This inspection was carried out on 26th September 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. These are things the inspector asked to be changed, but found they had not done.
The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.
CARE HOME ADULTS 18-65
Abbey Grange Residential Home Oaks Road Whitwick Coalville LE67 5UP Lead Inspector
Martin Hefferman Unannounced Inspection 26th September 2005 01:00 Abbey Grange Residential Home DS0000001661.V252282.R01.S.doc Version 5.0 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.V252282.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 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.V252282.R01.S.doc Version 5.0 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.V252282.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. No additional conditions of registration apply. Date of last inspection 21/06/05 Brief Description of the Service: Abbey Grange is registered to provide care for up to fourteen adults 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 DS0000001661.V252282.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 over the course of approximately five hours. 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 acting manager facilitated the inspection. What the service does well: What has improved since the last inspection? What they could do better:
The home must ensure that risk assessments are kept under review to ensure that they reflect any changes in residents’ needs. The home must keep a record of any health-related appointments attended by residents to demonstrate that their healthcare needs have been met.
Abbey Grange Residential Home DS0000001661.V252282.R01.S.doc Version 5.0 Page 6 The registered person must investigate a number of entries in records relating to residents’ finances and report the outcome of that investigation, providing suitable evidence, to the CSCI. It is strongly recommended that two members of staff should sign residents’ financial records. Staff members should receive training on the protection of vulnerable adults and whistle blowing. Work is needed to improve the standard of accommodation provided for residents. The home must submit an action plan detailing the timescales within which work required by the Fire Service will be completed. The owners must undertake monthly monitoring visits to the home and forward a copy of the reports arising from those visits to the CSCI. 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.V252282.R01.S.doc Version 5.0 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.V252282.R01.S.doc Version 5.0 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): 2 The outcome for standard 2 could not be assessed on this occasion. EVIDENCE: Two of the residents who were chosen for the purposes of case tracking moved to the home in 1997, the third in 1998. There have been no admissions since the date of the last inspection. The acting manager stated that he did not intend to accept any new referrals for the foreseeable future. Abbey Grange Residential Home DS0000001661.V252282.R01.S.doc Version 5.0 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 Individual plans are clear and appear to provide staff members with the information they need to meet residents’ needs. Failure to keep risk assessments under review could however put residents and staff at risk. EVIDENCE: Individual plans set out residents’ needs in respect of their health and personal care. All of the care plans that were inspected had been reviewed during April 2005. Individual risk assessments did not however appear to have been reviewed since the date on which they were completed in September 2003. Individual plans contained information about residents’ preferences. In the case of two of the residents who were chosen for the purposes of case tracking, this information is limited and is based upon knowledge of the resident built up over time. The file for the third resident contained a workbook entitled ‘My Life’, which set out information about her likes and dislikes. The acting manager stated that he intends to implement person-centred planning for all residents and to introduce house meetings to discuss issues like the home’s menus. Abbey Grange Residential Home DS0000001661.V252282.R01.S.doc Version 5.0 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 the following standard(s): 13 & 16 Arrangements for accessing the local community and residents’ daily routines appear to be well managed. EVIDENCE: Residents use a range of resources within the community. One resident stated that she had enjoyed swimming on the day of the inspection. The acting manager stated that specific time is allocated to enable keyworkers to undertake activities on a one-to-one basis. The home has its own transport. Residents stated that they could decide when to undertake the various activities of daily living. One resident stated that she preferred her keyworker to assist with personal care tasks. Information about her preferred daily routine had been recorded in her individual plan. Two of the residents who were present at the time of the inspection made their own hot drinks with the assistance of staff. Abbey Grange Residential Home DS0000001661.V252282.R01.S.doc Version 5.0 Page 11 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 Arrangements for managing residents’ healthcare needs must be strengthened in order to demonstrate that those needs have been met. EVIDENCE: The individual plans that were inspected detailed the personal support residents require. The plans 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. It was not possible to locate records of any health-related appointments for two of the three residents who were chosen for the purposes of case tracking. Whilst the requirements of standard 20 were not inspected on this occasion, medication administration records for the three residents who were chosen for the purposes of case tracking were viewed. The home was reminded that each dose of medication must be recorded and that a reason must be stated where it has not been administered. Abbey Grange Residential Home DS0000001661.V252282.R01.S.doc Version 5.0 Page 12 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 Arrangements for the protection of vulnerable adults need to be strengthened in order to fully protect residents’ rights. EVIDENCE: Since the date of the last inspection, the home has amended its complaints procedure. The acting manager stated that he would produce a more accessible version of the procedure to give to residents (a recommendation from the last inspection). He confirmed that a record would be kept of any complaints that were received and of the action taken as a result. The home has policies and procedures on the protection of vulnerable adults and whistle blowing. Staff members stated that they had not received any training or guidance regarding these issues. Records relating to residents’ finances were examined. A number of entries were identified for which no change had been given. A requirement has been made that the registered person must investigate those entries and report the outcome of that investigation to the CSCI. It was noted that one member of staff had signed residents’ financial records. Abbey Grange Residential Home DS0000001661.V252282.R01.S.doc Version 5.0 Page 13 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 The current standard of accommodation does not provide a safe and homely environment. EVIDENCE: The acting manager stated that he had completed an audit of the premises and sent a report identifying the areas that need attention to the registered person. Four residents’ rooms, all of the communal areas and part of the grounds were inspected during the course of this visit. The following issues were identified that require attention: a number of fire doors have been fitted incorrectly; paving slabs at the bottom of a fire escape were broken; cupboard doors in the dining room have been damaged; a number of residents’ rooms need to be redecorated; the ceiling on the middle floor has been stained; and there was an offensive odour in a resident’s room. The acting manager stated that a number of issues including those relating to the fire doors and fire escape had been identified during a recent inspection by the Fire Service and that the latter had given the home three months to rectify the problems. He reported that he was in the process of arranging for an electrician to test the hard wiring. The acting manager stated that he hoped to develop the garden and to improve the living environment over the following six to twelve months. The home had recently purchased a number of new beds and mattresses.
Abbey Grange Residential Home DS0000001661.V252282.R01.S.doc Version 5.0 Page 14 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): Not applicable EVIDENCE: None of the standards in this section were inspected fully on this occasion. Staffing levels on the day of the inspection complied with the requirements set by the previous regulatory authority. Residents appeared to enjoy a positive relationship with the staff on duty. The acting manager stated that he was in the process of arranging training on a range of issues including fire safety, first aid & epilepsy and that he hoped to access Learning Disability Award Framework–accredited training in the near future (a recommendation from the last inspection). Abbey Grange Residential Home DS0000001661.V252282.R01.S.doc Version 5.0 Page 15 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 The home’s working practices have improved since the date of the last inspection but need to be strengthened further in order to fully protect residents. EVIDENCE: The acting manager started work at the beginning of August. He stated that he would be applying to be registered with the CSCI. The Commission has received one Regulation 26 report (visits by the registered provider) since the date of the last inspection. The acting manager stated that he had completed a revised Fire Risk Assessment and evacuation procedure. Records indicate that fire tests and drills have been completed at the required frequency. Staff members are due to attend fire safety training on 10/10/05. A number of issues regarding the safety of the premises have been identified (see standard 24). Abbey Grange Residential Home DS0000001661.V252282.R01.S.doc Version 5.0 Page 16 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 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 2 X X X Standard No 24 25 26 27 28 29 30
STAFFING Score 1 X X X X X 2 LIFESTYLES Standard No Score 11 X 12 X 13 3 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X X X X X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Abbey Grange Residential Home Score 3 2 X X Standard No 37 38 39 40 41 42 43 Score 2 X 2 X X 1 X DS0000001661.V252282.R01.S.doc Version 5.0 Page 17 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 YA6 Regulation 15 Requirement The registered person must ensure that individual risk assessments are kept under review. The previous timescale of 31/08/05 was not met. The registered person must ensure that a record is kept of any health-related appointments attended by residents. The registered person must investigate a number of entries in records relating to residents’ finances and report the outcome of that investigation & provide suitable evidence to the CSCI. The registered person must submit an action plan detailing the timescales within which work required by the Fire Service will be completed. The registered person must ensure that the premises are kept in a good state of repair internally and externally. The registered person must ensure that all parts of the care home are kept clean and reasonably decorated. The registered person must ensure that regular authorised
DS0000001661.V252282.R01.S.doc Timescale for action 31/12/05 2 YA19 12 26/09/05 3 YA23 13 19/10/05 4 YA24 23 31/10/05 5 YA24 23 31/12/05 6 YA24 23 31/03/06 7 YA39 26 26/09/05 Abbey Grange Residential Home Version 5.0 Page 18 visits are made to the home and that the reports produced from the visits are forwarded to the local CSCI office. The previous timescales of 10/02/05 & 21/06/05 were not met. 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 Refer to Standard YA23 YA23 Good Practice Recommendations It is recommended that staff members should receive training on the protection of vulnerable adults and whistle blowing. It is strongly recommended that two members of staff should sign residents’ financial records. Abbey Grange Residential Home DS0000001661.V252282.R01.S.doc Version 5.0 Page 19 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.V252282.R01.S.doc Version 5.0 Page 20 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
