Inspection on 21/06/05 for Abbey Grange Residential Home

This inspection was carried out on 21st June 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.

Other inspections for this house

Abbey Grange Residential Home 09/12/08

Abbey Grange Residential Home 17/04/07

Abbey Grange Residential Home 25/04/06

Abbey Grange Residential Home 26/09/05

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 Leicestershire LE67 5UP Lead Inspector Martin Hefferman Unannounced 21 June 2005 13:20 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 C51 C01 S1661 Abbey Grange V233858 210605 STAGE 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Abbey Grange Residential Home Address Oaks Road Whitwick Leicestershire LE67 5UP 01509 600354 01509 600137 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) Woodley Holidays Limited Vacant Care Home 14 Category(ies) of Learning disability (14) registration, with number of places Abbey Grange Residential Home C51 C01 S1661 Abbey Grange V233858 210605 STAGE 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: No additional conditions of registration Date of last inspection 10/02/05 Brief Description of the Service: Abbey Grange is registered to provide care for up to fourteen residents 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 two lounges, a quiet room and a dining room. Residents rooms are situated on two floors and there is a lift to facilitate access to the first floor. The rooms vary in character and size, and most overlook gardens and fields. The majority of residents attend a community day service, which is run by the registered provider in a nearby town. Abbey Grange Residential Home C51 C01 S1661 Abbey Grange V233858 210605 STAGE 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over the course of four hours forty minutes. The primary method of inspection used was ‘case tracking’ which involved selecting three residents and tracking the care they receive through review of their records, discussion with them (where appropriate), the care staff and observation of care practices. Two of the residents who were chosen for the purposes of case tracking have no verbal communication. Two residents were spoken to during the course of this visit. The inspection was facilitated by a senior representative of the registered provider and a team leader. What the service does well: What has improved since the last inspection? What they could do better: The home should produce a more accessible version of its complaints procedure to give to residents. It must keep a record of any complaints that are received and of the action taken as a result. The home must also maintain appropriate records relating to residents’ finances. Work is needed to improve the standard of accommodation provided for residents. Immediate requirements were issued with regard to a self-closing mechanism on a fire door and a radiator cover, both of which had been damaged. Training arrangements could be strengthened by the incorporation of Learning Disability Award Framework–accredited training. Abbey Grange Residential Home C51 C01 S1661 Abbey Grange V233858 210605 STAGE 4.doc Version 1.30 Page 6 The owners must undertake monthly monitoring visits to the home and forward a copy of the reports arising from those visits to CSCI. Fire tests and drills must be completed at the required frequency in order to protect the safety of residents. 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 Residential Home C51 C01 S1661 Abbey Grange V233858 210605 STAGE 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Abbey Grange Residential Home C51 C01 S1661 Abbey Grange V233858 210605 STAGE 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Not applicable EVIDENCE: None of the Standards in this section were inspected on this occasion. Abbey Grange Residential Home C51 C01 S1661 Abbey Grange V233858 210605 STAGE 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 & 9 Individual plans are clear and appear to be comprehensive. Failure to keep each plan (and accompanying risk assessments) under review could result in them not being updated to reflect any changes in need and could consequently put residents at risk. EVIDENCE: The individual plans that were inspected set out residents’ needs in respect of their health and social care. Two of the plans that were inspected had been reviewed during April 2005; the third did not appear to have been reviewed since September 2004. Each of the files that were inspected contained behaviour management guidelines. The home had completed risk assessments on a range of areas. They did not appear to have been reviewed since the date on which they were completed in September 2003. Abbey Grange Residential Home C51 C01 S1661 Abbey Grange V233858 210605 STAGE 4.doc Version 1.30 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 15 & 17 Arrangements for social activities, maintaining appropriate relationships and the provision of meals appear to be well managed. EVIDENCE: Two of the three residents who were chosen for the purposes of case tracking attend a day service, which is run by the registered provider in a nearby town. Staff members stated that the third was not able to attend the day service due to a deterioration in his condition and that they were providing daytime activities for him at home. One of the residents who were chosen for the purposes of case tracking indicated that he had enjoyed planting vegetables in the home’s garden. The home was reminded that it must keep up-to-date records of any social and leisure activities that take place. Records indicate that residents are in regular contact with their families. One resident stated that he was looking forward to a forthcoming holiday with his mother. Residents appeared to enjoy the meal that was provided on the day of the inspection. Records indicate that they receive a varied and nutritious diet. The Abbey Grange Residential Home C51 C01 S1661 Abbey Grange V233858 210605 STAGE 4.doc Version 1.30 Page 11 home was reminded that it must keep a record of all of the meals that are provided to residents. Abbey Grange Residential Home C51 C01 S1661 Abbey Grange V233858 210605 STAGE 4.doc Version 1.30 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 20 Residents are protected by the home’s practices regarding the handling of medication. EVIDENCE: None of the residents are able to manage their own medication. Records are kept of all medicines received into the home, administered to residents and returned for disposal. A contract pharmacy inspected medication arrangements at the home during February 2005. Staff members stated that an issue identified at the time of that inspection had been addressed. Records indicate that staff members have received medication training. Abbey Grange Residential Home C51 C01 S1661 Abbey Grange V233858 210605 STAGE 4.doc Version 1.30 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 Arrangements for dealing with complaints and managing residents’ finances need to be strengthened in order to fully protect residents’ rights. EVIDENCE: The home has produced a complaints procedure. This needs to be amended to reflect changes to the regulatory inspector and to remove a reference to the Local Government Ombudsman. A recommendation has been made that the home should produce a more accessible version of the procedure to give to residents. The registered provider was in the process of investigating a complaint at the time of this inspection. The outcome of that investigation will be contained in the next inspection report. A record of the complaints received by the home was not available at the time of this inspection. Whilst the requirements of Standard 23 were not inspected on this occasion, records relating to residents’ finances were examined. The last entry in some of these records was dated March 2005. Staff members stated that more recent expenditure had been paid out of the home’s petty cash. The balance for one of the residents who were chosen for the purposes of case tracking was checked and found to be correct. It was noted that residents’ financial records had been signed by one member of staff. Abbey Grange Residential Home C51 C01 S1661 Abbey Grange V233858 210605 STAGE 4.doc Version 1.30 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 & 30 The current standard of accommodation does not provide a totally safe and homely environment. EVIDENCE: Four residents’ rooms and all of the communal areas were inspected during the course of this inspection. One of the rooms had recently been redecorated using Nottingham Forest wallpaper. The resident indicated that he was happy with his room. The following issues were identified that require attention: the self-closing mechanism on a fire door had been broken; a radiator cover in the quiet room had been damaged leaving a jagged edge; cupboard doors in the dining room had been broken; two of the residents’ rooms that were inspected need to be redecorated; the ceiling of the middle floor needs repainting; and the carpeted area between the laundry & the main building and the carpet on the middle floor need replacing. Staff members reported that the latter was responsible for an odour noticeable in that area. They also stated that the broken door mechanism had already been reported to the maintenance man. Abbey Grange Residential Home C51 C01 S1661 Abbey Grange V233858 210605 STAGE 4.doc Version 1.30 Page 15 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 & 35 Staff members are deployed in sufficient numbers to meet residents’ needs. EVIDENCE: Staffing levels on the day of the inspection complied with the requirements set by the previous regulatory authority. Staff are organised into two teams within the home. Staff members stated that communication had improved between the two teams and between the home & the day service since the date of the last inspection. Residents appeared to enjoy a positive relationship with the staff on duty. Records indicate that staff members have received training on a range of subjects including managing challenging behaviour, signing & communication and epilepsy in addition to the training provided on topics mentioned under Standards 20 & 42. A recommendation has been made that the home access Learning Disability Award Framework–accredited training. Abbey Grange Residential Home C51 C01 S1661 Abbey Grange V233858 210605 STAGE 4.doc Version 1.30 Page 16 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42 The home’s current working practices need to be strengthened in order to fully protect residents. EVIDENCE: The home has recently recruited a new manager who will start work at the beginning of August. It was noted that the registered provider had not complied with the requirements of Regulation 26 regarding unannounced visits to the home. Records indicate that staff members have received training on fire safety, first aid, food hygiene, health & safety and moving & handling. Fire tests and drills have not been completed at the required frequency. Abbey Grange Residential Home C51 C01 S1661 Abbey Grange V233858 210605 STAGE 4.doc Version 1.30 Page 17 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 ENVIRONMENT Score 2 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 x x x x x 2 Standard No 11 12 13 14 15 16 17 x 3 x x 3 x 3 Standard No 31 32 33 34 35 36 Score x x 3 x 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Abbey Grange Residential Home Score x x 3 x Standard No 37 38 39 40 41 42 43 Score x x x x x 2 x C51 C01 S1661 Abbey Grange V233858 210605 STAGE 4.doc Version 1.30 Page 18 Yes Are there any outstanding requirements from the last inspection? 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. 2. Standard 6 22 Regulation 15 17 Requirement The registered person must ensure that individual plans are kept under review. The registered person must ensure a record is kept of any complaints that are received and of the action taken as a result. The registered person must ensure that appropriate records are kept relating to residents’ finances. The registered person must ensure that a self-closing mechanism on a fire door is repaired. The registered person must ensure that a damaged radiator cover is replaced. The registered person must ensure that the premises are kept in a good state of repair. The registered person must ensure that the carpet on the middle floor is cleaned or replaced. The registered person must ensure that regular authorised visits are made to the home and that the reports produced from the visits are forwarded to the local CSCI office. The previous C51 C01 S1661 Abbey Grange V233858 210605 STAGE 4.doc Timescale for action 31/08/05 With effect from 21/06/05 With effect from 21/06/05 24/06/05 3. 23 17 4. 24 23 5. 6. 7. 24 24 24 23 23 23 24/06/05 31/07/05 31/08/05 8. 39 26 With effect from 21/06/05 Abbey Grange Residential Home Version 1.30 Page 19 9. 42 23 timescale of 10/02/05 was not met. The registered person must ensure that fire tests and drills take place at the required frequency. With effect from 21/06/05 10. 11. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard 22 24 24 24 35 Good Practice Recommendations It is recommended that the home produce a more accessible version of its complaints procedure to give to residents. It is recommended that the home redecorate two rooms identified at the time of the inspection. It is recommended that the home redecorate the ceiling of the middle floor. It is recommended that the home replace the carpet outside the laundry area. It is recommended that the home access Learning Disability Award Framework – accredited training. Abbey Grange Residential Home C51 C01 S1661 Abbey Grange V233858 210605 STAGE 4.doc Version 1.30 Page 20 Commission for Social Care Inspection 5 Smith Way Grove Park Enderby Leicestershire LE19 1SX 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. 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