Inspection on 19/07/05 for Abbey Dean

This inspection was carried out on 19th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 Dean 22/05/09

Abbey Dean 21/05/09

Abbey Dean 09/02/09

Abbey Dean 03/06/08

Abbey Dean 26/05/06

Abbey Dean 04/01/06

Abbey Dean 07/02/05

Abbey Dean 02/07/04

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

CARE HOMES FOR OLDER PEOPLE Abbey Dean 102 Barnham Road, Barnham Chichester West Sussex PO22 0EW Lead Inspector Jo Hartley Unannounced 19 July 2005, 10:30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Abbey Dean H60-H11 S14338 Abbey Dean V233580 190705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Abbey Dean Address 102 Barnham Road, Barnham, Chichester, West Sussex, PO22 0EW Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01243 554535 Mrs Laramie Dean Mr David Geoffrey Dean Mrs Laramie Dean Care Home (CRH) only (PC) 12 Category(ies) of Old age, not falling within any other category registration, with number (OP), (12) of places Abbey Dean H60-H11 S14338 Abbey Dean V233580 190705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7 February 2005 Brief Description of the Service: Abbey Dean is registered to provide personal care for up to twelve service users over the age of sixty-five years (category OP). The building is semi-detached and the accommodation is provided on the ground and first floor. Service users occupy single rooms which have en-suite facilities with a toilet and handbasin. A passenger lift is provided to the first floor. There is a lounge, conservatory and dining room on the ground floor. There are well kept gardens with lawns and walkways that are accessible to service users. Mr and Mrs Dean own Abbey Dean. Mrs Dean is the registered manager responsible for the day-to-day management of the establishment. Abbey Dean H60-H11 S14338 Abbey Dean V233580 190705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was carried out over a period of two and a half hours. The inspector read information held on the service file since the last inspection in February 2005, and read the previous two inspection reports. During the inspection the inspector spoke to all the service users, and two members of staff. The inspector undertook a tour of the premises and looked at four care plans and three staff files. Various record books, policies and procedures were also examined. The registered provider and manager, Mr and Mrs Dean, were on holiday on the day of the inspection and therefore unavailable. What the service does well: 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. Abbey Dean H60-H11 S14338 Abbey Dean V233580 190705 Stage 4.doc Version 1.30 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Abbey Dean H60-H11 S14338 Abbey Dean V233580 190705 Stage 4.doc Version 1.30 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 Service users are assessed prior to admission. Abbey Dean does not provide intermediate care therefore standard six is not applicable. EVIDENCE: Service users’ files inspected held pre-admission assessments that had been used to inform care plans. Abbey Dean H60-H11 S14338 Abbey Dean V233580 190705 Stage 4.doc Version 1.30 Page 8 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 10 The service user’s health, personal and social care needs are set out in an individual plan of care. The health care needs of the service users’ are fully met and service users feel they are treated with respect and dignity. EVIDENCE: Service users’ files included comprehensive assessments covering physical and mental health, falls and nutritional screening. These assessments along with the pre-admission assessments form the basis of individual care plans. Care plans are signed by service users and reviewed every four months. Staff were witnessed treating with service users with dignity and respecting their privacy. Service users said that staff use their preferred names. All bedrooms have telephone points to enable service users to make and receive calls in private. Abbey Dean H60-H11 S14338 Abbey Dean V233580 190705 Stage 4.doc Version 1.30 Page 9 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 Routines of daily living are flexible. Service users are able to maintain contact with family, friends, representatives and the local community. They are also able to exercise control over their lives. EVIDENCE: Abbey Dean provides a wide choice of activities including keep-fit, flower arranging, garden club and trips out in a minibus. Service users said they are able to choose which activities they take part in. A list of activities and services at the local church was seen on display. Service users said they are able to choose the clothes they wear. They also said that an alternative meal is provided if they don’t like what is on the menu. Visitors are welcome in the home and are able to have a meal with their relative if arranged in advance. Service users confirmed this and said they are able to entertain visitors in the privacy of their own room. Abbey Dean H60-H11 S14338 Abbey Dean V233580 190705 Stage 4.doc Version 1.30 Page 10 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) None of the above standards were inspected during this inspection. EVIDENCE: Abbey Dean H60-H11 S14338 Abbey Dean V233580 190705 Stage 4.doc Version 1.30 Page 11 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,26 Abbey Dean provides a safe, well-maintained environment that is clean, pleasant and hygienic. EVIDENCE: On the day of the inspection the home was seen to be clean, homely and free from offensive odours. Decoration was in good order and furnishings were comfortable and domestic in character. The environment was enhanced by the addition of many potted plants and flowers. The garden was seen to be wellkept and accessible to service users. Laundry facilities are sited appropriately, away from food preparation and storage areas. A maintenance man employed by the home carries out maintenance as required. No maintenance program or records were available on the day of the inspection. Abbey Dean H60-H11 S14338 Abbey Dean V233580 190705 Stage 4.doc Version 1.30 Page 12 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29, 30 Service users needs are met by the numbers and skill mix of staff who are trained and competent to do their jobs. Staff records need to include all the information in Schedule 4 of the Care Home Regulations to ensure that service users are supported and protected by the homes recruitment policy. The registered persons are advised that they must ensure that all newly appointed staff should not begin work until an enhanced CRB and POVA check and two written references have been received. EVIDENCE: On the day of the inspection two staff and a cook were on duty, which was adequate for the assessed needs of the current service users. A staff training record was seen showing that staff have received various training including an induction, Health and Safety, Elderly Abuse, Diabetes Management, Dementia and First Aid. The two members of staff spoken to said they had received induction training. They also said that they have regular supervision although no supervision records were available on the day of the inspection. Not all of the staff files inspected contained two written references, contracts, photos or terms and conditions. The registered provider needs to ensure that staff files include all the documents specified in Regulation 19 and Schedule 4 Abbey Dean H60-H11 S14338 Abbey Dean V233580 190705 Stage 4.doc Version 1.30 Page 13 of the Care Homes Regulations to ensure that the home’s recruitment policy protects service users. Abbey Dean H60-H11 S14338 Abbey Dean V233580 190705 Stage 4.doc Version 1.30 Page 14 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 This standard was not seen to be met at this inspection. EVIDENCE: The inspector was told that the views of service users are sought in regard in regard to the running of the home. There were no records of a quality monitoring system or an annual development plan available on the day of the inspection. Abbey Dean H60-H11 S14338 Abbey Dean V233580 190705 Stage 4.doc Version 1.30 Page 15 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x 1 x x x x x Abbey Dean H60-H11 S14338 Abbey Dean V233580 190705 Stage 4.doc Version 1.30 Page 16 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 29 Regulation 19 Requirement The registered person must ensure that staff files contain all records required by the Care Homes Regulations. See Schedule four. Timescale for action 19/09/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 33 Good Practice Recommendations The registered providers should put in place quality assurance and quality monitoring systems. Abbey Dean H60-H11 S14338 Abbey Dean V233580 190705 Stage 4.doc Version 1.30 Page 17 Commission for Social Care Inspection 2nd Floor, Ridgeworth House, Liverpool Gardens Worthing West Sussex BN11 1RY 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 Dean H60-H11 S14338 Abbey Dean V233580 190705 Stage 4.doc Version 1.30 Page 18 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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