Inspection on 23/10/06 for Abbey Grange

This inspection was carried out on 23rd October 2006.

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

The inspector 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 18/10/05

Abbey Grange 21/06/05

Abbey Grange 15/10/04

Abbey Grange 23/07/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

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 23rd October 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Abbey Grange DS0000024689.V316956.R02.S.doc Version 5.2 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.V316956.R02.S.doc Version 5.2 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 F/P 01432 271519 Mr Bissessur Ubhee Mrs Aileen Ubhee Mr Bissessur Ubhee Care Home 29 Category(ies) of Dementia (29), Dementia - over 65 years of age registration, with number (29), Mental disorder, excluding learning of places disability or dementia (29), Mental Disorder, excluding learning disability or dementia - over 65 years of age (29), Old age, not falling within any other category (29), Physical disability (29) Abbey Grange DS0000024689.V316956.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. That Mr Ubhee works a minimum of 30 hours a week at Abbey Grange in order to fulfil his responsibilities as the Care Manager. All residents must be at least 50 years of age on admission. Date of last inspection 18th October 2005 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. 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 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. The category shown on the current registration details and relating to physical disability is an administrative error and will be removed. 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. At the time of this inspection the fees ranged from £350-50p to £580-00p. Additional charges are made for hairdressing, transport, escort, chiropody, toiletries and newspapers. Abbey Grange DS0000024689.V316956.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Accumulated evidence used to inform this report has been obtained from the Commission’s records relating to the service, survey responses from residents, relatives and visiting professionals, and an unannounced inspection visit to the home. What the service does well: What has improved since the last inspection? The accommodation has been extended. It has increased the number of single bedrooms and now it is easier for the residents to get out into the grounds. The new accommodation has been designed with the needs of the residents in mind and has been furnished to a high standard. There is a new bathroom that is large enough and equipped for disabled residents to use. There are more staff employed now and they are receiving good training opportunities to help them do their job well. The kitchen facilities have been improved with the purchase of a new oven and water boiler. Abbey Grange DS0000024689.V316956.R02.S.doc Version 5.2 Page 6 Although social activities are provided, one or two relatives feel their resident doesn’t have enough variation in their day. Keeping up to date records of the leisure things each resident has done each day would clarify the situation. 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. The summary of this inspection report can be made available in other formats on request. Abbey Grange DS0000024689.V316956.R02.S.doc Version 5.2 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.V316956.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Admissions are well managed to ensure the home will suit the needs and preferences of the potential resident. EVIDENCE: There is up to date information about the home so that potential residents know what the service can offer. This is displayed at the home. Residents and relatives describe a comfortable introduction to the home – ‘Mr. Ubhee has been so helpful’, ‘we were shown all around – even the kitchen and laundry’. There are records of pre-admission assessment information and three examples were seen during the inspection visit. These were well written. Two signed contracts of residence were also available for inspection. Abbey Grange DS0000024689.V316956.R02.S.doc Version 5.2 Page 9 The Provider and Senior Care assistant were observed welcoming the relatives of a potential resident who had come to view the facilities. Abbey Grange DS0000024689.V316956.R02.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9, and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ health and personal care needs are being met but there needs to be a more consistent approach to recording the way this is done. EVIDENCE: When there are significant changes in residents’ health and welfare the Provider is appropriately letting the Commission know. These reports indicate that the staff recognise changes and deal with them quickly. They consult other health care professionals if this is necessary e.g. a possible chest infection was quickly identified in a newly admitted resident and medical attention was requested. A visiting district nurse was seen at the home during the inspection visit and she expressed confidence in the staff. When accidents occur e.g. falls, the staff record how they have acted to try and reduce the risk Abbey Grange DS0000024689.V316956.R02.S.doc Version 5.2 Page 11 of it happening again e.g. encouraging residents to ring for assistance rather than trying to move on their own. There are written records of the care given to each resident. There were entries to show how staff listen to residents’ personal preferences e.g. willingness to share a bedroom, preferred rising and going to bed times. A number of gaps were found in a sample of records that was inspected e.g. weight chart not up to date, social activity participation not recorded. It is important that care plans and risk assessments are fully completed to be sure everything is being addressed. They also need to be more regularly reviewed e.g. monthly, so that they reflect any changes in a resident’s condition. Some of these records didn’t show recent dates of evaluation/review. Two Senior Care assistants described a satisfactory method of safely managing medication. They had received training and were being given refresher training in the near future. This will help them keep up to date with good practice guidance. The storage arrangements would be better if they could be kept in an area where only staff have access, but the Provider is planning to fix another specially designed storage cupboard in the new extension and a dedicated fridge has already been purchased. Abbey Grange DS0000024689.V316956.R02.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The routines of the home are planned around each resident’s needs and wishes. Some residents may benefit from more one to one time from staff to help them enjoy their days. EVIDENCE: The relative of a recently admitted resident was very pleased that she was able to bring in a bird bath to put outside her mother’s bedroom window. When residents are admitted they are asked about their social history and leisure interests and a staff member explained how one particular resident was being supported by a friend and the staff to continue enjoying the things that he enjoys. It would be helpful if there was more attention to recording what social care has been offered to each resident on a daily basis because two relatives felt that there was not enough for their resident to do during the day. There are Abbey Grange DS0000024689.V316956.R02.S.doc Version 5.2 Page 13 entertainments e.g. bar.b.q., cheese and wine, dominoes, and there are also residents’ meetings where they can make suggestions. The residents say they enjoy the food and the menu for each day is displayed in the dining room. Food supplements are used and nutritional assessments are made as part of the admission assessment. Weights are being monitored although this may not be done consistently because there were some gaps in weight charts that were inspected. Abbey Grange DS0000024689.V316956.R02.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff understand how to keep residents safe. When problems arise they are dealt with promptly. EVIDENCE: There is information in the entrance hallway to help residents and their relatives e.g. a copy of the last inspection report, leaflets about ‘falls’ and benefits, a booklet explaining how care homes are checked and regulated. The Commission has received no complaints about the service since the last inspection. The Provider has investigated two complaints that he has received at the home. Information about these is recorded together with the way these were dealt with. Both of the received complaints were partly substantiated and action had been taken to put things right. The staff have written guidance to help them recognise and report any possible abuse of the residents. No allegations have been made. The Provider is an experienced health care professional and he spends a lot of time working at the home and monitoring the everyday care. Abbey Grange DS0000024689.V316956.R02.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The quality of the accommodation continues to improve and is generally good. However, there must be more robust attention to essential safety factors and to dealing with general maintenance work to keep everything tidy. EVIDENCE: The quality of the residents’ accommodation and staff facilities is being significantly improved through an ongoing programme of refurbishment e.g. new bedroom furniture, equipment, decoration and replacement carpeting. The cook was very pleased with a new oven and water boiler. The recently completed extension has been a significant part of this work and the Provider has plans for future development e.g. conservatory to increase communal Abbey Grange DS0000024689.V316956.R02.S.doc Version 5.2 Page 16 space. The home is clean and tidy although the new cleaner must be instructed to keep the cleaning cupboard locked to keep residents safe from potentially hazardous materials and equipment. Most of the current residents enjoy spending their day in the communal lounges rather than the privacy of their bedroom. They have been reluctant to make use of a small lounge in the extension and this means that the sitting areas are rather cramped. A base has already been laid for a conservatory lounge and this will ease the situation. A consultant was brought in to do a fire risk assessment of the premises when the extension was built. His report identifies work that needs to be done but this has not yet been addressed. This is important and an immediate requirement was made for this to be dealt with following the inspection visit. There is a maintenance book for staff to record when they find work that needs doing but this had no recent entries although the maintenance worker was seen at work in the home. There should be a more structured approach to identifying and dealing with premises work – particularly health and safety aspects e.g. a programme of work based on regular checks of the premises. The grounds had obviously been planted with summer flowers but had become untidy. There were also pieces of unwanted furniture and building materials still on site following the building of the extension and other refurbishment work. The staff receive training to help them maintain a hygienic environment e.g. infection control, food hygiene. Abbey Grange DS0000024689.V316956.R02.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are enough staff to deal with the residents’ needs and they are given the training they need to work competently. EVIDENCE: There has been an increase in staffing levels to take account of the recent increase in resident numbers and there are enough staff to care for the residents. On the day of the inspection visit the Provider was at work with a Senior and 3 care assistants. A cook, cleaner and maintenance worker were also on duty at the home. A high number of care staff have either achieved the recognised qualification – National Vocational Qualification- or are working to this end. Health and safety training is being provided e.g. all staff have an appointed persons First Aid certificate and 4 have a First Aid at Work certificate. Abbey Grange DS0000024689.V316956.R02.S.doc Version 5.2 Page 18 The way that staff are selected for employment was satisfactory when the last inspection took place. Applicants are subject to the required checks to be sure that they will be suitable to work with vulnerable adults. Abbey Grange DS0000024689.V316956.R02.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 35, 36,37 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of the home is generally satisfactory but there must be more consistent attention to essential safety aspects. EVIDENCE: The Provider is experienced and competent to fulfil his responsibilities. He spends time working alongside the staff so they, and the residents, know him well and can talk to him about everyday issues. He has a new office facility now the extension has been completed although other staff were still using an area of the main hallway for their administrative work. This is not ideal even Abbey Grange DS0000024689.V316956.R02.S.doc Version 5.2 Page 20 though confidential records are stored in a locked cabinet. Confidential discussions should be held in a private area although it is acknowledged that the current arrangement does mean that the staff are close to the areas of the home where most residents spend their day. The management of residents’ personal money and property was satisfactory when the home was last inspected. There is a regular programme of staff one to one supervision sessions and health and safety training is being kept up to date. The Commission is being kept informed of events at the home that must be notified. There are clear recording systems in place although sometimes the records are not being kept up to date and should be more closely audited e.g. records of checks on fire safety equipment were not up to date. The new extension has been designed with the residents’ comfort as a priority e.g. new disabled access bathroom and toilet, 4 adjustable beds. However, the ongoing management of safety factors and general maintenance must be more carefully planned so that work can be identified, prioritised and dealt with within a reasonable time frame e.g. last legionella checks were recorded in 2/05, need and methods for keeping open bedroom doors without compromising fire safety have not been addressed. Abbey Grange DS0000024689.V316956.R02.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x x x 3 3 3 2 Abbey Grange DS0000024689.V316956.R02.S.doc Version 5.2 Page 22 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. 1. Standard OP7 OP33 Regulation 17(3)a 24 Requirement Resident plans of care must be regularly evaluated to ensure they are up to date. 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. (Not reviewed. Previous timescale extended.) You must ensure that requirements of Regulatory Reform (Fire Safety) Order 2005 are complied with – ‘ensure that fire safety measures are maintained’ – fire alarm, emergency lighting, fire fighting equipment. Weekly and monthly tests of fire equipment must be reintroduced by 5pm on 24th October 2006. Immediate requirement DS0000024689.V316956.R02.S.doc Timescale for action 30/11/06 31/03/07 2. OP38 23(4)a 24/10/06 Abbey Grange Version 5.2 Page 23 3. OP38 23(4)a You must ensure that requirements of Regulatory Reform (Fire Safety) Order 2005 are complied with – ‘record the significant findings of the (fire risk) assessment and prepare an action plan (prioritised) for dealing with those findings and if necessary implement temporary measures to deal with any findings that require immediate attention’. You must submit an action plan to confirm compliance with the above by 20th November 2006. Urgent requirement There must be an audit procedure to identify unnecessary environmental risks to the health or safety of residents must be identified and, as far as possible eliminated. 20/11/06 4. OP38 13(4)c 30/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP7 OP17 OP38 Good Practice Recommendations Records of each resident’s participation in social activities should be kept up to date so that relatives can be reassured that this aspect of care is receiving attention. Staff should be provided with a private area to conduct confidential discussions about resident care. To introduce a programme of regular, recorded audits of premises health and safety aspects. (previous recommendation. Now subject to requirement. See above) Abbey Grange DS0000024689.V316956.R02.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V316956.R02.S.doc Version 5.2 Page 25 - 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!