Inspection on 16/11/09 for Abbey Grange

This inspection was carried out on 16th November 2009.

CQC found this care home to be providing an Adequate 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 Grange 14/10/09

Abbey Grange 06/08/09

Abbey Grange 20/05/09

Abbey Grange 24/02/09

Abbey Grange 02/10/08

Abbey Grange 11/03/08

Abbey Grange 10/10/07

Abbey Grange 23/10/06

Abbey Grange 18/10/05

Abbey Grange 21/06/05

Abbey Grange 15/10/04

Abbey Grange 23/07/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 13/03/2010.

Key inspection report Care homes for older people Name: Address: Abbey Grange 47 Venns Lane Hereford Herefordshire HR1 1DT     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home 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 full review a ‘key’ inspection. Lead inspector: Denise Reynolds     Date: 2 4 1 1 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 34 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought 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 The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) 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. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 34 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: Mrs Aileen Ubhee,Mr Bissessur Ubhee care home 29 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia mental disorder, excluding learning disability or dementia old age, not falling within any other category physical disability Additional conditions: 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 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 Care Homes for Older People Page 4 of 34 Over 65 29 29 29 0 29 29 0 29 2 0 0 5 2 0 0 9 Brief description of the care home 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 5 of 34 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: We spent three days at the home for this inspection; two inspectors did the first two days and an inspector and a specialist pharmacy inspector did the third day. We spent time out and about in the home, speaking to the people who live there and to staff and the owners. We looked at records which must be kept by the home to show it is being run properly, including those about care, medication and staffing arrangements. We sent survey forms to all of the people who live in the home a few weeks before the inspection; we also gave them surveys to pass on to their families if they chose to. We also sent surveys to all of the staff. In addition to this we took into account information from professionals we have had contact with in recent months while there has been a lot of contact with the home by staff from Herefordshire Council. Finally, we listened to what people who attended a meeting arranged by Herefordshire Council said about the home; this included most families and three people who live at the home. Care Homes for Older People Page 6 of 34 This was the second full inspection of the home in 2009 and the fifth time we have been to the home this year. This was because following our inspection in October 2008 the home was rated by us as a 0 star service and we have needed to go back to the home to check if improvements were being made. Earlier in the year we found that important improvements were not being made and as a result we took more formal action by issuing statutory requirement notices. We subsequently decided not to prosecute the owners for some continued failings. This was because they had begun to take more action and we wanted them to concentrate their energies on continuing with these. In September we met with the owners and their representatives to discuss their ongoing improvement plans and to stress the seriousness of the situation if this inspection did not establish that real progress was being made to make the service safer for people and provide an improved quality of care. At the start of October the owners sent us an improvement plan which confirmed that they had begun to take action to deal with outstanding concerns. Care Homes for Older People Page 7 of 34 What the care home does well: What has improved since the last inspection? There is a new sense of purpose in the home and a better feeling of teamwork between the staff and the owners. Everyone has worked hard to address the things that we highlighted over the last year as being inadequate or unsafe. Better information is available about the home and how it intends to meet peoples needs; this includes some information about dementia care (although this still needs more work). Following our last full inspection we said that the owners should give careful consideration to the suitability of the home to provide care for people with dementia. We acknowledge that they have increased staff training in this area and have begun to make some improvements to the building to make it easier for people to find their way around. Care records have continued to be developed by staff although these need some more work to address specific issues such as contradictory details left over from earlier care plans. (However, staff asked about care needs were able to give us the correct and most up to date information). Steps have been taken to make sure that people who need help with mobility are assisted safely and commfortably. Staffing levels have improved and an activity co-ordinator had been appointed. During the inspection we did not see any instances of people not having the attention they needed as we had done previously. It is important that this is maintained when the number of people living in the home increases. Staff rotas are now more accurate although Mr and Mrs Ubhee need to make sure their hours are always recorded accurately. Our pharmacy inspector found that there had been significant improvements in all aspects of the management and administration of medication. Storage was clean, tidy and secure and records were well maintained. The use of tabards identifiying that a member of staff is administering medication and should not be disturbed was one example of good practice that we saw. More is being done to provide people who live in the home with enjoyable things to do. Staff are already spending some time each day providing activities and a personal trainer is visiting the home twice a week to provide exercise and massage. An activity co-ordinator has been employed and was starting work on 1st December. While waiting Care Homes for Older People Page 8 of 34 for her pre-employement checks she had begun to make contact with relatives and to speak to people at the home to help her plan things people would like to do. Office arrangements at the home have been re-organised. This means that peoples care records, medication and the phone are now kept in a private room and not in an area where they were not secure or private. This means that peoples privacy is better protected. It also means there is a more professional and organised working environment for staff. A small but convenient area is now available for visiting health professionals to use as a surgery instead of people often being seen in the communal rooms as in the past. Because a number of people have moved from Abbey Grange the pressure on space in the sitting rooms has eased and the rooms feel more spacious and relaxed. Staff recruitment is now done more thoroughly and staff are not being allowed to start work before the required checks have been done; this protects people because it helps to reduce the risk of unsuitable people gaining employment in the home. Staff training has improved and most staff training in mandatory subjects is up to date. Induction training is now based on the national skills for care standards so that staff receive suitable training from the very start of their employment. The management arrangements in the home are changing. Mr Ubhee has decided to step down in due course from the day to day management of the home. The first person appointed as a new manager left after a couple of months and a replacement has recently been appointed. Eventually this will enable Mr Ubhee to concentrate on his responsibilities as a joint owner of the home. In the meantime, staff told us that Mr Ubhee has become a more supportive employer and is more respectful to them; they also valued the recent involvement of Mrs Ubhee in helping to deal with the things that needed to be improved. Although the impact on people who live in the home is indirect, we were pleased to learn that staff are happier because they are now getting the right pay. This is because the owners have retained the services of an external book-keeper to deal with the payroll. The safety of the building has improved because the finding of a fire service inspection have been acted on and an external consultant has been used to do a health and safety action plan. Overall we found that there had been improvements in all aspects of the running of the home to the extent that all the requirements we had made since October 2008 had been complied with. There are however some aspects of the service which still need to be improved and developed. What they could do better: Mr and Mrs Ubhee, supported by the staff at Abbey Grange have shown that they have the ability to make progress in making the home a safer and better place for people to live. It has however taken a lot of attention and input from ourselves, the local authority and more recently from concerned relatives to ensure that the need for change was recognised and acted on. There will be continued scrutiny from all interested parties who will be wanting to see that the improvements are not only sustained but that the quality of service continues to improve. Care Homes for Older People Page 9 of 34 The main areas which need continued attention are The suitability of the building for providing care to people with dementia needs to be developed further if the home is going to continue to offer a service to people with those needs. The information the home provides about the level of needs they are able to safely and effectively manage should be improved. This would help people make an informed decision about whether it is the best place for them, their relative or someone they are working with as a professional. The way care is planned and recorded should continue to be developed so that information is up to date and easy for staff to refer to and update. The records need to be checked to make sure information is consistent because the ongoing changes and updates have resulted in some contradictory details being in the files. Overall health and safety arrangements in the home (which should be achieved by dealing with all the matters identiifed in the external consultants action plan). Consolidation of staff training is needed so that all induction training, mandatory subjects and care related topics are up to date and staff have been able to share their learning and put it into practice. Staff induction progress needs to be monitored more closely with a process for monitoring progress to make sure staff progress through the programme without any slippage. People in bedrooms near to the new staffroom need to be given consideration by staff using the staffroom after people have gone to bed. Improved window covering is needed at the windows in the bedroom doors so that people are not disturbed by the staffroom light being on. 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 on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 10 of 34 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 11 of 34 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Improvements to the service at Abbey Grange mean that people will generally be well looked after although the home may not be suitable for people with significant dementia care needs. Evidence: No one new has moved in to Abbey Grange in recent months. This meant that we could not assess how new admissions are dealt with by the home. We know from previous inspections that people in the past felt that they had enough information about the home and that people are encouraged to visit before they move in if this is possible. Since our previous key inspection in May 2009 the owners have re-written the information they provide about Abbey Grange (the statement of purpose and service user guide). Both these tell people that their needs will be carefully checked before they move to the home and will be regularly reviewed to make sure Abbey Grange is Care Homes for Older People Page 12 of 34 Evidence: the right place for them. When we did our inspection in May 2009 we higlighted that the homes information did not explain how staff look after people who have dementia illnesses. The owners have now introduced a booklet about dementia care at Abbey Grange. This contains information about types of dementia and its effects. This should be developed further to explain the ways staff at the home will look after people who have needs due to this type of illness. All of the information about the home needs to be clearer about the level of dementia related care needs that the home can cope with. This is because in the past some people at the home who had dementia were not getting the level of care they needed and moved to other care services. During this inspection we found that the owners had begun to develop the service for people with dementia by giving staff more training, improving the building and developing the activities available for people. We strongly recommend that the owners are cautious about the number and level of needs of people with dementia moving into the home until the improvements are well established. Information is not yet available in other formats such as large print or audio. We were told that this will be done as soon as possible. Care Homes for Older People Page 13 of 34 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Improvements to the service provided at Abbey Grange mean that people are more likely to have their needs met and to have their privacy respected. Medication arrangements have been improved so that people will get their medication correctly. Evidence: Before we did our inspection we were given a lot of positive information in our surveys and at a meeting Herefordshire Council held, about the quality of care people at Abbey Grange experience. This was reinforced during our inspection by some of the people we spoke to including people who live there and relatives. Quotes in surveys sent back to us included The staff are lovely and I like having nice meals cooked for me. I feel safe and I like my seat in the lounge and my room is lovely. They look after me very well. (written by someone who lives in the home) and They give the love and care a relative would give but cannot. They make the clients life as secure and pleasant as possible so they do not feel a burdon. They are valued Care Homes for Older People Page 14 of 34 Evidence: and respected and allowed to be part of an extended family. (written by a relative). Some people indicated that there are not always enough staff on duty to give people enough time, although on the three days we spent at the home we did not observe staff being rushed. The difference could be explained by the reduction in the number of people living at the home since people sent us the surveys whilst staffing has not been reduced. A lot of work has been done to improve the quality of the care records in the last year and we found a lot of useful information in the ones we looked at. We identified that in some care records there was some duplication of information and some details which were contradictory. For example, one person had two lots of information about how to deal with a situation, one telling staff one thing and the other telling them the exact opposite. This could result in someone doing the wrong thing in dealing with this person. However, when we spoke to staff they could tell us what the correct action was. One member of staff was not aware of the matter at all indicating that communication still needs some improvement. Some details about another persons physical health needed to be highlighted and communicated to staff better although could describe to us how to give this person the right care. We saw that staff are now checking the care plans regularly to check they are still correct, this is good practice but we were concerned that we found some examples of staff signing to say plans had been reviewed but not updating some details which had changed - this could lead to care being inconsistent. People are being given better help with moving around (or being moved with staff help)comfortably and safely. This is because staff have had more training about moving and handling and some staff have done a more in depth course which enables them to assess the help people need. These improvements came about following an inspection we did in October when Herefordshire Council staff also visited the home. We made requirements about moving and handling risk assessments and training and Mr Ubhee sought help with the assessments from the council. A specialist in moving and handling employed by the council i made recommendations about some improvements needed in the building (please see the part of this report about the environment. Most, but not all people have the key to their rooms; one person told us they would like to have a key but had been told it want safe for them. No record was available to explain how this decision had been reached or who had been involved in making it. Care records and the telephone have been moved to a room which gives more Care Homes for Older People Page 15 of 34 Evidence: security and privacy for confidential information and for phone calls about peoples care. We were assured that reviews are no longer held in the dining room where other people may pass by and hear what is being said. The pharmacist inspector visited the home on 24th November 2009 to check the management and control of medicines within the service. We found that the overall management and control of medication within the service had improved a lot and was good. We saw that a medication policy was available in the medicine trolley for quick and easy access by staff. We saw the latest copy of Safe Handling of Medicines in Care Homes produced by the Royal Pharmaceutical Society of Great Britain, which was also available inside the medicine trolley. This means that staff had access to medication procedures to ensure medication was handled safely. We saw that medication was stored in a locked medicine trolley,locked cupboard and locked refrigerator which means that medication is safe. We saw that medication was neat and tidy which meant that it was easy to locate peoples medication. The temperature of all medication storage was checked and recorded daily. We saw records for the tempertaure in the refrigerator, which were within the recommended two to eight degrees Celcius. We saw records for the temperature in the medicine trolley and two locked cupboards, which were below 25 degrees Celcius. This means that records show that medication was stored within the recommended temperature ranges. Medication records were neat and clearly documented. We looked at the medication administration records (MAR) and overall found that they were well documented with a signature for administration or a reason was recorded if medication was not given.For example, one person was prescribed an anticoagulant to thin the blood.This medication requires blood checks to ensure the correct dose is prescribed, which can vary depending on the result.We saw that three different strengths of the tablet were available so that the correct prescribed dose could be given. We looked at the MAR chart for the medication and saw that the records were easy to follow and we could see exactly how much medication had been given to the person. We saw a separate stock record sheet which was available for each strength of the tablet. It recorded the stock balance of each strength of the tablet after each administration. This ensured that medication given to the person could be checked daily and there were good arrangements in place to ensure medication was given to the person as directed. We saw that any handwritten medication records were checked and signed by two Care Homes for Older People Page 16 of 34 Evidence: staff for accuracy. The proposed new manager informed us that regular checks are also made on the records to ensure that they are correct and up to date.We saw documented records which showed that checks were made twice a week to ensure that medication was administered correctly. We were shown records of a weekly audit which checked storage of medication and medication record checks. This was done on a Monday by the team leader. We were informed that the pharmacist had visited the home on 20th November 2009 to check medication storage and management within the service. We were shown the written report made by the pharmacist. This means that there are arrangements in place to ensure that medication is administered as directed by the prescriber to the person it was prescribed, labelled and supplied for. We found that other medication records were up to date. For example, we saw current records for the receipt and disposal of medication. The date of opening of boxes and bottles of medicines were recorded and balances of medication were carried forward from old records to new records. These records helped to ensure there was a clear audit trail of medication.We checked the medication available for one person who was prescribed ten different medicines and found that the medication available was accurate. This means that people who live in the service were being given medication as prescribed by a medical practitioner. We found information relating to medication was generally available in the care plans for individual people living in the service. We looked at two care plans. The first care plan detailed all of the medication prescribed for the person including what it was for and any side effects. The person was being given one tablet for behaviour control which was documented in their personal development plan reviewed on 6th November 2009. The same person was also prescribed an anticoagulant tablet to thin the blood. There was further information available for staff to follow if the person became unwell. The written information was clear, up to date and ensured that staff could access the information at any time.The second care plan we looked at also detailed the persons medication. The care plan recorded that the person was diabetic and liked to administer their own insulin with assistance from the senior or team leader. However, the record did not detail exactly what assistance should be given. We spoke to the proposed new manager who told us that staff need to dial up the dose on the insulin pen for the person because their eyesight was poor. This information was not written into the care plan. We were told that it would be added into the care plan. This means that medication information is documented in the care plans however some details relating to peoples individual needs were not always clearly documented to ensure safe administration of medication. Information relating to medication to be given when required was available. For Care Homes for Older People Page 17 of 34 Evidence: example, we saw that one person was prescribed a tablet used to treat anxiety and agitation. We saw a protocol which informed staff what calming measures should be used to help the person before administering a tablet. The protocol also informed staff under what circumstances the tablet should be given. The protocol was to be reviewed every six months.This means that there were clear written directions for care staff to follow and ensured that the health and well being of people who live in the home were protected. We were informed by the proprietor that staff had received medication training. We were informed that nine members of staff were trained to administer medication. We were shown certificates for staff who had completed training. We were informed that trained staff were currently doing training in Safe Handling of Medicines and had also received training from the pharmacy on how to use their medication system. We found that staff were knowledgeable and aware of the medication they were giving to people. For example, we spoke to the proposed new manager about a tablet prescribed to help with urinary incontinence and she was able to tell us what it was used for and when it was needed.We were shown that staff had easy access to a medication reference book called the BNF. This means that medication was being given to people by trained staff who were aware of what the medication was for. Care Homes for Older People Page 18 of 34 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at Abbey Grange are being given more influence over their day to day lives including having more choice of enjoyable ways to pass the time and a real say in the food they have to eat. It is a friendly place where visitors are made to feel welcome. Evidence: A positive part of life at Abbey Grange is the friendly atmosphere in the the home and the welcoming manner of the staff towards visitors. Some people used to be bored because there were limited things to do and because staff didnt have time to spend doing enjoyable things with people. This has improved during the last six months and a wider range of things have begun to happen. For example, two afternoons a week a qualified personal trainer comes to the home to do an hour and a half of gentle exercise and simple massage. She told us people now look forward to her visits and she has noticed that most people who take part have better stamina and balance. Currently she has no information from the home about peoples health needs; the home should give her basic health information with consent from the people concerned so she can take it into account in devising the right exercise level for each person. Care Homes for Older People Page 19 of 34 Evidence: A new full time member of staff has been recruited and was due to start work on 1st December. This persons main role will be to develop activities in the home and in addition she has agreed to do some laundry duties to improve the standard of care given to peoples clothing. Whilst waiting for her employment checks this person had begun to gather details of things that people might like to do by speaking to them and to families. This is a positive initiative which if successful will make daily life for people more active and interesting. People at the home are generally happy with the food and are now having more say in what is put on the menu so they can have their favourite foods from time to time. A choice of meals is provided at each mealtime with two options of main meal at lunchtime. A pictorial menu is used to help people with dementia choose which meal they would like to have. Cooking is done by two staff who also do some care shifts; they therefore know people well and understand that meals are part of the overall care. We found that some details about peoples dietary needs were readily available in the kitchen but some werent. We also found that more information needed to be recorded when people needed special attention to their diet (eg if they need an eye kept on their fluid intake or need help to keep their weight up). We talked to the two cooks and staff about peoples needs and found that were aware of the right information for most but not all people. The cooks quickly made some of the improvements needed by making a list of people who need extra snacks each day. The staff who work in the kitchen have had up to date level 3 food safety training recently. Three staff have recently done a course about nutrition and another is doing this in December. Care Homes for Older People Page 20 of 34 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live at Abbey Grange are given clear information about how to raise concerns if they have them and they are being given more opportunities to say what they think about the home. The manager and staff have had recent training about safeguarding adults to improve their knowledge about how to deal with any concerns about abuse or neglect which come to light. Evidence: Information in the surveys showed that people who live in the home know who they can go to if they have a concern. Staff surveys confirmed that they know what to do if someone tells them there is something they arent happy with. The complaints procedure has been updated and now includes a large print easy read version with pictures to help people who may find reading and understanding small print difficult. This has been put in each bedroom so people have easy access to it without needing to ask staff for a copy. Earlier in 2009 two situations at Abbey Grange were dealt with under safeguarding arrangements and in both instances the homes reporting and recording of what happened could have been done better. In one case the report sent to the Council by the home was incomplete and Mr Ubhee had not gathered enough information about what had happened by checking with staff; in the other case there had been a delay in making a referral under the multi agency arrangements. Mr Ubhee has since been on Care Homes for Older People Page 21 of 34 Evidence: a safeguarding course for the managers of care services and 75 of staff have done safeguarding training during 2009. This should help to ensure that concerns identified about possible abuse or neglect (which includes acts of omission) will be recognised and acted on correctly. We were pleased to find that information about safeguarding was readily available for staff to refer to. Recruitment practice at the home has been improved so that the risk of unsuitable people being able to gain employment has been reduced. Care Homes for Older People Page 22 of 34 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at Abbey Grange live in clean and homely surroundings which are being improved to make the building safer and more comfortable for the people who live there. Evidence: Abbey Grange is a listed building and this gives the owners a number of challenges in making sure the accommodation is suitable for people. The newer part of the building has wide doors and corridors but the benefits of this are limited because these rooms can only be reached by walking down some stairs or using a stairlift. Access to all floors above or below ground level is by stair lift because there is no passenger lift. The owners have told us that their applications for planning consent for a passenger lift have been turned down by Herefordshire Council. The house is clean and has a welcoming atmosphere. People are encouraged to make their rooms feel personal to them by having their own belongings such as pictures, photographs, books and furniture (where this is possible). All but one of the surveys we had from people who live in the home said that it is always fresh and clean; the other reply was that this was sometimes the case. All the rooms we saw when we inspected were clean and there was a cleaner busy around the house on each of the three days. Care Homes for Older People Page 23 of 34 Evidence: We saw that more has been done to help people with dementia find their way around the house, for example there are more signs and people have a photograph on their door to help them find their own room. This is something that could be developed more by creative use of decor and we have previously given Mr Ubhee information about where more information about this is available. A few weeks before this full inspection we did a shorter focused inspection at the same time as a visit to the home by Herefordshire Council adult social care staff. We and Council staff found problems with moving and handling during that visit and both wrote to Mr Ubhee about these. The Council did follow up work which included a review of the facilities available for people with poor mobility and reported on this to Mr Ubhee. Their report set out improvements that were needed in some rooms (mainly bathrooms and toilets) so people would be safer. During this inspection we saw that most of the recommendations had been acted on and other improvements were underway with builders on site each day we were at the home. We noted that more handrails had been fitted in corridors to help people move about the home. Further improvements had been recommended by an external consultant retained by Mr and Mrs Ubhee to review health and safety in the home and work they recommended was also in hand. When we inspected in February, March and May 2009 we were concerned that the communal space in the home often appeared overcrowded. Since then a number of people have moved from the home to other care services; this has given remaining people more space in the short term. The owners need to consider how to use the space in the home in future so that when numbers increase the same problem does not happen again. In doing so they need to give particular thought to how they will deal with the needs of people with dementia who may at times be unsettled and the impact this has on other people. We are aware that in the past they had a planning application for an extra communal area turned down by Herefordshire Council which is unfortunate as the additional space would make things much nicer for the people who live in the home. We saw that the small sitting room in the new extension was more comfortably furnished than before although its location and size does not help the overall space problem very much. Infection control at the home has improved a lot and staff are now more aware of good infection control arrangements. The introduction of racks in each bedroom for disposable gloves and aprons was described to us as clinical by some people but helps support good practice by making sure staff have what they need when they attend to each person. Care Homes for Older People Page 24 of 34 Evidence: During this inspection we found no evidence that cleaning products are not being stored safely and noted that COSSH records were kept where staff could get them. The consultancy firm have included improved sluice facilities in their action plan for the home and work to create a new sluice room within the laundry area was in hand. Plans are also in place to tile the laundry to make the walls easier to clean. Concerns have been voiced by Herefordshire Council about the ease of access from the garden to the front of the house which is mainly car park and from there to a busy road. The owners have been asked several times to fit a gate to reduce the risk of someone who may be at risk leaving the house and finding their way out into the traffic. We saw that a gate has now been fitted; this is not locked at present and Mr Ubhee said he has a padlock to use on it. We would advise the owners to take advise about this first to make sure this wont hinder access by emergency services. They also need to consider the needs of people who are able to go out and about. All external doors are alarmed to alert staff if someone leaves the building. Following our inspection in May we told Hereford Fire and Rescue Service that we had concerns about fire safety arrangements in the home. They inspected, made requirements and have been back to check what had been done. They have told us that they were satisfied with the work done, that this was to a good standard and all their requirements had been met. Care Homes for Older People Page 25 of 34 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People at Abbey Grange are cared for by hard working and caring staff. Arrangements for making sure staff have the training they need are improving as is the support given to staff by the owners and management. Recruitment of staff is now done correctly with the right checks done to reduce the risk of unsuitable people being employed. Evidence: We always get very positive comments from people who live at the home and their relatives about the staff. People tell us that they are friendly and caring, for example, one person wrote in their survey All the staff are very kind and polite to me. We found that all the staff were committed to working hard to help improve the service at Abbey Grange and several spoke of the recent improvement in teamwork which they felt was very positive. We spoke with nine of the 19 staff during our inspection and received surveys from 10. Information in these highlighted some staff concerns about their conditions of employment, including problems with their pay which some people said was often incorrect, and unhappiness about the way Mr Ubhee treated them. When we spoke to people during the inspection they told us that things had started to change for the better. They now feel more respected by Mr Ubhee and said he listens to them more. They also told us that their wages are now being done properly by someone from Care Homes for Older People Page 26 of 34 Evidence: outside and they are getting the right money. Whilst this is not specifically about peoples care, improved morale can only be good for the service people at the home receive. We found improvements in the way that staff recruitment is done and that the required checks (particularly criminal record bureau checks and references) are being done. This helps to reduce the risk of unsuitable people being employed. We looked at one example where one of a persons referees had not replied to requests for a reference. We saw evidence that Mr Ubhee had tried other avenues to get information about the person and had tried to contact the original referee by telephone. We advised Mr Ubhee that it would be good practice to make more detailed and structured notes about these efforts to provide good evidence to refer back to if needed in the future. We have also made recommendations about using a checklist to help monitor the progress of applications and recording when references have been seen and checked. More staff training has been organised during the last six months and a lot of this had taken place in recent weeks. In speaking to staff we got the impression that they were glad to be getting more training but had felt the pressure of doing a lot in a short space of time. We were given an up to date matrix showing all the training that has been done by staff and were able to cross check this with certificates in staff files. The majority of mandatory staff training is now up to date and Mr and Mrs Ubhee recognise that this needs to be maintained so that training does not fall behind again. Most of the recent training has been done locally in Herefordshire and staff had found this much better than in the past when they were often sent to courses in Swansea. We feel Mr and Mrs Ubhee should consider the benefits of local training where possible when making future training plans. We noted that in addition to the mandatory training that has been done, staff have also had more opportunities to do training in other things. In particular more staff have done or are doing dementia training. This has been organised in two ways; some staff have done a one day course and some are doing a distance learning course. This should help the staff group develop their knowledge and skills in this specialist area. In addition, the proposed new manager is looking into dementia training for herself at a level designed for people leading a team of staff. Mr Ubhee suggested that she do a degree course which she was unsure about. We confirmed that the important thing is to research course content to find one that is most suitable for her needs and those of the home. Some of the information we had before the inspection indicated that there are not Care Homes for Older People Page 27 of 34 Evidence: always enough staff on duty to do much beyond providing basic care. During the inspection we saw that staff did seem to have time to spend with people. The ratio of staff to residents has increased recently because some people have moved out while staffing levels have been maintained which is a possible explanation for staff having more time. When the number of people living in the home increases again, care will need to be taken to keep staff numbers at a level that means they can provide the same level of attention. Care Homes for Older People Page 28 of 34 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live at Abbey Grange will benefit from improvements being made in all aspects of how the home is organised and managed. Evidence: Since our last key inspection, Mr Ubhee, a joint owner of the home with his wife, has decided to step down from the day to day management of the home and to appoint a seperate manager. An earlier appointment to this post in August 2009did not work out and when we did this inspection a new proposed manager had just been appointed and was having her induction. She made herself available during the inspection so that we could speak to her. She also took part in the feedback at the end of the inspection to help her get a picture of what her priorities would be. We know that in recent months, Mr Ubhee has increased the amount of time he spends at the home and that Mrs Ubhee has played a more active role at the home recently to help make the required improvements. Staff told us that this has been positive, and that the atmosphere in the home has improved a lot. Care Homes for Older People Page 29 of 34 Evidence: Mr Ubhee has increased the amount of training he has been doing as well as that of the staff; this has included a number of health and safety related courses and a safeguarding course aimed at the managers of care services. Steps have been taken to introduce structured quality assurance processes at the home. We have already referred to the work done by a firm of consultants to carry out a comprehensive review of health and safety in the home which is resulting in improvements in the premises and in the procedures in the home. In addition, surveys have been used to get the views of people who live at Abbey Grange and their relatives. The results have been complied as an action plan for each person covering detailing things that they would like done differently or better. The topics covered range from how people spend their time to improving how well their clothes are looked after when they go to be washed. When we return to the home to monitor progress we would expect to see evidence that these things have been acted on. People who have their spending money kept by the home are now able to have access to this at all times because the team leaders have a key to a safe where smaller amounts are kept. Larger sums are kept in a different safe and only Mr Ubhee and one senior member of staff have keys to this. Records and receipts of any money deposited or spent are kept so that peoples money is safeguarded. The change of office location has been combined with the homes records being tidied up and better organised and we saw this continuing over the three days of the inspection. This should help with the overall smooth running of the business. Health and safety and fire safety in the home has been given a lot of attention in the last six months and with the input from outside specialists in those areas should continue to improve. Care Homes for Older People Page 30 of 34 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, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 31 of 34 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 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes 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 1 4 Very careful thought should be given before offering places to people who have dementia illnesses to make sure that the home is able to provide people with the care they need. The information about dementia in the statement of purpose, service user guide and dementia booklet needs to be clear about the level of dementia related needs the home can cope with; this will help people decide if it is the right place for them or their relatives to move to. It is very important for the improvements to the written information about peoples care to be consolidated and developed. This is to make sure that they do not contain conflicting details which could mean staff refer to the wrong information. The person who does physical exercise sessions with people in the home should (with peoples consent) be given relevant information about peoples health needs so she can take this into take into account when planning safe levels of exercise for them. Information kept in the kitchen about peoples dietary needs should be improved so that staff are well informed Page 32 of 34 2 4 3 7 4 12 5 15 Care Homes for Older People 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 about any special nutritional support a person needs. 6 7 26 27 The owners should seek advice about the most suitable way of making the gate from back garden secure. It is good practice to record clear and detailed information about the staff recruitment process for each person ( such as chasing references) so they provide good evidence to support employment decisions. It is good practice to use a checklist to help monitor the progress of applications and to record when references have been seen and checked. 8 29 Care Homes for Older People Page 33 of 34 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. 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