Inspection on 17/05/07 for Abbey Grange Nursing Home

This inspection was carried out on 17th May 2007.

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 Nursing Home 29/04/10

Abbey Grange Nursing Home 09/03/10

Abbey Grange Nursing Home 13/05/09

Abbey Grange Nursing Home 24/05/06

Abbey Grange Nursing Home 07/03/06

Abbey Grange Nursing Home 19/05/05

Abbey Grange Nursing Home 03/02/05

Abbey Grange Nursing Home 17/08/04

Abbey Grange Nursing Home 28/01/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Abbey Grange Nursing Home Cammel Road Firth Park Sheffield South Yorkshire S5 6UU Lead Inspector Ian Hall Unannounced Inspection 17th May 2007 08:20 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 Nursing Home DS0000021762.V331991.R01.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 Nursing Home DS0000021762.V331991.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbey Grange Nursing Home Address Cammel Road Firth Park Sheffield South Yorkshire S5 6UU 0114 256 0046 0114 261 7962 abbey.grange@btconnect.com None Larongrove Limited 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) Miss Tracey Jane Turner Care Home 87 Category(ies) of Dementia - over 65 years of age (37), Old age, registration, with number not falling within any other category (50) of places Abbey Grange Nursing Home DS0000021762.V331991.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th May 2006 Brief Description of the Service: Abbey Grange is a care home providing personal care and nursing care. Accommodation is provided for 88 service users. The home is owned by Larangrove Limited and is situated in the Firvale area near to the Northern General hospital a short walk away from the main bus route to the town centre. The nearest shopping area is situated at Firvale. The home is a converted property with extensions, accommodation is provided on three floors that are accessed by a lift. The original property has been extended to provide 88 beds for nursing and personal care with 66 single and 11 double bedrooms. The grounds are accessible and well laid out, the garden sitting areas are attractive and well maintained. The previous inspection report was made available to service users and their families, details of this was on the homes notice board. The weekly fees are: £318 for residential care and £494 for nursing. This information was provided on 17th May 2007. The home charges extra for chiropody, toiletries, clothing, telephone, holidays and hairdressing. Abbey Grange Nursing Home DS0000021762.V331991.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over six hours on the 17th May 2007. The emphasis of the inspection was placed upon meeting service users, relatives, visitors and the staff team. The inspector toured the site to observe the redecoration and refurbishment that had taken place since the last inspection. The inspector case tracked 3 service user files and associated records. What the service does well: What has improved since the last inspection? What they could do better: Areas of the building and furnishings remained in a poor state of repair and décor and require upgrading to improve the quality of life of people who use the service. Abbey Grange Nursing Home DS0000021762.V331991.R01.S.doc Version 5.2 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Abbey Grange Nursing Home DS0000021762.V331991.R01.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 Nursing Home DS0000021762.V331991.R01.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): 3, 6. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. The home had written information about the service for potential service users and their relatives. Assessments of service users had been completed prior to them moving into the home, these are required to ensure that the home and staff were able to meet these needs. The staff team had received a range of training to ensure that they understood the needs of service users. EVIDENCE: The three case records examined had copies of pre-admission service user care assessments. They provided a clear picture of the service user and their physical, psychological and social needs. These are needed to ensure that the Abbey Grange Nursing Home DS0000021762.V331991.R01.S.doc Version 5.2 Page 9 home is suitably equipped and able to meet prospective service users care needs. The assessment formed the basis of the initial care plan. A visitor and five service users spoken with confirmed that they had been involved in the choice of care home; several had taken the opportunity to visit before deciding to live at Abbey Grange. This was confirmed during discussions with care staff. Case files inspected contained a copy of a contract/statement of terms and conditions. These detailed the fees, including any extra charges, and the facilities and standard of care service users can expect to receive. Intermediate Care is not provided at Abbey Grange. Abbey Grange Nursing Home DS0000021762.V331991.R01.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, 10. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. There were assessments and care plans in place to identify the help and support service users needed. Service users appeared well cared for. The medication system was well managed with policies and procedures in place to guide staff and protect service users. EVIDENCE: Care records of three service users were inspected; they contained assessment of physical and psychological needs this enabled staff to compile a care plan. A range of recognised assessment documents had been used to measure service user needs. These included mobility, mental ability, state of nutrition, and areas of risk such as falls. These provided a baseline for staff to assess service Abbey Grange Nursing Home DS0000021762.V331991.R01.S.doc Version 5.2 Page 11 user progress or increasing level of need this enabled staff to plan the help and support they needed. Reassessment of service users and their changed needs were recorded. Care provided and each service users activities had been recorded in the daily record. Details of service users religious and cultural needs and the gender of staff that they wished to support them with their personal care were identified. A visitor and one service user confirmed that they had helped draw up care plans and that they could have access to them whenever they wanted. Records were kept of medication received, and disposed of. Medication was securely stored and administered according to the doctor’s instructions. Records of medicines given were completed in full and correctly. Staff had received additional training for the administration of medicines, they were observed assisting service users to take their medication safely. The manager confirmed that the supplying chemist provided guidance and support for staff to ensure service user safety. Policies and procedures to inform staff and protect service users taking medications were current and available for inspection. Service users and visitors to the home confirmed that “staff were caring and helpful” and that “nothing was too much trouble, they were always willing and keen to help”. All the service users spoken to said that the staff promoted their privacy and dignity. The inspector observed staff knocking on bedroom doors waiting to be invited in before entering. Service user meetings had been held on a regular basis and minutes of these meetings were available within the home. Discussion with five service users and four staff identified that a range of health professionals visited the home to assist in maintaining health care needs. These included district nurses, chiropodist and general practitioners. These visits and their outcome had been recorded in detail within care records. A wide range of aids to assist service users with mobility problems were provided; these included lifting hoists, assisted baths, walking frames and wheelchairs. Abbey Grange Nursing Home DS0000021762.V331991.R01.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, 15. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. Service users felt that suitable activities provided at the home to keep them stimulated Visits from relatives and friends were encouraged ensuring that service users kept in touch with people who were important to them. Service users said the food was good and they were offered choice; special dietary needs and preferences were recorded in the individual care plans. EVIDENCE: Service users confirmed that they were able to go to bed and rise as they chose. Breakfast was being served throughout the morning to service users who had chosen to stay in bed longer. Service users were observed to be reading, listening to music and watching television. None of the service users currently leave the home unless accompanied by members of their family or staff. Staff accompanied service Abbey Grange Nursing Home DS0000021762.V331991.R01.S.doc Version 5.2 Page 13 users to places of local interest weather permitting. Activities co-ordinators organised activities to stimulate and encourage social interaction. Musicians visited the home and provided entertainment for service users. Visitors confirmed that they were able to visit at any time and were always welcomed by the staff team. They stated that when they called to collect a service user for an outing staff was supportive and helped service users to prepare in good time. The inspector observed the breakfast and lunch offered to service users. The food provided both appeared and smelled appetising. It was served hot, was well presented with a good choice being offered. Several service users who required them had special diets provided for health reasons. Staff were observed to encourage and assist service users with meals as needed. Mealtimes were unhurried; meal size was in accordance with service user choice with extra portions available as required. The chef was observed preparing and baking cakes and buns for service users. He confirmed that these were freshly made each day. Service users said they enjoyed them with their cups of tea and there was always plenty to eat. A list of birthdays had been provided for the chef who said he prepared birthday teas for service users. The dietician had assisted with compiling the balanced diet. The menu was clearly displayed in the dining room there was evidence of service users choice of meal or amount of diet consumed. Adapted cutlery was available to assist service users to maintain their independence. Service users their visitors and staff confirmed that nourishing drinks and fluids were provided throughout the day and night time as needed. Abbey Grange Nursing Home DS0000021762.V331991.R01.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, 18. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. The home had a complaints procedure to allow service users to raise any concerns. The staff had been trained in the recognition and reporting of abuse and relevant checks were made prior to them starting work, this reduced the risk of harm to vulnerable service EVIDENCE: Service users who had no advocate or next of kin have been provided with access to advocacy services provided by Age Concern. Two complainants brought their concerns to the manager’s attention, two elements of their concerns that were investigated were acknowledged to be founded, actions were taken to remedy them. They were investigated, recorded and actioned promptly within the home’s policy and procedure. Visiting relatives and some service users were able to describe how they would raise concerns with staff. They stated that any matters they raise however trivial they may seem were acted upon promptly by staff and that they were satisfied with the outcome. However one survey stated that their ongoing concerns that items of personal clothing and toiletries had not been dealt with Abbey Grange Nursing Home DS0000021762.V331991.R01.S.doc Version 5.2 Page 15 effectively. The complaints procedure was available for service users, their relatives and staff. Staff had been provided with training in adult protection procedures to ensure service users were safe, and to inform staff what to do if an allegation was made. The inspector’s discussions with staff demonstrated that they felt confident and able to respond to concerns or complaints effectively. Abbey Grange Nursing Home DS0000021762.V331991.R01.S.doc Version 5.2 Page 16 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, 26. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. The home was overall clean, tidy and well maintained ensuring that service users live in pleasant and safe surroundings. Most bedrooms were comfortable, clean, homely and reflected personal choice. EVIDENCE: Service users said the home was always clean, warm, well lit and there was always enough hot water. Some areas of the home had been decorated to service users satisfaction; the handyman was observed redecorating areas of damaged paintwork. Abbey Grange Nursing Home DS0000021762.V331991.R01.S.doc Version 5.2 Page 17 There is level access throughout the home with handrails provided to assist service users to maintain their independence and mobility. Access to the first floor is helped by provision of a passenger lift. Toilets were easily accessible as they were close to both lounge and dining areas. Toilets had been adapted for service users with physical disabilities. Door locks for identified toilets promote service user privacy and independence. There was an adequate number of baths, assisted bathing facilities were provided in convenient locations for service users. Service users were able to smoke in a designated smoking area. Clinical waste was properly managed and stored. Staff confirmed that they were provided with protective clothing if they needed it and that equipment was in working order, being serviced as required. Abbey Grange Nursing Home DS0000021762.V331991.R01.S.doc Version 5.2 Page 18 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, 30. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. Adequate numbers of staff were deployed to meet service user’s needs. Staff had received statutory training to help them meet the needs of service users. Checks had been made on staff to reduce the risks to vulnerable people. EVIDENCE: Sufficient staff were available to meet service users care needs. Additional staff were on duty to undertake housekeeping and maintenance tasks. Staff confirmed that they were well supported in their work with a senior member of staff always being on duty. The staff files examined confirmed that CRB checks and correct staff recruitment policy and procedures had been followed in each of the three files selected for inspection. The staff training and development plan was examined and was seen to identify their training needs, courses completed and courses being undertaken. Staff spoken with confirmed they had undertaken statutory training and updates e.g. moving and handling, fire prevention. They were involved in Abbey Grange Nursing Home DS0000021762.V331991.R01.S.doc Version 5.2 Page 19 national vocational qualification training, medication administration training, and dementia care training. The numbers of staff trained to level 2 NVQ in care exceeded the minimum 50 required by The National Care Standards Act 2000 and the associated Regulations. Abbey Grange Nursing Home DS0000021762.V331991.R01.S.doc Version 5.2 Page 20 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, 33, 35, 38. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. Staff said the manager was supportive and approachable and there was an established system of professional supervision. Service users were involved in making decisions about their care and had control over issues that affected their lives. Checks had been made on the major systems in the home such as fire and gas installations to ensure the home was safe for service users. Fire training had been provided for staff to reduce the risk to service users in an emergency. Abbey Grange Nursing Home DS0000021762.V331991.R01.S.doc Version 5.2 Page 21 EVIDENCE: The manager, a registered nurse had achieved the registered managers award and NVQ4. She is well supported by an experienced and qualified deputy manager. The service users, relatives and staff spoken with said the manager was approachable, very professional and they felt complete confidence in her. The manager had a job description that clearly defines her roles and responsibilities and staff were aware of her role. The homes management employed a range of methodologies to measure service users satisfaction with the care and services provided. Results of the recently conducted satisfaction survey had been analysed and comments used to further develop the service. Regular service user and staff meetings are held minutes are kept and were available for inspection. The home’s owners visit the home regularly and submit detailed written reports of their monitoring visits to the CSCI (Commission for Social Care Inspection). All staff had received management supervision, this had taken place at regular intervals; this is required to fully ensure individual staff development and monitoring care practices. Staff had received training on moving and handling, first aid, fire prevention, food safety and infection control. This ensured staff were prepared for their roles and responsibilities to meet service users needs and maintain their safety. The manager handles money on behalf of some service users, account sheets were kept, receipts were available for all transactions, and all transactions were witnessed by a second individual. Records were up to date and well ordered to ensure the best interest of service users. The homes policies and procedures met the required standards. Statutory servicing and checks of equipment were complete. Health and Safety at Work risk assessments had been undertaken and reviewed regularly. Abbey Grange Nursing Home DS0000021762.V331991.R01.S.doc Version 5.2 Page 22 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 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 3 X 3 X X 3 Abbey Grange Nursing Home DS0000021762.V331991.R01.S.doc Version 5.2 Page 23 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 OP19 Regulation 23 Requirement The damaged decoration and furniture must be replaced or repaired. Original timescale for action 01/01/07, 27/02/07 Timescale for action 31/12/07 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. Refer to Standard OP9 Good Practice Recommendations Daily temperature monitoring and recording should take place in all medication storage areas. Statutory warning signs must be displayed in all areas where compressed gasses are stored. 2. OP9 Abbey Grange Nursing Home DS0000021762.V331991.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Nursing Home DS0000021762.V331991.R01.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!