Inspection on 29/01/07 for Abbey House

This inspection was carried out on 29th January 2007.

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 13/12/05

Abbey House 26/08/04

Abbey House 27/04/04

Abbey House 14/05/03

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Abbey House Abbey House Heortnesse Chertsey Meads Chertsey Surrey KT16 8LN Lead Inspector Mavis Clahar Key Unannounced Inspection 09:30 29th January 2007 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.V309810.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Abbey House DS0000013543.V309810.R01.S.doc Version 5.2 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.V309810.R01.S.doc Version 5.2 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 13th December 2005 Date of last inspection Brief Description of the Service: Abbey House is a small care home on the outskirts of Chertsey 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 owner’s home, and consists of three single bedrooms with en-suite facilities, and situated close by is an assisted bathroom and toilet with adapted facilities for service user with mobility issues. There is also a kitchen/diner and a large sitting room/formal dining room with direct access to a pleasant garden. Fees at this home are £650.00 per week. Abbey House DS0000013543.V309810.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit, which forms part of the homes first key inspection to be undertaken by the Commission for Social Care Inspection was undertaken by Mrs Mavis Clahar on the 29th January 2007 and lasted for four and one half hours; commencing at 09:30 hours and concluding at 14:00 hours. The first part of the visit was spent updating the manager about the improvements and changes to the inspection processes under inspecting for better lives. This was followed by discussions on the running of the home and the manager/owner’s understanding of how equality and diversity issues impact upon the care offered to service users in the home. Discussions around training needs of the care workers and how these needs were being identified and met were also discussed. The second part of the inspection was spent touring the home and visiting and discussing with service users their opinion on the running of the home, how they are treated in the home and life in general in the home. Service users commented positively on the care and respect they receive and they all stated “this is not your typical home”; when asked to explain what they meant they said, the care they receive here is very individual, and they can spend time with the care worker doing exactly what they want to do and not what is planned for them to do. The final part of the inspection was spent reviewing service users files, where it was observed that medication was entered on the Medication Administration Sheet by care workers was not in line with the homes’ policy on recording of medication. A requirement was issued on this standard to ensure service users are protected by the home’s policies and procedures for dealing with medicines. Time was speaking with care workers and sampling care workers records, followed by the inspector giving feedback on the visit to the manager. The inspector would like to thank all three-service users, relative who completed the pre inspection questionnaire; service users and care workers who spent time speaking with the inspector. What the service does well: The home has completed the requirements made on the last inspection. Service users spoke highly of the care and support provided by the home; they said, “We love our home”. Comments included in the response of the CSCI questionnaire stated that the care workers always made visitors and relatives feel welcome and service users spoken to confirmed that their relatives were treated well by the whole team. Abbey House DS0000013543.V309810.R01.S.doc Version 5.2 Page 6 The service users were complimentary about the level, quality and amount of activities the home supplied. They informed the inspector that they have group and individual activities to suit their needs, and not necessarily planned activities. A relative in the response in the pre inspection questionnaire supported this statement where it was documented that “this is not the normal run of the mill care home where activities are planned for the service users. Here activities are individually planned and takes place at a time suitable to the service users.” 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 DS0000013543.V309810.R01.S.doc Version 5.2 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.V309810.R01.S.doc Version 5.2 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): 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service Prospective service users and their relatives have the information needed to choose a home, which will meet their needs. EVIDENCE: The home has a policy and procedure on admission and discharge of service users. Within the admission policy all service users must have an assessment prior to being admitted into the home. The manager who is trained in the principles of assessment of service users’ needs based on what the care the home says it will provide carries out all pre admission assessments. Review of a random sample of service user’s files demonstrated that pre admission assessments are being carried out. Standard 6 does not apply to this home. Abbey House DS0000013543.V309810.R01.S.doc Version 5.2 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 the following standard(s): 7 8 9 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a good and clear care plan in place for service users, which also includes appropriate risks assessments. This forms the basis for care based on the agreed care needs of the service users and demonstrated that health and personal care needs were met. Care staff receives training to meet the assessed care needs of the service users ensuring that competent staff supports service users and their health and care needs are met. The home’s medication policy on receiving, storing and administering and return of medication was in place and being adhered to thereby ensuring the safety and protection of the service users. Care workers were observed treating service users with respect and to maintain their dignity and privacy when delivering personal care. EVIDENCE: Abbey House DS0000013543.V309810.R01.S.doc Version 5.2 Page 10 The randomly selected care plans were clear and easy to read, identifying potential and actual risks to service users. The daily work sheet along with discussion with service users demonstrated that service users care needs are fully met. No service user at the time of inspection was responsible for their medication, but the manager was knowledgeable about what to do should this situation arise. Good clear records are kept of medication receipts, storage, administration and returns. Care staff had entered a medication ordered by the GP on the MAR sheet without obtaining the GP signature. A requirement was issued on this standard to ensure service users are protected by the homes policy on administration of medication. There were no visitors to the home to speak with the inspector, but relatives response to the CSCI pre inspection questionnaires were very positive. One relative wrote, “The set –up here is different from larger, more “institutional” homes”. Service users spoken to, rated the personal care they receive at the home as very good. All three of them said they were contented, they had enough to eat and can do as they like. The inspector observed care workers knocking on service users bedroom doors, and asking permission to enter. Abbey House DS0000013543.V309810.R01.S.doc Version 5.2 Page 11 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 13 14 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users lifestyles matched their needs and preferences and where possible they are able to maintain contact with family, friends and the local community. Service users are able to make choices in accordance with their abilities and were provided with a balanced diet in pleasant surroundings and in an unhurried way. EVIDENCE: Service users spoken to say they were able to go to bed and get up when they choose, take part in activities as they wished and consulted on how they would like to spend their time. This statement was supported by one relative who wrote in the pre inspection questionnaire “Activities are built into normal routine, rather than having activities and entertainment arranged. It works well”. One service user told the inspector I am able dress myself with help from my carer, after she helps me with my bathing”. “Staff are kind. I can’t knock the staff”. Another service user said, “the food is good really good and I Abbey House DS0000013543.V309810.R01.S.doc Version 5.2 Page 12 get enough to eat. The staff are so very good. I walk in the garden when the day or weather is ok”. In discussion with the care worker she said she has been with the home for a long time and she has completed her induction and the National Vocational Qualification (NVQ) Level 2 (L2) course, and has attended all the mandatory courses and have had yearly updates to enable her to care for the service users. Service users said their friends and families are always welcome to visit at any time, and over the Christmas period she had all her relatives come to visit. The inspector did not observe any visitors to the home during the visit. At the time of writing this report only two questionnaires were received at CSCI for this home and they were both complimentary on all areas. All service users are registered with a General Practitioner (GP). Further health care provision is obtained from the District nurse, Community Psychiatric Nurse, Occupational Therapist Dentist Audiologists Physiotherapist and Chiropodist as requested by the GP. Records of visits are kept and are available for inspection. The inspector observed that service users were dressed appropriately for the cold weather. In discussion with the service users the inspector complemented one service user on how well groomed she looked. She told the inspector she has an appointment at the hospital and feels she must look her best. Catering facilities are managed and carried out by the home’s resident care worker, who has a good knowledge of the dietary needs of the service users. On the day of the visit the service users and the family agree two main menus. The inspector did not sample the meals, but the service users all said the food is good, the texture just right and the amount was what they ordered. The inspector observed a large amount of fresh fruit on the dining table and service users said they are able to help themselves to the fruit whenever they want. Abbey House DS0000013543.V309810.R01.S.doc Version 5.2 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): 16 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints policy and procedure and training in place that evidenced that service users and relatives concerns are listened to and acted upon. Robust Safeguarding adults’ policies are in place to protect the service users from abuse and care workers undertake relevant training. EVIDENCE: CSCI Eashing received no complaints about the home. No complaints were logged at the home, and the manager informed the inspector that she is in touch with service users on a daily basis and issues raised are dealt with immediately; this prevents any need for service users to complain. Service users spoken to said they have no need to complain, as they are able to discuss everything with the manager/owner. The care workers were aware of the homes’ policy and procedure on Safeguarding Adults and felt secure in the knowledge that if they had to use the whistle blowing procedure the manager/ Owner of the company would support them. Review of the training files indicated regular updating on Safeguarding Adults have been undertaken. Care workers were knowledgeable about the different types of abuse of the elderly. Abbey House DS0000013543.V309810.R01.S.doc Version 5.2 Page 14 A random sample of care workers training record demonstrated that care workers are being trained to undertake the duties of meeting the service users assessed needs, thereby protecting them from abuse. Abbey House DS0000013543.V309810.R01.S.doc Version 5.2 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 the following standard(s): 19 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables service users to live in a safe, well-maintained and comfortable environment, which encourages independence. EVIDENCE: The management and staff encourage service users to see the home as their own home. It presents as a comfortable, attractive home, which has all the specialist adaptations, needed to meet the service users needs. It was noted that call bells were left within reach of each service users and service users said the bells are answered promptly. The home has attractive gardens, which are well maintained and there is good access to the gardens from various parts of the home. Some service users told the inspectors that they try to go out daily weather permitting to enjoy the gardens. The inspector noted that adverse weather would not stop service users enjoying the garden, as the Abbey House DS0000013543.V309810.R01.S.doc Version 5.2 Page 16 windows are low enough to allow service users to view the gardens from their armchairs. It was noted that service users were able to personalise their bedrooms with small items of furniture, paintings on the wall and many family photographs. Generally, the home presents as clean, safe, pleasant, hygienic and tidy and free from offensive odours. Random review of care workers training record demonstrated they have had training in infection control and this was evident in the storage of waste. Abbey House DS0000013543.V309810.R01.S.doc Version 5.2 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 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 28 29 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff in the home are trained, skilled and in sufficient numbers to fulfil the aims of the home and meet the changing needs of the service users. EVIDENCE: The staff rota demonstrated the number and grade of staff on duty to provide care and attention to service users for any twenty-four period was adequate to meet the assessed care needs of the service users. The home has a programme of planned training in place and all members of staff have an individual training record. Over 50 of care workers have attained the National Vocation Qualification at Level 2 (NVQ L2). Care workers are encouraged and enabled to undertakedevelopmental training as well as the mandatory training. . All newly appointed staff undertakes an induction programme. The home ensures that staff undertakes the mandatory training with yearly updates as necessary to maintain their competency to fulfil their duties. This was evidenced through discussion with the manager and care workers and from review of care workers training records. It was noted that staff turnover at the home is relatively low. All care workers are Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) Abbey House DS0000013543.V309810.R01.S.doc Version 5.2 Page 18 checked prior to commencing employment, and they are in receipt of terms and conditions of employment as evidenced in their randomly selected files. The manager informed the inspector that supervision record were up to date and this was verified during random sampling of care workers files. The manager had shown the inspector her planned programme of improvements and supervision of staff was high on her agenda. Abbey House DS0000013543.V309810.R01.S.doc Version 5.2 Page 19 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 33 35 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager has the experience to run the home and works to continuously improve services and provide an increased quality of life for the service users. There is a strong ethos of being transparent and open in all areas of running the home and the views of service users and their relatives are actively sought. Service users financial interests are safeguarded and the health, safety and welfare of service users and staff are protected and promoted by the homes’ policies and procedures. EVIDENCE: Abbey House DS0000013543.V309810.R01.S.doc Version 5.2 Page 20 The manager has demonstrated that she has kept herself updated on issues relating to care of the service users and staff in her charge. She has attained the Registered Managers Award and also the National Vocational Qualification Level 4 in care. In discussion with the manager it was evident she was knowledgeable about the care needs of the service users and the training needs of the care workers to meet these identified needs. There are clear lines of accountability within the home, each member of staff spoken to on the day of inspection aware of their role and responsibilities. The three residents of the home are treated as part of the owner’s family and meetings are held at meal times when carers, service users and the owner/manager eat together. Every one is then able to contribute to the running of the home, whether it is to plan the week’s menu or to replace major items in the home. The manager explained that this approach is preferable by all concern parties as any occurrence in the home affects us all. The home does not become involved in service user’s finance. The relatives/court manages all their finance. Review of documented records demonstrated that health and safety checks are routinely carried out at the home. All equipment examined on the day was properly maintained. Records indicated that fire drills, fire alarm, water temperature fridge and freezer recordings were regularly checked. Random sample of care workers’ training files demonstrated that up to date and relevant training were carried out by care workers to protect service users’ health, welfare and safety. In discussion with care workers they discussed their understanding and implementation of appropriate procedures to safeguard service users. Furthermore they spoke about their understanding of promoting safe working practices based on their health and safety training. Throughout the service there is a highly evolved understanding of the equality and diversity needs of the individual service users. Care workers are confident in delivering high quality outcomes for service users in the areas of age, sexuality, gender, disability and belief. Although the care workers are knowledgeable about issues relating to race and equality and diversity, they are not able at the moment to put this knowledge into practice, as the current service users are all Caucasians. Abbey House DS0000013543.V309810.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Abbey House DS0000013543.V309810.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? NO 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 OP9 Regulation 13 (2) Requirement The registered person shall make arrangements for the recording, of medicines received into the care home: all medication requested by the GP and entered by hand on the medication record sheets must be signed in accordance with the homes policy. Timescale for action 28/02/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Abbey House DS0000013543.V309810.R01.S.doc Version 5.2 Page 23 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 © 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 DS0000013543.V309810.R01.S.doc Version 5.2 Page 24 - 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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