Inspection on 14/01/08 for Abbey Court Nursing Home

This inspection was carried out on 14th January 2008.

CSCI found this care home to be providing an Good service.

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 Court Nursing Home 11/05/09

Abbey Court Nursing Home 17/11/08

Abbey Court Nursing Home 06/06/06

Abbey Court Nursing Home 10/02/06

Abbey Court Nursing Home 09/09/05

Abbey Court Nursing Home 27/10/04

Abbey Court Nursing Home 22/06/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Abbey Court Nursing Home Heath Way Heath Hayes Cannock Staffordshire WS11 7AD Lead Inspector Yvonne Allen and Wendy Jones Key Unannounced Inspection 14th January 2008 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 Nursing Home DS0000022389.V346425.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 Nursing Home DS0000022389.V346425.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbey Court Nursing Home Address Heath Way Heath Hayes Cannock Staffordshire WS11 7AD 01543 277358 01543 277876 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) Restful Homes (Cannock) Limited Miss Sarah Edwards Care Home 117 Category(ies) of Dementia (59), Mental disorder, excluding registration, with number learning disability or dementia (10), Mental of places Disorder, excluding learning disability or dementia - over 65 years of age (25), Old age, not falling within any other category (80), Physical disability (58), Physical disability over 65 years of age (35) Abbey Court Nursing Home DS0000022389.V346425.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. DE Minimum age 60 years MD Minimum age 50 years PD Minimum age 55 years Date of last inspection 6th June 2006 Brief Description of the Service: Abbey Court is a purpose-built care home, providing nursing and residential care, located within a residential area on the outskirts of Cannock. The home can accommodate up to 117 service users in the following categories; Dementia care (59), Mental disorder, excluding learning disability or dementia (10), Mental disorder, excluding learning disability or dementia- over 65 years of age (25), Old age not falling in any other category (80), Physical disability (58), Physical disability over 65years of age (35). Current scale of charges range from £290 - £575 per week. The home is on two floors and all areas have access via the stairs and/or passenger lift. Within the home there are a total of 13 lounges available, including a specific smoking lounge. There are four dining rooms and ample facilities in the home including two hairdressing salons. The home has an enclosed garden with a suitable patio area. The registered care manager (RGN) is in charge of the home. First level nurses (both RGN and RMN), and teams of care assistants, provide care. Local GP practices and a pharmacist service the home. Community nurses, health service professionals, and NHS facilities are accessed as and when required. Several local GP practices and a pharmacist service the home. Activities, hobbies and entertainment take place with transport provided as required. The fees charged are available on request from the manager and will be included in the Service User Guide. Abbey Court Nursing Home DS0000022389.V346425.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means that the people who use this service experience good quality outcomes. This unannounced Key inspection was carried out by two inspectors and the visit to the home took 5 hours to complete. Prior to the inspection visit, the Providers had completed a self-assessment tool called an Annual Quality Assurance Assessment (AQAA). This provided the CSCI with information about the home and helped with the planning of the inspection visit. During this inspection all of the Key standards for Older Persons were assessed and judgements were made for each outcome. This gives an overview of what it is like (outcomes) for the people who live in the home. The evidence we used to assess the outcomes for individuals was gained from a variety of sources. This included the following – Discussions with residents and visitors to the home Discussions with the manager and staff in the home Examination of relevant records and documentation A walk around the home Observation of care practices Information received by CSCI about the home since the last key inspection Examination of the AQAA We were made to feel welcome by the manager, staff and residents in the home and the manager and her deputy were very helpful in assisting us. This was a pleasing inspection with positive outcomes for the people who live at the home. Most of the minimum standards were fully met with one requirement and fourteen recommendations made which the Providers should consider addressing in order to improve outcomes further. Abbey Court Nursing Home DS0000022389.V346425.R01.S.doc Version 5.2 Page 6 What the service does well: This is a modern purpose built home which as been constructed according to the needs of the people who live there. Corridors are wide and spacious and allow for easy movement of people either walking or wheelchair users. Bedrooms are well equipped and all have en suite facilities. Bathrooms and toilets have been adapted to meet the needs of the residents. There are a number of communal sitting areas as opposed to just one main lounge. This gives people a choice and allows for them to sit in a quiet area if they wish. Residents and visitors spoken to were happy with the home and the care provided. The following comments were made About the home and the staff “What I like best about this home is the cleanliness, the kindness of staff and the layout of the home.” “High quality nursing care, good food and friendly atmosphere.” “I like all my things around me, I have photographs of my family on the wall and I have been able to bring in some of my belongings from home.” About the meals “You can’t grumble about the food, it’s lovely and there’s plenty of it.” Staff are carefully selected to work at the home, receive regular training and have the necessary skills and expertise and are provided in sufficient numbers to meet the needs of the residents. The maintenance of the home is very good and regular checks are carried out on all equipment and in all areas – these are over and above that which is required by CSCI. This ensures that a safe environment is provided for all. The maintenance person is to be congratulated on his work in this area. The home is very well managed and the same manager has been in post for several years. This has provided consistency of management. A deputy manager is in post and supports the manager. Residents, relatives and staff all feel that the management is open and inclusive. This ensures that the home is run in the residents’ best interests. Abbey Court Nursing Home DS0000022389.V346425.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: The range of fees charged must be included in the Service User Guide so that individuals planning to move in to the home are aware of what the charges will be and how much they will have to pay. In respect of individual care plans the following comments had been received from residents and their representatives “I have not received a care plan every month.” “I have not been involved with the care plan and evaluations as much as I would like to.” There is little evidence seen of care plan evaluations having been carried out with residents and/or their representatives. This should be encouraged so that individuals feel included and are aware of and agree with their plan of care including any changes. Care plans on the mental health unit should be more focussed on assessment of mental health needs and ensuring that a care plan is put into place for each identified need. This is so that it can be evidenced that mental healthcare needs are monitored and met on a continuous basis. The programme of entertainment and activities is not fully effective in meeting the social and therapeutic needs of individuals. This should be reviewed with a view to improving records of activities and the outcome for the people who live at the home. A comment from a relative read “More afternoon entertainment needed.” The Catering Manager could be more involved in speaking to individuals about the types of food they would like and menus planning and advice should be sought in relation to improving the provision of meals for individuals with diabetes. This will help ensure that residents’ choices are upheld and that their nutritional needs are met. Abbey Court Nursing Home DS0000022389.V346425.R01.S.doc Version 5.2 Page 8 Although the environment is clean and well presented throughout – it would benefit from a more stimulating environment especially in the mental health unit. Here such things as themed corridors and pictorial signage to help with orientation would help meet the specific needs of individuals. This was discussed with the manager at the time of the inspection visit and she plans to implement this. Also - baths, showers and toilets would benefit from being more homely, to provide a more welcoming environment for residents. It is recommended that Criminal Record Bureau checks be repeated periodically for all employees. It is also recommended that where there may be issues identified that there is a record of this being discussed and risk assessed. This will help ensure the ongoing safety of the people who live at the home. More staff training sessions in managing “challenging behaviour” should be provided for staff in order to ensure that all staff who deliver care feel that they are able to deal with difficult situations. The abuse training programme should be delivered to all staff who work at the home, not just care staff so that all staff members are able to recognise and report abuse. 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 Nursing Home DS0000022389.V346425.R01.S.doc Version 5.2 Page 9 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 Nursing Home DS0000022389.V346425.R01.S.doc Version 5.2 Page 10 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals are only offered a place at the home following an assessment of their needs. This ensures that this is the right kind of home for them. Once they are in this home people can be assured that their assessed needs will be met. EVIDENCE: We looked at standards 3 and 4. The service has a Statement of Purpose and Service user Guide; the contents were discussed briefly with the manager and advice given regarding the inclusion of the range of fees charged by the service in the Service User Guide. Abbey Court Nursing Home DS0000022389.V346425.R01.S.doc Version 5.2 Page 11 This provides people who may use the service with an idea of the costs the service charges. Six care plans were examined randomly where it was identified that a trained nurse from the home had carried out pre-admission assessments. The manager confirmed that this was usually herself or her deputy that did these. It was also noted that placement officers (such as Social Services) had also carried out assessments on individuals prior to admission to the home. This was also applicable for emergency admissions. These assessments then went on to form the basis of the individual care plans. It was identified through examination of records and documentation, discussions with residents, staff and visitors and observation of care practices, that the home was able to meet individual assessed needs. Abbey Court Nursing Home DS0000022389.V346425.R01.S.doc Version 5.2 Page 12 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each individual has a plan of care based around an assessment of their needs and personal and nursing care are delivered with dignity and respect. This outcome would be further improved on the second floor unit by developing care plans for specific mental health care needs. Including residents and/or representatives in evaluations would also be an improvement. EVIDENCE: We looked at standards 7,8,9 and 10. A random sample of six care plans were examined – four from the second floor nursing unit which caters for elderly individuals with mental health needs, and Abbey Court Nursing Home DS0000022389.V346425.R01.S.doc Version 5.2 Page 13 two from the ground floor unit which caters for elderly people with general nursing needs. Care plans were comprehensive, based around an initial assessment of needs and had been evaluated regularly. There were short-term care plans in place for immediate medical and nursing interventions. All areas of activities of daily life had been risk assessed and a care plan put into place where required. Of the four plans looked at on the mental health unit – these were very general and based around general nursing needs rather than mental health needs. One plan identified – “suffers from Alzheimer’s, tearful, anxious, physically aggressive, confused and disorientated”. But there was no specific care plan in place to assess the degree of each problem and/or care plan in place to meet each identified need. Neither was there a care plan in place to meet the times when this person could be physically aggressive – such as a challenging behaviour care plan. There were examples of input from health care professionals - General Practitioners, tissue viability nurse specialists, community psychiatric nurses, opticians and chiropodists –although chiropody visits were not frequent, some only recorded as one visit per year. There were relatives’ communication forms in place in care plans but most of those seen had not been completed/signed. This was reiterated by comments seen in relatives’ surveys – “I have not received a care plan every month.” “I have not been involved with the care plan and evaluations as much as I would like to.” One gentleman on the mental health unit had bedrails in place but no suitable risk assessment could be found. Discussions with the manager identified that she was in the process of introducing a new risk assessment for the use of bedrails and this was shown to us. There was evidence in place to identify that diverse needs of individuals were assessed and met. The care plan for an individual who was registered blind was examined. There was a specific care plan in place for maintaining his safety and promoting his independence and examination of his bedroom confirmed that this had been adapted to meet his needs. Another care plan was examined in belonging to an individual who is deaf and blind and again this had been taken into account when planning her care. The procedures for receipt, storage, administration, recording and disposal of medication were examined. These procedures were found to be in keeping with requirements. The nurse was observed administering the lunchtime medication on the mental health unit and this was done in a safe professional manner. Individuals were assisted to take their medication in their own time and at their own pace. Abbey Court Nursing Home DS0000022389.V346425.R01.S.doc Version 5.2 Page 14 We were informed that the dispensing Pharmacist carries out medication audits at the home. Care staff and nurses were observed delivering care with dignity and respect and were at ease with individuals who had challenging behaviour needs. Two visitors were interviewed as part of the inspection visit. Their relative was accommodated on the mental health unit and had been there for some time. They were both very happy with the care their relative received and felt that the home met her needs very well. They spoke highly of the staff and had an open relationship with them. They visited at different times – sometimes together and sometimes separately and were satisfied that care was consistent throughout the day. They stated that there had been one or two problems early on but that once it was identified what they wanted for their relative –and what she would like (as she lacked capacity) –then this had been attended to. They felt that any concerns they had were listened to and acted upon. Abbey Court Nursing Home DS0000022389.V346425.R01.S.doc Version 5.2 Page 15 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The programme of activities and entertainment is in need of reviewing and improving in order to ensure that social and therapeutic needs of individuals are met. People who use the service can be sure that they receive a varied and nutritionally sound diet and are offered a choice of meal at each mealtime. EVIDENCE: We looked at standards 12,13,14 and 15. The manager informed us that she now employs 2 activities co-ordinators who work for a total of 50 hours per week. A hairdresser visits the home twice per week and has a salon on each floor to work in. Abbey Court Nursing Home DS0000022389.V346425.R01.S.doc Version 5.2 Page 16 The manager gave an example of how the service strives to meet the diverse needs of the residents, by working to address the spiritual needs of an individual from a minority ethnic background. Examination of the record of activities and entertainment identified that there was no record for 2007. The activities co-ordinator stated that she had had problems with her computer and that this information had been lost. She was able to show us her planning for 2008. This included trips out to local places of interest but was lacking in entertainment for residents on a daily basis. It is a recommendation that individuals are reassessed as to their preferences and abilities in relation to activities and entertainment and that more entertainment is organised for them. It is also recommended that records are stored more securely to prevent them being lost. Examination of residents and relatives questionnaires done in August 2008 identified a comment from one of the relatives “More afternoon entertainment is needed.” Menus are planned by the catering manager and his team and are based upon the known preferences of residents. Care staff collect this information at the time each resident is admitted to the home. Alternatives to the main menu are provided on request and a record is made of all those provided. Special diets are also catered for; the catering manager stated that currently there are residents who require a soft, pureed, diabetic, gluten free or vegetarian diet. He described how pureed diets are prepared and offered to residents to ensure individual items are pureed separately, this ensures that residents are able to distinguish individual food flavours and also means that the meal is pleasant to look at. The issues identified include ensuring that persons with diabetes receive an appropriate diet, it is suggested that the Cook consults with diabetic or dietetic advisors. The quality of food provided is of a high standard with fresh vegetables, meat and dairy products delivered two or three times per week from local shops and producers. Fresh fruit is also provided, some of which is placed in fruit bowls and left in the dining room for residents. Catering staff check and record the temperatures of hot food and the temperatures of the fridges and freezers on a daily basis. Cooked food is put into heated trolleys before being taken to the dining rooms to residents. This ensures that it is hot at the point of delivery. One resident said, “ you can’t grumble about the food, it’s lovely and there’s plenty of it.” The catering manager was asked to consider attending resident meetings to ensure that residents can be involved in menu planning and it was also suggested that a compliments and grumbles book could be put in the dining rooms, which would also provide him with feedback on the food provided. Abbey Court Nursing Home DS0000022389.V346425.R01.S.doc Version 5.2 Page 17 Abbey Court Nursing Home DS0000022389.V346425.R01.S.doc Version 5.2 Page 18 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals who live in the home can be assured that any concerns they have about the home will be taken seriously and, if necessary, acted upon. The systems in place at the home help to keep individuals safe from harm. EVIDENCE: We looked at standards 16 and 18. Discussions with the manager and examination of the complaints file identified that she deals with concerns and complaints effectively and as they arise. Residents and the visitors spoken to confirmed this. There is an accessible clear complaints procedure in place in the home. There have been 2 complaints received since the above inspection – CSCI investigated one and the Provider investigated the other. There have also been 2 Vulnerable Incidents investigated at the home Abbey Court Nursing Home DS0000022389.V346425.R01.S.doc Version 5.2 Page 19 Information in the records show that training in the recognition and reporting of abuse has been provided for the majority of staff. The manager stated that this is an area that is now included in each persons induction and that those undertaking National Vocational Qualifications (NVQ) also cover this topic as part of their training. In addition she said that she had attended Training the Trainers course and is planning other training days to ensure all staff are up to date. It is also suggested that this training should be extended to all staff in the home including catering, domestic, laundry and maintenance. Abbey Court Nursing Home DS0000022389.V346425.R01.S.doc Version 5.2 Page 20 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home offers a clean, comfortable, pleasant, purpose built environment for the people who live there. EVIDENCE: We looked at standards 19,21 and 26. This visit included a brief tour of the environment which established that it is well maintained, clean and offers a save comfortable home for the people who live there. The service offers accommodation for up to 117 people and currently has 4 vacant beds. All except 4 bedrooms are single and from the sample seen. The bedrooms are spacious and provide en-suite facilities. Abbey Court Nursing Home DS0000022389.V346425.R01.S.doc Version 5.2 Page 21 One resident said, “ I like all my things around me, I have photographs of my family on the wall and I have been able to bring in some of my belongings from home.” One resident said that staff didn’t always knock before entering her bedroom, or she couldn’t hear them do so. This matter was discussed with the manager and advice given about aids available that may be useful in this case. The service is divided into two units with an EMI unit on the first floor. There are a number of lounges for the benefit of residents providing quiet areas and other more lively areas. There is a smoking room on the first floor although the manager stated that they had plans to change this. There are also plans to create another quiet seating area in the current lobby on the first floor. The manager confirmed other plans to develop the first floor to provide a more therapeutic environment for the residents who live there she is currently researching suitable ideas. Some of the corridors in the home appeared to be quite stark minus any pictures or distinguishing features. This is something the manager also hopes to address. The service provides a payphone in a small room for the benefit of residents, this would benefit from minor adaptations to make it more user friendly. Baths, showers and toilets are provided throughout the home providing functional, spacious and adapted facilities for residents, although they would benefit from being more homely, to provide a more welcoming environment for residents. Some of the floors in these rooms were stained and in need of a deep clean. The manager confirmed that this is done regularly. All bedrooms have door locks fitted that offer residents privacy if they want it, each resident is asked and risk assessed before they have a bedroom door key. The laundry is located on the first floor of the home, and is manned by a dedicated team of staff. The facility operates to expected guidelines, which require dirty laundry to be taken in to the facility through one door and clean is removed for distribution from another, reducing the risk of cross contamination or infection. At the time of the site visit staff discussed the current difficulties they have managing to meet the laundering needs of the service because of a broken down washing machine. The manager stated that the part needed for the machine had been ordered and it is hoped the repairs will take place this week. The Kitchen is located on the ground floor and offers a clean and well-equipped environment for staff to work in. A recent environmental health visit has confirmed that the service is now compliant with the standards of hygiene they expect. Abbey Court Nursing Home DS0000022389.V346425.R01.S.doc Version 5.2 Page 22 Abbey Court Nursing Home DS0000022389.V346425.R01.S.doc Version 5.2 Page 23 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service can be sure that they are cared for by a staff team that have been properly recruited, have the necessary skills and training and are deployed in sufficient numbers to meet their needs. EVIDENCE: We looked at standards 27,28,29 and 30. The service provides sufficient staff hours to ensure that the needs and welfare of residents are met. The current resident numbers are 113. The manager reported and the records confirmed that there are 4 Nurses in combinations of Registered General nurses (RGN) and Registered Mental Nurses (RMN) provided during the waking day from 7.30am-8.30pm. 2 nurses are deployed during the night. 17 carers are provided for the day shift starting 7.00-14.00 and 14 carers from 14.00-21.00. 8 carers are deployed at night. Additional weekly hours include 234 catering. The kitchen is manned from 7.00-19.00 each day. 80 hours maintenance are also provided, in addition to a fulltime housekeeper and domestic and laundry staff as well as 70.5 hours Abbey Court Nursing Home DS0000022389.V346425.R01.S.doc Version 5.2 Page 24 administration. Activities co-ordinators provide an additional 50 hours per week. There is no use of agency staff and any additional hours required to cover staff sickness or annual leave are covered by the existing team, this can mean that some staff are regularly doing 2-4 additional shifts per week. While this may be the choice of the individual, the manager should ensure perhaps through supervision that staff have sufficient time off to meet their own family worklife balance. Regular additional hours can affect staff performance over time; this should be something that is also monitored. It should be noted that most staff have signed working time directive disclaimers. Staff meetings are held approximately 3 times pre year this was confirmed by those staff spoken to. The manager confirmed that she discusses domestic and catering issues with the relevant individuals on a daily. The numbers of care staff who have achieved an NVQ at level 2 or above exceeds the recommended minimum standards, and some of the ancillary staff have also been provided with opportunities to undertake this type of training. Two members of staff confirmed that they had received required training, but one said she would like more training in the management of challenging behaviour. This was discussed with the manager for her attention. A qualified nurse stated that she is able to attend courses and training to ensure she maintains her nursing registration. Recruitment records show that appropriate pre employment checks are undertaken; these include 2 written references and Criminal Records Bureau checks. All staff have received job descriptions and contracts of employment which show their hours of work. It is recommended that CRB checks are repeated periodically for all employees. It is also recommended that where there may be issues identified that there is a record of this being discussed and risk assessed. Abbey Court Nursing Home DS0000022389.V346425.R01.S.doc Version 5.2 Page 25 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed and run in the best interests of the people who live there. The maintenance of the service is very well managed thus ensuring the safety of the people who live in, work at and visit this home. EVIDENCE: We looked at standards 31,32,33,35,36 and 38. Abbey Court Nursing Home DS0000022389.V346425.R01.S.doc Version 5.2 Page 26 Discussions with residents staff and visitors identifies that the manager has an open management style and is approachable. Discussions with 2 visiting relatives confirmed that the manager sorts out problems and issues as they arise. There is a quality assurance programme in place at the home which includes the audit of the following – care plans, menus, medication, complaints and accidents. Questionnaires are also sent out regularly to residents and relatives – the last being dated August 2007. The following comments were included – “What I like best about this home is the cleanliness, the kindness of staff and the layout of the home.” “High quality nursing care, good food and friendly atmosphere.” “I have not received a care plan every month.” “I have not been involved with the care plan and evaluations as much as I would like to.” “More afternoon entertainment needed.” “The home is understaffed at weekends.” Residents/Relatives meetings are also arranged on a regular basis where the people who live in the home are able to air their views and opinions and offer suggestions for improvement. The manager explained how this is addressed and changes are brought about as a result of these meetings. The manager stated that staff meetings are held quarterly and discussions with staff members confirmed this. The home offers a secure facility for the safekeeping of personal allowances. The maintenance of these was examined during which four random samples were assessed. All of these were in order except for one, which did not balance and has been left with the manager to address. Two signatures are obtained for the receipt and expenditure of money. Receipts and invoices are maintained and audit trails can be easily carried out if required. Records seen show that staff receive regular one to one supervision and where there are concerns about individual performance these sessions are more frequent. Records were examined in respect of the maintenance and health and safety and these were found to be exemplary. There had been a new maintenance person employed since the last Key inspection. Discussions with him and examination of his records and files identified that he excelled in his job role. Checking of equipment exceeded that required by CSCI and helped to ensure the health and safety of all who worked at lived in and visited the home. Checks were carried out on fire doors during this visit to ensure that they closed properly. The maintenance person said he had identified a problem with Abbey Court Nursing Home DS0000022389.V346425.R01.S.doc Version 5.2 Page 27 one he was dealing with during this visit. Also an electrician was visiting at the time of this site visit to carry out the annual checks of the electrical circuits and equipment. The absence of self closing doors to bedrooms is noted in the fire safety officers report of May 2007 with the recommendation that risk assessment have been carried out for each of the rooms. This was not checked during this visit. Abbey Court Nursing Home DS0000022389.V346425.R01.S.doc Version 5.2 Page 28 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 x 3 3 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x 3 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 3 3 x 3 3 x 4 Abbey Court Nursing Home DS0000022389.V346425.R01.S.doc Version 5.2 Page 29 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 OP1 Regulation 5(1)(b) Requirement The Providers must include, in their Service User Guide, the scale of fees charged by the home so that the people moving into the home have information about these charges Timescale for action 25/02/08 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 OP12 Good Practice Recommendations The frequency of in house entertainment should be increased for residents accommodated on the mental health unit in order to help meet social and therapeutic needs. PREVIOUS RECOMMENDATION The environment on the mental health unit should be further adapted in order to meet the specific needs of the service users accommodated there. PREVIOUS RECOMMENDATION The Catering Manager should consult with diabetic or dietetic advisors in order to ensure that the nutritional needs of individuals with Diabetes are met. The Catering Manager should attend residents’ meetings in DS0000022389.V346425.R01.S.doc Version 5.2 Page 30 2. OP22 3. 4. OP15 OP15 Abbey Court Nursing Home 5. OP12 6. 7. 8. 9 OP18 OP19 OP21 OP38 10 OP27 11 12 OP30 OP29 13 OP7 14 OP7 order to ensure that residents can be involved in menu planning and a compliments and grumbles book could be put in the dining rooms, which would also provide him with feedback on the food provided. Individuals should be reassessed as to their preferences and abilities in relation to activities and entertainment and more entertainment should be organised for them. Records of activities should be stored more securely to prevent them being lost. Abuse training should be extended to all staff in the home including catering, domestic, laundry and maintenance. The payphone in the small room would benefit from minor adaptations to make it more user friendly. Baths, showers and toilets would benefit from being more homely, to provide a more welcoming environment for residents. The absence of self closing doors to bedrooms is noted in the fire safety officers report of May 2007 with the recommendation that risk assessment have been carried out for each of the rooms. The Provider should ensure that this has been done. The manager should ensure perhaps through supervision that staff have sufficient time off to meet their own family work- life balance. Regular additional hours can affect staff performance over time; this should be something that is also monitored. More training sessions in “challenging behaviour” should be provided for staff. It is recommended that CRB checks be repeated periodically for all employees. It is also recommended that where there may be issues identified that there is a record of this being discussed and risk assessed. Psychological health care needs should be assessed for those individuals accommodated on the mental health unit and a care plan put into place in order to meet these specific needs Residents and/or their representatives must be given the opportunity to participate in care plan evaluations and this must be documented Abbey Court Nursing Home DS0000022389.V346425.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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. 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