Inspection on 05/02/07 for Abbey Court Care Home

This inspection was carried out on 5th 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

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Abbey Court Care Home Buxton Road Leek Staffordshire ST13 6NF Lead Inspector Mr Keith Jones Key Announced Inspection 5 February 2007 10:00 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 Court Care Home DS0000068853.V329679.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 Court Care Home DS0000068853.V329679.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbey Court Care Home Address Buxton Road Leek Staffordshire ST13 6NF 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) 01538 386523 01538 386573 Knights Care Ltd Mrs Wendy Goodwin Care Home 52 Category(ies) of Dementia (10), Mental disorder, excluding registration, with number learning disability or dementia (2), Mental of places Disorder, excluding learning disability or dementia - over 65 years of age (10), Old age, not falling within any other category (52), Physical disability (32), Physical disability over 65 years of age (52), Terminally ill (5) Abbey Court Care Home DS0000068853.V329679.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 2 MD over 50 years 4 PD over 50 years Also providing 2 day places Date of last inspection 28/02/06 Brief Description of the Service: Abbey Court is a care home providing personal care and nursing care for up to 52 elderly service users. This includes care for service users with mental disorder and dementia, care for elderly service users with physical disabilities and care for elderly service users with a terminal illness. The home is owned by Mr Adam Knights under the registered name of Knights Care Limited. The home is located on the outskirts of the Staffordshire Moorlands town of Leek. There are no amenities within the immediate vicinity but transportation can be provided to take service users to Leek town centre where there is a choice of shops, public houses, banks and churches. The home was purpose built several years ago and consists of two floors served by a passenger lift. There is a car-parking facility at the entrance and rear of the home. Gardens are accessible to service users including wheelchair users. The accommodation provides mostly single bedrooms, some of which have ensuite facilities. Two bedrooms are large and equipped with bed-sit facilities. A separate room is identified for relaxation and is equipped with relaxation equipment. There is ample dining and sitting accommodation provided in the establishment. Abbey Court Care Home DS0000068853.V329679.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was conducted with the Registered Care Manager, Provider and senior nursing staff. A pre-inspection questionnaire had been completed in preparation. The last inspection report was discussed, and it was noted that there were no outstanding requirements or recommendations. The inspection tour of the home was carried out in a professional, relaxed and courteous manner, all concerned expressed confidence in the general atmosphere. Those visitors and residents approached were highly complimentary of the care, service and attention they received from a willing and attentive care team. There were 48 Service Users on the day of inspection, 28 categorised as requiring nursing care. Five service users were case tracked confirmed the establishment of a well run, very comfortable and welcoming establishment. There were 11 comment cards received, including one from the GP attached to the Home, all remarked on the positive attributes. Relatives who were present were equally complimentary of the professional, yet friendly approach to care, the freedom they enjoyed, and the involvement in the process of care that the manager and her staff encouraged. Everyone appeared comfortable and at ease with their surroundings. A sample review of the administration confirmed solid practice and effective management. A full report was offered at the end of the inspection with open discussion involving the registered Care Manager and Provider. What the service does well: Abbey Court offers a high standard of care and service, is extremely well organised, with a committed care management team. Emphasis goes into involving the residents and their families in the process of care, ensuring a highly personal approach to meeting individual needs. Throughout the entire inspection a sense of homeliness and familiar confidence pervaded into all aspects of daily activity expressed by those people met. The establishment of a professionally accountability towards effective assessment, detailed care planning and review of resident’s needs are meaningful and robust, in formulating an excellent standard of care. The overall management style demonstrated a positive and professional approach in maintaining an environment suitable to the care of the elderly. There is a constant appraisal of facilities and services to maintain that Abbey Court Care Home DS0000068853.V329679.R01.S.doc Version 5.2 Page 6 environment, by the close working relationship of the Registered Provider and Care Manager 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 Court Care Home DS0000068853.V329679.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 Court Care Home DS0000068853.V329679.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 The quality in this outcome area is adequate This judgement is based on the examination of the homes policies, procedures, practices and discussions with management. Abbey Court ensures that prospective residents have the necessary information to enable an informed choice to be made. Aims and objectives, terms and conditions are clearly presented in a way to facilitate easy understanding of services and standards of care. It is recognised that the Statement of Purpose represents the foundation on which the home operates upon, offering service users and their relatives the opportunity to make an informed choice about where to live, along with the Service User Guide. The Statement of Purpose needs to be updated to meet contemporary situations. The Care Manager ensures that the admission process is a reflection of a joint understanding that residents are aware, and that staff are able to meet expectations to realise a comfortable transition. Following an assessment, the senior/nurse assessor determines the suitability of the application in view of the facilities available, and of the capacity of the home, to manage the Abbey Court Care Home DS0000068853.V329679.R01.S.doc Version 5.2 Page 9 individual and any special needs. The Home has demonstrated their commitment to promote a partnership of care, to meet the objectives of providing a home to meet individual needs. EVIDENCE: The Statement of Purpose continues to represent a description of the Home’s aims and objectives, philosophy of care and terms and conditions, although needs to be updated to meet the contemporary situation, and to allow Service Users and their relatives the opportunity to make an informed choice about where to live. A separate service user’s guide serves as an easily readable summary of the Statement of Purpose and supporting information, widely used to inform all interested parties. Case tracking of five individual residents clearly identified that the Care Manager, or her deputy, at the point of reference, conducts the pre-admission assessment. The documentation was examined and found to be comprehensive, providing a solid foundation for progressive care planning. This assessment is produced with the full involvement of service users and family, allowing them to influence the direction of care. The assessment initiates the process of care, each individual having a plan of care, which includes a daily living plan and longer-term goals and outcomes. Following an assessment the assessor determines the suitability of the application in view of the facilities available, and at the capacity of the home, to manage the individual and any special needs. Likewise the applicants are informed in writing of those facilities and are encouraged to seek clarification concerning the general and specific services available for the prospective service user. Any special needs of the individual were discussed fully and documented, ensuring their individual needs would be met. Case tracking confirmed that a valuable exchange between service users and assessor took place and resources made available. These resources were seen to be an appraisal of staffing skills, equipment and general environment. From discussions with staff and service users it was evident that prospective service users and their relatives are able to visit and assess the quality, facilities and suitability of Abbey Court at any reasonable time, to meet with staff and management. At all times relatives are involved in the process. Abbey Court Care Home DS0000068853.V329679.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 and 11 The quality in this outcome area is excellent. This judgement is based on the examination of five care plans, discussions with service users, staff, managers, general observations and the Home’s medication system. The care assessment, planning and review system is a highly organised, yet personalised process offering meaningful and valid documentation of care administered. A broad vision of needs is addressed through the care planning process, meeting personal and health needs. It is recognised that this reflects an individual profile of needs, discussed fully with family. The provision of a secure and safe medicines administration is managed efficiently. The Inspector was impressed with the confidence and closeness within the Home of staff, residents and visitors, and the mutual respect that prevailed. Abbey Court Care Home DS0000068853.V329679.R01.S.doc Version 5.2 Page 11 EVIDENCE: Care records and case tracking clearly showed that this standard is well met, maintaining a high quality process of assessment. The pre-admission assessment represented the foundation for a well-considered and detailed care planning process. A comment from a relative “ fully aware of its standards” reinforced this standard. A profile of the service user’s social, physical and psychological status offered an individual plan of care, based upon activities of daily living, to be implemented and frequently reviewed. Each service user’s health, personal and social care needs are carefully assessed in an individual plan of care that is reviewed monthly, including service users and relatives views, to reflect their changing needs. That review is more frequent, dependant upon the individual’s needs and clinical condition. The strength of purposeful planned care lies within the frequency of the review process in monitoring and adapting care profiles. As is appropriate, a checking chart ensures that constant monitoring of high dependency residents is carried out. A daily report is maintained to control monitoring, and offer a very comprehensive account of care and service given. Risk assessments were carried out on an individual basis and frequently reviewed. Included in the care records were applications of established monitoring systems following a process of goals, care and evaluation models of monthly assessment. Case tracking confirmed the extent that the carefully prepared, and well-recorded care plans were appreciated by service users and relatives alike. Tissue viability, continence, psychological and special needs are assessed and documented, along with nutritional screening, hearing and sight tests as appropriate. The GP service is thorough and supportive; through this service, arrangements are made to provide professional support. Continence is assessed on admission and promoted within the plan of care, and there was evidence that service users nutritional needs, and weights were frequently reviewed. Care staff maintain all aspects of service users personal care, overseen by the trained nurse on a daily basis. The administration of medicines adheres to procedures to maximise protection to service users. The storage was secure with satisfactory added security for controlled drugs. A controlled drug register was examined and found to be in order. Each service user has the opportunity of their own lockable facility in their bedrooms on request. The Statement of Purpose, admission assessment and care plans are geared to engender a sense of individuality and privacy. These policies are reinforced Abbey Court Care Home DS0000068853.V329679.R01.S.doc Version 5.2 Page 12 with a staff induction programme and supervised practice. Case tracking confirmed that the policies were implemented, with all service users spoken with being complimentary of the degree of respect given, by each and every member of staff. The inspector observed the free, courteous interaction between service users and staff based on a level of confidence of mutual trust and respect. There was also an observed knowledgeable, and positive attitude towards residents and feedback from the residents: “We are well looked after, and “ well pleased with my situation” Visitors revealed: “Excellent working relationships”, “We come and go as we please, there are no visiting restrictions.” Relatives have freedom of visiting, emphasising on the importance of maintaining social contact. Adequate privacy policies exist for all toilet/bathroom areas and bedrooms. It was noted that a very effective liaison with a Community Matron, engaged by the PCT, in effecting hospital discharges and aftercare, arranging for specialist advice, especially on tissue viability, medical equipment, and McMillan contacts in supporting palliative care. It was also acknowledged that there exist extremely good working relationships with regular District Nurses and a single General Practitioner for the Home. The Community Specialist Nurse was in attendance at the time of inspection, and spoke well of the working relationship and cooperation she receives from the Home. The policy and procedure on care of the dying and death were in place with the full knowledge of both service users and relatives. The home was registered to provide palliative care services and therefore, staff were trained to deal with end of life needs. Individual spiritual persuasions were documented and individual diversity respected at all times. Communion and Church of England services are offered monthly and Roman Catholic services given as requested. Relatives are welcome to stay as long as they liked in times of stress, including overnight stay. The Inspector was impressed with the confidence and closeness within the Home of staff, residents and visitors, and the mutual respect that prevailed. Abbey Court Care Home DS0000068853.V329679.R01.S.doc Version 5.2 Page 13 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 The quality in this outcome area is excellent. This judgement is based on discussions with service users, staff and examination of records in relation to social activities undertaken and general observations during to course of the inspection. The home had a relaxed and welcoming atmosphere where people were encouraged to continue with their individualised lifestyle. The quality of activity and socialisation, monitoring and management was acknowledged. EVIDENCE: From talking to service users and staff it was pleasing to report a continuing daily routine that is flexible and non-institutionalised, offering choice for meal times, personal and social activities including recognition of varied religious needs. The issue of diversity was discussed with the manager and staff, and it was evident that individuals’ needs would be well researched, and met. At pre-admission the service user’s personal interests and customs are determined, and where possible accommodated within the routine of the Abbey Court Care Home DS0000068853.V329679.R01.S.doc Version 5.2 Page 14 Home. That routine is seen as flexible; to acknowledge individuality, yet maintain a focal point for service users to latch on to without dictating events. Discussions with service users and staff clearly identified a relaxed and informal atmosphere in which the service user’s needs were paramount. Abbey Court employs two activity coordinators in social activities, seen as an integral part of care. This is applied within the care planning process as an important aspect of care, as evidenced in examination of records and discussion with staff. An activity board at the reception area identifies the social events of that week, which included a visit that day to the Fairways garden centre. The Home operates a mini-bus, which is consistently used to ferry up to 5 residents to a variety of functions/events. Relatives and friends are encouraged to maintain social links as part of the planning of care. Comments received from relatives confirm their appreciation and involvement with the progress of their loved one’s health and social status; a relative commented: “Care of my mother is of the highest order”. Service users are encouraged to exercise choice and control over their life as far as is possible, and are actively encouraged to bring into the home personal possessions. The tour of the Home demonstrated a high degree of expressed individuality in each of the bedrooms inspected. The Home operates a secure system of handling resident’s monies, with only small amounts of petty cash, which was efficiently handled through the administrator’s office, and subject to internal inspections/audits. It was pleasing to see the high standards of catering at Abbey Court, offering an excellent service, to which all service users spoken to were complimentary of all aspects of quality. A menu on a four weekly cycle offered a wholesome, varied and excellent choice. Individual preferences were recorded in assessment and conveyed to cook, who met with, and discussed their requirements. It was confirmed that the cook knew each service user, and some of the relatives. An excellent lunch was served during inspection, served in pleasantly furnished and clean dining rooms. Staff were seen to offer discreet assistance to those who required it. The choice of dining room, lounge or bedroom was at the discretion of service users. The kitchen was inspected and found to present a well equipped and organised area. All fridges and freezers were well maintained and checked daily by the kitchen staff. A cleaning schedule was in place and seen to be up to date and accurate. COSHH notices were in evidence with cleaning chemicals secure, appropriate and under control. The process would benefit from COSHH poster displays in all areas dealing with chemicals. There is a food preparation room on the 1st floor with a ‘dumb-waiter’ service hatch facility. Food is transferred via heated food trolleys. Abbey Court Care Home DS0000068853.V329679.R01.S.doc Version 5.2 Page 15 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, 17 and 18 The quality in this outcome area is good. The home had a meaningful complaints policy, clearly identifying the CSCI as a resource to approach with a complaint or grievance. No complaints had been received via the Commission since the last inspection. Service users’ legal rights are protected by the systems in place. Staff induction and in-house training programmes clarified the responsibilities of all staff in their daily contact with service users, especially their privileged position in protecting service users from abuse, of all natures. EVIDENCE: Service users’ legal rights are protected by the systems in place in the home to safeguard them, including their contract, the continual assessment of care planning and policies in place i.e. the complaints procedure. The complaints policy was seen and records examined. There were few complaints, which would be better dealt with through a ‘record of concerns’, to record residents and families concerns in a meaningful and effective manner. On discussions it was evident that any small matters were handled immediately, discretely and to the satisfaction of all concerned. The overall policy of openness and transparency was acknowledged. Abbey Court Care Home DS0000068853.V329679.R01.S.doc Version 5.2 Page 16 All service users had received information on the procedure to complain, including reference to the CSCI. This process was evidenced on examination and case tracking as previously reported upon. Discussion with the Care Manager confirmed that there is satisfactory evidence of a protocol and response, to anyone reporting any form of abuse, to ensure effective handling of such an incident. The policy and procedure for handling issues of abuse was examined, and found to be supplemented with the Stoke City Social Services procedure. Staff induction and in-house training programmes clarified the responsibilities of all staff in their daily contact with service users. Abbey Court Care Home DS0000068853.V329679.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,23,24,25,26 The quality in this outcome area is good. This judgement was based on discussions with service users, staff and a tour of the premises. The home is well appointed to meet the needs of an elderly population of service users in providing a safe and comfortable environment. On inspection, bedrooms were highly personalised with most displaying service user’s own furniture, and with personal belongings. All communal areas are of a good standard, offering social as well as private reflection, as the mood takes. The overall environment was found to be safe for service user’s comfort within risk assessed limits. The domestic services in the home were seen to be of a very high standard, with no evidence of unpleasant smells or unsightly debris anywhere throughout the inspection. Abbey Court Care Home DS0000068853.V329679.R01.S.doc Version 5.2 Page 18 EVIDENCE: On admission the provider or care manager assesses each individual service users’ needs for equipment and necessary adaptations. Internal access was facilitated with ample fittings of hand and grab rails, in adequate, well-lit and airy corridors. Wheelchair access was satisfactory throughout all areas of the home. There are 6 variable-height nursing beds available. Bedrooms were well maintained to meet service user’s personal preferences. On inspection, most bedrooms were highly personalised, with most displaying service user’s own furniture, and some with personal belongings. It is the policy that on bedrooms becoming vacant that each room is reappraised for redecoration, as confirmed during the Inspection. There is throughout a good standard of furnishing complemented, with a variety of personal belongings. Several service users spoken to expressed a sense of belonging and satisfaction in the quality and presentation of their living areas. All communal areas are of a high standard, offering social as well as private reflection, as the mood takes. Two main lounge spaces allow activities to be presented in very pleasant areas of the home with furniture and fittings of good quality, doubling up as dining areas, well furnished and presented, to provide a conducive environment to enjoy a good meal. There are two small lounges available for the reflective mood, and a small snoozlan, which is to be redecorated for an activity area. A hairdressing salon is used twice a week by 2 hairdressers. The external and internal environment was well maintained and secure. Heating and ventilation were found to be satisfactory and lighting was domestic in style. Aids, adaptations and equipment were available throughout the Home. Fire equipment was inspected and seen to be serviced up to date. The home presented a clean and pleasant, odour-free atmosphere, much to the credit of staff. An effective call system is installed; care staff reacted speedily to tests. The care manager expressed a willingness to meet any reasonable demand for special needs. A locked facility and lockable bedroom doors are made available on request, following suitable risk assessment. The evidence seen on inspection of service user’s rooms, and on discussion with the individual service users and family, assured that this standard was well met. “ Very much like my own home”, “.. cleanliness and hygiene of the highest order”. Sluice facilities have suitable arrangements to assist in control of infection. Notices regarding chemical handling in the areas that store chemicals are displayed. The process would benefit from COSHH poster displays in all areas Abbey Court Care Home DS0000068853.V329679.R01.S.doc Version 5.2 Page 19 dealing with chemicals. A suitable security safeguard is advised for all storage/sluice areas. Kitchen presentation showed good standards of cleanliness and evidence of sound food hygiene practices. The laundry was well organised and equipped to a good standard. Abbey Court Care Home DS0000068853.V329679.R01.S.doc Version 5.2 Page 20 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 The quality in this outcome area is adequate. Staffing stability has been maintained with consistent levels to ensure equilibrium between numbers, skills and qualifications, with a strong presence of long serving experienced staff. Care bank are occasionally used, with agreed overtime and flexible rostering to accommodate shortfalls. The Provider and Care Management have established a procedure for interview, selection and appointment of staff, which requires reinforcement in ensuring the protection of service users. Staff training records are to complement the effort placed into staff training. EVIDENCE: Four weeks of off-duty were examined, and showed adequate balance between skills, qualifications and numbers to provide a foundation for a good standard of care. The Care Manager works supernumerary and is supported by an able team of Registered Nurses and Carers. Bank coverage has been used occasionally to support shortages of care staff, in tandem with overtime and flexible rostering to meet shortfalls. At the time of inspection the duty rotas confirmed a staff coverage as thus: Abbey Court Care Home DS0000068853.V329679.R01.S.doc Version 5.2 Page 21 a.m - 1 trained 7 carers p.m - 1 trained 5 carers N.D - 1 trained 3 carers The home has 2 activity coordinators, working 45 hours a week. There is also a satisfactory complement of housekeeping and laundry staff, supplemented with 2 ‘breakfast’ staff, who assists for 2 hours in the mornings with serving breakfasts. There is a maintenance man (20 hours/week), a gardener (average 4 hours/week), an administrator working 30 hours/week and a satisfactory establishment of catering staff. The Registered Provider works full time in admin and management support. The Provider and Care Management have established a procedure for interview, selection and appointment of staff. It is a declared policy that recruitment is based on equal opportunity. Four staff files were sampled and found to be generally well organised, although there were inconsistencies. It was noted that the procedure for obtaining CRB clearance was unclear and that a Nurse’s Registration details were not on file. Each staff file would be more informative with a suitable photograph of each staff member. Personal and training records were kept secure in accordance of the Data Protection Act 1998. Policy clearly states an equal opportunity position. Three members of staff were interviewed, each being pleased and satisfied with the professional foundation offered to them through effective management. Each were very settled and enjoyed their positions, and proud of the high standards of care given. All staff have a statement of terms and conditions, and the General Social Care Council code of practice has been secured and deployed to all staff. Service users are supported and protected by these practises and all new staff goes through an induction process that will ensure that they are going to be the right person for the home. The Registered Provider remains steadfastly committed to a learning environment. Staff induction programmes are comprehensive and well established, forming the base upon which in-service supervision and training are planned. Overall the evidence shows a satisfactory account of a meaningful and important schedule of training, to meet internal and external demand, although a more organised training programme and record would facilitate a fuller understanding of training needs. Supervision is conducted by the Care Manager, with delegated responsibilities cascaded throughout the staff, to include all staff. Abbey Court Care Home DS0000068853.V329679.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36,37 and 38 The quality in this outcome area is good. This judgement was based on discussions with the Registered Provider and Care Manager, the examination of the home policies and procedures with regards to the effective management of the home, general observations during the process of the inspection and discussions with service users and staff. There is a confidence apparent in the interaction of residents, staff and the Home’s management, that demonstrated a highly positive relationship that pervades throughout the Home. EVIDENCE: The Care Manager Wendy Goodwin has demonstrated evident competence over 12 years in running Abbey Court, in establishing a solid professional policy portfolio that has been implemented, to achieve a high standard of set aims Abbey Court Care Home DS0000068853.V329679.R01.S.doc Version 5.2 Page 23 and objectives. She is in the process of completing the Registered Manager’s Award this springtime. The inspector was impressed by the openness, professional and pleasing confidence in the observed interactions of staff, relatives and service users. The relationships were seen to be of mutual trust and respect. Appropriate risk assessments are in place for service users, through care planning and recording, staff selection and the general environment, these are up to date and accurate. Health and safety notices can be seen throughout the home. The process would be enhanced with a room catalogue of risk assessment to update the present room based risk reports. A full schedule of daily, weekly and monthly checks of all utilities ensure a well maintained home. The home has an open door policy and a commitment to equal opportunities. The Registered Provider, Adam Knight, presents a high profile in Direction and managerial involvement in the smooth running of the Home, delegating a wide range of management responsibility to good effect. The case tracking undertaken reinforced the effectiveness of service user’s involvement in their care and environment. The Management is committed to maintaining and improving the quality of the Home’s services. An examination of administrative, monitoring, planning and care records showed an organised and professional attitude to effective record keeping. They were found to be well maintained, accurate and up to date, ensuring that the service users’ rights and best interests are safeguarded. The Manager offered evidence of safe working practices including: - accident management, abuse awareness, COSHH management, and management of challenging behaviour. It was noted that there is no formal first aid policy for the Home. Training on a multitude of subjects was acknowledged and evidenced. The health and safety of service users and staff are promoted with safe storage of hazardous substances, regular electrical PAT and servicing of electrical and gas appliances, and regulation of the water system, each record examined, and found to be satisfactory. The accident book was seen and found to be in order for staff, service users and reporting arrangements to Riddor. The administration and management of the home is efficient, uncomplicated and sensitive to the needs of service users. Abbey Court Care Home DS0000068853.V329679.R01.S.doc Version 5.2 Page 24 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 2 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 4 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 4 3 3 4 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 3 3 3 3 2 3 Abbey Court Care Home DS0000068853.V329679.R01.S.doc Version 5.2 Page 25 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 Standard OP29 Regulation Sch. 2 (5) Requirement You demonstrate robust recruitment, application and interview procedures within the home. Timescale for action 01/04/07 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 OP26 2 3 4 5 OP33.9 OP38.3 OP30.1 Refer to Standard OP1 Good Practice Recommendations The Registered Provider provide an update of their Statement of Purpose for submission and approval. That COSHHE signs and information be displayed in all areas involving the use of hazardous chemicals, i.e. destainers. That a regular review of procedures be established, i.e First Aid. That sluice areas be secure when not in use. That a training programme be established to monitor frequency of training. Abbey Court Care Home DS0000068853.V329679.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Abbey Court Care Home DS0000068853.V329679.R01.S.doc Version 5.2 Page 27 - 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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