Inspection on 12/11/05 for Abbey Grove

This inspection was carried out on 12th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 Grove 18/07/07

Abbey Grove 19/06/06

Abbey Grove 05/02/06

Abbey Grove 30/11/04

Abbey Grove 15/07/04

Abbey Grove 24/02/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Abbey Grove 2-4 Abbey Grove Eccles Gtr Manchester M30 9QN Lead Inspector Sylvia Brown Unannounced Inspection 12th November 2005 08:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Abbey Grove DS0000008331.V264933.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Abbey Grove DS0000008331.V264933.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Abbey Grove Address 2-4 Abbey Grove Eccles Gtr Manchester M30 9QN 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) 0161 789 0425 Coveleaf Ltd Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Abbey Grove DS0000008331.V264933.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th November 2004 Brief Description of the Service: Abbey Grove is an established care home providing accommodation for 19 older people who require personal care only. The registered provider is Coveleaf Ltd and Mrs Christine Evans is the registered manager. Abbey Grove is a detached property situated in a residential area of Eccles. The home is set in small, enclosed grounds, which provide parking facilities to the side, rear and front of the property, and a patio area leading to a formal lawn area to the side of the building. A ramp provides access to the patio area. Accommodation for residents is provided on the ground and first floor: a passenger lift provides access to all floors. The home offers accommodation in 13 single bedrooms and 3 double rooms. There is ample communal space comprising of two lounge areas, quiet sitting areas and a designated smoking area. The dining room is situated next to the kitchen. Abbey Grove DS0000008331.V264933.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection of Abbey Grove was unannounced commencing at 9.30am on Saturday morning, 12 November 2005. The manager was not on duty, however the senior carer made herself available and facilitated the inspection. Resident’s daily routines were observed throughout the inspection. Mealtime practices were evaluated, as was the provision of activities and care practices of staff. Inspection of the building was undertaken and samples of records were looked at. At the conclusion of the inspection, the feedback of the findings was given to the senior in charge who took detailed notes of all issues raised. What the service does well: What has improved since the last inspection? What they could do better: Care plans require more detail in order to accurately reflect the residents’ care needs and how they should be met. In addition, risk assessments require improving and in some instances introducing for some residents. Residents without mobility require professional assessments carrying out to determine the best method of assisting them to meet their needs and the supplying of appropriate and suitable equipment if required. Abbey Grove DS0000008331.V264933.R01.S.doc Version 5.0 Page 6 Staff files did not contain information to confirm that Criminal Record Bureau checks had been undertaken by the home or POVA First checks completed. The registered person has been required to submit an application for the registration of the manager, and as a matter of urgency fire safety procedures need improving. 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 Grove DS0000008331.V264933.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Abbey Grove DS0000008331.V264933.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 and 3 Prospective residents have their needs assessed and received information about the home prior to being accommodated. EVIDENCE: The home has a statement of purpose and service users’ guide which details the services and amenities available at the home. Both documents are provided to residents and their families prior to and at the point of admission. Resident’s needs are assessed prior to admission by the placing authority and the manager of the home. Upon admission residents receive a contract and terms and conditions of residency which are agreed to and signed for by the resident and or their representative. Abbey Grove DS0000008331.V264933.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Residents written care plans do not contain sufficient details. However, residents appear to have their healthcare needs met. EVIDENCE: Residents spoken to commented positively on the care and attention they received. They stated care staff “were nice’”and “looked after them well”. Throughout the inspection staff were attentive to residents, ensuring their care needs were met. Residents were well dressed in clean, ironed and maintained clothes with some wearing items of jewellery and accessorises, as they preferred. All residents have written care plans in place. After evaluation it was evident that they did not detail all the residents care needs and preferences for care or how those needs should be met. Staff were observed to manually lift one of the residents when assisting with a transfer. When asked they stated the resident had not been assessed for use of a hoist. The care plan failed to identify information regarding the residents immobility or how transference should take place. There was no recorded risk assessment associated with transference support. The manual lifting of Abbey Grove DS0000008331.V264933.R01.S.doc Version 5.0 Page 10 residents places both residents and staff at significant risk and is not permissible. Care files failed to record either daily oral care requirements or annual checks nor was optical monitoring evident for those with failing eyesight. Though medication storage was in the main adequate, best practice is to have an appropriate medication administration trolley from which medication can be safely dispensed. The current practice of setting up medication on the homes tea trolley is not advisable. Medication that required refrigeration was observed to be stored within the domestic refrigerator which is not best practice. Temperature was not monitored to ensure correct temperatures were maintained. Best practice is to have separate medication refrigerator for prescribed medication which requires refrigeration. Medication records were maintained correctly and systems were in place to clearly identify signatures of administration. One member of staff was at the time of the inspection being assessed regarding her competence in administering medication. However it became apparent that training is mainly completed through a mentoring system rather than formal training. Abbey Grove DS0000008331.V264933.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,14 and 15 Residents were satisfied with their lifestyle and they were able to make some decisions. Menus available did not reflect choice being offered. EVIDENCE: Though most residents stated they were satisfied with their day to day living arrangements it was evident that some residents would enjoy more stimulation and socialisation. Staff said that activities are carried out in the afternoon. Although the television was on in one lounge it was difficult to see due to the glare of sunlight on the screen. Furthermore the televisions in both lounges had children’s programmes on for most of the morning. When asked what activities had been completed the day before, staff were somewhat confused and stated that staff had spoken with residents about Remembrance Day. It appeared that the planned Friday ‘video with tea and cakes’ as stated on a notice within the home was not provided. Staff stated that the homes current activities programme was being evaluated for ‘Investors in People’ and therefore not available. Two residents files were evaluated and found to contain little or no information about the individuals previous hobbies and interest and no information relating to any social activities undertaken whilst living at the home. One residents’ Abbey Grove DS0000008331.V264933.R01.S.doc Version 5.0 Page 12 daily record failed to identify anything other than sleeping periods and bowel movements. Some residents were observed maintaining their independence and were encouraged to carry out day to day routines. They were observed baking in the kitchen, washing dishes and clearing up after drinks were served. It was therefore with some surprise that the inspector observed that residents were not permitted to pour their own drinks either at meal times or when provided during the day. The inspector observed mid morning and afternoon drinks being prepared and poured in the kitchen then served collectively. This meant that some residents received their drink up to 15 minutes after being poured. When asked, staff stated it was done this way because only one resident had coffee and “everyone else has tea”. Best practice would be to have both tea and coffee available so residents have a choice. Residents meetings have in the past identified the meals served in the home as being “all right” and “adequate”. The two week rotating menu identified that chips were frequently served and that minced type meat/meals were repeated over the two week period. The menu did not demonstrate a nutritionally balanced diet was served or that the alternative meal offered was appropriate. Fresh fruit and vegetables were also absent from the menu and around the home. Nutritional assessments were not evident within residents’ files and residents’ weights were not sufficiently monitored. Support was provided at meal times to those who required assistance, however there was insufficient seating culminating in one member of staff having to kneel or stand over the resident when assisting. Records of food served was repetitious of the menu, failing to identify individuals intake and if alternatives were provided. On the day of the inspection it was pleasing to see the desert made by a resident being served and enjoyed by other residents. Abbey Grove DS0000008331.V264933.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 A complaints procedure is in place as are adult protection procedures. EVIDENCE: The homes complaints procedure is displayed within the home and residents and their families receive information detailing the complaints procedures and how to access it if and when required. An evaluation of the homes complaints log confirmed staff comments that no complaints had been received since the last inspection. Adult protection procedures were in place. However, training records of two staff could not confirm that training in adult protection procedures had been undertaken. One staff stated although she was aware of reporting procedures she had not received formal training. Abbey Grove DS0000008331.V264933.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,23,24,25 & 26 Residents live in a clean environment. Health and safety was not always appropriately maintained. EVIDENCE: The home offers residents suitable living space; of the nineteen residents thirteen have single rooms. Inspection of the building confirmed that residents had personalised their rooms according to their own taste and had brought in small items of personal effects from their own homes. Since the last inspection new carpets and curtains have been fitted in the main communal areas. Lighting in some areas was not suitable to meet the needs of those with failing eyesight nor was it suitable to enhance or create a homely environment. Fluorescent lighting was in at least one bedroom and within other parts of the home and such lighting is not suitable for use in areas used by residents. Other light fittings had long life bulbs, which gave off poor light and appeared unsuitable for use for those with failing eyesight. Abbey Grove DS0000008331.V264933.R01.S.doc Version 5.0 Page 15 Residents were observed receiving hot drinks without having a suitable side table or convenient surface to place them on. Residents were seen balancing drinks on the arms of chairs. Laundry areas were observed to be clean and tidy and well maintained. Staff explained laundry routines and the practice for managing soiled linens and laundry. The homes washing machines although sufficiently large did not have a suitable sluicing facility or disinfectant programme, which would reduce the effectiveness of any infection control procedures. Also it became evident that there was no specific management of soiled linens and clothing, in that it was not kept separate. The home was free from any unpleasant odours and appeared to be well maintained. Outdoor areas were not well maintained and fallen leaves at the entrance of the home created a slipping hazard and placed residents, staff and visitors to the home at risk. The main garden areas were in need of considerable upgrading to make it suitable and safe for residents. However, staff said that a new gardener had recently been employed and plans were underway to improve the external areas of the home. The testing of fire doors identified that five failed to close when released from their magnetic catch. One fire door was wedged open and most bedroom doors failed to close correctly and did not fit into their rebates effectively. The home therefore was failing to meet fire safety regulations. The senior in charge ensured that staff were aware of action to be taken in the event of a fire and commenced making arrangements to have the faulty doors repaired. As a result, a serious concerns letter has been issued to ensure that immediate action was taken and that the home was compliant with fire safety regulations. Abbey Grove DS0000008331.V264933.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 and 29 Staffing levels in the home did not appear sufficient. EVIDENCE: Examination of the rota identified that on occasions staffing levels were not maintained appropriately. On the weekend of the inspection no ancillary staff were deployed in the home culminating in staff completing domestic and cooking tasks. Furthermore at times the rota indicated that only two carers were on duty after 5pm and on one occasion after 2pm. Whilst there are no set staffing levels the expected ratio minimum is one care staff to eight residents plus a person in control. Due to demand at peak periods in the day or increased dependency of residents the minimum staffing levels should be increased. Ancillary staff should be deployed each day to support the care staff team including at weekends. Evaluation of two staff files confirmed that perspective staff complete an application form and attend an interview. One file contained information which confirmed that staff had received, read and understood the homes policies and procedures and that induction had been undertaken. One file failed to identify that statutory Criminal Record Bureau checks had been undertaken prior to employment being offered or that Protection of Vulnerable Adults first checks had been carried out. Abbey Grove DS0000008331.V264933.R01.S.doc Version 5.0 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 and 38 The home is run in the best interest of residents. EVIDENCE: Since the last inspection the home has employed a new manager. Staff spoke favourably of the manager and that she has made positive changes at the home. At the time of the inspection an application for registration of the manager had not been submitted to the Commission for Social Care Inspection. The home records indicated that fire safety checks were completed weekly in accordance with fire safety regulations, however the outcome of the inspection found a number of fire doors ineffective (as previously stated in the report) which indicated that fire safety checks had not been carried out appropriately. The previous inspection required that the home consult with the fire safety service for advice on fire safety matters. No evidence was available to indicate that any such consultation had taken place and the requirement has been reiterated in this report. The manager must up date her knowledge regarding her responsibilities in relation to fire safety within the home. Abbey Grove DS0000008331.V264933.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 3 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 1 2 3 3 x X X 2 STAFFING Standard No Score 27 2 28 X 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X X X X X X 1 Abbey Grove DS0000008331.V264933.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement The registered person must ensure that all residents needs are identified within their care plans and the action required to meet those needs. The registered person must ensure that all residents have completed risk assessments in placed. The registered person must ensure that a person who is qualified and trained to undertake assessments is used to assess moving and handling requirements for individual residents. The registered person must store medication within the manufacturers recommended temperatures. A suitable refrigerator must be used for this purpose and records maintained of temperature. The registered person must ensure that the routines of daily living and activities made available to residents are flexible and varied to suit their expectations, preferences and DS0000008331.V264933.R01.S.doc Timescale for action 01/01/06 2 OP7 13 & 14 01/01/06 3 OP7 14 01/01/06 4 OP9 13 01/01/06 5 OP12 12 01/01/06 Abbey Grove Version 5.0 Page 20 6 OP15 16 7 OP15 16 8 OP15 17 9 OP18 13 10 OP19 13 11 OP20 23 12 13 OP26 OP27 13 18 14 OP29 Schedule 2 capacities. The registered person must ensure that all food and drinks served are done so at an appropriate temperature. The registered person must ensure that the homes menu offers residents a well balanced, nutritional diet which offers residents choice and variety. The registered person must ensure that residents have nutritional assessments in place, that they receive the nutrition required and that their weight is accurately monitored and routinely recorded. The registered person must ensure that all staff receive up to date adult protection procedures and are aware of whistle blowing procedures and their responsibility to report all suspicions of abuse and or poor practice. The registered person must ensure that all external walkways are maintained in a safe manner and are free from hazards. The registered person must provide residents with suitable side tables in the lounge areas on which to place such things as hot drinks in order not to be placed at risk. The registered person must ensure that infection control procedures are maintained. The registered person must ensure that sufficient staff are employed in the home to meet the needs of the residents. The registered person must ensure that CRB checks are received or POVA First verifications are received for new staff prior to them commencing DS0000008331.V264933.R01.S.doc 01/12/05 15/12/05 15/12/05 01/02/06 13/11/05 27/01/06 01/02/06 15/12/05 15/12/05 Abbey Grove Version 5.0 Page 21 15 OP31 8 16 OP38 23 17 OP38 23 their first duty. The registered person must submit an application for the registration of the manager to CSCI. The registered manager must after consulting with the fire safety officers ensure that all staff are aware of their responsibilities for maintaining fire safety standards. The registered person must ensure that all equipment including fire safety doors are maintained in good and safe working order at all times. 01/12/05 01/12/05 12/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations It is recommended that information recorded on the individual resident on a day-to-day basis be done so in a manner that reflects the information contained within the Care Plan. It is recommended that a suitable medication trolley be purchased. The registered person should replace fluorescent tube lighting in areas used by residents with appropriate domestic style lighting. 2 3 OP9 OP20 Abbey Grove DS0000008331.V264933.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ 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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