Inspection on 26/05/06 for Abbey Dean

This inspection was carried out on 26th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Abbey Dean 22/05/09

Abbey Dean 21/05/09

Abbey Dean 09/02/09

Abbey Dean 03/06/08

Abbey Dean 04/01/06

Abbey Dean 19/07/05

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 Ms J Hartley Key Unannounced Inspection 26th May 2006 14:00 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 Dean DS0000014338.V292435.R01.S.doc Version 5.1 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 Dean DS0000014338.V292435.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Abbey Dean Address 102 Barnham Road Barnham Chichester West Sussex PO22 0EW 01243 554535 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) Mrs Laramie Dean Mr David Geoffrey Dean Mrs Laramie Dean Care Home 14 Category(ies) of Old age, not falling within any other category registration, with number (14) of places Abbey Dean DS0000014338.V292435.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th January 2006 Brief Description of the Service: Abbey Dean is registered to provide personal care for up to fourteen service users over the age of sixty-five years (category OP). The building is semidetached and the accommodation is provided on the ground and first floor. Service users occupy single rooms that have en-suite facilities with a toilet and hand basin. 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. The current fee range is £430 to £450. Abbey Dean DS0000014338.V292435.R01.S.doc Version 5.1 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 examined information held on the service file since the last inspection in January 2006, and read the previous two inspection reports, the Service User Guide and the Statement of Purpose. A Pre-Inspection Questionnaire was also received from the home. Information from this is included in this report. During the inspection the inspector spoke to five service users, two members of staff and two visitors. The inspector undertook a tour of the premises and looked at three care plans and three staff files. Various record books, policies and procedures were also examined. What the service does well: What has improved since the last inspection? What they could do better: The registered person should ensure that there is a minimum ratio of fifty percent trained members of care staff with an NVQ level two or equivalent qualification. Effective quality assurance and quality monitoring systems, based on seeking the views of service users, should be put in place to measure success in meeting the aims, objectives and the statement of purpose of the home. Abbey Dean DS0000014338.V292435.R01.S.doc Version 5.1 Page 6 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 DS0000014338.V292435.R01.S.doc Version 5.1 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 Dean DS0000014338.V292435.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 5 The Statement of Purpose and Service User Guide are up to date and contain the required information. New service users admitted on the basis of a full assessment. Every service user has a plan of care for daily living. New service users are able to visit the home prior to admission and move in on a trial basis. The home does not provide intermediate care; therefore Standard Six does not apply. The outcome for residents is good. EVIDENCE: The Statement of Purpose and Service User Guide were seen to be up to date and to include the required information. There have been no changes since the last inspection. Evidence was seen on residents’ files that a full assessment is undertaken prior to admission. Residents have a care plan for daily living. Abbey Dean DS0000014338.V292435.R01.S.doc Version 5.1 Page 9 Residents told the inspector that they were able to visit the home prior to moving in. A letter was seen from a prospective resident arranging a visit to the home. The registered manager confirmed that residents move in on a trial basis. The manager confirmed that the home does not provide intermediate care. Abbey Dean DS0000014338.V292435.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 There are plans of care in place that set out individual personal, health and social needs. Service users have access to health services to meet their assessed needs. Medication policies are in place. Service users are able to take responsibility for their own medication if they wish, within a risk management framework. Service users feel that they are treated with resprect and their right to privacy is upheld. The outcome for service users is good. EVIDENCE: All the residents’ files looked at during case tracking included an individual care plan. Care plans that were seen were detailed and included the action to be taken by staff to ensure that all aspects of health, personal and social care needs of residents are met. Care plans stated the health, personal, religious, cultural and social needs of residents. There is a twenty-four hour care chart for each resident on which daily care and changes are recorded. Residents’ files showed that community Abbey Dean DS0000014338.V292435.R01.S.doc Version 5.1 Page 11 health resources, including doctor, dentist, optician, chiropodist and hospital are accessed to meet residents’ health needs. Evidence was seen that care plans are reviewed regularly. The manager said that they are updated more regularly if there are any changes to residents’ needs. Policies and procedures regarding the receipt, recording, storage, handling, administration and disposal of medication were seen and found to be adequate for their purpose. Following a risk assessment service users are able to administer their own medication if they wish. At present there are no service users who self medicate. Records were seen of all medication received, administered and leaving the home. These were accurately recorded and signed. The medicine cabinet was well organised with no evidence of over-stocking. Staff records show that staff have received training in the administration of medication. There are no controlled drugs held at the home at present. Residents said that their personal care needs are addressed in private and that staff are sensitive and treat them with dignity. All bedrooms have telephone points to enable residents to make and receive calls in private. Abbey Dean DS0000014338.V292435.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Routines of daily living are flexible. Residents are able to maintain contact with family, friends, representatives and the local community. They are also able to exercise control over their lives. The food provided is wholesome and appealing and enjoyed by the residents. The outcome for service users is good. EVIDENCE: Abbey Dean provides a wide choice of activities including musical afternoons, flower arranging, crafts, beetle drive, Scrabble school and trips out in a minibus. Every summer they have a cream tea afternoon for residents and their friends and relatives. Service users said they are able to choose which activities they take part in. Residents’ interests are recorded in their care plans. Service users said they are able to exercise choice in their lives. 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. Two visitors confirmed that they are able to visit their relative at any reasonable time, and that the home makes them welcome. Abbey Dean DS0000014338.V292435.R01.S.doc Version 5.1 Page 13 Residents manage their own financial affairs for as long as they are able to. Service users said they are able to exercise choice in their lives. The menu for the home was seen and contained a varied, wholesome diet. Service users said the quality of food provided is good. Residents confirmed that if they do not like something on the menu an alternative is offered. One resident said that “you don’t get boring food here, there is lots of variety, and it is very good food.” Mr Dean said that the cook regularly tries new recipes and the residents are asked for feedback on whether they like them or not. Hot and cold drinks are available throughout the day and on request. Abbey Dean DS0000014338.V292435.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Residents are confident that their complaints will be listened to, taken seriously and acted upon. Residents are protected from abuse by the homes policies, procedures and staff training. The outcome for service users is good. EVIDENCE: The complaints procedure was seen and found to be clear and accessible. The procedure is contained in the service user guide. The home has a book in which it keeps a record of any complaints made. There have been no complaints since the last inspection. Residents said that if they had any complaints they would discuss them with the owners. They were confident that the owners would take the complaint seriously and address it. The homes’ adult protection and whistle blowing policies were seen and found to be robust. Staff records show that they have received training in recognising and responding to abuse. Abbey Dean DS0000014338.V292435.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25, 26 Abbey Dean provides a safe, well-maintained environment that is clean, pleasant and hygienic Residents live in safe, comfortable and clean surroundings that are pleasant and hygienic. The outcome for service users is good. EVIDENCE: Abbey Dean is clean, homely and free from offensive odours. Decoration is in good condition and of a high standard. Furnishings are comfortable and domestic in character. The environment is enhanced by the addition of many potted plants and flowers. The garden is very attractive, well-kept and accessible to residents. There are areas for seating in the sun and shade Laundry facilities are sited appropriately, away from food preparation and storage areas. Floor and wall surfaces are easily cleanable. The floor surface is impermeable. Abbey Dean DS0000014338.V292435.R01.S.doc Version 5.1 Page 16 A maintenance man employed by the home carries out maintenance as required. Bedrooms are well decorated, comfortably furnished and have evidence of residents’ private possessions in them. Resident said that they were able to bring their own furniture and possessions with them when they moved in. Mr Dean said that bedrooms are redecorated prior to new residents moving in. Rooms are centrally heated and individually and naturally ventilated. Radiators and pipe work are covered, and windows have restrictors in place. There is emergency lighting throughout the home. Water temperatures are restricted to within the required limits by thermostatic valves. In the new extension the height of the windows enable service users to see out of them when seated or in bed. Since the last inspection a bathroom has been refurbished and the dining room has been redecorated. A new “sleeping- in” bed has been provided for the sleeping staff on night duty. Abbey Dean DS0000014338.V292435.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Residents’ needs are met by the numbers and skill mix of staff that are trained and competent to do their jobs. Abbey Dean is working towards having fifty percent of care staff with an NVQ Level Two or above. Service users are protected and supported by the homes’ recruitment policies and procedures. The outcome for service users is good. EVIDENCE: The number and skill mix of staff at Abbey Dean are appropriate to the assessed needs of the residents and the size of the home. The rota showed that there are two to three care staff are on duty during the day and evening, and there are one waking and one sleeping night staff on duty at night. The home also employs a cook, office administrator, cleaners and a maintenance man. Staff records show that staff have received various training including an induction, Health and Safety, Moving and Handling, Elderly Abuse, Understanding the Elderly, Falls Prevention, Catheter Care and First Aid. Staff records also show that Abbey Dean has a stable staff team with a very low turnover of staff. The home is currently working towards having fifty per cent of its staff with NVQ level 2 or equivalent qualifications. Thirty-three percent of staff have this Abbey Dean DS0000014338.V292435.R01.S.doc Version 5.1 Page 18 level of qualification, the rota indicates that more than fifty per cent of care hours are provided by staff with the minimum qualification level. The home has a thorough recruitment procedure in place. Staff records show that two written references, CRB and POVA checks are required before appointing a member of staff. The home has its’ CRB checks completed by an umbrella body. Reference numbers for completed CRB checks are held on file. The two members of staff spoken to said they had received induction training. They also said that they have regular supervision and feel very well supported by Mr and Mrs Dean. Abbey Dean DS0000014338.V292435.R01.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Abbey Dean is well run by Mrs Dean, who has the appropriate qualifications and experience to manage the home. Abbey Dean should put a quality monitoring system in place to measure their success in meeting the aims, objectives and statement of purpose of the home. The home’s policies, procedures and record keeping safeguard the health, safety, welfare and financial interests of service users. It is recommended that the home arrange for a Legionella test. The outcome for service users is good. EVIDENCE: Abbey Dean DS0000014338.V292435.R01.S.doc Version 5.1 Page 20 Mrs. Dean is a first level nurse and has a Masters Degree in Business Studies. She has been managing the service at Abbey Dean since the home opened in 1991. Residents spoken to during the inspection praised the staff and the owners for their support and care. The home has no formal quality assurance/monitoring system in place. The inspector was told that the views of service users are sought in regard in regard to the running of the home. Residents confirmed this and said that regular residents meeting are held. Residents control their own money wherever possible. In the event they are unable to family or solicitors take control of their finances. The home does hold personal spending money for some service users. A record is kept of all transactions made, copies are available for relatives and service users to see. Staff records seen show that training is provided regarding Moving and Handling, Fire Safety, First Aid, Infection Control and Food Hygiene. All radiators and pipe work throughout the home were seen to be covered and window restrictors are fitted to windows. Water temperatures are restricted by the use of thermostatic valves. Mr Dean said that hot water is stored at a temperature over 60 degrees. The home has not had a Legionella test. Fire appliances were checked in April 2006, electrical appliances were tested and the boiler serviced in May 2006. The accident records were seen and found to be in order. Abbey Dean DS0000014338.V292435.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X 3 N/A 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 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Abbey Dean DS0000014338.V292435.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP28 Regulation 18 Requirement Timescale for action 26/08/06 2. OP33 24 The registered person should ensure that there is a minimum ratio of fifty percent trained members of care staff with an NVQ level two or equivalent qualification. Effective quality assurance and 26/08/06 quality monitoring systems, based on seeking the views of service users, should be put in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 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 OP38 Good Practice Recommendations It is recommended that the registered provider arrange for a Legionella test. Abbey Dean DS0000014338.V292435.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Worthing LO 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 DS0000014338.V292435.R01.S.doc Version 5.1 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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