Inspection on 18/07/07 for Abbey Grove

This inspection was carried out on 18th July 2007.

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 Grove 19/06/06

Abbey Grove 05/02/06

Abbey Grove 12/11/05

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 Helen Dempster Unannounced Inspection 18th July 2007 11:25 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.V339508.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V339508.R01.S.doc Version 5.2 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 vacant post Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Abbey Grove DS0000008331.V339508.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th December 2006 Brief Description of the Service: Abbey Grove is a care home providing accommodation for 19 older people who require personal care only. The registered provider is Coveleaf Ltd. The home is a detached property, situated in a residential area of Eccles. It has small, enclosed grounds, with 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 three double rooms. There is ample communal space comprising of two lounge areas, quiet sitting areas and a dining room. The home does not have a designated smoking area because the manager said that the current residents do not smoke and it has been decided that the home will be smoke free. The fees charged are £364.19 per week, with additional charges for hairdressing, personal toiletries, newspapers and magazines. Abbey Grove DS0000008331.V339508.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was conducted by gathering lots of information about how well the home was meeting the residents needs. This included the manager filling in a questionnaire about the service, which gave information about the residents, the staff and the building. The inspection also included carrying out an unannounced visit to the home on 18th July 2007 from 11:25am to 7.25pm. During this visit, lots of information about the way that the home was run was gathered. Time was taken in talking with residents, the manager and the staff team about the day-to-day care, staff training and support and what living at the home was like for the residents. Other information was also used to produce this report. This included reports about things and events affecting residents that the home’s staff had informed the Commission about. The term preferred by the people consulted during the visit was “residents”. This term is, therefore, used throughout the report when referring to those people living at the home. What the service does well: The staff assess residents’ needs before they are admitted which ensures that the home can meet each resident’s needs. A resident’s relative described the admission process and said that staff were “very understanding” of the resident’s “feelings” and that of the family and are still considerate of feelings. The resident’s benefit from having their choices and social needs respected and being supported to maintain contact with family and friends. Residents said that they have “good meals”. A resident’s relative said that the food at the home was good and that their relative had stated, “we’re always well fed”. Residents and a relative said that visitors to the home are made welcome. One resident’s relative said that a family member visits every day and said, “you are never made to feel that you’re in the way”. This relative talked about how much this resident’s family appreciated the fact that the manager supported them to hold this resident’s birthday party at the home and said ”everybody was made to feel very welcome”. This is good for the residents. Residents said that they would tell the manager if they had a problem. A resident said that they would “go to the manager right away”, another resident said we have “no worries, none whatsoever” and a resident said that the manager was “not a person to be frightened of”. Abbey Grove DS0000008331.V339508.R01.S.doc Version 5.2 Page 6 Residents liked the staff. One resident said that they “couldn’t have better staff”. A resident’s relative said of staff “they’re all very approachable” and are “absolutely lovely”. This is good for the residents. Residents liked the manager. One resident said the “new manager is “excellent” and that the “manager is one of us, she mixes with us”. This is good for the residents. Staff liked the manager. They said that they were “encouraged to learn and progress” and that the manager was “very keen on us progressing”. She was also described as “very good” and “very experienced” and as having “lots of new ideas”. The kitchen was clean and the staff had been awarded with Salford Council’s Silver Award for kitchen hygiene. Overall, health and safety at the home was good. What has improved since the last inspection? What they could do better: The service had been going through a process of change and the manager was in the early stages of implementing positive change. Some aspects of the service needed improve. This included the following: Care plans and risk assessments needed development and consistent review, so that residents are fully safeguarded and risk assessments needed to say what exactly staff needed to do to minimise risks. Nutritional plans needed to be in place, and professional advice needed to be consistently sought, when concerns about residents’ nutrition and weight were identified. Residents needed to have a care plan concerning medication, which detailed the level of support they needed and any problems they had in taking medication. The manager needed to hold a complaints record to record the outcomes of any concerns raised by residents. Abbey Grove DS0000008331.V339508.R01.S.doc Version 5.2 Page 7 Some furniture needed to be repaired, and bathrooms would benefit from refurbishment. Privacy locks should always be in place and an individual resident’s privacy and security should be respected by not using their bedroom for dressing the hair of other residents. All hoists must be in working order. The manager needed to collate the outcome of the home’s quality assurance process, and to report them to residents/families etc. Fire drill records need to be more detailed. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Abbey Grove DS0000008331.V339508.R01.S.doc Version 5.2 Page 8 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.V339508.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 4 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Completing a full assessment of needs, and sensitively supporting residents and their relatives during the admission process, ensures that residents’ personal care and emotional needs are met. EVIDENCE: The admission process for four of the residents was discussed and their files were seen. All four residents’ files had a copy of the assessment completed by a Social Worker and a copy of the assessment completed by the staff at the home before their admission. Abbey Grove DS0000008331.V339508.R01.S.doc Version 5.2 Page 10 The manager said that prospective residents were always assessed in hospital, or in their own home, before admission. The manager said that this ensured that the staff felt confident that they could meet that resident’s needs. This is good for the residents. One resident’s relative talked about the way their family member was admitted. This person explained that the resident made a choice when in hospital, someone from the home did an assessment of the resident in hospital and family members visited the home three times before the planned admission, (as this person was unable to). This relative spoke highly of the staff member who assisted with the admission. This staff member was said to be “absolutely wonderful” and this relative added that “I don’t know what we’d have done without” this member of staff. In particular the relative talked about the sensitivity of this member of staff, and staff in general, who were said to be “very understanding” of the resident’s “feelings and that of the family and are still considerate of feelings”. Two residents also described their admission to the home. One of these residents said that they had a list of care homes and “chose this one” and when this person visited before admission they said that “as soon as I came in I knew it was right”. Abbey Grove DS0000008331.V339508.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall, the health and personal care needs of the residents were met, but care plans, risk assessments and nutritional plans needed development so that residents are fully safeguarded. EVIDENCE: The care plans for four of the residents were seen. Care plans are completed on a computer. The form has headings to guide the staff to record what the resident’s needs are, what needs to be done to meet these needs, how often and by whom. Some of the care plans were detailed and explained how staff needed to support an individual resident in the way they preferred to be supported. However, some care plans were lacking in detail. One example was a care plan about an individual’s continence, which noted, “on occasions may Abbey Grove DS0000008331.V339508.R01.S.doc Version 5.2 Page 12 have an accident”. The care plan did not note in what circumstances this may happen and what staff needed to do to minimise this. One resident said that they had “never seen” their care plan, but this resident had signed it, as had other residents. All care plans contained a “pen picture”. These provided important and meaningful information about a resident’s personality, which were written in a positive way. One example was a resident who had a poor short-term memory, but whose pen picture noted that this person “can remember back to the year dot and loves to tell stories”. Pen pictures also noted the reasons for residents’ behaviour. One example was a resident being described as “a fighter” who tries to do things independently and who “finds it frustrating when they can not do something independently”. This is good for the residents. Residents were usually weighed each month. The weight chart for one resident, who had been unwell, noted that this resident had weighed 9 Stone in July 2006, but by March 2007 this resident’s weight had dropped to 6Stone 9 pounds. The resident had not been weighed again since March, as they were unable to weight bear to stand on the scales. In March 2007, the manager had introduced daily monitoring of this resident’s diet, until April 2007, when the staff felt that this resident had improved. Although this was good, a nutritional plan had not been put in place to detail how the weight loss may be addressed and, although a doctor had been consulted, the advice of a dietician was not sought. Another resident was said to have a heart condition and staff were concerned about rapid weight gain. This included a gain of 13lb in one month. Again, a nutritional plan was not in place to address this, and the advice of a dietician had not been sought. Through discussion, the manager demonstrated a professional and open approach to the need to record residents’ likes and dislikes and a nutritional plan. Care plans were reviewed on a monthly basis, but the reviews did not always reflect all changes in needs. One example was a resident who had lost a lot of weight, yet the care plan review did not reflect this. Risk assessments were in place to cover some aspects of risk, including mobility, medication, continence and safety in bed. However, there had not been a comprehensive assessment of all risks associated with daily living for each individual resident. This included one resident who only had a risk assessment concerning the risk of falls. Risk assessments did not always detail what staff needed to do to minimise risk. One example was a resident who was said to need “staff to be with them when mobilising”. The risk assessment needed to detail what exactly staff needed to do to minimise this risk. Abbey Grove DS0000008331.V339508.R01.S.doc Version 5.2 Page 13 One of the strategies the manager had adopted to reduce the risk of falls was to audit the circumstances in which residents had fallen. This included checking for risks in the room in which people had fallen and monitoring the way that certain behaviour increased risk. Checking for recurring patterns of falls had proved to be a good way of minimising some risks, which is good for the residents. The relative of one resident who visited the home frequently was asked about any observations of the way that the residents were supported by the staff. This person said, “I really can’t say I’ve ever seen anything I’ve not liked”. The relative went on to describe how caring the staff were to residents. Medication was stored in a trolley in a communal area, but was not secured to the wall. The manager explained that the lock had been purchased and was about to be fitted. The medication administration records (MARS) included a record of the staffs’ signatures and a photograph of each resident. The staff were using loose leaves in a file to record the administration and balances of controlled drugs. The need to obtain a controlled drugs register was discussed. Overall, medication records had a high level of accuracy. The manager said that this was maintained by doing regular spot checks and audits. One resident’s medication administration record included medication that the manager said that this person self medicated, but the record did not show this. During discussion, the manager agreed that staff would benefit from knowledge gained by each resident having a care plan concerning medication, which detailed the level of support they needed and any problems they had in taking medication. Abbey Grove DS0000008331.V339508.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The resident’s benefit from having their choices and social needs respected, being supported to maintain contact with family and friends and having good food. EVIDENCE: Care plans contained some details of social preferences and religious needs. This included the care plan of one resident which noted that this person “likes to get up early and down for breakfast”, “loves a good banter” and “joins in all social events with enthusiasm and loves the singing”. The manager said that some care plans do need to be more fully developed to reflect social needs and that she was working on this. One resident talked about current hobbies and previous employment. This resident had worked in clothing manufacture and enjoyed knitting, sewing and reading. This was noted on the care plan, there was a sewing machine, wool Abbey Grove DS0000008331.V339508.R01.S.doc Version 5.2 Page 15 and lots of books in this resident’s room and this person said that the staff at the home understand their need to be independent and to “help with jobs around the house”. This resident talked about being “miserable if I have nothing to do” and said that the staff respected this. Residents and a relative said that visitors to the home are made welcome. One resident’s relative said that a family member visits every day and stated, “you are never made to feel that you’re in the way”. This relative talked about how much this resident’s family appreciated the fact that the manager supported them to hold this resident’s 90th birthday party at the home. The relative explained that 24 family members, including grandchildren and great grandchildren attended the party, and that the other residents joined in. The relative said that ”everybody was made to feel very welcome” and that the family “felt able to approach” the staff to discuss planning the party. This is good for the residents. One resident talked about the new television donated to the home. This resident said that “the new television was donated by the family of a resident who died, because they were so pleased with how they were looked after, in appreciation”. It was obvious that staff communicated news of this nature to the residents, and that they were included in decision making at the home. Residents talked about their enjoyment of an entertainer who visited the home every 12 weeks and on special occasions, including Independence Day, Valentines Day and Easter. The manager said that has weekly discussion with residents to plan that weeks food shopping. She said that she asks about favourite foods and that the residents agree what they want for Sunday Dinner and other meals. The manager said that this enabled the cook to provide seasonal favourites e.g. strawberries and cream. The manager said that a four-week rotating menu has been planned, based on these discussions and that she plans to introduce table menus. The cook on duty said that when new residents are admitted, the cook talks to them and finds out their likes and dislikes. The cook added that residents are asked for their menu choices each day and this was seen to be recorded. On the day of the visit the main meal was chicken, vegetables, potatoes and gravy, followed by banana custard or fruit. Two of the residents said that they have “good meals”. A resident’s relative said that the food at the home was good and that their relative had stated, “we’re always well fed”. The relative said that visitors can go in the kitchen and make a cup of tea and that this room is only locked for safety reasons if staff were busy elsewhere. Abbey Grove DS0000008331.V339508.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were confident that their views and concerns would be heard, but outcomes needed to be recorded, and staff knowledge gained from recent training in the protection of adults from abuse, safeguarded residents. EVIDENCE: A copy of the complaint’s procedure was on the notice board, but residents said that they had not seen it. Despite this, without exception, residents said that they would tell the manager if they had a problem. One resident said that they would “go to the manager right away”. Another resident said we have “no worries, none whatsoever”, this person added that residents could talk to the manager who understands people”. Another resident described the manager as “approachable” and “ sociable” and added, “if there’s anything I don’t like I speak my mind”. The fact that the manager was approachable was summed up by a resident, who said that the manager was “not a person to be frightened of”. One resident’s relative said that they had not seen the complaints procedure, “but never needed it”. Abbey Grove DS0000008331.V339508.R01.S.doc Version 5.2 Page 17 The manager said that she did not have a complaints record, as there have not been any complaints for years. Through discussion, the manager said that some time ago, a resident said that they’d heard a member of staff “speaking out of turn” to another member of staff and that this upset them. This was not recorded as a complaint/concern and the staff involved had not therefore been interviewed about the issue. The need to reconsider the definition of a complaint and to record such issues was discussed and the manager agreed that this would be done. The manager ensured that a copy of the Protection of Vulnerable Adults Policy was in place and all staff had signed the policy to confirm that they had understood it. All the staff had attended training in the protection of vulnerable adults on 27/09/06. This training was provided by Salford Council. Abbey Grove DS0000008331.V339508.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall, the premises are comfortable, safe and well maintained. However, some furniture needed to be repaired and residents’ privacy was not always fully respected. EVIDENCE: Some residents’ bedrooms, bathrooms, the kitchen and communal areas were seen. The three bathrooms were bare and were not homely. They would benefit from refurbishment. One bathroom had a broken privacy lock and all three were fitted with baths. Not having a shower restricted choice. The manager said Abbey Grove DS0000008331.V339508.R01.S.doc Version 5.2 Page 19 that some residents use a hand held shower in the bath. The hoist in one bathroom was working, but the one in the other was not. This needs to be addressed. Overall, residents’ bedrooms were clean and homely and had been personalised. However, some of the furniture was damaged and had ill-fitting doors and the manager agreed to complete an audit of which furniture should be repaired or replaced. Residents said that they were happy with their rooms. One resident said that they had a “lovely room” and that the “place is clean”. At the time of the visit, a hairdresser was using one resident’s bedroom to do the hair of most of the residents at the home. The fact that this practice did not respect the privacy and dignity of this resident was discussed. The manager said that this was historical practice, which had “always been done here”. The manager agreed that this needed to be reviewed. The kitchen was clean and the staff had been awarded with Salford Council’s Silver Award for kitchen hygiene. The window was open and the fly screen was damaged. This needed addressing. There was lots of space for storing food. One freezer door had not been closed properly and the food had partially defrosted and the freezer had iced up. The manager disposed of the food and said that the freezer was under warranty and would be repaired. The manager said that since the last inspection, four bedrooms had been decorated, three bedroom carpets had been replaced, and the hall stairs and landing carpet had been replaced. The manager said that there were plans to purchase new curtains, new chairs and to have some commodes recovered. Abbey Grove DS0000008331.V339508.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staff had the relevant skills and training to be competent in their job role, but recruitment procedures did not fully protect residents. EVIDENCE: The home is staffed by a manager, a deputy manager, five senior carers, four carers, two cooks and a cleaner. The residents expressed their satisfaction with the staff. One resident said that they “couldn’t have better staff”. A resident’s relative said of staff “they’re all very approachable” and are “absolutely lovely”. This is good for the residents. The manager supervises all the staff, and had clear evidence, on a supervision planner, that each member of staff should receive six supervision sessions each year. Through discussion, the manager explained that staff completed a record in preparation for supervision, which asks how they are. The manager then records the outcomes of the supervision meeting. There was an emphasis on training, but the process would benefit from review to include discussion of care practice and the progress of residents for whom the member of staff was Abbey Grove DS0000008331.V339508.R01.S.doc Version 5.2 Page 21 the key worker, and assessing training needs based on how staff were performing their role. Staff did have individual records of training, but the training audit needed to be updated for ease of planning of training. Seven of the nine carers had a National Vocational Qualification (NVQ) Level 2. Three staff recruitment files were seen and recruitment practice was discussed with the manager. The manager stated that the deputy manager deals with employment files and that the proprietor sends for the Protection of Vulnerable Adults (POVA) First checks and the Criminal records Bureau (CRB) checks. It was later clarified that the manager did oversee the recruitment process and interview staff. Concern was expressed about recruitment practice. In particular staff were being consistently being employed when their POVA First Checks had been made, but the CRB Check had not been received. This was the case on all three staff files seen. The manager said that she believed that this was acceptable practice. It was explained that staff should only be started on the basis of a POVA First check in an emergency situation, and only then, if they are fully supervised and are not working alone with residents. Concern was also expressed about inadequate employment histories on application forms and the fact that gaps in employment were not always questioned. Examples included a member of staff who commenced employment in April 2007, following a POVA First Check, whose application form stated that this person had finished their last job in “2005”. No date in 2005 was given and there was no explanation for the gap in employment. The remainder of this person’s employment history had the year of employment noted, but not the month. The most recent named employer for this person had refused to give a reference and the reason given was that they believed that this person had “been employed since leaving our company 2 years ago”. The manager said that she had rang this company for a verbal reference, but had not recorded this on the file. The file reference for this person was from a “friend and work colleague”. A further example was a member of staff who commenced employment in May 2007, following a POVA First Check. The CRB for this person had not yet been received and the person was working as a carer on night duty. The application form for this person had unexplained gaps in employment, and a reference had been accepted, which was handwritten and did not have the name or signature of the person who wrote the reference on it. The manager said that she “assumed” that it was from a person that this employee had cared for, who was noted as a referee on the application form. The other reference for this person was from a “friend”, rather than from a recent employer in the care industry noted on the employment history, but not proposed as a referee. Abbey Grove DS0000008331.V339508.R01.S.doc Version 5.2 Page 22 Two staff members were interviewed, both of whom were senior carers. The staff described recent training in Abuse Awareness, Food Hygiene, Health and Safety, Dementia and Fire Safety. They said that they were “encouraged to learn and progress” and that the manager was “very keen on us progressing”. Evidence of induction training was seen on the staff files and the staff were signing policies and procedures to note that they had read them. Abbey Grove DS0000008331.V339508.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager was in the early stages of implementing positive change and overall, systems and procedures were in place, which safeguard and protect residents. EVIDENCE: The manager had been employed at the home since August 2006 and was about to be interviewed as part of the registration process. Abbey Grove DS0000008331.V339508.R01.S.doc Version 5.2 Page 24 The manager said that she did not have Internet access at the home, but that she obtains information from the Commission’s website at home and that the. Proprietor also passes information to her. The manager said that the service had been going through a process of change and this was evident from observation of the interactions of staff in the home and the comments of staff, residents and a resident’s relative. The manager said that the home had two managers before her, each of whom were employed for approximately six months. She said that both previous managers had made lots of changes and that this had unsettled staff. It was agreed that her main aim was to stabilise the service and provide continuity. One member of staff said that the home had always had a “stable staff group” and had only recently had a few changes. This person said that key worker role had been “disrupted due to changes”, but that the manager was “very good” and “very experienced” and had “lots of new ideas”. Residents also talked about staff finding it hard to cope with the changes, but that things had improved since the manager had started working at the home. A resident’s relative said that relatives had been concerned about “continuity”, and that while the family knew that their relative “was being looked after” they “wanted continuity”. This person added that the manager was “very, very, helpful”. One resident said that the “new manager is “excellent” and that the “manager is one of us, she mixes with us”. This is good for the residents. Many of the residents had family members as the appointee for their finances. The manager said that these families bring in money to be held on behalf of residents as and when they need it. Receipts were held for all purchases made on behalf of residents and the records were audited regularly. The home has a quality assurance process, which includes sending questionnaires to residents and their relatives. The need to collate the outcomes of these surveys and report them to residents/families etc was discussed. One resident’s relative said that relatives do fill in a form every so often to see if “everything’s alright” and that they had “done this a few times”. The fire safety checks of the means of escape, fire bells, emergency lighting etc were completed on a weekly basis. The last fire drills took place on 14/07/07, but it does not note the response time of staff and the duration of the drill. The manager agreed to address this. The fire risk assessment was in the hallway, staff knew where it was and the manager said that it is reviewed every month when doing a health and safety check. The questionnaire, which was completed by the manager prior to the inspection, noted that safety checks, including checks of gas and electrical systems were up to date. Abbey Grove DS0000008331.V339508.R01.S.doc Version 5.2 Page 25 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 X X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 x 2 X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X x 2 Abbey Grove DS0000008331.V339508.R01.S.doc Version 5.2 Page 26 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 13(4) and 15 Requirement To ensure that residents’ needs are always met, care plans must be developed for each individual resident, which address all aspects of need, and staff support required to meet those needs. Care plans must also be consistently reviewed when residents’ needs change. To ensure that risks to residents are minimised where possible, risk assessments must be in place to assess all risks applicable to an individual resident, including the risk of falls. These must also be subject to consistent review to take account of any changes. 2. OP8 12(1) and 13(4) Residents’ nutritional assessments must be detailed and clear and the home’s staff must also have recorded strategies where any concerns/risk about a resident’s weight exist, in order that residents are protected. 18/08/07 Timescale for action 18/08/07 Abbey Grove DS0000008331.V339508.R01.S.doc Version 5.2 Page 27 3. OP9 12(1) and 13(2) 4. OP16 22 5. OP29 19 6. OP38 13 To ensure that the staff know each individual resident’s needs concerning medication, care plans must be in place concerning each resident’s needs, including what items they self medicate and what level of support they need to take medication. The home must hold a record of the investigation and outcomes of all complaints so that people are assured that any concerns are fully investigated. The home must ensure that the recruitment and selection procedures ensure the protection of the residents. This includes taking a full employment history, taking appropriate references and completing CRB checks before employment wherever possible. The registered person must ensure that all manual handling equipment is charged and in working order. (Previous timescale of 31/12/07 not met). 18/08/07 18/08/07 18/08/07 18/08/07 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 OP9 OP19 Good Practice Recommendations It is strongly recommended that a locking system be fitted to the fridge used to store medication. It is strongly recommended that an audit be completed to prioritise which bedroom furniture should be replaced first. Abbey Grove DS0000008331.V339508.R01.S.doc Version 5.2 Page 28 3. OP21 It is strongly recommended that bathrooms are refurbished and that they are always fitted with privacy locks. It is strongly recommended that the manager review the audit of training of the staff group so that necessary training could be prioritised. It is strongly recommended that the outcomes of quality assurance surveys are collated and the results reported them to residents/families etc. It is strongly recommended that staff supervision practice is reviewed to include discussion of care practice, the progress of residents for whom the member of staff was the key worker and assessing training needs based on how staff are performing their role. It is strongly recommended that the response time of staff and the duration of fire drills be recorded in the fire logbook. In order to maintain the privacy and dignity of residents, the hairdresser should not use the room of one resident to do the hair of other residents. 4. OP30 5. OP33 6. OP36 7. 8 OP38 OP10 Abbey Grove DS0000008331.V339508.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Manchester Local Office 11th Floor West Point 501 Chester Road Manchester M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI - 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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