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Inspection on 19/05/05 for Abbey Grange Nursing Home

Also see our care home review for Abbey Grange Nursing Home for more information

This inspection was carried out on 19th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Residents who are at present in the area highlighted for the care of people with dementia had been consulted with a view to moving rooms. They have been given a choice of 3 rooms to choose from and where they had their own telephone line the home is to pay for a new line installed in the new rooms they will occupy.

What has improved since the last inspection?

As part of the on-going re-decoration programme several areas of the home have been redecorated and re-decoration was in progress at the time of the inspection. There has been a review of the menus involving all of the residents by means of a questionnaire.

What the care home could do better:

Staff training needs to be reviewed to ensure all staff are fully aware of the importance to respect residents` privacy and dignity. The manager has already commenced additional training. One new initiative is staff have to experience `being a resident for a day`.

CARE HOMES FOR OLDER PEOPLE Abbey Grange Nursing Home Cammel Road Firth Park Sheffield S5 6UU Lead Inspector Ann Micklethwaite Unannounced 19 May 2005 09:00am th 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 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 J55 S21762 Abbey Grange V218759 19.05.05 UI Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Abbey Grange Nursing Home Address Cammel Road Firth Park Sheffield S5 6UU 0114 2560046 0114 2617962 None Larongrove Limited Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Tracey Jane Turner N Care Home with Nursing 88 Category(ies) of OP Old age (88) registration, with number of places Abbey Grange Nursing Home J55 S21762 Abbey Grange V218759 19.05.05 UI Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 3rd February 2005 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 and is 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. Abbey Grange Nursing Home J55 S21762 Abbey Grange V218759 19.05.05 UI Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over a period of 7 hours. At present the home has applied for a variation to the registration to include the provision of a service for 25 people over 65 years who have dementia. The manager has shown commitment by accessing information and putting in place plans for the specialist training for staff on dementia. Alterations are taking place in the home to enable people with dementia to be cared for in an appropriate safe environment. What the service does well: 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 Nursing Home J55 S21762 Abbey Grange V218759 19.05.05 UI Stage 4.doc Version 1.30 Page 6 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 Standards Statutory Requirements Identified During the Inspection Abbey Grange Nursing Home J55 S21762 Abbey Grange V218759 19.05.05 UI Stage 4.doc Version 1.30 Page 7 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 standard(s) 1, 3, 5 On the whole all prospective residents are given the opportunity to visit the home and given information on the home. This enables them to know if the home is suitable to meet their needs. The home obtains a full needs assessment before admission to ensure that they have the full information required to care for the residents and to aid the compilation of the plan of care. EVIDENCE: Several residents were spoken to and asked if they had been offered the opportunity to visit the home before admission and were they given any information about the home. One or two said no, but the manager stated that if it had been an emergency admission this would not be possible. The one resident file checked contained a full needs assessment carried out before admission. Abbey Grange Nursing Home J55 S21762 Abbey Grange V218759 19.05.05 UI Stage 4.doc Version 1.30 Page 8 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 standard(s) 7, 8, 10 Care plans contained sufficient information so that staff were aware of the level of care required to meet the residents’ needs effectively and maintain their health and wellbeing. However the one care plan checked did not contain information on appointments with health professionals to ensure the health needs were being met. One resident was seen with dirty fingernails, which was not hygienic or dignified for the resident. Abbey Grange Nursing Home J55 S21762 Abbey Grange V218759 19.05.05 UI Stage 4.doc Version 1.30 Page 9 EVIDENCE: The one resident’s file checked in detail contained clear information on the personal care and wellbeing needs of the resident, social interests, hobbies and mobility needs, but there was no record made if they had received input from health service professionals. One resident expressed concerns that on the odd occasion when staff was giving care some staff talked over their head by talking to themselves about their private lives. A staff member was observed to enter a residents’ room without knocking. One resident spoken to had dirty fingernails and their drinking cup was stained. Abbey Grange Nursing Home J55 S21762 Abbey Grange V218759 19.05.05 UI Stage 4.doc Version 1.30 Page 10 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 standard(s) 12, 13, 14, 15 Residents are provided with appropriate activities and social recreation events. Residents make their own decisions if they wish to join in or not. Family and friends can visit in the privacy of the resident’s own room, thus maintaining residents privacy and comfort. Residents are able to have their own telephone giving them the opportunity to make a call in private. A pay phone is also available. On occasions a resident may request to use the phone in the office, in this instance staff should make every effort to enable the resident to make the call in private. Residents are encouraged to bring their personal possessions into the home to help in maintaining their independent personal choices and comfort of having familiar things around them. Abbey Grange Nursing Home J55 S21762 Abbey Grange V218759 19.05.05 UI Stage 4.doc Version 1.30 Page 11 EVIDENCE: Residents spoken to could say what they enjoyed doing to keep themselves occupied. Some said they enjoyed joining in with activities that the home provides. Others said they enjoyed doing their own thing such as reading crosswords or watching their own television in their own rooms. They spoke of visits from their relatives and that they can see them in the privacy of their own rooms. Mixed opinions were voiced on the quality and choice of the food provided. Two residents described the food as “soggy potatoes”, “cold tea”, and “poor choice”, “you are asked for your choice at mealtimes but it would be better to be asked earlier so that you know what the choices are being offered for the day”. Two others made positive comments about the food provided saying that they always like what is on the menu, they were offered a choice and they were given sufficient quantities. Abbey Grange Nursing Home J55 S21762 Abbey Grange V218759 19.05.05 UI Stage 4.doc Version 1.30 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 standard(s) 16, 17, 18 Resident’s complaints are listened to and where needed appropriate action is taken Residents are given the opportunity to vote using the postal system thus ensuring they maintain their rights to be part of the community and civic processes. Residents feel safe at the home however one or two expressed concerns that the attitude and behaviour of a minority of staff made them feel uncomfortable. EVIDENCE: Residents spoken to said that they knew whom to go to if they had a complaint. Those who had made a complaint said that they had been listened to and appropriate action had been taken. All had received a postal vote for the recent general election. Residents said that they felt safe in the home and commented that staff were “affectionate”, mothering”, “the same one bathes me and we have a right laugh’’, however one or two made comments that a few staff had “poor manners’’. Abbey Grange Nursing Home J55 S21762 Abbey Grange V218759 19.05.05 UI Stage 4.doc Version 1.30 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 standard(s) 19, 21, 23, 24, 26 Although in the main the home is a pleasant environment some bedrooms and bathrooms are in need of refurbishment to ensure that residents experiences are of living in a pleasant safe well decorated and maintained home. Abbey Grange Nursing Home J55 S21762 Abbey Grange V218759 19.05.05 UI Stage 4.doc Version 1.30 Page 14 EVIDENCE: It was noticed that corridor doorframes were badly marked, but all were due for re-decoration as part of the rolling programme for decoration. The majority of the bathroom floor coverings were old, worn and stained and some fittings were also in need of replacement due to wear and tear. These were all planned to be re-furbished in the next month. One toilet on the ground floor has no call system installed. However a new call system for all the home is due to be installed shortly. The manager said that new furniture for the dining rooms had been ordered and new bed linen had been purchased. Residents spoken to said that they liked their rooms and they were comfortable. The room that was used as a staff smoking room has been refurbished and is now a pleasant small meeting room. Abbey Grange Nursing Home J55 S21762 Abbey Grange V218759 19.05.05 UI Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 29, 30 All staff receive a 6-week induction to TOPPS standard followed by on going training. This ensures that staff are competent to meet the needs of the residents. EVIDENCE: The manager maintains a staff-training matrix, which forms part of the training audit to ensure all staff receive all the relevant training. Abbey Grange Nursing Home J55 S21762 Abbey Grange V218759 19.05.05 UI Stage 4.doc Version 1.30 Page 16 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35, 37, 38 The monthly Regulation 26 report produced by the providers representative is brief and should be more comprehensive to ensure it reflects the quality standards of the home and identifies the homes strengths and weaknesses. The representative has not got an enhanced CRB check in place to ensure the protection of residents is maintained. This is necessary as residents may wish to speak to them in private. Resident’s finances are not independently audited. CSCI guidance issued to inspectors recommends that these records are included in any independent audit of financial records undertaken on behalf of the provider. Abbey Grange Nursing Home J55 S21762 Abbey Grange V218759 19.05.05 UI Stage 4.doc Version 1.30 Page 17 EVIDENCE: The provider does carry out a monthly visit and produces a report, however the report is not comprehensive enough to form an opinion of the standard of care provided by the home. . The person authorised by the provider to carry out the regulation 26 visits has not undergone an enhanced Criminal Records Bureau check. CSCI guidance recommends that service users accounts held at the home are included in any independent audit of financial records undertaken on behalf of the provider. On the day of the inspection no hazardous substances were seen insecurely stored. Fire doors and alarms are checked regularly and a record was kept of these checks. Abbey Grange Nursing Home J55 S21762 Abbey Grange V218759 19.05.05 UI Stage 4.doc Version 1.30 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 3 2 3 3 3 3 3 STAFFING Standard No Score 27 x 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x 3 2 x x 3 x 3 2 3 3 Abbey Grange Nursing Home J55 S21762 Abbey Grange V218759 19.05.05 UI Stage 4.doc Version 1.30 Page 19 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 7,4 Regulation 15,43 Timescale for action Service users plans must include 1st Sept 05 details of their health needs, also details of specialist treatment received and what action is needed/taken by staff to meet these needs. (Previous timescale 1st May not met) Where risks have been identified 1st Sept 05 the risk assessment must give details of why they are at risk, how the risk can be reduced and what action staff need to take to reduce the risk. (Previous timescale 1st May 2005 not met) When residents have received 1st Sept 05 input from health service professionals this must be recorded in their care plan. Service users must be treated Immediate with respect at all times. Service users requiring assistance with personal care must be provided this in accordance with assessed needs. Staff must undertake this with respect and courtesy. The manager must ensure that staff are instructed on how to maintain dignity. The manager must investigate the concerns raised during the inspection and ensure appropriate action is Version 1.30 Page 20 Requirement 2. 7 15, 43 3. 8 17, 43, Schedule 3. 12/ 43 4. 10 Abbey Grange Nursing Home J55 S21762 Abbey Grange V218759 19.05.05 UI Stage 4.doc taken. 5. 10 Staff must maintain residents dignity and hygiene by checking that their fingernails are kept clean. 12, 43 Staff must not enter residents rooms without knocking and waiting for a reply. 12, 13, The manager/provider must 18, 43 carry out a thorough investigation into the comments made that the attitude and behaviour of some of the staff is not acceptable to some of them and action taken to protect the welbeing of the residents. 23,43 The homes corridors must be redecorated.Damaged radiator covers on the homes corridors must be repaired. (Previous timescale 1st July 2005 not met). 16, 23, 43 The bathrooms and bedrooms identified to the manager must be refurbished. 26, 43 The Regulation 26 report must be more comprehensive to ensure it reflects the quality standards of the home. 7, 26, 43, The responsible individual Schedule authorised by the provider to 2 carry out the regulation 26 visits to the home must undergo an enhanced CRB check. 12, 43 Immediate 6. 7. 10 18 Immediate Immediate 8. 19 1st Nov 05 9. 10. 21 33 1st Nov 05 1st sept 05 11. 36 1st Sept 05 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. Abbey Grange Nursing Home J55 S21762 Abbey Grange V218759 19.05.05 UI Stage 4.doc Version 1.30 Page 21 23. 24. 25. 26. 27. 28. 29. 30. 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 35 Good Practice Recommendations Service users accounts should be included in any independent audit of financial records undertaken on behalf of the provider. Abbey Grange Nursing Home J55 S21762 Abbey Grange V218759 19.05.05 UI Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Nursing Home J55 S21762 Abbey Grange V218759 19.05.05 UI Stage 4.doc Version 1.30 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. 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