Inspection on 28/11/05 for Abbey House

This inspection was carried out on 28th November 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 House 26/09/08

Abbey House 26/09/06

Abbey House 31/05/05

Abbey House 16/11/04

Abbey House 08/06/04

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

CARE HOMES FOR OLDER PEOPLE Abbey House 20 - 22 Albert Road Bexhill on Sea East Sussex TN40 1DG Lead Inspector James Houston Unannounced Inspection 28th November 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 DS0000048567.V262005.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 DS0000048567.V262005.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Abbey House Address 20 - 22 Albert Road Bexhill on Sea East Sussex TN40 1DG 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) 01424 222534 Angel Healthcare Limited Vacant Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places Abbey House DS0000048567.V262005.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Service users should be aged 65 (sixty five) years or over on admission. The maximum number of service users to be accommodated is 23 (twenty three). Only older people who have been assessed as requiring residential care are to be accommodated. 31st May 2005 Date of last inspection Brief Description of the Service: Abbey House is a well-maintained, large detached Victorian property situated in the centre of Bexhill-on-Sea in East Sussex. The shops, transport and Bexhill seafront are all within easy walking distance from the home. The interior of the house has been extensively refurbished to provide a pleasing and comfortable environment for up to twenty-three older people. Residents accommodation is all in single rooms, provided on three floors, with level access via a passenger lift. The residents private garden at the rear of the premises is well maintained. Abbey House DS0000048567.V262005.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place during the morning and afternoon of 28th November 2005. The inspector read papers held on the service by the Commission for Social Care Inspection, and prepared those sections of the standards to be inspected. The inspection in the home took 4.8 hours. During the inspection a tour of the whole premises was made. The inspector spoke with the acting manager, the assistant manager, a staff member, ten residents, two relatives and a visiting health care professional. A variety of records including three care plans, and policies and procedures were read. On the day of the inspection 20 persons were resident in the home. What the service does well: 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 DS0000048567.V262005.R01.S.doc Version 5.0 Page 6 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 DS0000048567.V262005.R01.S.doc Version 5.0 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 and 6. The home gives full information to prospective residents and their representatives. Pre-assessment documents need some attention. EVIDENCE: The home’s statement of purpose and service users’ guide give the required information. A requirement was made at the last inspection regarding the full completion of pre-admission assessment documents. The documentation of the resident admitted since the last inspection had not been fully completed and the requirement has therefore been repeated. The home does not offer intermediate care. Abbey House DS0000048567.V262005.R01.S.doc Version 5.0 Page 8 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,10 and 11. Plans of care need some attention. The privacy and dignity of residents is respected. The needs of dying residents are well met. EVIDENCE: The home keeps daily notes of care given to residents. These were inspected and found to be up to date. Further work is required to complete the introduction of the system of care planning, eg with plans signed by the resident where capable and with monthly reviews by care staff. Residents confirmed that staff call them by their preferred name and knock before entering their rooms. Staff are instructed during induction how to treat residents with respect at all times. Staff said that all residents have their own rooms and that care is given in private. The home has suitable policies on care of the dying and arrangements to be made after death, of which staff said that they were aware. A record inspected contained clear information about the action to be taken to ensure that the wishes of the resident about arrangements to be made after their death were carried out. Advice was given about one record. Abbey House DS0000048567.V262005.R01.S.doc Version 5.0 Page 9 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 13. Social activities are well managed, and provide variation and interest for people living in the home. Visitors are made welcome. EVIDENCE: A requirement was made at the last inspection that the home reviews its social activities for residents. This has been satisfactorily addressed. The home keeps logs of activities and these were inspected. The home has a range of activities in house, including entertainers and shows, music and movement, Tai Chi, quizzes and bingo, which a range of residents said that they enjoy. Residents said that they could go out alone or with family and friends. Staff take residents out on occasion and the manager is looking into taking out interested residents on a Christmas shopping trip. Residents can attend a religious service in the home if they wish to. Residents said that their visitors are always made welcome, and relatives visiting the home during the inspection confirmed that this was so. Staff said that they make visitors welcome. Abbey House DS0000048567.V262005.R01.S.doc Version 5.0 Page 10 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. The home has suitable arrangements to deal with complaints made to it. The home’s adult protection processes are designed to protect residents from abuse or the allegation of abuse. EVIDENCE: The home has a suitable complaints procedure. Residents said that they are aware of the procedure. The home has a log in which to record any complaints made about it and action taken. There have been no complaints recorded in the home, or referred to the Commission for Social Care Inspection since the last inspection. The home has suitable whistle blowing and adult protection policies of which staff said that they were aware. Staff said that they had recent training on adult protection. Staff were aware of the home’s policies of staff not receiving gifts and gratuities from residents. Abbey House DS0000048567.V262005.R01.S.doc Version 5.0 Page 11 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,23 and 24. The home provides a pleasing environment for residents. Some physical items need attention. Bathing and toilet facilities are appropriate. Residents’ rooms are well appointed. EVIDENCE: The home provides spacious accommodation on three floors, all served by a passenger lift. The home has a pleasant and well-kept garden. The proprietor has their own maintenance staff and staff in the home said that requests for repairs are responded to quickly. The home is generally well maintained. Some exterior paintwork would benefit from attention. The fire officer visited recently, and matters raised in his report need attention. He will re-inspect shortly. The level of lighting in the dining room, and the fitting of window restrictors where these are judged to be needed, should be attended to. The home has rooms for single occupancy, and almost all with en-suite WCs. The home has two assisted bathrooms for the use of residents. Residents said that staff assist them with bathing as needed. Abbey House DS0000048567.V262005.R01.S.doc Version 5.0 Page 12 Residents said that they like their rooms, and that they have been able to bring in their own possessions with them if they so wish. Rooms are lockable and residents choose whether to hold keys. Abbey House DS0000048567.V262005.R01.S.doc Version 5.0 Page 13 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 and 28. The home has a committed and enthusiastic team. The level of staff qualification (NVQ) needs addressing. EVIDENCE: The home has a staff rota that was available for inspection. This showed that three carers are on duty during the working day, with two carers on duty at night. The acting manager and assistant manager share on call duties. Residents said that there is a core of long serving staff, with quite a lot of turnover amongst newer staff. They said that staff are busy, but that call bells are answered promptly. They described staff as friendly and helpful. The home has currently no staff holding the NVQ qualification in care. The acting manager said that she has put forward four staff for NVQ level 2 in Care and one for Level 3. Abbey House DS0000048567.V262005.R01.S.doc Version 5.0 Page 14 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,34,35,36 and 37. An application for a registered manager is required. Administrative systems are appropriate. Staff supervision needs attention. EVIDENCE: The acting manager has been in post for several months. She is an experienced and competent senior carer who appears to have the skills to carry out the varied requirements of this post. She has a job description and has undertaken appropriate training to update her skills. She has not yet commenced taking the recommended qualifications but hopes to do so shortly. An application in respect of a registered manager for the home is required. The home has suitable administrative systems. The home’s acting manager has support from her line manager and the home’s owner, and from the head office in personnel and finance and administrative issues. The home has appropriate insurance and a current certificate was on display in the home. Abbey House DS0000048567.V262005.R01.S.doc Version 5.0 Page 15 The home has the facility to keep securely valuables and money held on behalf of residents. Monies held in respect of two residents were found to tally with the home’s record. Receipts are kept. Advice was given in respect of one record. The home has just recommenced supervision of care staff and the acting manager said that she has had appropriate training. It is recommended that care staff are given formal recorded supervision at least six times per year. The acting manager intends to recommence staff meetings shortly. Records are generally well kept except where mentioned elsewhere in this report. Residents are able to access their records if they so wish. Abbey House DS0000048567.V262005.R01.S.doc Version 5.0 Page 16 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 2 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 X X 3 3 X X STAFFING Standard No Score 27 3 28 2 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X 3 3 2 3 X Abbey House DS0000048567.V262005.R01.S.doc Version 5.0 Page 17 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 OP3 Regulation 14(1a) Requirement That the homes pre-admission assessment documentation is satisfactorily completed. (Previous timescale of 1/5/05 not met) That a satisfactory system of care planning is introduced that is regularly reviewed in consultation with the resident concerned, unless it is impractical to do so, and that individual needs and how these are to be met are clearly documented and maintained up to date. (Previous timescale of 01/11/05 not met) That a minimum ratio of 50 of care staff receive the required training i.e. NVQ at level 2, or 3 in Care. (Timescales from previous inspections of 31/12/05 not yet reached) An application for registered manager from a suitably qualified and experienced manager is submitted. That the acting manager obtains NVQ at level 4 in Management with RMA. DS0000048567.V262005.R01.S.doc Timescale for action 31/12/05 2. OP7 15(1) & 15(2) 28/02/06 3. OP28 18(1) 31/12/05 4 OP31 8&9 28/02/06 5 OP31 9(2)(b)(i) 31/12/05 Abbey House Version 5.0 Page 18 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 3 Refer to Standard OP19 OP19 OP36 Good Practice Recommendations That window restrictors are fitted, wherever low windowsills in residents private rooms may pose a significant risk to personal safety. That physical items identified at the inspection are addressed. That care staff receive formal recorded supervision at least six times per year. Abbey House DS0000048567.V262005.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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. Extracts may not be used or reproduced without the express permission of CSCI Abbey House DS0000048567.V262005.R01.S.doc Version 5.0 Page 20 - 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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