Inspection on 19/04/05 for Abbey Hey Care Home Ltd

This inspection was carried out on 19th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 Hey Care Home Ltd 26/09/07

Abbey Hey Care Home Ltd 11/07/06

Abbey Hey Care Home Ltd 22/12/05

Abbey Hey Care Home Ltd 17/11/04

Abbey Hey Care Home Ltd 25/05/04

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 Hey Care Home Ltd 1 Delemere St Oldham Lancashire OL8 2BY Lead Inspector Sandra Bennett Unannounced 19/04/05 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 Hey Care Home Ltd Version 1.10 Page 3 SERVICE INFORMATION Name of service Abbey Hey Care Home Ltd, Address 1 Delemere St Oldham Lancashire OL8 2BY 0161 624 9518 0161 624 9518 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Dignity Care Group 11 Bamburgh Close, Radcliffe, Manchester, M26 3TU Carole Ann Kearns CRH 40 Category(ies) of DE(E) DE(E) Dementia - over 65 - 10 registration, with number OP OP Old age - 15 of places PD(E) PD(E) Physical disability - over 65 15 Abbey Hey Care Home Ltd Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: 1 Service Users to include up to 15 OP up to 10 DE (E) and up to 15 PD (E) Date of last inspection 17th November 2004 Brief Description of the Service: Abbey Hey is a purpose built residential home for up to 40 service users, situated close to Oldham town centre, public transport and local amenities. The home is registered to provide care for service users in the following categories: Older People, service users with Dementia and those with a Physical Disability. Accommodation is provided in 34 single rooms, of which 33 have en-suites, and three shared rooms with en-suites. On the ground floor there are two large lounges and two smaller rooms, which can be used for dining or socialising, plus a large dining room. There is an additional lounge for service users on the first floor. Bathrooms and toilets are fitted with aids and adaptations in order to promote service users’ independence. Service users have access to a small-enclosed patio area and a small seating area to the front of the property. Abbey Hey Care Home Ltd Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unscheduled inspection took place on the 19/4/05 over an eleven-hour period. It found that many of the National Minimum Standards had been met or partially met. The inspector had the opportunity to speak to eight service users and two relatives all who were positive about the care they received. Four staff members were interviewed all who had a good knowledge of the needs of the service users. At the end of the inspection the manager was advised of the action they need to take to remedy shortfalls identified in this report. What the service does well: What has improved since the last inspection? A registered manager has been in post since the last inspection who has made improvements in the recording systems in the home. Care planning is now more detailed and matches the assessed needs of service users; staff have received training in the specific needs and problems associated with old age. Staff routines in cleaning and laundry have improved resulting in the home being free from odours at the time of inspection. Service users confirmed that they are consulted about routines in the home, usually on an informal basis. The administration and recording of medication has improved following the recent staff training in the administration of medication. The majority of matters and concerns identified during the last inspection have been resolved. Abbey Hey Care Home Ltd Version 1.10 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Abbey Hey Care Home Ltd Version 1.10 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 Standards Statutory Requirements Identified During the Inspection Abbey Hey Care Home Ltd Version 1.10 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 standard(s) 1-5. The 6 standard is not applicable to Abbey Hey The home was aware of the service user need prior to admission, however there was a lack of information available to service users in order for them to make an informed choice on the facilities and services the home offers. All service users are not given the terms and conditions of residency. EVIDENCE: Information in the service user guide provided insufficient details of the services on offer. Interviews with relatives confirmed they were encouraged to visit the home prior to the service user admission although they were not always given a copy of the service user guide. One service user reported that they had lived in the area all their life and therefore knew the home well resulting in them feeling less isolated. One service stated they had not received a contract detailing their terms and conditions. Abbey Hey Care Home Ltd Version 1.10 Page 9 Four files of service users recently admitted to the home were examined and found to have detailed service user assessments from appropriate professionals to ensure their needs could be met. Additional training has been provided to staff to ensure the home can meet the needs of specific service users. Observations throughout the day found that staff were undertaking appropriate moving and handling techniques. During staff interviews they were able to give examples of training they had undertaken in addition to NVQ training. Abbey Hey Care Home Ltd Version 1.10 Page 10 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 standard(s) 7,8,9,10 The homes efficient recording systems ensures that the health care needs of service users are met. Service users are treated with respect and personal care needs are undertaken in private. EVIDENCE: The home has an effective system for recording the health care need of service users. There was evidence on files of service users receiving visits from health care professionals in the home and attendance at hospital appointments. Two service users were receiving treatment from districts nurses for leg ulcers with progress being monitored by the home. The accident book showed a number of falls sustained by service users these had been well documented and included in daily reports and care plans. An accident analysis is completed on a regular basis to ensure any service users who may have additional needs are monitored and risked assessed. This method also identifies any risk areas in the environment and times of care delivery. Abbey Hey Care Home Ltd Version 1.10 Page 11 Service users confirmed at interview they had been provided with aids and adaptations to meet their needs. Examples were given of special mattresses and walking frames. Observation of the administration of medications found them to be administered at the prescribed time with staff having received the appropriate training in the administration of medication. The recording and ordering of medication was completed correctly. At interview staff gave examples of how they maintain service users privacy and dignity in daily routines of bathing and giving personal care. Service users stated they felt staff were sensitive to there needs and encouraged them to attend to their own personal care to the level of their capabilities. Abbey Hey Care Home Ltd Version 1.10 Page 12 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 standard(s) 12,13,14,15 Service users social needs are met subject to staff availability. Choice is promoted for service users in other aspects of their daily lives. A varied nutritional diet is provided for service users. EVIDENCE: Lunch was taken with service users who talked freely regarding routines in the home and the “kind nature “ of staff. Service users confirmed they felt able to make choices in their daily lives. One service stated that staff pick clothes out of the wardrobe for them and ask which they would prefer to wear that day. Some service users expressed a disappointment with the lack of social activities in the home, but confirmed that staff did undertake this task and provided bingo, games and music groups when time permitted. A number of service users reported that they preferred to be left alone to do their “own thing” and that staff respected this. Two service users went out on a daily basis unaccompanied or with family, one collected the daily newspapers for the home. Service users may dine in several areas of the home tables were presented in an attractive manner. Menus are planned in advance and displayed daily on the notice board outside of the large dining room. Abbey Hey Care Home Ltd Version 1.10 Page 13 Food served provided a balanced diet and choices. Service user confirmed that wine is sometimes served with lunch. On a previous inspection the inspector spoke to a newly admitted service user who was confused and distressed because she was missing her dog so much. On this inspection the service user was much happier with the home having been able to accommodate the dog, which alleviated the service user’s distress and improved the service user’s quality of life. Other service users found that the dog was a source of comfort and liked having it around. The home offers several lounge areas so that those service users who do not like animals are not subjected to them. Abbey Hey Care Home Ltd Version 1.10 Page 14 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 standard(s) 16,17,18 Service users legal rights are protected and safe guards are in place to ensure their protection from abuse. Service users were confident that complaints about the home would be addressed EVIDENCE: The home’s complaint procedure stipulates timescales for action with each service user having a copy in their bedrooms. At interview service users were aware of whom they could complain to. A record is maintained in the home of any complaints and action taken. Neither the home nor the CSCI have received a complaint since the last inspection. Service users had received postal votes for the forth-coming general election. Adult protection and whistle blowing policies and procedures were in place. Staff at interview were aware of these procedures and their responsibility in reporting any such event. The manager and seven staff had undertaken training by Oldham Social Services in the protection of vulnerable adults. Abbey Hey Care Home Ltd Version 1.10 Page 15 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 standard(s) 19,20,21,22,23,24,25,26 The home provides a clean homely environment, which promotes service users independence. Certain areas inside and outside now require attention in order to ensure the safety and comfort of service users. EVIDENCE: Since the last inspection the home has continued with their programme of redecoration. A number of areas still require attention in particular:• Carpets in corridors, which have become very worn and stained; • The garden areas were not well maintained; • Perimeter fencing around the home should be provided to ensure the security of service users using the garden areas. Abbey hey is a purpose built home, which provides mostly single ensuite accommodation. Many rooms have been personalised by service users with some choosing to lock their bedroom doors throughout the day. Abbey Hey Care Home Ltd Version 1.10 Page 16 The inspector interviewed a married couple who had a large room and had chosen to bring in their own double bed and furniture. A telephone had been installed and the furniture arranged to provide a homely atmosphere. Grab rails and bath hoist are fitted to promote the independence of service users. Abbey Hey Care Home Ltd Version 1.10 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30 Staff recruitment procedures and induction training were robust and provided protection for service users. The lack of ancillary staff over the weekend period compromises the safety and hygiene standards in the home. The number of staff who hold NVQ needs to be increased. EVIDENCE: Two newly recruited staff files were examined and found to have the appropriate references and, criminal records bureau checks. Gaps in employment had been explored with the applicants during their interviews the outcomes were recorded and included on staff files. All staff receive a two day induction with an outside agency as an introduction to good care practices. This is then continued through a more in depth induction in line with service users needs in the home. NVQ training in the home is ongoing, however this still remains short of the 50 of staff required to be trained to this level. Examination of duty rotas, interviews with staff and service users highlighted a shortfall of care and ancillary staff over a weekend period, with care staff being required to perform domestic duties. This resulted in service users receiving a lesser degree of attention and hygiene standards than they were normally use to. Abbey Hey Care Home Ltd Version 1.10 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,21,33,34,35,36,37,38 Improvements have been made in management structures, communication and task allocations, which have promoted effective, care delivery and staff support. Service users are consulted about how the home is run. All records are appropriately maintained. Systems in the home ensure the welfare of service users are promoted. EVIDENCE: The manager has been in post for approximately one year and has recently been through a successful registration process with the CSCI. There was evidence of on going training to compliment their experience and management training. Abbey Hey Care Home Ltd Version 1.10 Page 19 One member of staff interviewed during the inspection had been at the home one year and was able to identify how the home had moved forward since the recruitment of the new manager by confirming there had been improvements to communication systems and staff training in the home. Staff meetings were held monthly and recorded. Staff also reported on the benefits of supervision towards their personal development. Questionnaires are sent out by the companies’ head office, these were not available for inspection. Interviews with service uses confirmed that they are consulted regularly on an informal basis with service user meetings being held add hoc. Three service users retain their personal finances. The records of monies held by the home for four service users were examined. All were found to be appropriately maintained. Records were maintained of health and safety checks in the home. Staff confirmed that first aid; food hygiene, fire, infection control and moving and handling training were undertaken. Abbey Hey Care Home Ltd Version 1.10 Page 20 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 2 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 3 3 3 3 3 3 3 Abbey Hey Care Home Ltd Version 1.10 Page 21 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 1 Regulation 4/5 Requirement Timescale for action 7/07/05 2. 2 5 3. 27 17 (2) 4. 28 18 The registered person must ensure service users and their representatives are provided with a statement of purpose and service user guide which meets all aspects of this standard. The registered person must Immediate ensure service users are provided with a detailed contract of their terms and conditions on admission to the home The registered person must mmediate ensure that addittional ancillary staff are employed over the weekend period to ensure that at all times suitably qualified, competant and experianced persons are working in the homein such numbers as are appropriate for the health and welfare of service users. The registered person must 31/12/05 ensure that 50 of staff are trained to NVQ 2 Abbey Hey Care Home Ltd Version 1.10 Page 22 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 12 19 Good Practice Recommendations The registered person should ensure that a service users activity programme is developed with records being maintained for evidence. The registered person should secure the perimeter of the home to ensure thae safety of service users using the garden areas. Abbey Hey Care Home Ltd Version 1.10 Page 23 Commission for Social Care Inspection 2nd Floor, Heritage Wharf Portland Place Ashton-under-Lyne OL7 OQD 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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