Inspection on 11/07/05 for Abbey House

This inspection was carried out on 11th July 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Abbey House 24/07/07

Abbey House 05/07/06

Abbey House 06/12/05

Abbey House 18/01/05

Abbey House 21/07/04

Similar services:

Applegarth

Trevayler Residential Care Home

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

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

CARE HOMES FOR OLDER PEOPLE Abbey House Stokes Drive Leicester Leicestershire LE3 9BR Lead Inspector Rajshree Mistry Unannounced 11.45am, 11th July 2005 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 House C51 C01 S37630 Abbey House V237578 110705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Abbey House Address Stokes Drive Leicester Leicestershire LE3 9BR 0116 2312350 0116 2875186 None Leicester City Council 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) Mrs Jennifer Glover Care Home 33 Category(ies) of OP - Older Age - 33 registration, with number DE(E) - Dementia - over 65 - 20 of places MD(E) - Mental Disorder - 20 PD(E) - Physical Disability over 65 - 8 SI(E) - Sensory Impairment over 65 - 10 Abbey House C51 C01 S37630 Abbey House V237578 110705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: No one falling within category Dementia (DE(E)) or Mental Disorder (MD(E)) may be admitted into the home when 20 persons who fall within categories/combined DE(E) or MD(E) are already accommodated within the home. No one falling within category Physical Disability (PD(E)) may be admitted into the home when there are 8 persons of category PD(E) already accommodated within the home. No one falling within category Sensory Impairment (SI(E)) may be admitted into the home when there are 10 persons of category SI(E) already accommodated within the home. Date of last inspection 18th January 2005 Brief Description of the Service: Abbey House is a registered care home providing accommodation for up to thirty-three older persons and is owned by Leicster City Council. The home is situated along a main road in a residential area. The home is accessible by private transportation with car parking to the front of the home. The city centre is approximately a ten minute bus journey from the home. Shop, pubs, the post office and other local amenities are approximately half a mile from the home. The home is a large and purpose built property. There is level entry access to the home. Accommodation is offered on the ground and first floor level, which can be accessed by a passenger lift or the stair lift. Bedrooms are all single rooms with wash hand basins. Bath/shower and toilet facilities are located throughout the home. There are a choice of lounges and dining area accessible to resident on the ground and first floor and a designated smoking area. There is seating available for residents to the front of the home and the garden to the rear is landscaped. All areas of the home are accessible to people using mobility support, aids and equipment. The home is well maintained with comfortable furniture and decor. Abbey House C51 C01 S37630 Abbey House V237578 110705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place from 11.45am on 11th July 2005 and lasted for over 4 hours. The method of inspection consisted of examining the information received in the pre-inspection questionnaire prior to the inspection. On the day of the inspection the method used consisted of a tour of the premises, examination of the health and safety records for the home, three residents were spoken with and observed, specifically to look at their lifestyle at the home, how their care needs were met and concerns addressed. Individual plans of care and relevant care records were examined. Key workers for residents’ talked about care provisions, how the identified needs were met and their training and management support. Visiting relatives shared their views about the home, which were very positive and complimentary about the care provided. Staff spoke about the training and support they receive and how information is accessed. Towards the latter part of the inspection visit, time was spent with the manager discussing some of the findings, information received and observations made. What the service does well: Abbey House is tastefully decorated to create a bright, homely and a comfortable atmosphere for the residents. Residents move freely around their home and have a choice of lounges to relax in. There is a range of specialist equipment is available, to promote independence. Residents can have their own keys to their bedrooms. Residents have a good choice of meals, prepared on the premises, these are nutritionally balanced and meet dietary needs. Management of medication is good with systems in place to monitor. Records relating to residents, staff training and health and safety are accessible, in good order and stored in line with data protection. Residents are consulted and encouraged to express their views, raise issues and exercise choice. Care plans are regularly reviewed and updated. Abbey House has a stable staff team, with clear roles and responsibilities. The management team operates a named key working system. The management team strive to look to continuously improve the standard of the home by welcoming and sharing of good practices. Communication between staff and other health and social care professional is good. Staff receive good induction training and access the scheduled programme of new and refresher training. Abbey House C51 C01 S37630 Abbey House V237578 110705 Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: 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 House C51 C01 S37630 Abbey House V237578 110705 Stage 4.doc Version 1.40 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 House C51 C01 S37630 Abbey House V237578 110705 Stage 4.doc Version 1.40 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, 3, 5. Standard 6 is not applicable. The whole admission process is well managed and residents are given clear and detailed information about the provision of care. The assessment process is robust to ensure that care needs can be met and individually tailored. EVIDENCE: Prospective residents and/or their relatives are encouraged to visit the home. The Service Users’ Guide giving information about the home, facilities and provision of care is made available at the earliest opportunity. All prospective residents are assessed as part of the referral process. The assessment is carried out by the social worker and a qualified member of the home’s management team carries out specific assessment of risk. Three residents care files were examined as part of the case tracking method; the files contained evidence of the assessment, identified care needs and how the needs could be met in consideration of the residents’ preferred lifestyles, likes and dislikes. A trial period of stay is offered to all prospective residents. Several residents and one visiting relative that spoke to the Inspector said they visited first, were informed at all times and found the process was not complicated. Abbey House C51 C01 S37630 Abbey House V237578 110705 Stage 4.doc Version 1.40 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 standard(s) 7, 9, 10 Residents’ are well looked after having their health and social care needs met. Management of medication in the home is robust and secure. Residents’ privacy is upheld and they are treated with respect. EVIDENCE: Residents care files examined contained comprehensive individual plans of care that reflected their health and social care needs. The plans were specific to the individuals’ needs covering mobility, continence, sensory impairment and respecting the residents’ choice of lifestyle such as prefers a cup of tea in bed in the morning. Residents who spoke to the Inspector indicated that they are consulted regularly about the provision of care. Visits from the GP and the District Nurses are recorded in the individual files with clear instructions and treatment given. Observations made in the lounge showed that staff have a good awareness of how to protect residents’ privacy and dignity. Residents who spoke with the Inspector stated felt they were treated with respect and their privacy was upheld. Medication is stored in a locked medication trolley and stored in the treatment room. Staff are trained to administer medication. Medication examined against records for residents were accurate and considered safe. Residents spoken with say that they received their medication on time. Abbey House C51 C01 S37630 Abbey House V237578 110705 Stage 4.doc Version 1.40 Page 10 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, 15 Residents have a varied life at the home and are provided with a good social and recreational programme which meets their needs. All residents are able to maintain contact with families and friends. There are good choices of meals that are nutritionally balanced and meet special dietary needs, which is served in pleasant surroundings. EVIDENCE: Residents care plans indicate social, leisure interests, religious observance and links with family and friends. On the day of the inspection there were no planned activities, although staff would offer activities daily. Daily newspapers are delivered for some residents. Each months planned activities are displayed in the foyer. The activities ranged from bingo, trip to Ulverscroft Grange, dominoes to short walks. Delegated staff each day plan activities in small groups or individually. The main lounge has a small selection of library books, some in large print. One resident that spoke to the Inspector has his own collection of library books, which is replenished regularly. The resident enjoys reading autobiography of sports stars of rugby, cricket and football. Residents indicated that holy communion held every 6 weeks. Residents indicated that their visitors are welcome at any time and can meet with their relatives in the ‘visitors room’ in private. The home no longer has a licensed bar. Abbey House C51 C01 S37630 Abbey House V237578 110705 Stage 4.doc Version 1.40 Page 11 Meals are varied, nutritionally balanced and appealing. The menus for the week are displayed at the entrance to the dining room. Meals are prepared on the premises and special dietary requirements are accommodated, such as sugar free meals, for residents with diabetes. On the day of the inspection the lunch looked appealing and a choice of main course was available. Lunch is the main meal and is served in the dining room although residents can choose to eat in the privacy of their own rooms or the small dining room upstairs. The residents spoken with were satisfied with the choice of meals and stated, meals are offered to their visiting relatives. Drinks and snacks are available throughout the day. On the day of the inspection, staff were seen serving drinks to the residents, as it was a hot day and leaving jugs of water in the communal areas and in residents bedrooms for those residents who were resting. Staff were commended for being attentative to ensure residents remain cool and are not at risk from dehydration. Abbey House C51 C01 S37630 Abbey House V237578 110705 Stage 4.doc Version 1.40 Page 12 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, 18 The complaints system is robust, clear and accessible to all. Adult protection procedures are in place and staff aware of the procedures to respond to any suspicion or allegation of abuse. EVIDENCE: The home’s complaints procedure is displayed on the notice board at the entrance of the home and included in the service user guide, which is given to all residents. Since the last inspection the home has not received a complaint. The residents that spoke with the Inspector felt confident to complain and were confident that their concern would be addressed promptly. Comments received“ find the staff are really kind, you can’t complain about anything” and “no complaints, quite happy here”. Staff who spoke to the Inspector including the agency staff were aware of the actions to take in response to inappropriate behaviour being observed or an allegation being made. Staff confirmed that they have received training in the new adult protection procedures and records showed that training on adult protection is provided. Residents spoken with felt they were safe and protected. Abbey House C51 C01 S37630 Abbey House V237578 110705 Stage 4.doc Version 1.40 Page 13 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, 21, 22, 23, 24, 26 A comfortable, well maintained, personalised and a good standard of accommodation is provided collectively and suited to individual residents needs. The atmosphere in the home is warm and welcoming. Specialist equipment is available to promote residents’ independence. EVIDENCE: Access to the home is wheelchair friendly, with a stair chair and a passenger lift. There are handrails throughout the home. Residents have a choice of lounges including a designated smoking area known as the “circle”. The home has a good standard of décor, and is bright with ample natural light. All areas of the home were considered safe and well maintained. There is a handy person who is responsible to repair minor faults, such as replacing batteries in hearing aids to responding to the lift breaking down on the day of the inspection. Abbey House C51 C01 S37630 Abbey House V237578 110705 Stage 4.doc Version 1.40 Page 14 The three residents bedrooms, which were viewed were personalised with family photographs and ornaments. Rooms were comfortable and decorated to suit the residents’ needs. Several residents spoken with felt they had sufficient space to use their walking frames. Bedrooms are close to bathrooms and disabled toilets. Since the last inspection the home has had a new bath with a hoist; access to hoists and stand aids is available on both floors. Staff are trained to use specialist equipment to maximise the residents’ independence. A relative of one resident who recently moved in said she had viewed the home and had a choice of bedrooms offered. All areas of the home were cleaned to a high standard with pleasant smells. There is a team of domestic staff responsible for the cleanliness of the home. Abbey House C51 C01 S37630 Abbey House V237578 110705 Stage 4.doc Version 1.40 Page 15 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, 30 Residents’ needs are well met by the number and skill mix of staff. Staff at the home are well trained and supported, and deployed in sufficient numbers to meet the resident needs. EVIDENCE: The staff rota for the day was examined and reflected the staff on duty, including four agency staff. Observations made during the inspection indicated that the staff were responding to service users needs promptly. The senior management at the home consists of the Registered Manager, two assistant managers, senior carers, carers and domestic staff. Residents spoken with confirmed they have a named key-worker who responds to their needs in a timely manner. All staff receive an induction-training programme that is a minimum of three weeks and can be extended. Agency staff spoken with confirmed that they are a regular agency staff, had received an induction on the first day and work alongside a permanent member of staff. Staff training records were examined and these contained evidence of training (both completed and planned), which included: moving and handling, hoist awareness, health and safety, finance and IT training for senior staff, principles of care, basic food and hygiene, Care of Substances Hazardous to Health (CoSHH), promoting independence, managing behaviour and adult protection, dealing with stress and depression. Abbey House C51 C01 S37630 Abbey House V237578 110705 Stage 4.doc Version 1.40 Page 16 Twelve staff have completed the National Vocational Qualification (NVQ) level 2 and above. A further group of staff are in the process of completing NVQ 2. Observations made of two staff transferring a resident. Discussion with the staff indicated that they were trained to competently do their jobs. Abbey House C51 C01 S37630 Abbey House V237578 110705 Stage 4.doc Version 1.40 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 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, 32, 33, 35, 37, 38 The leadership and management approach of the home is good for the benefit of the residents at the home. Residents are consulted about living in the home and their finances are safeguarded with a robust system. The health, safety and welfare of residents and staff are well promoted and protected through policies and procedures. EVIDENCE: The management team were observed to work well together, and have a good understanding of each other’s roles and responsibilities. The Registered Manager offers a clear sense of leadership and openness in the management of the home, which is reflected on the day-to-day basis. Staff spoken with said that information and instructions are cascaded through the management structures. Residents spoken with felt the home was well managed irrespective of the staff on duty. Abbey House C51 C01 S37630 Abbey House V237578 110705 Stage 4.doc Version 1.40 Page 18 Residents Meetings are held regularly to discuss issues or concerns relating to the provision of care at Abbey House, which residents can choose to attend. Residents have lockable facilities in their own bedrooms. Records of residents’ valuables are recorded. Residents were observed receiving their money on a weekly basis and signed for it. A random sample of records checked relating to the maintenance, health and safety requirements of the home including fire drills and risk assessments for the home and the residents. Residents care plans and care records examined were in good order, and the key working system works well to provide residents with continuity of care. Records are stored securely and residents are aware of their rights to access their records. All staff have access to the home’s policies and procedures. Notices are displayed around the home with information for staff and notices boards for residents and visitors to the home. During the tour of the home fire exits were clearly marked and were not obstructed. Records of tests to fire safety equipment were in good order and health and safety issues were well documented. The Fire Risk Assessment was available and had been reviewed; generic risk assessments are in place, along with individual risk assessments for residents. Fire inspection took place 14/04/05. The home has a handy person who is responsible for minor repairs and checks. There is a programme of maintenance and testing of all equipment in the home. Abbey House C51 C01 S37630 Abbey House V237578 110705 Stage 4.doc Version 1.40 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 4 COMPLAINTS AND PROTECTION 3 x 3 3 3 3 x 3 STAFFING Standard No Score 27 3 28 3 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 3 x 3 x 3 3 Abbey House C51 C01 S37630 Abbey House V237578 110705 Stage 4.doc Version 1.40 Page 20 N/A Are there any outstanding requirements from the last inspection? 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 Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Abbey House C51 C01 S37630 Abbey House V237578 110705 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection The Pavilions, 5 Smith Way Grove Park Enderby Leicestershire LE19 1SX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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