Inspection on 25/04/06 for Abbey Grange Residential Home

This inspection was carried out on 25th April 2006.

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 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 17/04/07

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 Unannounced Inspection 25th April 2006 10:35 Abbey Grange Residential Home DS0000001661.V290113.R01.S.doc Version 5.1 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.V290113.R01.S.doc Version 5.1 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.V290113.R01.S.doc Version 5.1 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.V290113.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. No additional conditions of registration apply. Date of last inspection 26th September 2005 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 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 a community day service, which is run by the registered provider in a nearby town. At the time of the inspection, the fees ranged from approximately £600 to £1200 depending upon individual need. Information for prospective residents about the service provided was not available. Abbey Grange Residential Home DS0000001661.V290113.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A visit to the home took place on 25th April 2006, lasting approximately seven and a quarter hours. The main method of inspection used on that day was ‘case tracking’ which involved selecting two residents and tracking the care they received through review of their records, discussion with them (where appropriate), the care staff and observation of care practices. One of the residents who were chosen for the purposes of case tracking had no verbal communication. Four residents were spoken to during the course of the visit. The inspection also took account of the findings from a visit to the home on 9th March 2006. The reason for that visit was to follow up the requirements made at the time of the last inspection. Any information received since the date of the last inspection was also reviewed as part of the preparation for this visit. What the service does well: What has improved since the last inspection? What they could do better: Any future residents and their representatives should have access to the information they need to make a choice about whether to move to the home. Abbey Grange Residential Home DS0000001661.V290113.R01.S.doc Version 5.1 Page 6 Individual plans and risk assessments must be reviewed to ensure that staff members have the information they need to meet residents’ needs. A record must be kept of all complaints and of the action taken as a result to demonstrate that the views of residents and their representatives have been listened to and acted upon. Work is needed to improve the standard of accommodation provided for residents. Record keeping practices need to be improved to demonstrate that residents are protected by the home’s arrangements for recruiting and training staff. Action must be taken to appoint a registered manager. The fire authority must be consulted with regard to the proper frequency of fire tests and drills. A record of all visitors to the home must be kept to assist emergency services in the event of a fire. The management of the home should look into ways in which it can judge the quality of the service provided to 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 DS0000001661.V290113.R01.S.doc Version 5.1 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.V290113.R01.S.doc Version 5.1 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 the following standard(s): 1&2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents and their representatives do not have access to the information they need to make an informed choice about whether to move to the home. EVIDENCE: Information about the service provided to residents was not available at the time of the inspection. Mr McKean (who represents Woodley Holidays Limited) stated that the documents that had been used in the past needed to be reviewed. The outcome for standard 2 could not be fully assessed on this occasion. There have been no admissions since the date of the last inspection. The residents who were chosen for the purposes of case tracking moved to the home in 1997 & 2003. Their files contained assessments completed by social workers. Mr McKean stated that he did not intend to accept any new referrals for the foreseeable future. Abbey Grange Residential Home DS0000001661.V290113.R01.S.doc Version 5.1 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 the following standard(s): 6, 7 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are encouraged to make decisions about their lives wherever possible. Individual plans and risk assessments must be reviewed to ensure that staff members have the information they need to meet residents’ needs. EVIDENCE: At the time of the inspection, staff members were in the process of transferring care-planning information from residents’ files to a new format. One of the plans that were inspected appeared to be clear and comprehensive. A second contained minimal information about the majority of the resident’s needs. The file for that resident contained a person-centred plan, which had not been dated. The resident and her family had been involved in the preparation of the plan, which contained information about her preferences. Workbooks for developing person-centred plans for all of the residents have been obtained but have yet to be completed. Individual risk assessments have yet to be reviewed despite this issue having been identified at the last inspection (September 2005). Abbey Grange Residential Home DS0000001661.V290113.R01.S.doc Version 5.1 Page 10 One of the residents who were chosen for the purposes of case tracking stated that she had chosen the colours for her bedroom. She reported that she could decide when to get up and go to bed, indicating that she preferred to lie-in at the weekend. A second resident stated that he had spent the morning shopping with a member of staff and had then gone out for lunch to celebrate his birthday. Residents stated that they are able to undertake a range of activities whilst attending the day service (see Lifestyle). Abbey Grange Residential Home DS0000001661.V290113.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 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 appear to be well managed. EVIDENCE: Residents attend day services, which are run by the registered provider in a nearby town. Residents stated that they are able to undertake a range of activities - including swimming, bike riding, bowling and ‘shop & cook’ sessions - whilst attending the day service. One resident stated that she enjoys going shopping with staff at the weekend. A second resident attends a social group for older people with learning disabilities. Specific time is allocated to enable staff members to undertake activities with residents on a one-to-one basis. The acting manager stated that she intends to revise the staff rota to enable residents to undertake more activities in the evenings. Progress regarding this issue will be checked at the next inspection. The home has its own transport. One resident stated that she spoke to her mother on the phone every evening and that her family visited her at the home. Records indicated that other residents were in regular contact with their families. Abbey Grange Residential Home DS0000001661.V290113.R01.S.doc Version 5.1 Page 12 Residents stated that they enjoyed the meals that were provided on the day of the inspection. Staff members reported that the quality of the food had improved since they started to purchase ingredients from a supplier and that they were now able to cook freshly prepared meals and cakes. Abbey Grange Residential Home DS0000001661.V290113.R01.S.doc Version 5.1 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 at least once during a 12 month period. 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. Arrangements for managing residents’ personal & healthcare needs appear to be generally well managed. EVIDENCE: Residents stated that they received personal support in the way they preferred. The individual plans that were inspected detailed the personal care each person requires. The plans also set out details of any healthcare needs that had been identified and of any action that was felt to be necessary as a result. A requirement has been made that individual plans must be reviewed to ensure that the information contained within them is up-to-date. A record had been kept of healthcare appointments attended by residents (a requirement from the last inspection). None of the residents who were chosen for the purposes of case tracking were able to manage their medication. Records had been kept of all medicines received into the home and administered to residents. A contract pharmacy inspected medication arrangements at the home during October 2005. Records indicated that no issues had been identified. Staff members stated that they had received medication training – a receipt appeared to verify this although certificates for individual members of staff were not available (see Staffing). Abbey Grange Residential Home DS0000001661.V290113.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A record must be kept of all complaints and of the action taken as a result to demonstrate that the views of residents and their representatives have been listened to and acted upon. EVIDENCE: One resident stated that she would speak to staff if she had any concerns. It was not possible to ascertain whether other residents were aware of the home’s complaints procedure. Staff members stated that complaints had been received since the date of the last inspection. It was not possible to locate any record of those complaints or of the action taken as a result. The home has policies and procedures on the protection of vulnerable adults and whistle blowing. A senior member of staff indicated that she was aware of the action to be taken in the event of an allegation or suspicion of abuse. The acting manager stated that she would ensure all staff members were aware of the procedures to follow. It was noted that one member of staff had signed some of the entries in residents’ financial records. It was recommended at the time of the last inspection that two members of staff should sign each entry. Abbey Grange Residential Home DS0000001661.V290113.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The current standard of accommodation does not provide a homely and comfortable environment. EVIDENCE: 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, new dining room furniture has been obtained and the dining areas have been reorganised. Paving slabs at the bottom of a fire escape have been repaired. The following issues were identified that require attention: the wallpaper in a number of residents’ rooms had been damaged; the blinds in two residents’ rooms let in a lot of light; the lock on a bedroom door needed replacing; areas of wall in one of the dining areas needed to be repaired; a number of radiators had yet to be covered and a tap in a downstairs toilet was not working. Staff members stated that some of the soft furnishings were not appropriate given the needs of individual residents. Outside there were piles of rubble and other debris. The fence surrounding a pond had been broken. Abbey Grange Residential Home DS0000001661.V290113.R01.S.doc Version 5.1 Page 16 A new maintenance man has started since the date of the last visit. The acting manager has introduced a maintenance book in which staff can record any issues that require attention. Abbey Grange Residential Home DS0000001661.V290113.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Record keeping practices need to be improved to demonstrate that residents are protected by the home’s arrangements for recruiting and training staff. EVIDENCE: A number of residents stated that they got on well with staff members. Other residents appeared to enjoy a positive relationship with the staff on duty at the time of the visit. The staff records that were inspected were incomplete. One of the files contained one written reference. There was no record of the outcome of Criminal Records Bureau disclosures in two of the files that were inspected. One of the files contained certificates from a range of training courses completed over the course of the previous three years; the second file (for a member of staff who had worked at the home for over two years) contained details of one course. Both members of staff stated that they had completed training for which no records were available. A recently appointed member of staff had completed the home’s induction programme. The acting manager stated that the home had yet to access Learning Disability Award Framework–accredited training (a recommendation from an inspection in June 2005). Staff members stated that they had recently Abbey Grange Residential Home DS0000001661.V290113.R01.S.doc Version 5.1 Page 18 completed training on fire safety, first aid, food hygiene and moving & handling but that they had yet to receive their certificates. Information about the number of staff who have completed National Vocational Qualifications was not available at the time of the inspection. Abbey Grange Residential Home DS0000001661.V290113.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents would benefit from the appointment of a permanent manager. EVIDENCE: The acting manager at the time of the last inspection was no longer employed at the home. The current acting manager, who had been in post for approximately four weeks at the time of the visit, stated that her contract ran until the end of June 2006 and that she would not be applying to be registered with the Commission for Social Care Inspection. The home has been without a registered manager since March 2005. Mr McKean stated that he was in the process of applying to be the Responsible Individual. The Commission has received Regulation 26 reports (visits by the registered provider) since the date of the last inspection. The acting manager stated that she was not aware of any other procedures for assessing the quality of the service provided to residents. She plans to introduce her own audit checklist. Abbey Grange Residential Home DS0000001661.V290113.R01.S.doc Version 5.1 Page 20 Staff members stated that they had recently attended training on a number of safe working practices (see Staffing). Records indicated that the fire alarm system had last been tested on 7th April 2006 and that the last fire drill had taken place in December 2005. A record of visitors to the home was not available at the time of the inspection. The acting manager stated that she would speak to staff members about the need to report incidents under Regulation 37. Abbey Grange Residential Home DS0000001661.V290113.R01.S.doc Version 5.1 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 2 2 X 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 2 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 2 X X 2 X Abbey Grange Residential Home DS0000001661.V290113.R01.S.doc Version 5.1 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. 1. 2. 3. 4. 5. 6. 7. 8. Refer to Standard YA1 YA6 YA6 YA22 YA24 YA34 YA37 YA39 Good Practice Recommendations It is recommended that the registered person produce an up-to-date service user guide. It is strongly recommended that individual plans be reviewed. It is strongly recommended that individual risk assessments be reviewed. It is strongly recommended that a record be kept of all complaints and of the action taken as a result. It is strongly recommended that the environmental issues identified in this report be addressed. It is strongly recommended that records relating to the recruitment and training / qualifications of staff are complete and up-to-date. It is strongly recommended that the registered person submit an action plan relating to the appointment of a registered manager. It is recommended that the management of the home investigate systems for assessing the quality of the service DS0000001661.V290113.R01.S.doc Version 5.1 Page 23 Abbey Grange Residential Home 9. 10. YA42 YA42 provided to residents. It is strongly recommended that the home consult the fire authority with regard to the proper frequency of fire tests and drills. It is strongly recommended that a record be kept of all visitors to the home. Abbey Grange Residential Home DS0000001661.V290113.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester 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. Extracts may not be used or reproduced without the express permission of CSCI Abbey Grange Residential Home DS0000001661.V290113.R01.S.doc Version 5.1 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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