Inspection on 27/11/07 for Abbey Care Rest Home

This inspection was carried out on 27th November 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Abbey Care Rest Home 08/09/09

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 16/06/05

Abbey Care Rest Home 18/01/05

Abbey Care Rest Home 28/09/04

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Thames House

Creative Support

Sunny Bank (P.R.S.) Ltd

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Alfred House Residential Care Home

Barkerhouse Road (123)

Fernhaven

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 Mrs Jackie Riley Key Unannounced Inspection 09:30 27th November 2007 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 Abbey Care Rest Home DS0000060139.V351929.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. Abbey Care Rest Home DS0000060139.V351929.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbey Care Rest Home Address 14 Hampton Road Blackpool Lancashire FY4 1JB 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) 01253 341458 abbey_care@yahoo.co.uk Mr Gulan Asger Abdullah Mukadam Dr Bilqis Mukadam Care Home 11 Category(ies) of Dementia (9), Mental disorder, excluding registration, with number learning disability or dementia (2) of places Abbey Care Rest Home DS0000060139.V351929.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 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. 9th January 2007 Date of last inspection Brief Description of the Service: Abbeycare is a registered facility, providing residential care for up to ten adults who have dementia and two adults with 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 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. There is a written Statement of Purpose and Service User Guide outlining the home purpose, and the services it will provide to residents. This information is made available to all prospective residents or their relative’s representatives to help them make an informed choice about going to live at the home. At the time of the inspection 27.11.07 the information provided to the Commission showed that care home fees were £280-£350 per week, any additional expenses including chiropody, newspapers and additional toiletries are met by the resident or third party. Abbey Care Rest Home DS0000060139.V351929.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit that took place on the 27/11/07, over a period of approximately 3.0 hours as part of the inspection process. The Inspector spoke to the registered proprietor, one staff member, and three of the residents. Comments received will be included throughout the report. We talked to people using the service, and asked staff about those peoples needs. We also looked at the care plans, records and daily notes for three people, this is called case tracking. We toured the home to look at the environment. There were four responses from surveys sent to people who use the service for their views on how the home is run. There were no surveys returned from GP surgeries. Comments were very positive about the standard of care and support provided by the staff and management of the home. The records of two members of staff were also looked at. What the service does well: Family members who live on the premises run the home, so it is of a homely environment, and one in which we saw people communicate in a relaxed and informal way. Comments included, “we work as a team, and as most of us are all family it works really well”. “they do everything well”, “there is nothing to improve”, “they do the best they can and are really nice people”, “fantastic care package for residents”. We found the way the home operates on a day to day basis, means there is choice in all aspects of how people live their lives. We saw staff spent time with individual residents who needed reassurance, and they were sensitive in how they provided care and support. Staff said “we really know the in’s and out’s of the residents they are all different and we appreciate that”. There are no rules, which may restrict residents in what they choose to do on a day to day basis. Comments included, “I get up when I want and go out when I want”. We found the manager and staff members are committed to make sure residents needs are met in a way which is not intrusive, so that residents feel they can live their lives in a way in which they choose, with restriction only being in place based upon their safety and well being. Abbey Care Rest Home DS0000060139.V351929.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Abbey Care Rest Home DS0000060139.V351929.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 Abbey Care Rest Home DS0000060139.V351929.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. Admission and assessment procedures are in place so the home can meet individual needs. EVIDENCE: We looked at the records of three residents. They had assessment details recorded, so that staff had a good insight into what the needs of residents are and how they will be met. We saw evidence on the records of social workers, community psychiatric nurses being involved in the assessment and review procedures, so that their specialist needs are going to be met and the home knows the level of care, which will be required. Staff spoken to said, “we get all the information we need before residents come into the home”. We saw some residents at the home are not permanent. Their care is for short stay and day care. Their records show they have had an assessment carried out by a professional and also by the home so the home knows it can meet the residents needs prior to them using the services of the home. Abbey Care Rest Home DS0000060139.V351929.R01.S.doc Version 5.2 Page 9 The records we looked at had in place regular reviews for residents and there was evidence of changes being made in the care of residents when this was found to be necessary due to the changing needs of individual residents. There is evidence residents are having their health care needs met, by visits from doctors and district nurses. Individual residents spoken to confirmed they have been involved in the review process and able to give their views of the support they required. Comments included, “ we get asked about what we need and how we are getting on”. Staff spoken to said,“ We get to know what the needs of a resident are before they come here, so that we can provide the right care for them”. Standard 6 was not assessed, as Abbey Care does not provide intermediate care. Abbey Care Rest Home DS0000060139.V351929.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): 7,8,9,10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Promotion of health is taken seriously. Resident’s welfare is monitored and health needs are identified and met. Medication administered to people who are not living permanently at the home is not always recorded so there is no clear audit trail available. EVIDENCE: We looked at the records of three resident’s, they were accurate and had good information about the health and social care needs of people who live at the home. We saw plans recording the care needs of people living at the home were up to date and reviews were taking place, so that there are changes made when necessary. Staff spoken to have a good knowledge of the various health care needs of people living at the home. We saw staff spent time with individual residents who needed assistance, this was provided in a sensitive way, spending time with individual residents who were in need of reassurance to reduce their anxiety. Staff spoken to said “its important we spend time with people who need support”. Abbey Care Rest Home DS0000060139.V351929.R01.S.doc Version 5.2 Page 11 Significant events had been recorded and daily entries made by carers demonstrate the care given. Residents spoken to said, “I’m going to the doctors tomorrow, I often go and get sorted out”, “ The staff are really helpful, and nothing is to much trouble”. Staff comments included, “we get to know the history of residents so we know exactly what they like and don’t like as well as what’s important to them”. We looked at the way the home manages its medication procedures. They were seen to be managed by a small number of staff who have had training in medication procedures based upon current good practice guidance. Staff spoken to were familiar with how medication should be stored and recorded, however the home must make sure medication being administered to residents who are on short stays must be recorded in accordance with any other medication administered by the home so that there is a clear audit trail of medication administered by staff. Resident’s rights to dignity and privacy are upheld by staff who are aware of the need to make sure the rights of residents are met with respect at all times. We confirmed this by observing staff members assist residents to carry out tasks, and the way staff talked and responded to residents. This was carried out with sensitivity and patience on all occasions. Residents observed were seen to interact well with staff members, and appeared relaxed and receptive to things going on around them. Abbey Care Rest Home DS0000060139.V351929.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): 12,13,14,15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Daily life and social activities are designed to be flexible to meet the needs of people living in the care home EVIDENCE: The home does not have a formal approach to how residents choose to live their daily lives. There are no rules in respect of getting up and going to bed. We saw two residents were still in bed when the inspection commenced. Staff said this was the normal routine for them. We spoke to both residents who appeared happy with the way they get up later. They were assisted by staff to enjoy their breakfast. Other residents spoken to said “I get up and about when I feel like it”. We spoke to residents who like to go out independently on a daily basis. They said they like to go out every day. They said they go for a coffee of a drink at the club and a game of snooker sometimes. The manager and staff recognise this is important to the resident and help them to continue to maintain their independence within the safety perimeters for that resident. Abbey Care Rest Home DS0000060139.V351929.R01.S.doc Version 5.2 Page 13 One resident spoken to cannot go out as much as they used to do, but said they get help with the staff or their family when they choose to go out. We spoke to residents about the meals they receive on a day to day basis, comments included, “the foods nice they know what I like and don’t like”, “if I’m usually back for my meals”. All comments about food were good and they showed us that meals and mealtimes are flexible to meet individual needs and likes and dislikes. We spoke to staff members who knew the likes and dislikes of residents, and they said how flexible they are in delivering good quality food at the times residents choose. Abbey Care Rest Home DS0000060139.V351929.R01.S.doc Version 5.2 Page 14 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): 16,18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for recording and reporting of complaints are good ensuring people feel listened to. Staff have access to safeguarding adults training for the protection of users of the service. EVIDENCE: We looked at the homes complaints procedure, which is made available to the residents their relative or advocate during the admission process. We spoke to two individual residents who said they knew about the complaints procedure and knew who to make complaints or raise concerns to. They said they felt that if they are not happy about something they can tell somebody and it will get sorted out. Comments included, “I tell the manager if I’m not happy with something and they sort it out”. “They’ve sorted a few things out for me”. There have been no complaints made to the Commission for Social Care Inspection (CSCI), in the previous twelve months. The home has a procedure in place for dealing with allegations of abuse. Staff spoken to are aware of the procedures to be followed in the event of any allegations or suspicion of abuse or neglect, and have received training in this area. Comments included, “ staff have had training for protecting people, and Abbey Care Rest Home DS0000060139.V351929.R01.S.doc Version 5.2 Page 15 it’s covered in NVQ training”. We saw evidence that staff had training certificates in place to confirm they have attended training in safeguarding adults so people are protected. Abbey Care Rest Home DS0000060139.V351929.R01.S.doc Version 5.2 Page 16 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): 19,22,26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is designed to be homely and comfortable, however the need for general decoration means this has the potential to have a negative impact on people living at the home. EVIDENCE: We found the home is clean and free from offensive odours. Residents spoken to said they were happy with the home in general, comments included, “Its nice and warm and they’ve changed all the windows and doors”. “I like to sit in the lounge and do my own thing”, “the showers better now its been decorated”. There has been some decoration to rooms which are occupied by residents, however there is a need to decorate rooms which are unoccupied if they are to be used by residents in the future so that they are pleasant for people to live in. Abbey Care Rest Home DS0000060139.V351929.R01.S.doc Version 5.2 Page 17 We spoke to the manager who stated they are planning to work through the home in respect of redecoration. The ground floor shower room has been upgraded and is now a ‘wet room’, which means resident’s can shower without the previous constraints of lack of space. Comments included, “its easier to have a shower now”. We saw work has commenced on upgrading the first floor bathroom so that it is suitable to meet the needs of residents using the facility. There has been a programme in place to replace all the windows and doors, which will be completed by January 2008. This has insulated the home and all areas were found to be warm and comfortable. We spoke to some residents who said they like to use their own bedrooms as they choose, and they like to keep them in a way in which they choose. We found this is respected by the staff team who acknowledge this is their home and they have choice in how they use their personal rooms. Abbey Care Rest Home DS0000060139.V351929.R01.S.doc Version 5.2 Page 18 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): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are enough staff on duty to meet the needs of people using the service. People living at the home are protected well by the recruitment procedures. There is a staff training and development programme in place. EVIDENCE: We found there have been no changes to the staff team since the previous inspection. The staff team mainly comprise of family members who also live on the premises. We saw they work closely together as a team, which means there is continuity in the care provided. People spoken to spoke highly of the level of care they receive. Comments included, “they can’t do enough for you”, “they’re always around to help”. The observations we made during the visit confirmed staff know the individual needs of the residents living at the home, and they show sensitivity in how they approach the care they provide, for the benefit of people who live there. There was evidence staff working in the home have access to training in areas which benefit residents, so that they are competent in their individual roles. We saw staff are offered training in a number of topics such as manual handling, medication, fire safety, and Protection of Vulnerable Adults. Staff spoken to confirmed they have attended training, and feel this has helped them in how they provide care to residents. Abbey Care Rest Home DS0000060139.V351929.R01.S.doc Version 5.2 Page 19 We saw recruitment procedures make sure people are ‘fit’ to work in the care home so that people are protected. Abbey Care Rest Home DS0000060139.V351929.R01.S.doc Version 5.2 Page 20 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): 31,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed well and systems and policies in place for the protection and safety of staff and residents are good. EVIDENCE: We say the manager has the necessary skills and experience required to support the staff and residents and enable the home to meet its stated purpose and objectives. Comments from surveys received say they feel the manager is supportive and is a good listener. Staff spoken to say they found the management team to be supportive providing clear leadership. Comments included, “we are well supported by the manager”, “it’s a small home but we all get on well together”, “the manager gets things sorted out”, Abbey Care Rest Home DS0000060139.V351929.R01.S.doc Version 5.2 Page 21 There is ongoing quality monitoring carried out through informal discussion with all users of the service including staff. The management team takes the views of people who use the service seriously, so that changes can be made to improve the service wherever possible. As this is a small family run home there are no formal meetings taking place, but there is evidence there is constant communication between the manager and staff so that the views of people who live and work in the home are taken into account. We found the home links closely with family members who take an active part in the way the home provides care to their relatives. Comments included, “they do everything well”, “there is nothing to improve”, “they do the best they can and are really nice people”. We spoke to the manager about how information and comments are received and he stated all comments are taken seriously and listened to, so that issues raised are addressed and recorded if necessary All appliances in the home are checked regularly for the health and safety of all users of the service. We looked at Gas, Electric, Fire, and lifting equipment certificates which were current and were satisfactory to meet the requirements of current legislation for health and safety. Abbey Care Rest Home DS0000060139.V351929.R01.S.doc Version 5.2 Page 22 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 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 2 X X 2 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 Abbey Care Rest Home DS0000060139.V351929.R01.S.doc Version 5.2 Page 23 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 OP21 Regulation 23(2)(d) Requirement Improvements to the first floor bathroom must continue so that it is maintained to a good standard for the comfort of residents using it. Short stay residents must have a record of medication administered by the home, so that there is a clear audit trail of medication administered to the resident and to meet the requirements of legislation. Timescale for action 31/01/08 2. OP9 13(2) 30/11/08 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 OP19 Good Practice Recommendations Redecoration of the homes environment should continue so that it is a pleasant environment in which to live. Abbey Care Rest Home DS0000060139.V351929.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Regional Contact Team Unit 1 Tustin Court Portway Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries.northwest@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 Abbey Care Rest Home DS0000060139.V351929.R01.S.doc Version 5.2 Page 25 - 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. 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