Inspection on 04/01/06 for Abbey Dean

This inspection was carried out on 4th January 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 26/05/06

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 Jo Hartley Unannounced Inspection 4th January 2006 14:30 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.V274832.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.V274832.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.V274832.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th July 2005 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. Abbey Dean DS0000014338.V274832.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 July 2005, and read the previous two inspection reports, the Service User Guide and the Statement of Purpose During the inspection the inspector spoke to six service users. 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. This report should be read in conjunction with the report of the announced inspection held on 19th July 2005. All the key standards, which should be inspected in a twelve-month period, are covered in these two reports. What the service does well: What has improved since the last inspection? What they could do better: The registered providers need to ensure that they request a full employment history from prospective staff, and that any gaps in employment are explored. Some recommendations have been made regarding Health and Safety, these include arranging for a Legionella test and checking and recording water temperatures. It is also recommended that a pharmacy inspection be arranged as it is over a year since the last one took place. Abbey Dean DS0000014338.V274832.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.V274832.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.V274832.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 Abbey Dean has a Service User Guide that provides prospective service users with information to enable them to make an informed choice about where to live. Standard Three was inspected during the last inspection and was found to have been met. Abbey Dean does not provide intermediate care, therefore Standard Six does not apply. EVIDENCE: Abbey Dean has a Statement of Purpose and Service User Guide that are given to prospective service users. Both contain all the required information to enable service users to make an informed choice of where to live. Since the last inspection Abbey Dean has had two extra bedrooms added. The Service User Guide has been updated to reflect this change in registration. Abbey Dean DS0000014338.V274832.R01.S.doc Version 5.1 Page 9 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): 9 There are no service users at Abbey Dean that are responsible for their own medication. Policies and procedures regarding medication are robust. The manager is to arrange a pharmacy inspection, as one has not been done for over a year. Standards Seven, Eight and Ten were inspected during the last inspection and were found to have been met. EVIDENCE: 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. Abbey Dean DS0000014338.V274832.R01.S.doc Version 5.1 Page 10 Staff records show that staff have received training in the administration of medication. The home has not had a pharmacy check for over a year. The registered manager says she has asked their local pharmacist for one but they haven’t responded. She says she will chase this up immediately. There are no controlled drugs held at the home at present. Abbey Dean DS0000014338.V274832.R01.S.doc Version 5.1 Page 11 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): 15 Service users say that they enjoy the food provided for them. Food is wholesome and appealing. Standards Twelve, Thirteen and Fourteen were inspected during the last inspection and were found to have been met. EVIDENCE: The menu for the home was seen and contained a varied, wholesome diet. Service users said the quality of food provided is good. Service users confirmed that if they do not like something on the menu an alternative is offered. Hot and cold drinks are available throughout the day and on request. Abbey Dean DS0000014338.V274832.R01.S.doc Version 5.1 Page 12 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 Service users are confident that their complaints will be listened to, taken seriously and acted upon. Service users are protected from abuse by the homes policies, procedures and staff training. 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. Service users 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 receive training in recognising and responding to abuse. Abbey Dean DS0000014338.V274832.R01.S.doc Version 5.1 Page 13 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): 25, 26 Service users live in safe, comfortable and clean surroundings that are clean, pleasant and hygienic. Standards Nineteen was inspected during the last inspection and found to have been met. EVIDENCE: Service users bedrooms are well decorated and have evidence of service users private possessions in them. Two service users said that they were able to bring their own furniture and possessions with them when they moved in. Rooms are centrally heated and individually and naturally ventilated. Radiators and pipe work were seen to be 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. Abbey Dean DS0000014338.V274832.R01.S.doc Version 5.1 Page 14 On the day of the inspection the home was found to be clean, pleasant and hygienic and free from offensive odours throughout. The home is well decorated and maintained to a high standard. Furniture in communal areas is comfortable and domestic in character. The laundry is sited away from areas of food storage and preparation. Floor and wall surfaces are easily cleanable. The floor surface is impermeable. Abbey Dean DS0000014338.V274832.R01.S.doc Version 5.1 Page 15 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): 28, 29 Over fifty percent of care hours are provided by staff with an NVQ level two or above. Service users are protected and supported by the homes’ recruitment policies and procedures. The registered manager needs to ensure that prospective staff provide a full employment history, and that any gaps in employment are explored. Standards Twenty- Seven and Thirty were inspected during the last inspection and were found to have been met. EVIDENCE: The home is currently working towards having fifty per cent of its staff with NVQ level 2 or equivalent qualifications. 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 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. Application forms do not currently request a full employment history from applicants. The application form needs to be changed to include this. Any gaps in employment need to be explored by the manager with the applicants Abbey Dean DS0000014338.V274832.R01.S.doc Version 5.1 Page 16 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 random checks are made on water temperatures and the results recorded. It is recommended that the home arrange for a Legionella test. EVIDENCE: 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. Abbey Dean DS0000014338.V274832.R01.S.doc Version 5.1 Page 17 There was no evidence of a quality monitoring system although it was clear that informal feedback is received from service users on a daily basis. Service users 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. It is recommended that the home make regular random checks on the water temperature and record the results. A new boiler was fitted in July and Mr. Dean said that the second boiler was serviced at this time. However, the certificate could not be found on the day of the inspection. Mr Dean said he would forward a copy to the inspector as soon as he locates it. Fire appliances were checked in December 2005. The home has not had a Legionella test. The accident book was seen and found to be in order. Abbey Dean DS0000014338.V274832.R01.S.doc Version 5.1 Page 18 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X X 3 3 STAFFING Standard No Score 27 X 28 2 29 3 30 X 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.V274832.R01.S.doc Version 5.1 Page 19 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 OP29 Regulation 19 Requirement The registered person must ensure that application forms request a full employment history and that gaps in employment are explored. The registered person is to forward the last boiler service certificate to the CSCI. Timescale for action 04/02/06 2. OP38 23 04/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard OP9 OP33 OP38 OP38 OP38 Good Practice Recommendations The registered person should arrange for a pharmacy inspection. The registered person should put in place quality assurance and quality monitoring systems. It is recommended that the registered provider make random checks on the hot water temperatures at regular intervals and record the results. It is recommended that the registered provider arrange for a Legionella test. The registered provider needs to forward a copy of the DS0000014338.V274832.R01.S.doc Version 5.1 Page 20 Abbey Dean latest gas boiler service to the CSCI. Abbey Dean DS0000014338.V274832.R01.S.doc Version 5.1 Page 21 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.V274832.R01.S.doc Version 5.1 Page 22 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!