Inspection on 10/08/06 for Abbey Chase Residential and Nursing Home Ltd

This inspection was carried out on 10th August 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

Abbey Chase Residential and... 27/10/05

Abbey Chase Residential and... 19/04/05

Abbey Chase Residential and... 19/10/04

Abbey Chase Residential and... 17/05/04

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The Shelley

Thorndene

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Abbey Chase Residential And Nursing Home Ltd Abbey Chase House Bridge Road Chertsey Surrey KT16 8JW Lead Inspector Lesley Garrett Key Unannounced Inspection 10th August 2006 08:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Abbey Chase Residential And Nursing Home Ltd DS0000017587.V307545.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 Chase Residential And Nursing Home Ltd DS0000017587.V307545.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbey Chase Residential And Nursing Home Ltd Address Abbey Chase House Bridge Road Chertsey Surrey KT16 8JW 01932 569768 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) abbeychase@hotmail.com Abbey Chase Residential and Nursing Homes Limited Mrs Jean Short Care Home 62 Category(ies) of Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (62), of places Physical disability over 65 years of age (2) Abbey Chase Residential And Nursing Home Ltd DS0000017587.V307545.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. People requiring Nursing Care may be admitted to the home from the age of 60 years. Up to 60 persons may receive Nursing Care. Up to two of the older people accommodated may be in the category PD(E), people with a physical disability. Up to five named people accommodated may be in the category DE(E), older people with Dementia 27th October 2005 Date of last inspection Brief Description of the Service: Abbey Chase Care Home is privately owned and operated by Abbey Chase residential and Nursing Homes Limited in premises situated next to the Thames in a rural part of Chertsey. Accommodation is provided in fifty-three single rooms and five shared rooms. The gardens are well maintained and are accessible to the service users if they choose to sit and enjoy the scenery and life on the river. There are arrangements for disability access, which includes ramps and pathways. There is a pleasant shaded and safe central courtyard, which can be enjoyed by service users in the ample seating areas and also viewed by residents from bedrooms. The home also provides plenty of car parking facilities. The range of fees in the home is between £485 - £835 (depending on preadmission assessment and dependency). Abbey Chase Residential And Nursing Home Ltd DS0000017587.V307545.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit took place over ten and a half hours commencing at 0830 and finishing at 1900. Lesley Garrett lead inspector for the service, carried out the inspection and the, registered manager, represented the establishment. A tour of the premises took place and the inspector saw some service users and spoke to some of them in more detail. A pre-inspection questionnaire has been sent to the service and will assist with this report. Records were also sampled as part of the inspection process including care plans and policies and procedures and employment records. This was a positive inspection and the inspector would like to thank the service users, staff and manager for their time, assistance and hospitality during this inspection. What the service does well: What has improved since the last inspection? All requirements made at the previous inspection have now been met regarding bells being in reach of service users, accurate information to be available about service users at all times, staff to sign documents with their full name, staff folders should contain their photograph and there should be an ongoing programme to replace the divan beds. The manager told the inspector that the refurbishment programme for the east wing is now underway. The inspector saw the rooms that had been decorated and new carpets laid and they also have new curtains and bedspreads. The home continues to replace old divan beds with profiling or high low beds to the benefit of both staff and service uses. Since the last inspection the home has also employed a head housekeeper and activities organiser. Abbey Chase Residential And Nursing Home Ltd DS0000017587.V307545.R01.S.doc Version 5.2 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 Chase Residential And Nursing Home Ltd DS0000017587.V307545.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 Chase Residential And Nursing Home Ltd DS0000017587.V307545.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users needs are assessed through pre-admission assessments, which take place prior to a service user moving into the home. The home does not provide intermediate care. EVIDENCE: The manager or her deputy carries out all pre-admission assessments. These are of a good standard and allow the manager to make an informed decision about the prospective service user. Abbey Chase use a standard form incorporating the activities of daily living which the inspector sampled. Care plans are generated from this initial assessment and this was evidenced in their individual plans of care. The home does not have intermediate care beds. Abbey Chase Residential And Nursing Home Ltd DS0000017587.V307545.R01.S.doc Version 5.2 Page 9 Abbey Chase Residential And Nursing Home Ltd DS0000017587.V307545.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 at least once during a 12 month period. 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. The service users individual plans of care are comprehensive and demonstrate that their health and personal care needs are met. The home has policies and procedures in place, which protect the service users for the safe handling of medications. No issues around privacy and dignity were raised by the service users and observations indicated staff promoted this area of care. EVIDENCE: Individual plans of care were sampled by the inspector, who found them to be comprehensive and they contained detailed care plans and risk assessments. A recent admission to the home had all care plans and risk assessments in place and was found to be of a good standard as this documentation was read by the inspector. The inspector sampled other care plan and found that they had been reviewed every month by the registered nurses. Abbey Chase Residential And Nursing Home Ltd DS0000017587.V307545.R01.S.doc Version 5.2 Page 11 The inspector met the general practitioner on the day of inspection who stated that he always visits when called, sees all new admissions within forty-eight hours of admission and does reviews for all service users every three months. The manager told the inspector that the home also has access to other health care professionals including the dietician, speech and language therapist and physiotherapist. Community opticians visit every six months and the dentist visits when needed. The inspector did not check the medication procedures in detail but spoke with the unit manager and sampled their local medication policy. The home has the services of a local pharmacy and uses the monitored dose system. The pharmacy supplies the home with a policy that details their contact address, telephone number and opening times. It also details when orders for medication are due and when it will be delivered. Medication fridge temperatures are checked daily and remain in the recommended limits for the storage of medicines. The home has a privacy and dignity policy and this is discussed during staff induction. The inspector observed staff knocking on doors prior to entering and all service users are seen in private if the doctor or other visiting professionals call. Abbey Chase Residential And Nursing Home Ltd DS0000017587.V307545.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 at least once during a 12 month period. 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. The home has an activities programme, which service users have knowledge of, and families and friends are welcomed to the home. Service users are offered a well balanced diet and are encouraged to exercise control over their lives EVIDENCE: The inspector met the activities organiser who spoke with her about the programme of events in the home. She stated things had been slow as many service users were reluctant to join in but gradually, she said, they are showing an interest and one of the popular events is the monthly church service. The organiser told the inspector that she had also made the home their own hymnbooks for these occasions. She also organises one to ones and many service users told the inspector, as she toured the building, that the activity organiser had done their nails and they had enjoyed that activity. Biographies are written by the activity organiser for each service user and a record kept of attendance at any activity and their response to it. The home welcomes visitors and on the day of inspection a number of relatives and friends were visiting. The inspector was told by the proprietor that local Abbey Chase Residential And Nursing Home Ltd DS0000017587.V307545.R01.S.doc Version 5.2 Page 13 schools visit at Christmas to sing and entertain the service users and the Salvation Army have also visited but this is an area the activity organiser wishes to develop. The inspector observed choice being given to service users. One gentleman was asking for the menu for that day from a member of staff and another told the inspector they had choice about things ”too much choice sometimes” she stated. On the day of inspection the chef manager was not on duty and the home had an agency chef to prepare the breakfast and lunch. The inspector received no complaints about the food except one service user said that the vegetables were sometimes hard. The home has three dining rooms and all were laid with tablecloths and napkins. The carers do not have to prepare any food as the home also employs super chefs. The manager stated that the kitchen is open at night and carers have access to make sandwiches for the service users if they request it. Abbey Chase Residential And Nursing Home Ltd DS0000017587.V307545.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 inspected at least once during a 12 month period. 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 home has a complaints policy and concerns are listened to and are acted upon. Service users are protected from abuse by the policies and procedures that are in place at the home. EVIDENCE: The home has a complaints policy, which is available in the service user guide and displayed in reception. A complaints log is kept by the home but the home had received no complaints this year. The home also has a protecting adults procedure but this was found not to be in line with Surrey’s procedures. The inspector knew from past experience that this was the policy that was followed by the home and staff had all received training. It will be a requirement at the end of the report for the home to review the safeguarding adults policy and to bring this in line with Surrey. The manager had arranged for training to take place for staff this year. The home had one local authority referral under their safeguarding adult’s procedures this year that has now been resolved satisfactorily. Abbey Chase Residential And Nursing Home Ltd DS0000017587.V307545.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a home that is well maintained internally and externally and is clean and free from offensive odours. EVIDENCE: The home has been subject to some refurbishment recently, which has improved the appearance of the east wing, and the manager told the inspector that the refurbishment programme would continue. There is a full time maintenance person who has been responsible for the decorating. The home has also purchased new curtains, bedspreads, high low and profiling beds and bedroom furniture. Abbey Chase Residential And Nursing Home Ltd DS0000017587.V307545.R01.S.doc Version 5.2 Page 16 The inspector spoke with the head housekeeper who monitors the cleanliness of the rooms with a checklist, which is completed daily and this, has helped to improve standards within the home. The home has good size gardens, which have been kept neat and tidy and safe for service users. Some service users that the inspector spoke with enjoyed going for walks outside and looking at the river, which runs at the bottom of the garden. The home has a gardener who is responsible for the grounds. The manager stated that a new laundry assistant will be starting next week and this will now cover laundry cover every day. Infection control training is scheduled for when she starts. The home has plenty of hand washing facilities and paper towels available. Abbey Chase Residential And Nursing Home Ltd DS0000017587.V307545.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 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. The staffing levels in the home are sufficient to meet the needs of service users. The home is able to demonstrate that trained and qualified staff is able to carry out their role competently and support service users. The home ensures that adequate checks are completed prior to staff working in the home, which ensures that service users are protected by the homes recruitment policy and procedures. Staff training is carried out on a regular basis. EVIDENCE: There were adequate numbers of staff on duty for the number of service users. The inspector looked at the rotas and numbers were consistent during that month. The manager stated that she does dependency levels every month and this determines the staffing levels. Induction is given for all new staff and the manager said it is in line with the skills for care programme. Over 50 of the care staff have the national vocational qualification and more are on the course. The manager told the inspector that she also has staff on the level 3 programme. Recruitment folders were sampled by the inspector who found that all necessary documentation was in place. The folders that were looked at had a clear employment history with no gaps. Abbey Chase Residential And Nursing Home Ltd DS0000017587.V307545.R01.S.doc Version 5.2 Page 18 The manager told the inspector that she is very enthusiastic about training and all mandatory training has taken place or is planned for this year and this includes safeguarding adults, food hygiene, manual handling and a new distance-learning course on MRSA. The registered nurses have also completed a medication course provided by a local college. Abbey Chase Residential And Nursing Home Ltd DS0000017587.V307545.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 & 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 by a person fit to do so who has registered with the Commission for three years. The home has some quality audits in place and the views of the service users are sought. The financial interests of the service users are safeguarded and the health and safety of all service users are promoted and protected by the various checks that take place on a regular basis. EVIDENCE: The registered manager has been at the home for three years and had all the necessary qualifications. She told the inspector that she has commenced her registered managers award and has started to complete some units. Abbey Chase Residential And Nursing Home Ltd DS0000017587.V307545.R01.S.doc Version 5.2 Page 20 The manager has just completed the quality audits for the home and asked for the views of the service users their relatives or representatives and other visiting professionals. These results will be fed back to the service users at a meeting to be arranged. The results were shown to the inspector and the manager’s action plan had already been drafted for implementation. No service user manages their own money. Small amounts of cash may be deposited with the home and all transactions are logged and receipts given. The home has the services of a full time maintenance person who carries out all routine safety checks including water temperatures and fire alarm tests. Abbey Chase Residential And Nursing Home Ltd DS0000017587.V307545.R01.S.doc Version 5.2 Page 21 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 X 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 Abbey Chase Residential And Nursing Home Ltd DS0000017587.V307545.R01.S.doc Version 5.2 Page 22 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 OP18 Regulation 13(6) Requirement The registered persons must ensure that the homes safeguarding adult’s procedures are in line with and reflect the Surrey Multi Agency procedures. Timescale for action 10/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Abbey Chase Residential And Nursing Home Ltd DS0000017587.V307545.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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. Extracts may not be used or reproduced without the express permission of CSCI Abbey Chase Residential And Nursing Home Ltd DS0000017587.V307545.R01.S.doc Version 5.2 Page 24 - 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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