Inspection on 18/10/05 for Abbey Grange

This inspection was carried out on 18th October 2005.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Abbey Grange 16/11/09

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 21/06/05

Abbey Grange 15/10/04

Abbey Grange 23/07/04

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Heathlands

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Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Abbey Grange 47 Venns Lane Hereford Herefordshire HR1 1DT Lead Inspector Wendy Barrett Unannounced Inspection 18th October 2005 09:30 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 Grange DS0000024689.V260180.R01.S.doc Version 5.0 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 Grange DS0000024689.V260180.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Abbey Grange Address 47 Venns Lane Hereford Herefordshire HR1 1DT 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) 01432 271519 01432 271519 Mr Bissessur Ubhee Mrs Aileen Ubhee Mr Bissessur Ubhee Care Home 21 Category(ies) of Dementia - over 65 years of age (2), Old age, registration, with number not falling within any other category (21), of places Physical disability over 65 years of age (10) Abbey Grange DS0000024689.V260180.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. That Mr Ubhee works a minimum of 30 hours a week at Abbey Grange in order to fulfil his responsibilities as the Care Manager. 21st June 2005 Date of last inspection Brief Description of the Service: Abbey Grange is situated in a residential area on the outskirts of Hereford city. There is a drive-in parking area at the front of the home and local buses pass within easy reach. Work has started on building an extension to the home. 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 although permission was granted and a purpose built extension was added prior to the registration of Mr. And Mrs. Ubhee. The home is registered to provide care to 21 older people who have needs arising from the normal ageing process. Ten of these places are also registered for older people who have a physical disability. Two of the places are registered for older people who have dementia related needs. The accommodation comprises of seventeen single bedrooms. Thirteen of these rooms have en-suite facilities. There are two double bedrooms. A stair lift, ramps, hand rails and non-slip flooring have been fitted to help residents who have mobility difficulties. Abbey Grange DS0000024689.V260180.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection involved two visits to the home. An unannounced inspection took place between 9.30am and 12.15pm. Two days later a second visit was undertaken between 9.30am and 12.10pm when the Provider was available. Feedback questionnaires were sent to the home at the end of August 2005 and the Provider was asked to distribute them to residents, relatives and professional visitors. Eight residents, six relatives and four professional visitors sent back completed questionnaires and their comments have been referenced in writing this report. Two residents were interviewed in the privacy of their bedroom and time was also spent in communal areas meeting other residents. One recently recruited staff member was interviewed. The Provider and a Senior Care Assistant spent time helping with the inspection visits. Other staff were met as they went about their work. A sample of records at the home was inspected. Action taken to comply with requirements and recommendations arising from the last inspection was reviewed and core National Minimum Standards that were not inspected last time were addressed. What the service does well: Residents who need help with their everyday personal care are well supported by the staff with very good attention to dignity and physical wellbeing. The staff are flexible and relaxed in the way they go about their work so that each resident can receive attention when they need or want it rather than when it suits the staff. Senior staff make regular checks to be sure the care they are giving a resident is altered if there is a need. There are good records kept of any complaints made to the home and what action has been taken to deal with these. The accommodation is kept very clean with plenty of pot plants and flowers that make it look very homely. The experienced staff make sure that new staff aren’t asked to perform any tasks until they have been shown how to do it properly and safely. Abbey Grange DS0000024689.V260180.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Abbey Grange DS0000024689.V260180.R01.S.doc Version 5.0 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 Grange DS0000024689.V260180.R01.S.doc Version 5.0 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): none EVIDENCE: Abbey Grange DS0000024689.V260180.R01.S.doc Version 5.0 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): 7&8 Each resident has a plan of care to make sure his or her health and personal care needs are met. Occasionally the overall service may be improved if there was further consultation with the resident, or other health care professionals, in preparing the plans. EVIDENCE: A sample of two care records included plans of care. There were records of risk assessment e.g. use of bed rails, pressure area care, falls. Plans were being regularly reviewed and there was evidence of consultation e.g. residents had signed medication consent forms. There were references to involvement from other health care professionals in care planning work e.g. G.P. medication reviews, district nurse attention, six monthly dental checks. The health care professionals who completed feedback questionnaires were satisfied with the overall care provided to residents. There were two comments suggesting that sometimes the home should be quicker to seek professional advice or an alternative placement when residents’ health care needs increase. Abbey Grange DS0000024689.V260180.R01.S.doc Version 5.0 Page 10 A few residents have indicated that they would appreciate social opportunities better suited to their individual preferences. Although there is a record of each resident’s involvement in social activities the care planning process should be extended to include plans based on individual assessment. Abbey Grange DS0000024689.V260180.R01.S.doc Version 5.0 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): 12 & 14 Residents are able to continue with their preferred lifestyle when they come into the home. EVIDENCE: There were a number of examples of staff helping residents to spend their day as they prefer e.g. residents are able to choose what time they would like to get up in the morning, additional food between meals if that is what the resident enjoys, continuing attendance at a local day centre. Staff were observed enabling a resident to pursue her interest in helping with household chores by taking the time to work alongside her, guiding her, and ensuring her safety. Abbey Grange DS0000024689.V260180.R01.S.doc Version 5.0 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 There are satisfactory arrangements for dealing with complaints although some relatives may need to be given more guidance about the home’s procedure for expressing their concerns. EVIDENCE: There is a policy and procedure for dealing with complaints. Although this is advertised at the home and the staff knew where to find the information, three relatives were not aware of it. One of these relatives did, however, express confidence – ‘if I had a complaint, I would make it directly to the staff and be confident of a reasonable response’. All residents who completed feedback questionnaires, or were interviewed during the inspection, knew who to talk to if they had a problem. There is a register of complaints received at the home. This is subject to a monthly audit by the Provider. The Commission has received a complaint since the last inspection. The Commission requested the Provider to investigate the issues raised and the complainant has since indicated satisfaction with the outcome of this work. The involved resident was met during this inspection and although unable to communicate effectively she appeared relaxed and well cared for. The Provider has invested in a new carpet and piece of furniture in the resident’s bedroom to try and improve the situation that was causing concern. A care record contained a letter confirming approval of the resident’s application for a postal vote. Abbey Grange DS0000024689.V260180.R01.S.doc Version 5.0 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): 19 The standard of the accommodation is generally good providing residents with an attractive and homely place to live. Any shortfalls to the building will be addressed within an extension that is already being built although this will further reduce garden space. EVIDENCE: The home was warm, clean and well maintained with many pot plants attractively displayed around the communal areas. The Commission has received preliminary proposals for the extension to the premises. The plans indicate that this work will make required improvements to bathing, sluice and staff ‘station’ facilities. Two relatives commented on the limited garden facilities – ‘it is a pity that there are not better facilities for being outside in fine weather’, ‘we do feel there should be a pleasant garden, easily accessible, so that the residents may Abbey Grange DS0000024689.V260180.R01.S.doc Version 5.0 Page 14 be urged to go outside in the fine weather’. The new extension will, in fact, further reduce open space although it is intended to provide raised sitting areas and a walkway around the building. These will be easily accessible to residents whereas the current garden is not. Prospective residents will need to have a good description of the new facilities so that they can make an informed choice e.g. whether a garden is important for them. Some people may value the closeness to bus routes and town facilities rather than garden space. Abbey Grange DS0000024689.V260180.R01.S.doc Version 5.0 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): 27, 28, 30 There are enough staff who are competent to cope with the residents’ needs. Staff are being encouraged to develop their knowledge and skills. New staff will need to have a more extensive programme of introduction to the work. EVIDENCE: There was a satisfactory level of staff at work during the inspection visits. Information from a Senior Care Assistant and reflected on the duty rota confirmed that this level was being maintained and the Provider was complying with a condition of registration to spend a minimum of 30hours a week working at the home. A recently recruited staff member felt well supported during his introductory period e.g. supervised by senior staff during his first few days, not asked to perform any task until he had received relevant instruction. There was a record of his induction programme. The trainee and his supervisor signed this. The programme did not indicate that it had been devised in line with national specifications for induction training and a repeated requirement is made for this work to be addressed. Although many of the staff employed at the home use English as a second language they were observed communicating effectively with residents. Written records are well written with appropriate use of professional terminology. Abbey Grange DS0000024689.V260180.R01.S.doc Version 5.0 Page 16 Five staff had been registered to start work on the NVQ (National Vocational Qualification) level 3 in October 2005. One of these people has already completed level 2. The scheme assessor has decided that the remaining four staff should go straight to level 3 based on their previous experience. One staff member has already achieved an NVQ level 3 award. The home does not employ agency staff or employees under 18 years of age. Abbey Grange DS0000024689.V260180.R01.S.doc Version 5.0 Page 17 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): 33, 35 The Provider is committed to regularly reviewing the quality of the service. There are safeguards in place to protect residents’ property. EVIDENCE: When the home was inspected earlier this year the Provider was due to undertake a quality assurance exercise. The situation was not reviewed at this inspection. A repeated requirement is made for a report of the outcome of this exercise to be submitted to the Commission. A copy of the report of the last inspection of the service was displayed at the home and the Provider co-operated in distributing feedback questionnaires as part of the inspection process. Abbey Grange DS0000024689.V260180.R01.S.doc Version 5.0 Page 18 There was evidence of careful management of residents’ property. A care record contained a receipt for money and valuables held in safekeeping at the home. The document was detailed, dated and signed by three staff, including two senior staff. Two sampled care records contained personal property inventories and a resident was aware that her money was in the home’s safe. Abbey Grange DS0000024689.V260180.R01.S.doc Version 5.0 Page 19 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 x x x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 2 X X X X X X X X STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 X X X Abbey Grange DS0000024689.V260180.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? Yes 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 OP33 Regulation 24 Requirement A system of reviewing and improving the quality of care provided at the home must be introduced. This should include consultation with residents and their representatives. A report in respect of any review should be supplied to the Commission and made available to residents. (Previous timescale of 31/08/05 not met) Induction and foundation training must be in line with National Training Organisation specifications (Previous timescale of 31/08/05 not met) Training provision must be developed to increase staff participation in the NVQ award scheme. (Previous timescale of 31/12/05 not yet expired. Progress on training planned to commence in near future will be reviewed at next inspection) Timescale for action 31/12/05 2 OP30 18 30/11/05 3 OP30 28 31/12/05 Abbey Grange DS0000024689.V260180.R01.S.doc Version 5.0 Page 21 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 Refer to Standard OP7 OP16 OP38 Good Practice Recommendations It may be beneficial to consider ways of increasing residents and health care professionals involvement in preparing plans of care. It may be helpful to re-issue copies of information literature, including copies of the complaints procedure. To introduce a programme of regular, recorded audits of premises health and safety aspects. (not reviewed. Carried forward for future review) Abbey Grange DS0000024689.V260180.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Hereford Office 178 Widemarsh St Hereford Herefordshire HR4 9HN 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 Grange DS0000024689.V260180.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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