Inspection on 05/07/06 for Abbey House

This inspection was carried out on 5th July 2006.

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 06/12/05

Abbey House 11/07/05

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 Inspection 5th July 2006 09:30 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 DS0000037630.V302826.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 DS0000037630.V302826.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbey House Address Stokes Drive Leicester Leicestershire LE3 9BR 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) 0116 2312350 0116 2875186 socis209@leicester.gov.uk Leicester City Council Mrs Jennifer Glover Care Home 33 Category(ies) of Dementia - over 65 years of age (20), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (20), Old age, not falling within any other category (33), Physical disability over 65 years of age (8), Sensory Impairment over 65 years of age (10) Abbey House DS0000037630.V302826.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service User Numbers DE(E) or MD(E) No one falling within category DE(E) or MD(E) may be admitted into the home when 20 persons who fall within categories/combined categories DE(E) or MD(E) are already accommodated within the home Service User Numbers PD(E) No one falling within the category PD(E) may be admitted into the home where there are 8 persons of category PD(E) already accommodated within the home Service User Numbers SI(E) No one falling within the category SI(E) may be admitted into the home where there are 10 persons of category SI(E) already accommodated within the home 6th December 2006 2. 3. Date of last inspection 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 Leicester City Council. The home is situated along a main road in a residential area with car parking space to the front of the home. The home is located approximately a ten-minute bus journey from the city centre. There are shops, pubs, a post office and other local amenities approximately half a mile from the home. There is level entry access to the home with accommodation 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 with bath/shower and toilet facilities close by. Residents have a choice of lounges, including a smoking lounge and dining room. There is seating available for residents to the front of the home and the garden to the rear is landscaped. The home’s brochure provides information about the service to prospective and current residents and includes the terms and conditions of the stay. The fees are in the range of £379 as detailed in the written information provided by the Registered Manager. People that live at the home are responsible for any additional charges such as private chiropodist, toiletries, hairdressing and newspapers. The CSCI published inspection reports are available at the home and referred to in the home’s brochure. The people who live there are informed of the CSCI inspection individually and through sharing information with relatives. Abbey House DS0000037630.V302826.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection of this service consisted of pre-planning work undertaken prior to the visit to the home. This consisted of reviewing the completed preinspection questionnaire submitted to CSCI and review of the events that have taken place at the service since the last inspection. This was followed by the site visit on the 5th July 2006 that lasted over 6 hours. The primary method of inspecting was ‘case tracking’ the care of four residents living in the home. The inspection consisted of the Inspector looking at the care provided to four residents living at the home by talking to the residents themselves; talking with the staff supporting their care; checking records relating to their health and welfare; viewing their personal accommodation (with their consent) as well as communal living areas. The Inspector made observations of the care practices and the interaction between the staff and the residents. During the inspection observations were made of how the staff implemented the homes procedures. The Inspectors also checked other issues relating to the running of the home including health and safety and management and staffing areas. The findings from the inspection were shared with the Registered Manager at the end of the visit. Comments received from the residents have been incorporated into this inspection report. The Commission for Social Care Inspection is inspecting Abbey House against the Care Standards Act 2000. What the service does well: The residents live a comfortable home that is welcoming. The home is spacious, well maintained with inviting décor, a range of complimentary furniture and décor. Residents have a choice of lounges to relax in both on the ground floor and first floor. Residents move freely around the home and can receive visitors at any time. The activities programme for the month is displayed on the notice board in the main reception area. There is a small shop within the home, where residents can purchase small items, drinks and confectionary. There are good choices of meals provided daily to suit special dietary needs and snacks and drinks are available throughout the day. Visitors are welcomed in the home at any time. Staff have a good understanding of the residents needs, routines and lifestyle. Staff are visible throughout the home, having awareness of their roles and responsibilities, whilst being with the residents. Abbey House DS0000037630.V302826.R01.S.doc Version 5.2 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 DS0000037630.V302826.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 DS0000037630.V302826.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): 3. Quality in this outcome is good. This judgement has been made using the available evidence including a visit to the site. The assessment process is robust and well managed to ensure that residents care needs identified are met safely. EVIDENCE: The admission procedure was viewed in relation to four the residents tracked, including a new resident. The care files contained a copy of the social worker’s assessment of needs undertaken as part of the referral process and a further assessment carried out by the qualified person. All four residents files viewed, detailed the specific care needs of the residents that would be met by the carers, key information in relation to medication, history of falls, mobility, diet, known communication and mental wellbeing and social. Additional information was included such religious and cultural needs. Residents spoken with indicated they and their family were involved in the process and were satisfied with the care provided. The Inspector spoke to the relatives of one resident who was moving in on the day, stated they have been fully involved in the assessment, prior and during the move to the home. Abbey House DS0000037630.V302826.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 is good. This judgement has been made using the available evidence including a visit to the site. The residents are well cared for having their social and health care needs met that promotes and maintains their independence. EVIDENCE: The Inspector spoke to the residents tracked including a new resident who was moving into the home. The residents and relatives confirmed their views are sought and how their individual care needs would be met. All residents indicated that they have identified key-workers. The care plans showed how the residents’ care needs should be met with including the need for two carers, special diet, observance of religious practice, other impairments that would affect that restricts them ability to maintain their own independence and any health care support. The staff records viewed indicated that staff have received training in ‘person centred’ care although the residents care plans are not reflective of this. Residents spoken with stated that their care needs were being met in a way that suited them. Residents felt the carers were polite and treated them with respect and dignity. Comments included “I can’t grumble because they will Abbey House DS0000037630.V302826.R01.S.doc Version 5.2 Page 10 look after me here”. Carers were observed speaking to this resident on a faceto-face basis, speaking clearly and patiently allowing the resident to respond. The daily records showed that residents’ health and wellbeing was being monitored. The records showed visits made by the GP’s and District Nurses, detailed any treatment and/or advice given. Details of residents and their medication are maintained. Residents spoken with indicated they receive their medication on time. Medication is stored in a locked medication room and administered by trained staff. The storage, administration and recording of medication for four residents tracked were viewed were in good order, auditable and up to date. There is a photo album containing photographs of the resident with details of any known allergies. The Pharmacist inspected the service earlier this year and no serious concerns were identified. Abbey House DS0000037630.V302826.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 is good. This judgement has been made using the available evidence including a visit to the site. The residents make choices about their lifestyle, interests and offered good choices of meals. EVIDENCE: The activities planned for the month is usually displayed on the notice board, although on the day of the inspection this was being updated. One resident stated “usually the activities board tells you what’s happening in the month – always have bingo on Wednesdays”. The Inspector sat with one resident in the dining room where Bingo was being played. Many residents participated, some with the help of the carers or their family. It appeared that all were very focussed and enjoyed the Bingo session. A carer told the Inspector that residents have been out for a meal in Mountsorrel by the water and a boat trip is being planned. Records viewed showed there was good communication with family. This was directly witnessed by the Inspector when a relative informed the Registered Manager that a review meeting had been scheduled, which was already known. There is Holy Communion at the home on Sundays for those residents who wish to participate. There was a relaxed atmosphere in the home and residents Abbey House DS0000037630.V302826.R01.S.doc Version 5.2 Page 12 were seen moving around the home freely. Visitors were seen arriving at the home and were seen chatting with the residents in the smaller lounge or in the privacy of their own rooms. There is a small shop for residents to purchase small items, confectionary and drinks. Residents had developed ‘memory books’ and excerpts about their life, was displayed along with their photographs, outside the dining room. A resident tracked said she was able to manage her own personal care and dressing but needed assistance with walking. The Inspector observed residents being offered hot and cold drinks throughout the day especially as the day was getting particularly hot and humid. Carers were seen taking drinks to the residents that preferred to relax in their rooms after lunch and whilst playing bingo. The menus seen demonstrated that meals were varied and nutritious. The residents confirmed they have individual choices and portions. The chef told the Inspector that lighter meals and salad options have been introduced onto the menu during the recently as residents were not wanting hot meals. Abbey House DS0000037630.V302826.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 is good. This judgement has been made using the available evidence including a visit to the site. Residents are protected by robust and accessible complaints and by staff aware of the safe guarding adults’ procedures. EVIDENCE: The Complaints Procedure is included in the ‘service user guide’ and displayed in the entrance and the library. The Complaints Log was not available to view although the Registered Manager stated no complaints were received since the last inspection, which was also stated in the information submitted to CSCI. No complaints have been received by the CSCI. Residents tracked, other residents and visiting relatives spoken with indicated they were aware of how to complain and were confident to complain. The relatives of the new resident confirmed that they were told how to complain and a summary of the process. One carer who is the key-worker for one resident tracked demonstrated a good understanding of her responsibility and procedures to follow in relation to protection of vulnerable adults. The carer indicated that she would have no hesitation to whistle-blow if she witnessed bad practice. Abbey House DS0000037630.V302826.R01.S.doc Version 5.2 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, 26. Quality in this outcome is good. This judgement has been made using the available evidence including a visit to the site. The residents’ benefit from having a clean, well-maintained, safe and personalised standard of accommodation that promotes their lifestyle. EVIDENCE: The remaining double-glazing has now been completed. All the bathrooms have been re-tiled, which now have a bright, fresh and a clean look. The home is accessible to people using a variety of walking aids such as frames and wheelchairs. The corridors and lounges were clean and the Inspector observed domestic staff carrying out their cleaning duties. Residents were seen relaxing in various lounges, from the large to the small smoking lounge. All the lounges had freestanding fans to keep the residents cool during the warm weather. Sun canopies have been fitted over the large lounge windows on the ground floor, although one has been removed as it was unsafe. The Inspector spoke with the new resident in his room whilst the relatives were making the bedroom feel more homely. The resident was still getting his Abbey House DS0000037630.V302826.R01.S.doc Version 5.2 Page 15 ‘bearings’ to the home and was aware of the toilet and bathroom being opposite his room. Two resident showed the Inspector their bedrooms, which were very personalised with photographs and pictures. Both bedrooms were clean, decorated with complimentary bedroom furniture. Resident confirmed they had a key to their bedroom if they prefer. The Inspector observed staff wearing aprons depending on whether they were involved in helping with personal care or serving meals. The domestic staff clean the residents bedrooms on a daily basis. One resident said, “home is clean, tidy and the ladies clean and vacuum my room”. The room to store cleaning materials is kept locked in line with COSHH regulations. The Handy Person was at the home supporting the domestic staff and sorting out bedrooms in preparations of new residents moving to the home. The laundry room is located away from the communal areas. The carers were aware of how they do the residents laundry and the procedure followed for soiled clothes or for residents with any type of communicable disease such as MRSA. Abbey House DS0000037630.V302826.R01.S.doc Version 5.2 Page 16 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 is good. This judgement has been made using the available evidence including a visit to the site. Sufficient numbers of trained staff recruited through a robust recruitment process ensure resident’s needs are met safely and on time. EVIDENCE: On the day of the inspection, the carers and ancillary staff were on duty as indicated by the staff rota viewed. Fourteen carers have NVQ in care level 2 and above, equivalent to 85 of the staff team. Six staff currently qualified first aiders’ within the home and at least one first aider is on duty at all times. The local authority’s recruitment procedure is robust, which is managed by the Human Resource Team. The Inspector examined two carer’s personnel files, which primarily contained a record of the induction training and certified training. The home does not keep records of the application forms, preemployment checks such as references and confirmation of the criminal records bureau (CRB) clearances. These are held at the Human Resource Office and were not available to view at the home. The Registered Manager confirmed she would receive confirmation checks carried out are satisfactory although there was no documentation to evidence on the two carers files viewed. Further discussion took place with the Registered Manager regarding the need to demonstrate and evidence that pre-employment checks have been carried out for all staff. Abbey House DS0000037630.V302826.R01.S.doc Version 5.2 Page 17 The carers spoken with described the induction training undertaken, which included the home’s policies, procedures, adult protection, health and safety, food hygiene and a period of shadowing a senior carer. The carer showed an awareness of the residents’ care needs, how to support and assist residents to maintain and continue living independently. Information received in the pre-inspection questionnaire was confirmed by training certificates found on carers files for training completed in moving and handling, COSHH, health and safety, first aid, dementia care, stroke awareness, communicable diseases and person centred care. Further training is scheduled for dementia and mental health awareness and stroke awareness. The residents and their visiting relatives spoken with indicated that staff were always around and appeared to know what to do. Abbey House DS0000037630.V302826.R01.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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 is good. This judgement has been made using the available evidence including a visit to the site. Residents’ and staff’s health, safety and welfare are being promoted and protected through the home’s policies and procedures. EVIDENCE: The Registered Manager manages a team of an Assistant Manager and Senior Carers and has clear lines of responsibility and accountability. In the absence of the Registered Manager the Assistant Manager resumes the duty to manage the home. Staff spoken with confirmed they receive timely supervision and receive a record of the meeting. The Registered Manager confirmed she receives monthly visits and reports of the findings are sent to CSCI. Residents spoken with confirmed they are consulted about the care they receive. Where the resident is unable to comprehend, their relatives are consulted. Abbey House DS0000037630.V302826.R01.S.doc Version 5.2 Page 19 Residents spoken with confirmed that have keys to their bedrooms and also a lockable cabinet to store valuables and money. The residents manage their own financial affairs with the support of their family and can access their money to pay for hairdressing or for shopping they usually get the money immediately and sign for it. Resident finance records examined clearly showed financial reconciliation and management of the residents’ money, which is double-signed and auditable against the sums of money kept on behalf of the resident. The Inspector noted that staff are using tippex to score errors in recording of balances. This was brought to the attention of the Registered Manager with consideration to refrain from using this method of correcting errors. Residents spoken with indicated that they felt safe both in the home and with the carers. Residents care files contained copies of the risk assessments carried out for mobility, use of hoist and measure to control the spread of infection. However, one carer told the Inspector of her concern for one resident and the use of a shower chair, which caused the resident considerable pain. The carer was still considering what the alternative option and had not shared the concerns with anyone. This was brought to the attention of the Registered Manager who acted on the information received, whilst making contact with the District Nurse. The home has a Handy Person who is responsible for repairing minor faults and supported by the Maintenance Team when required. The cleaning materials and equipment are stored in a locked room. Records relating to health and safety procedures such as regular fire drills and fire alarm tests are completed and were up to date. The Accident book viewed was consisted with the notifications sent to the CSCI detailing events that have affected the residents’ safety and wellbeing. Abbey House DS0000037630.V302826.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. 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 3 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 DS0000037630.V302826.R01.S.doc Version 5.2 Page 21 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. 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. Refer to Standard Good Practice Recommendations Abbey House DS0000037630.V302826.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester 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. Extracts may not be used or reproduced without the express permission of CSCI Abbey House DS0000037630.V302826.R01.S.doc Version 5.2 Page 23 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!