Random inspection report
Care homes for older people
Name: Address: Abbey Grange 47 Venns Lane Hereford Herefordshire HR1 1DT zero star poor service 20/05/2009 The quality rating for this care home is: The rating was made on: A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed review of the service. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Denise Reynolds Date: 1 4 1 0 2 0 0 9 Information about the care home
Name of care home: Address: Abbey Grange 47 Venns Lane Hereford Herefordshire HR1 1DT 01432271519 01432271519 ubheedave@yahoo.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Mrs Aileen Ubhee,Mr Bissessur Ubhee care home 29 Number of places (if applicable): Under 65 Over 65 29 29 29 0 dementia mental disorder, excluding learning disability or dementia old age, not falling within any other category physical disability Conditions of registration: 29 29 0 29 All residents must be at least 50 years of age on admission. That Mr Ubhee works a minimum of 30 hours a week at Abbey Grange in order to fulfil his responsibilities as the Care Manager. Date of last inspection Brief description of the care home Abbey Grange is situated in a residential area on the outskirts of Hereford city. There is a parking area at the front of the home and local buses pass within easy reach. The
Care Homes for Older People Page 2 of 10 0 6 0 8 2 0 0 9 Brief description of the care home original part of the premises has been adapted for its current use. It carries a listed building status. This places some restriction for making desired alterations. The original building has been extended to provide additional, purpose-built accommodation. The home is registered to provide care to 29 people who are over 50 years of age and who have needs arising from old age, dementia or mental disorder. Information about the service is displayed in the main entrance hall of the home. A copy of the most recent inspection report is also displayed. A schedule of fees is available from the home. Additional charges are made for hairdressing, transport, escort, chiropody, toiletries and newspapers. Care Homes for Older People Page 3 of 10 What we found:
We did this inspection because of information we received telling us that a recently appointed manager had left the home. We wanted to check what the management and staffing arrangements were and to check that risks at the home had not increased. We went to the home with two staff from Herefordshire Council who wanted to make their own checks of the service. We jointly explained the reason for the visit to Mr Ubhee and that it had been decided to visit at the same time to avoid multiple visits by different agencies, especially as we would all be looking at similar issues. We identified during the inspection that the moving and handling assessment for a person living at the home had not been updated following advice given by a physiotherapist on 12/10/09. The manager, Mr Ubhee, checked the persons file and confirmed that the most recent moving and handling assessment was done by him in April 2009. Information written by a member of staff in the daily notes on 12/10/09 included information that at times a handling belt should be used and that at times she should be assisted by two staff. This information was not included in the April 2009 moving and handling assessment. This means that the persons care plan has not been updated to include new information about how to manage her mobility safely. We also saw a sheet in the front of their file headed mobilising, this was blank and did not specify what information should be recorded on it. We asked Mr Ubhee about how the moving and handling needs of people moving to the home would be assessed. He explained that he asks the GP for help and gave us the example (above) where a physiotherapist had been to the home. He also said that he uses a company as and when required to help him with this. Mr Ubhee subsequently confirmed that he is the person at the home responsible for doing moving and handling assessments. He said that he and/or a persons key worker does these. Staff from Herefordshire Council who were also at the home asked him if he had done moving and handling training and he said that he had, although it was due for updating. He told us that his last moving and handling training was last year and that he did that at Y Plas, the home in Swansea. (Y PLas is owned by Endless Care Ltd, a company Mr Ubhee is a director of). Another member of staff from Herefordshire Council asked what level of training this was (ie was it awareness training or assessor training?) and he said it was awareness training. We are concerned that people at the home may not have had their moving and handling needs assessed by staff with the training necessary for this task. We are also concerned that neither Mr Ubhee nor staff working at the home have done such training. On the day of the inspection there was roast lamb or faggots for lunch. We saw a list in kitchen showing people had chosen which they wanted. We looked briefly at the food stocks but did not do a detailed check; however we noted that the dry food store and freezers had quite a lot in them. The cook told us she has done food hygiene training and is booked on a more in depth course soon. Since our last key inspection an incident had occurred when a person had left the home unnoticed and was found later in Hereford; she had fallen and broken her arm. This was investigated under multi-agency safeguarding arrnagements. During this inspection we
Care Homes for Older People Page 4 of 10 asked Mr Ubhee for a copy of his internal investigation into what happened. He gave us a brief handwritten note which provided no evidence that he had carried out an investigation into what happened. It was evident that Mr Ubhee had not obtained robust information about the events of that day. However, he assured us that all external doors are now alarmed to make sure staff know if someone has gone out who may not be safe if alone. Staff from Herefordshire Council asked Mr Ubhee if the door alarms are tested - he said no. He explained that they rely on the fact that doors get used so they would know if an alarm is not working. We queried this and asked surely if staff go out through the doors they turn the alarm off? Otherwise staff would have to go and check whenever a colleague opened a door. He said they do check if the alarms work but confirmed he has no records to evidence this. At one point during the inspection, we and Herefordshire Council staff found a door where the alarm was not turned on. During the inspection Mr Ubhee asked how to make a referral to the POVA list (this related to an incident earlier in the year when he had said he would refer an ex member of staff to the list. He had not done anything about this. We explained to him where he could find this information on the internet. We noted that the door to the cellar steps was locked for safety and a health and safety poster was displayed on wall opposite the kitchen. The building felt warm and we saw a cleaner coming in and out of rooms during the morning. The door to the laundry was locked to make sure people with dementia living at the home do not have access to cleaning materials (such as bleach) which could harm them. Outside we noted that there was still no gate fitted to limit access from the garden to the front of the property. We know that Herefordshire Council have asked for this to be done. This is to enable people to go outside in the garden but be safe from the risk from traffic or getting lost if it is unsafe for them to go out alone. Parts of the grounds have items of equipment, furniture and building rubble in them. None of these were immediately in the way of paths but looked untidy and could pose a risk. When we arrived at 7:50am we saw two staff within a few moments. One told us that she had started at 7.30am and was the team leader for the morning. She told us that there had been two waking staff over night and one person sleeping in. She went on to tell us that she was the team leader that morning with three other carers, a cook and a cleaner. She also told us Mr Ubhee was expected and he arrived at 8am. We saw a staff rota which showed that this was the level of staffing planned for the week. However, the names of staff on duty that day did not fully match the rota. Later, Mr Ubhee explained that this was due to a team leader not being able to come to work and arranging to swop shifts. We noted that the information about the hours being worked by Mr Ubhee did not match what he told us. In discussion Mr Ubhee said Mrs Ubhee worked at the home the day before (Tuesday 06/10/09) and that he was the cook. We pointed out that rota does not show this and also does not show that the team leaders shifts had changed. Mr Ubhee said he had not had time to change the rota. We emphasised that rota must show what actual staffing is (including hours that he and Mrs Ubhee work). Care Homes for Older People Page 5 of 10 Mr Ubhee told us he might make the new team leader deputy or that he may give this post to a current team leader. It is important for any person given this responsibility to be suitably trained and experienced. We looked at the training records for the team leaders and saw that each of them had done recent training in mandatory topics. We spoke to Mr Ubhee about why he had advertised the acting managers job while she was still working at the home. Mr Ubhee said she had done some good things at the home but kept telling him she was going to leave. He said that she did not sit down with him and tell him what was wrong and confirmed that he advertised the job while she was still working at the home because of this. Mr Ubhee explained to us that she was named in the recently submitted improvement plan as the person dealing with improvements because he had not had time to amend it before sending it to us by the deadline. We asked Mr Ubhee about staff being able to deal with problems with the building if he isnt there eg if one of the stairlift breaks down. Mr Ubhee said staff have names and numbers of firms and can do this. I asked if they had to get consent from him and he said no. Later we asked a member of staff who said she would phone the owners first to get their agreement. What the care home does well: What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 2. Care Homes for Older People Page 6 of 10 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements
These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards.
No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 7 of 10 Requirements and recommendations from this inspection:
Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours.
No. Standard Regulation Requirement Timescale for action 1 7 14 Regulation 14(2) (a), (b) You must arrange for the moving and handling assessment for (person) to be revised. By 21st October 2009 This is to ensure that it takes into account the new professional guidance that has been provided about how this aspect of her care should be managed. 21/10/2009 2 8 12 You must arrange for all 11/11/2009 people living at the home who may have care needs related to mobility to have a moving and handling assessment done by a person who has been trained to do so. To make sure that people have their moving and handling needs dealt with safely and comfortably. 3 30 18 Regulation 18(1)(c)Any 11/11/2009 person carrying out moving and handling assessments for people living in the home must do training for this at a level that provides them with the necessary knowledge to do so. To make sure that people have their moving and handling needs dealt with safely and comfortably. Care Homes for Older People Page 8 of 10 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set.
No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service.
No Refer to Standard Good Practice Recommendations Care Homes for Older People Page 9 of 10 Reader Information
Document Purpose: Author: Audience: Further copies from: Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Older People can be found at www.dh.gov.uk or got from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 10 of 10 - 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!
