Inspection on 17/04/07 for Abbey Grange Residential Home

This inspection was carried out on 17th April 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Abbey Grange Residential Home 09/12/08

Abbey Grange Residential Home 25/04/06

Abbey Grange Residential Home 26/09/05

Abbey Grange Residential Home 21/06/05

Abbey Grange Residential Home 10/02/05

Abbey Grange Residential Home 01/06/04

Abbey Grange Residential Home 27/01/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Abbey Grange Residential Home Oaks Road Whitwick Coalville LE67 5UP Lead Inspector Martin Hefferman & Bhavna Keane-Rao Key Unannounced Inspection 17th April 2007 10:30 Abbey Grange Residential Home DS0000001661.V333998.R01.S.doc Version 5.2 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 Residential Home DS0000001661.V333998.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 Adults 18-65. 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 Residential Home DS0000001661.V333998.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbey Grange Residential Home Address Oaks Road Whitwick Coalville LE67 5UP 01509 600354 01509 600137 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) Woodley Holidays Limited *** Vacant *** Care Home 14 Category(ies) of Learning disability (14) registration, with number of places Abbey Grange Residential Home DS0000001661.V333998.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No additional conditions of registration apply. Date of last inspection 23rd November 2006 Brief Description of the Service: Abbey Grange is registered to provide care for up to fourteen people with learning disabilities. Residents live in a large old country house, situated in grounds with gardens, trees and pleasing views of the countryside. They have access to lounges and dining areas. Residents rooms are situated on the ground, first and second floors. There is a lift to facilitate access to the first floor. The rooms vary in character and size, and most overlook gardens and fields. Residents attend community day services, which are run by the registered provider in a nearby town. At the time of the inspection, fees ranged from approximately £568 to £1063 a week depending upon individual need. Abbey Grange Residential Home DS0000001661.V333998.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A visit to Abbey Grange took place on 17th April 2007, lasting approximately seven hours. The main method of inspection used on that day was ‘case tracking’ which involved selecting three people who live at the home and tracking the care they receive through review of their records, discussion with them & staff and observation of care practices. The inspector was not able to communicate with one of the three people who were chosen for the purposes of case tracking. Random inspections of the home took place on 12th September and 23rd November 2006. This inspection took account of the findings from those visits and all information received since the date of the last key inspection, including the provider’s self-assessment. No comment cards had been received at the time of writing this report. What the service does well: What has improved since the last inspection? A company who provide healthcare consultancy have been employed to assist with the management of the home. They have begun a programme of improvements, which include reviewing the information produced about Abbey Grange, revising individual plans & risk assessments, updating policies & procedures and surveying the views of families & staff members. In addition, work has been undertaken to improve the environment provided for residents. Since the date of the last random inspection, the dining room and an additional living room – which had been out of use - have been refurbished. Other areas of the home including the hall, stairs & landing have also been redecorated. Staff members commented upon the overall improvement in the running of the home since the last key inspection. Abbey Grange Residential Home DS0000001661.V333998.R01.S.doc Version 5.2 Page 6 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 Residential Home DS0000001661.V333998.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Abbey Grange Residential Home DS0000001661.V333998.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who may be considering Abbey Grange as a home for themselves or a relative have access to the information they need to make an informed choice about whether to move to the home. EVIDENCE: The acting manager stated that he was in the process of reviewing information about Abbey Grange at the time of the inspection. A draft copy of a guide was available incorporating information that has previously been produced using photographs & symbols and more detailed information regarding the home’s policy on referral & admission and its aims & objectives. He agreed to amend the policy on referral & admission to reflect the National Minimum Standards for Adults aged 18 – 65. He also agreed to consider producing two versions of the guide, one of which would be accessible to the people living at the home. The outcome for standard 2 could not be fully assessed on this occasion. There have been no admissions since the date of the last key inspection. The people who were chosen for the purposes of case tracking moved to the home in 1997, 1998 & 2000. The acting manager stated that he did not intend to accept any new referrals for the foreseeable future. Abbey Grange Residential Home DS0000001661.V333998.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff members have access to the information they need to meet residents’ needs. EVIDENCE: Staff members were in the process of revising individual plans at the time of the inspection. The plans that were inspected appeared to be clear. Additional sheets have been introduced to enable staff to evaluate the support provided. It was noted that staff have begun to record information about any spiritual & cultural needs that have been identified and that action has been taken to meet those needs. Updated risk assessments have been completed on a range of issues. One of the people who were chosen for the purposes of case tracking stated that he could decide when to get up & go to bed and reported that he preferred to watch TV in his room in the evening. He told inspectors about his plans to celebrate his upcoming birthday. Other people who live in the home Abbey Grange Residential Home DS0000001661.V333998.R01.S.doc Version 5.2 Page 10 were observed making use of the dining room, lounges & grounds during the course of the visit. The acting manager stated that residents are able to access kitchen facilities, depending upon the outcome of a risk assessment. A resident stated that he prepares his own ‘pack-up’ to take to the day service. Other residents are encouraged to make their own drinks. Abbey Grange Residential Home DS0000001661.V333998.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements relating to the various aspects of residents’ lifestyles are well managed ensuring that their needs are met. EVIDENCE: People who live at Abbey Grange attend day services, which are run by the registered provider in a nearby town. They stated that they are able to undertake a range of activities - including swimming, horse riding, bowling and baking sessions - whilst attending the day service. One person stated that she had been to a library on the day of the inspection. A second person stated that she had had her nails varnished. One of the people who were chosen for the purposes of case tracking attended a social group for older people with learning disabilities on the day of the visit. Records indicate that residents also undertake activities at weekends. A second person who was chosen for the purposes of case tracking had recently visited a nearby monastery. Abbey Grange Residential Home DS0000001661.V333998.R01.S.doc Version 5.2 Page 12 One of the people who were chosen for the purposes of case tracking stated that she is in regular contact with her family. Records indicate that the other two no longer have any contact with remaining family members. The acting manager stated that staff members were in the process of organising a party to which families and friends would be invited. Residents stated that they enjoyed the meal that was provided on the day of the inspection. Records indicate that they receive a varied diet. The acting manager stated that staff were in the process of implementing healthy eating guidelines and of increasing the proportion of freshly prepared food. Abbey Grange Residential Home DS0000001661.V333998.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Working practices help ensure residents’ personal & healthcare needs are met. EVIDENCE: A number of people who live at Abbey Grange stated that they are happy with the support they receive. The acting manager reported that various options were being explored to enable one of the people who were chosen for the purposes of case tracking to have a shower, which he would prefer. His room has an en-suite bath. Individual plans detail the personal support each person requires. They also set out details of any healthcare needs that have been identified and of any action that is felt to be necessary as a result. Records demonstrate that residents are in contact with healthcare professionals when required. None of the people who live at Abbey Grange are able to manage their medication. Records are kept of all medicines received into the home and administered to residents. The acting manager stated that staff members had recently received medication training. He agreed to forward a copy of the certificates as soon as they were available. Abbey Grange Residential Home DS0000001661.V333998.R01.S.doc Version 5.2 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live at Abbey Grange appear to be protected by the home’s arrangements for handling complaints and for dealing with allegations of abuse. EVIDENCE: Since the date of the last key inspection, the complaints procedure has been produced in a more accessible format. Copies of the procedure were on display in communal areas. The acting manager agreed to amend the procedure to reflect recent changes to the management of the home. Records indicate that there have been two complaints since the date of the last inspection, both of which related to issues between staff members. The home’s policies and procedures on the protection of vulnerable adults and whistle blowing have recently been updated. Staff members have signed to indicate that they have read the revised copies. The acting manager agreed to amend the protection of vulnerable adults policy to reflect local guidance on reporting allegations. Financial records relating to the three people who were chosen for the purposes of case tracking were inspected. Two members of staff had signed entries in all three. Abbey Grange Residential Home DS0000001661.V333998.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live at Abbey Grange live in an increasingly comfortable and homely environment. EVIDENCE: Four residents’ rooms, communal areas and part of the grounds were inspected during the course of this visit. Residents stated that they were happy with their rooms, which were generally decorated to a satisfactory standard. Since the date of the last inspection, further work has been undertaken to improve the environment provided for residents. An additional living room – which had been out of use - has been refurbished and is now being used by residents. A new ceiling has been installed in the dining room blocking off a mezzanine floor, which could not be used. The hall, stairs, landing and dining room have also been redecorated. Electricians were in the process of rewiring the home at the time of the visit. Abbey Grange Residential Home DS0000001661.V333998.R01.S.doc Version 5.2 Page 16 During a tour of the premises, it was noted that a self-closing mechanism on a fire door was broken; a resident had stuck tape over the emergency call button in the lift and a leak had damaged a ceiling tile in a bedroom. Immediate action was taken to rectify these issues before the end of the visit. Abbey Grange Residential Home DS0000001661.V333998.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live at Abbey Grange appear to be protected by the home’s arrangements for recruiting & training staff. EVIDENCE: Several of the people who live at Abbey Grange stated that they get on well with staff members. Other residents appeared to enjoy a positive relationship with the staff on duty at the time of the visit. Most of the staff records that were inspected indicated that appropriate preemployment checks had taken place. One of the files contained one written reference. This omission was identified during a previous visit to the home. Records indicate that a request for a second reference had been sent following that visit. The deputy manager agreed to check progress on this issue. Staff members stated that they have completed the home’s induction programme. Completed copies were available for inspection. The acting manager stated that he intends to introduce an induction programme based upon the standards set by Skills for Care for new starters. Ten of the fourteen Abbey Grange Residential Home DS0000001661.V333998.R01.S.doc Version 5.2 Page 18 members of staff have completed National Vocational Qualification level 2 or above. Three members of staff are due to start NVQ level 2, five, level 3 and one, level 4 later in the year. Staff members stated that they have completed training on fire safety, first aid, food hygiene and moving & handling amongst other issues. The deputy manager stated that she had contacted the training provider to request certificates for these courses. The acting manager agreed to forward a copy of the certificates as soon as they were available. Abbey Grange Residential Home DS0000001661.V333998.R01.S.doc Version 5.2 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Action is being taken to ensure that Abbey Grange is run in the best interests of the people who live there. EVIDENCE: Since the date of the last inspection, the registered provider has employed a company who provide healthcare consultancy to assist with the management of the home. Two representatives of the company were present on the day of the visit. One is the acting manager; the second – a qualified nurse – was assisting staff with the development of individual plans. Staff members commented upon the overall improvement in the running of the home since the last key inspection. The Commission continues to receive Regulation 26 reports (visits by the registered provider). The acting manager stated that survey forms have been Abbey Grange Residential Home DS0000001661.V333998.R01.S.doc Version 5.2 Page 20 sent to the families of people who live at Abbey Grange and to staff members. A number of returned forms were available at the time of the visit. The acting manager stated that he would pull together the findings and address any issues that were identified. Minutes of a residents meeting indicate that they are involved in discussions regarding the running of the home. Staff members stated that they have attended training on a number of safe working practices (see ‘Staffing’). Records indicate that fire tests & drills have been completed at the required frequency. A revised fire risk assessment has been completed. The acting manager stated that a number of issues that were identified as a result of the assessment would be addressed by the end of April 2007. Abbey Grange Residential Home DS0000001661.V333998.R01.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 Adults 18-65 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 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Abbey Grange Residential Home DS0000001661.V333998.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Abbey Grange Residential Home DS0000001661.V333998.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Residential Home DS0000001661.V333998.R01.S.doc Version 5.2 Page 24 - 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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