CARE HOMES FOR OLDER PEOPLE
Abbey Grange Nursing Home Cammel Road Firth Park Sheffield South Yorkshire S5 6UU Lead Inspector
Claire McAuley Unannounced Inspection 7th March 2006 09:00 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 Nursing Home DS0000021762.V268798.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 Nursing Home DS0000021762.V268798.R01.S.doc Version 5.0 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 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) Larongrove Limited Miss Tracey Jane Turner Care Home 88 Category(ies) of Dementia - over 65 years of age (28), Old age, registration, with number not falling within any other category (60) of places Abbey Grange Nursing Home DS0000021762.V268798.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 19th May 2005 Brief Description of the Service: Abbey Grange is a care home providing personal and nursing care for up to eighty eight older people, including twenty eight beds for people who have dementia. The home is owned by Larangrove Limited and is situated in the Firvale area of Sheffield near to the Northern General hospital and close to public transport, and shopping area. The home is a converted property with extensions. Accommodation is provided on three floors accessed by a lift. There are sixty six single and eleven double bedrooms. The grounds are accessible and well maintained, and there is a car park. Abbey Grange Nursing Home DS0000021762.V268798.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place from 9.15am to 3.30pm. Previous requirements were checked and key standards not assessed at the previous inspection were checked. A proportion of the environment was inspected. The inspector spoke to eight residents and two relatives who expressed their views on the service. Five members of staff were also asked their opinions. A number of records were checked and discussion with the manager took place. The home had applied to extend the number of beds for people with dementia. What the service does well: What has improved since the last inspection? What they could do better:
Areas of the environment still required redecoration, including corridors doorframes and skirting boards. Some carpets including resident’s bedroom carpets needed to be replaced and some dining room chairs and tables were in poor condition. Bathroom and toilet floors had not yet been replaced. There
Abbey Grange Nursing Home DS0000021762.V268798.R01.S.doc Version 5.0 Page 6 was a rolling programme in place for this. Some risk assessments on care plans required revision. There were some errors in medication administration. To prevent an institutional atmosphere at the home, beds should not be made with hospital sheets and notices about resident’s dietary needs should not be displayed on dining room doors. 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 DS0000021762.V268798.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 Nursing Home DS0000021762.V268798.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): 2, 3. Each resident had a statement of terms and conditions (contract) in place. Full needs assessments were completed for all residents prior to them moving in to the home. EVIDENCE: Each resident had a statement of terms and conditions (contract) in place. The contract was in the process of being revised to include the name of the new owners of the home. Each resident had a full needs assessment completed prior to moving in to the home. A plan of care based on the assessment was in place Abbey Grange Nursing Home DS0000021762.V268798.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, 9, 10. Care plans contained sufficient information to meet the residents’ needs and maintain their health and wellbeing, and resident’s healthcare needs were met. There was a policy and procedure in place for the safe administration of medicines. Two errors were found in medication administration that did not maintain residents safety. Residents were treated with respect and their privacy upheld. EVIDENCE: 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. It was however unclear as to which parts of the plans had been updated, and one care plan contained an inappropriate disclaimer in relation to a resident’s risk of falling. It was also unclear on some plans as to whether residents had been regularly weighed, and there was no indication if keys to rooms had been offered to residents. Resident’s healthcare needs were met. There was evidence of appointments with health professionals in plans of care, including GP, dentist, chiropodist,
Abbey Grange Nursing Home DS0000021762.V268798.R01.S.doc Version 5.0 Page 10 and CPN. The home had links with professionals such as continence and pressure care nurses. There was a policy and procedure in place for the safe administration of medicines to residents. Staff were appropriately trained in this. Three residents medications were checked. There was one omission in the recording of administration of a medication, and an inhaler no longer in use had not been safely disposed of. Residents all said that staff were very kind and looked after them properly. Staff interviewed were well aware of the ways in which they maintained the dignity and privacy of residents, and were observed giving personal care and speaking politely and in a friendly manner to them. All residents were well groomed and well dressed in clean clothes. Residents saw health professionals and visitors in private. Residents all confirmed that staff responded quickly to their calls and that routines at the home were flexible. There were notices about residents individual dietary needs pinned to the doors of the dining rooms. This did not maintain their privacy and dignity. Abbey Grange Nursing Home DS0000021762.V268798.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. Suitable activities were provided. Residents were consulted about their preferred activities and individual needs were met. EVIDENCE: The home employed an activities co-ordinator who provided appropriate activities and social events. Residents could make their own decisions if they wished to join in or not. Activities included reminiscence, crafts, knitting, bingo, gentle exercises, concerts, and trips out. All the service users had an assessment completed of their preferred activities; individual needs were met. A number of residents preferred to stay in their rooms and read or watch television. They said that they were always asked if they wished to join in with activities. Abbey Grange Nursing Home DS0000021762.V268798.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, 18. For the protection of residents, there was an appropriate complaints procedure and adult protection procedure in place. Staff had received training in adult protection and complaints were appropriately dealt with. There was an adult protection enquiry in process. EVIDENCE: The home had a complaints procedure in place and complaints were appropriately recorded and dealt with. The manager monitored all complaints. Residents interviewed said they would speak to staff or the manager if they had any worries or complaints. The home had a policy and procedure on adult protection. Staff members had training on adult protection and were confident that any abuse or potential abuse would be reported to the manager. Management were aware that any incidents of abuse should be reported to Social Services Adult Protection. There was an adult protection enquiry in process, although no conclusions had yet been reached, and a case conference was to be held in the near future. Abbey Grange Nursing Home DS0000021762.V268798.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, 24. To maintain the comfort and dignity of residents, some redecoration and refurbishment was outstanding, including renewal of floors, and dining room furniture, but the general standard of the environment was good. Some floorboards were very squeaky, disturbing residents. There was a rolling programme of maintenance and renewal in place. One bed was made with hospital sheets and some bedrooms were awaiting refurbishment. EVIDENCE: The home was clean and the environment was generally of a good standard. Corridors, skirting, and doorframes were in poor condition and needed redecorating. Carpets in corridors and some resident’s bedrooms were stained and required replacing. Furnishings and fixtures were generally of a good standard but some dining room tables and chairs were in poor condition. Floorboards on the top floor corridor were very squeaky. Bathroom and toilet flooring was in poor condition and none had yet been replaced. The grounds around the home were tidy and attractive, and accessible to residents. There was a programme of maintenance and renewal in place.
Abbey Grange Nursing Home DS0000021762.V268798.R01.S.doc Version 5.0 Page 14 Residents spoken to said they were happy with their bedrooms. Some resident’s bedrooms were still awaiting refurbishment. The manager said that when rooms became vacant they would be redecorated. One resident’s bed was made with hospital sheets; this did not maintain their dignity. There was a rolling programme of refurbishment and redecoration in place. Abbey Grange Nursing Home DS0000021762.V268798.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, 29, 30. The home maintained the agreed staffing levels. 50 of staff were trained to NVQ level 2 or above. The recruitment information obtained for staff was sufficient to adequately protect the welfare of residents. One staff file did not contain a full history of employment. There was an extensive and up to date staff training programme in place. EVIDENCE: The staffing rotas showed that the home maintained the agreed staffing levels. Staff absence and sickness was covered by staff who worked extra shifts; agency staff were rarely used. The home was fully staffed and there were no vacancies. Staff and residents said there were sufficient staff on duty to meet the needs of the residents. There were sufficient domestic staff employed by the home. The home had met the requirement of 50 of staff trained to NVQ level 2 or above. The recruitment information obtained for staff was sufficient to adequately protect the welfare of residents who lived at the home. The manager confirmed that staff did not start at the home until a Criminal Records Bureau check had been completed. One file seen did not contain a full history of employment. To ensure staff were competent to meet resident’s needs, there was an extensive staff training programme in place, including induction to TOPPS
Abbey Grange Nursing Home DS0000021762.V268798.R01.S.doc Version 5.0 Page 16 standards. Work had been undertaken to ensure that all staff treated residents with respect. A training officer had been appointed to ensure they were properly supervised and supported. Supervision, appraisal and staff meetings all took place as required. The mandatory training was delivered on a rolling programme and was up to date for all staff members. Training included health and safety, fire, food hygiene, first aid, moving and handling and infection control. Adult protection training had been completed, and additional training was also offered including dementia training and computer training. Abbey Grange Nursing Home DS0000021762.V268798.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): 31, 33, 35. The manager was suitably qualified and experienced to run the home. Regulation 26 visits were in place. Resident’s finances were not independently audited. EVIDENCE: The manager was suitably qualified and experienced to run the home. She had an NVQ 4 in Care and Management qualification. Staff members expressed confidence in her abilities and said they would discuss any concerns with her. The open environment of the home was conducive to maintaining the safety and welfare of residents. Regulation 26 visits were in place. Abbey Grange Nursing Home DS0000021762.V268798.R01.S.doc Version 5.0 Page 18 Resident’s finances were 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 DS0000021762.V268798.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 3 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X 2 X X STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X X Abbey Grange Nursing Home DS0000021762.V268798.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 OP7 Regulation 15 Requirement Care plans must clearly show that information has been updated, that residents have been regularly weighed, and that residents have been offered keys to their rooms. All risk assessments on falls must be revised to include how risk can be reduced and what action staff will take to reduce the risk. (Timescales of 01/05/05 and 01/09/05 not met). A disclaimer in relation to a resident’s risk of falling must be replaced by a comprehensive risk assessment. All medication administered must be properly recorded. Medication no longer in use must be safely disposed of. Resident’s dietary needs must not be displayed on dining room doors. The homes corridors must be redecorated (Timescales of 01/07/05 and 01/11/05 not met. Damaged doorframes and skirting boards must also be redecorated.
DS0000021762.V268798.R01.S.doc Timescale for action 01/06/06 2 OP7 15 01/05/06 3 OP9 13 07/03/06 4 5 OP10 OP19 12 23 07/03/06 01/07/06 Abbey Grange Nursing Home Version 5.0 Page 21 6 7 OP19 OP24OP19 23 23 8 9 10 OP24OP19 OP19 OP24 23 23 12 11 OP29 19 The squeaking floorboards must be mended so that they do not disturb residents. The bathrooms and bedrooms identified to the manager must be refurbished. (Timescales of 01/07/05 and 01/11/05 not met. Stained and damaged carpets in corridors and residents bedrooms must be replaced. Dining room tables and chairs in poor condition must be replaced. The hospital sheets must be removed from the resident’s bed and appropriate bed linen provided. Staff recruitment information must include a full history of employment of prospective employees. 01/07/06 01/07/06 01/07/06 01/07/06 07/03/06 01/06/06 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 Refer to Standard OP35 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 DS0000021762.V268798.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Sheffield Area Office 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
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