rest Home F57 F09 S60139 Abbey Care V211417 160605 Stage 4.doc Version 1.30 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 standard(s) 16, & 18 The arrangements for recording and reporting of complaints are good ensuring people feel listened to. Staff must be provided with training in the protection of adults in order to ensure all residents are protected from all forms of abuse or neglect. EVIDENCE: The home has a detailed complaints procedure and staff were able to explain the process. One resident spoken to knew who to complain to and said, “I talk to the manager”. The home has a procedure in place for dealing with allegations of abuse. The staff spoken were not familiar with the procedures for investigating instances of alleged abuse or the whistle blowing policy for the home. Staff spoken to should receive training in relation to complaints and abuse, in order to ensure the protection of vulnerable people. There have been no complaints since the last inspection. Abbey Care Rest Home F57 F09 S60139 Abbey Care V211417 160605 Stage 4.doc Version 1.30 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 standard(s) This area was not fully inspected. EVIDENCE: The requirements regarding the environment remain as the inspector was informed they have not yet been complied with. The environmental standards will be fully inspected during the next inspection. Abbey Care Rest Home F57 F09 S60139 Abbey Care V211417 160605 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29, & 30 The small staff team provides appropriate levels of care to residents ensuring their individual needs are met. Staff undergo all recruitment checks to ensure residents are protected. EVIDENCE: Residents spoke highly of the care they receive from staff, one resident commented “they are always there when you need them”. Staff have access to training and one staff member had recently completed National Vocational Qualification (NVQ) level 2 training, which she commented had helped her to develop her skills in caring for the residents needs. There is a need to ensure all staff have access to training in the protection of residents. Staff spoken to were motivated in their work. One staff file examined confirmed all areas of recruitment and fitness checks had been carried out. Abbey Care Rest Home F57 F09 S60139 Abbey Care V211417 160605 Stage 4.doc Version 1.30 Page 14 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, & 36 The home is staffed by the registered provider, registered manager and one other staff member, who promote the health, safety and welfare of the people using the service. The home is well managed and run in the best interests of residents. EVIDENCE: Residents and staff made positive comments about the level of care received and provided by the home. There is a clear understanding of the needs of residents and the service necessary to meet individual need. There is open dialogue between the management and staff, which ensures communication and recording systems are good. Staff supervision should be undertaken more formally with records being made, in order to ensure staff development takes place. Abbey Care Rest Home F57 F09 S60139 Abbey Care V211417 160605 Stage 4.doc Version 1.30 Page 15 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 2 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 3 COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 3 x 3 x x 2 x x Abbey Care Rest Home F57 F09 S60139 Abbey Care V211417 160605 Stage 4.doc Version 1.30 Page 16 no Are there any outstanding requirements from the last inspection? 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. 2. Standard 2 12 Regulation 5 16(a) Requirement A written and signed contract must be available to all residents The home should must ensure there is a social activity programme in place appropriate to meet the residents needs. Staff must receive training in Adult protection The registered person must develop a maintenance plan for the renewal of the fabric and decoration of the premises.(extended 31.3.05) Unoccupied rooms that have no radiator guards fitted must do so prior to admitting a service user to the bedrooms. (extended 31.3.05) Timescale for action 31.7.05 1.9.05 3. 4. 18 20 13(6) 23(20)(b) 31.7.05 31.7.05 5. 25 13(4)(a) 31.7.05 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 36 Good Practice Recommendations Staff should receive regular supervision with records made available for inspection. F57 F09 S60139 Abbey Care V211417 160605 Stage 4.doc Version 1.30 Page 17 Abbey Care Rest Home Commission for Social Care Inspection Unit 1, Tustin Court Portway Preston PR2 2YQ 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. 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