CARE HOMES FOR OLDER PEOPLE
Abbey House Abbey House Heortnesse Chertsey Meads Chertsey Surrey KT16 8LN Lead Inspector
Pauline Long Unannounced Inspection 13th December 2005 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Abbey House DS0000013543.V273180.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Abbey House DS0000013543.V273180.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Abbey House Address Abbey House Heortnesse Chertsey Meads Chertsey Surrey KT16 8LN 01932 568275 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) Mrs Jean Kennedy Mrs Jean Kennedy Care Home 3 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (3) of places Abbey House DS0000013543.V273180.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. Within the category/categories `OP` (Older People) one of whom may be `DE(E)` (Older Person with Dementia). The age/age range of the persons to be accommodated will be Over 60 years of age 21st July 2005 Date of last inspection Brief Description of the Service: Abbey House is a small care home on the outskirts of Chertsy town. The home provides care and accommodation for 3 people over 60 years of age, and who may have dementia. The resident’s accommodation is on the ground floor of the owners home, and consists of three single bedrooms with washing facilities, a bathroom and toilet, a kitchen/diner and a large sitting room with direct access to a pleasant garden. Abbey House DS0000013543.V273180.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the second Inspection of the CSCI year April 2005- March 2006 and was unannounced. The inspection was carried by one inspector and lasted for two hours. On the day the service had a homely and welcoming atmosphere and was being prepared for the festive celebrations. Discussions were held with the manager, care staff, and the 3 residents who live at the home. Documents sampled, included service users files, care plans, staff records and policies and procedures. A full tour of the home took place. The feedback from some of the residents was limited in view of their communication difficulties. CSCI would like to thank the residents and staff for their hospitality and cooperation during the inspection. What the service does well: What has improved since the last inspection?
The requirements made at the last inspection had been met. The resident’s bedrooms are being refurbished and have had new vanity units installed. The
Abbey House DS0000013543.V273180.R01.S.doc Version 5.0 Page 6 manager discussed redecorating and replacing the bedroom carpets. A large wide screen television has been bought for the communal sitting room. The manager has reviewed and developed the homes service user feedback questionnaire. 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 DS0000013543.V273180.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Abbey House DS0000013543.V273180.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,6 Files sampled evidenced that arrangements were in place to ensure a full needs assessment takes place before any new admission. Residents are routinely issued with a contract of care service provided. The home does not provide for intermediate care. EVIDENCE: Three resident’s files were sampled. All of them had a comprehensive documented assessment of needs, which was carried out by the manager. The manager commented that she would carry out a needs assessment, at the prospective resident’s home and that she would encourage a visit to the care home to provide a further assessment period. It was pleasing to note that each of the residents had an up to date contract, and that they were signed by the residents. This home does not provide an intermediate care service.
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The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,10,11 On the day, the staff had a good understanding of the resident’s health and personal care needs. These needs were well met. Privacy and dignity were respected EVIDENCE: The residents care plans were good, and included needs assessments, risk assessments with regard to manual handling, falls and other potential risks. There was documentation regarding changes in healthcare needs. All of the files sampled had been regularly reviewed. Through out the inspection process, one member of staff was observed carrying out various aspects of personal care for the residents. This was carried out in a respectful manner, bedroom and bathroom doors were not left open, staff were observed knocking on doors and waiting to be invited in, before entering rooms. One resident commented that the staff are always respectful and always knock on the door before entering the room. A discussion was had around how the home addressed resident’s wishes around death and dying. The manager stated that, whilst this was a difficult issue it had been discussed with the residents and that their wishes had been documented, and that each resident had a funeral plan on their file.
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The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 The Managers and staff enable the residents to maintain fulfilling lifestyles inside and outside the home and are enabled to exercise choice and control over their own lives. The home promotes and encourages contact with family and friends. EVIDENCE: The residents care plans, included information with regard to social and recreational interests and needs. One resident enjoys going to one of the local clubs, where he can maintain his independence and longstanding friendships. Another resident commented that she prefers not to go out, and is happy just to stay at the home. On the day of inspection, the care assistant on duty was courteous and respectful and was observed offering choices and enabling the residents to make safe decisions. Abbey House DS0000013543.V273180.R01.S.doc Version 5.0 Page 13 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1617,18 The home has satisfactory policies and procedures and training in place for dealing with the protection of the residents, and for addressing concerns and complaints. EVIDENCE: The home has a complaints policy and procedures. The manager commented that she had received no complaints at the home. CSCI have received no complaints about this home since the last inspection. All of the residents have been registered on the electoral register, and received voting cards for the last general and local authority elections, however they decided not to use their votes. The manager and staff have a good understanding of the Protection of Vulnerable Adult from Abuse procedures. Abbey House DS0000013543.V273180.R01.S.doc Version 5.0 Page 14 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,25,26 The overall standard of the environment within this home is satisfactory, and currently meets needs of the residents. However more attention must be paid to the cleaning regime. EVIDENCE: On the whole the home is well maintained. The communal areas were clean and pleasant. No malodours were noted. It was disappointing to observe that resident’s bedrooms were not properly cleaned. Whilst residents commented that the staff vacuumed their rooms every day, there was evidence to suggest that this was not carried out properly. As mentioned earlier in this report, the home is undergoing refurbishment, new wash hand basins and vanity units have been installed. It was pleasing to note that plans had been made to redecorate and re-carpet all of the bedrooms. The bathroom was clean and odour free. A requirement was made in this area. Please refer to page 20 of this report. Abbey House DS0000013543.V273180.R01.S.doc Version 5.0 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed on this occasion. EVIDENCE: Abbey House DS0000013543.V273180.R01.S.doc Version 5.0 Page 16 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,36,37,38 The home has good leadership, guidance and direction. Residents benefit from the ethos and management approach in the home. Residents are safeguarded by the accounting and financial procedures. The home has clear Policies and Procedures and the standard of record keeping is good. Health and safety checks are routinely carried out at the home and records kept. EVIDENCE: The manager was observed as having a very open approach. Residents and staff appeared confident and relaxed in her presence. The staff and residents hold meal time meetings on a regular basis, where residents can air their views about the home. The last meeting was held on the 2nd of December. Records of the homes financial accounts were sampled and found to be in order. The home does not manage any of the resident’s financial affairs as they
Abbey House DS0000013543.V273180.R01.S.doc Version 5.0 Page 17 are managed by relatives or advocates. However the manager stated that if a resident required any items of clothing or toiletries, that she would provide them and invoice the relatives or advocate. . The home has policies and procedures in place, which the residents and staff can access them as they wish. There is a staff supervision process in the home, however it was disappointing to note that no documented staff supervision meetings have taken place since April 2005. This was discussed with the manager, who stated that she meets with the staff on a day to day basis, but does not record this. Health and safety checks are routinely carried out at the home. All equipment in use on the day of inspection was properly maintained and records kept. Water temperatures were checked, and were found to be satisfactory. Records relating to food hygiene regulations were kept. Food storage in the kitchen fridge did not comply with food hygiene regulations, open packs of food were not labelled or dated. Throughout this inspection the home records were accessed. The recordkeeping was good. Records were stored appropriately, securely and confidentially. Requirements were made in these areas . Please refer to page 20 of this report. Abbey House DS0000013543.V273180.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 X X X X X 3 2 STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 X 3 X 2 3 2 Abbey House DS0000013543.V273180.R01.S.doc Version 5.0 Page 19 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 OP36 Regulation 18(1)(a) Requirement Timescale for action 13/03/06 2 3 OP26 OP38 The registered person must ensure that all staff receive one to one supervision meetings the required six times a year and records kept. 23(2)(d) The registered person must ensue that all areas of the home are kept clean. 12(1)(b) The registered person must 13(4)(a-c) ensure that food is stored in compliance with food hygiene regulations. Foodstuffs in the homes fridge must be dated on opening. 21/12/05 14/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Abbey House DS0000013543.V273180.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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