Inspection on 13/06/06 for Abbey Lodge Care Home

This inspection was carried out on 13th June 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 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 Lodge Care Home 20/05/09

Abbey Lodge Care Home 04/12/08

Abbey Lodge Care Home 25/02/08

Abbey Lodge Care Home 19/10/05

Abbey Lodge Care Home 10/08/05

Abbey Lodge Care Home 25/01/05

Abbey Lodge Care Home 08/06/04

Similar services:

Abbey The

Snydale Care Home

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Abbey Lodge Care Home 10 Leeds Road Selby North Yorkshire YO8 4HX Lead Inspector Kate Shackleton Key Unannounced Inspection 13th June 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 Lodge Care Home DS0000044443.V300152.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 Lodge Care Home DS0000044443.V300152.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbey Lodge Care Home Address 10 Leeds Road Selby North Yorkshire YO8 4HX 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) 01757 703339 01652 655888 rob.pursey@tesco.net North Lincolnshire Care Limited Miss Emma Louise Dodgson Care Home 23 Category(ies) of Dementia - over 65 years of age (23), Old age, registration, with number not falling within any other category (23) of places Abbey Lodge Care Home DS0000044443.V300152.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service Users to include up to 23 (OP) and up to 23 (DE(E)) up to a maximum of 23 Service Users. 19th October 2005 Date of last inspection Brief Description of the Service: Abbey Lodge Care Home is owned by North Lincolnshire Care and was registered with the National Care Standards Commission in November 2003. The home provides personal care and accommodation for up to 23 older people, a number of whom have dementia. Abbey Lodge Care Home is located close to the centre of Selby and is situated in its own grounds. The accommodation provided is both in single and double rooms. The front door is locked for security and safety purposes and there is a stair lift for access to the first floor. Abbey Lodge Care Home DS0000044443.V300152.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The accumulated evidence used in this report has included: • A review of the information held on the homes file since its last inspection. • Information submitted by the registered provider in the Pre Inspection Questionnaire. • An unannounced visit to the home which lasted seven hours and included a tour of the premises, talking to service users and staff, examining some records and observing staff working with service users. • Information contained in surveys received from nine people who use the service, four relatives, one General Practitioner and one Care Manager. Staff had assisted the majority of service users to complete their surveys. What the service does well: What has improved since the last inspection? Abbey Lodge Care Home DS0000044443.V300152.R01.S.doc Version 5.2 Page 6 Thermostatic valves have been purchased and are to be fitted to the radiators in bedrooms. This will allow service users to regulate the temperature of their bedrooms to suit their individual needs. The manager has almost completed her professional qualification. This will enable her to manage more effectively in the best interests of service users. Staff are receiving fire training at regular intervals in line with the local fire authorities guidance. As a result of this service users will be better protected in the event of a fire. 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 Lodge Care Home DS0000044443.V300152.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 Lodge Care Home DS0000044443.V300152.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): 1,2 and 3. Standard 6 does not apply to this service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. People who use the service and their relative or representatives have good information about the home in order to make an informed decision about the homes ability to meet their needs. The personalised needs assessment ensures that the diverse needs of service users are identified and planned for before admission EVIDENCE: Case tracking confirmed good practice. The manager visits prospective service users at home or in hospital and undertakes a comprehensive assessment of their care needs. Relatives are always involved where possible to find out more information that the service user may not be able to provide. One of the service users whose care was case tracked had visited the home before deciding to move there. She said, “I wouldn’t leave now I like it that much”. Another service user spoken with had only recently moved in and was experiencing real difficulties settling. She said “I would do anything if I could go home.” The manager was aware of the situation and has arranged a Abbey Lodge Care Home DS0000044443.V300152.R01.S.doc Version 5.2 Page 9 meeting with the care manager and informed the General Practitioner of the service users distress. The majority of service users surveys state that the service user did not receive enough information about the home before they moved in so that they could decide if it was the right place for them. Comments included statements like “ I would have like to have known the nature of staff and their nationality because lack of adequate English has posed a problem and the mental attitude of other residents would irritate and isolate me” and “Any information I received was from the care staff” Admission documents provided good information and included a copy of the care management assessment. The diverse needs of service users are identified. The information was available to staff to ensure they could meet the social, personal and emotional needs of people who use the service. Six staff were spoken to and they were able to describe how they welcome new service users to the home and help them to settle in. They were sensitive to the ordeal that service users experience when having to make this life changing decision A copy of the Service User Guide is in each bedroom and service user files contained a written contract that detailed the weekly charge. This means that service users/representatives have information about the service they can expect to receive and how much it will cost. Abbey Lodge Care Home DS0000044443.V300152.R01.S.doc Version 5.2 Page 10 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 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The needs of service users are identified and arrangements are in place to ensure that their diverse care needs are met. Systems have been established to ensure that the storage and administration of medication protects service users from the risk of error. EVIDENCE: Case tracking confirmed that Service user plans are comprehensive. They contain sufficient detail to ensure that care staff knows the support they have to provide to meet the diverse needs of service users in a manner that promotes independence and respects privacy and dignity. One service user spoken to was aware of her care plan. Her key worker had explained it to her. For service users with dementia other people who hold valuable information about them e.g. family members, General Practitioners, are consulted. This helps to ensure that the information in the plan is accurate. Case files contained regular reviews of the plan. This makes sure that service users changing needs are identified and acted upon. Abbey Lodge Care Home DS0000044443.V300152.R01.S.doc Version 5.2 Page 11 Staff act as key workers for named service users. Staff spoken to were involved in the care planning process and were knowledgeable about the needs of people who use the service. Staff were observed providing support in a kind and helpful manner and service users looked clean and well cared for. Staff were able to give numerous examples of best practice relating to the promotion of respect for the privacy and dignity of service users. Comments within the relative’s surveys stated that the overall care provided is satisfactory. One relative commented “the staff are kind and caring to all the residents” The majority of service users surveys stated that they always receive the care and support they need. One service user commented, “Sometimes my requests are ignored though I understand that the staff are busy” The one General Practitioner survey received confirmed that the health care needs of service users are met. Service users are registered with a GP and are able to access the primary health care team. Medication is stored and administered in a safe manner. The care plan identifies if a service user wishes to self medicate. A risk assessment is completed to ensure the service users ability to do this safely. Abbey Lodge Care Home DS0000044443.V300152.R01.S.doc Version 5.2 Page 12 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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Activities are well organised and provide stimulation and interest for people living in the home. Meals are nutritious and offer a varied diet. EVIDENCE: Case tracking confirmed that an activities assessment is completed about each service user. An activities co- coordinator is employed to devise a programme reflecting the wishes of service users. Discussions with staff showed that activities take account of the interests of both men and women. A notice displayed in the dining room invites service users to submit ideas for activities. Discussions with two service users and feedback from the majority of service user surveys showed that activities are arranged by the home that they can take part in. During this visit the activities co-ordinator visited bringing with her some newborn ducklings to show service users. Throughout the day service users were occupying themselves watching TV, conversing with each other and staff, completing a crossword, sitting in the garden and moving freely around the house. Clergy visit monthly to give communion. One service user sometimes walks along to the church nearby Abbey Lodge Care Home DS0000044443.V300152.R01.S.doc Version 5.2 Page 13 Menus are varied and nutritionally balanced. There is a choice of food at each mealtime and special diets are catered for. Discussions with catering staff showed that they knew the food preferences of individual service users. Service users mostly eat in the dining room but some have their meal in the lounge or their bedroom. Service users arrive for breakfast as and when they get up. Dining room tables were set properly with appropriate cutlery and condiments. Staff served meals from a tray with discreet support being provided when needed. Mealtimes were relaxed and unhurried allowing service users as much time as they needed to complete their meal. Service users confirmed that they were happy with the quality and quantity of food provided. Abbey Lodge Care Home DS0000044443.V300152.R01.S.doc Version 5.2 Page 14 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Complaints and concerns raised are properly followed up and appropriate action is taken to resolve the situation in the best interest of service users. Robust procedures and staff training protect service users from abuse. EVIDENCE: The complaints procedure is displayed in the entrance hall. It bore the title that the home had been previously known by. This is confusing for service users. The area manager said she would make arrangements for this to be corrected. At the last inspection the manager had been asked to provide a more user- friendly procedure and this has been done. Two service users spoken to say they would complain if there was a need to, one saying she would talk to the manager or her key-worker. Surveys confirmed that service users know who to speak to if they are not happy and they felt they were listened to. There is a vulnerable adults procedure and staff receive training in this aspect of their work including whistle blowing. Staff spoken to were very clear about reporting any suspicion or allegation of abuse. Staff felt very strongly about reporting anyone that acted in an abusive manner towards service users. Abbey Lodge Care Home DS0000044443.V300152.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 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The unpredictable nature of the hot water system has the potential to place service users at risk of scalding. EVIDENCE: The home was clean and fresh and had a friendly atmosphere. The majority of bedrooms are single with a few doubles. Some rooms have an en suite facility. Service users felt that the cleanliness of the home was good. The home employs domestic staff to do the cleaning and laundry duties. Service users are able to furnish their rooms with personal possessions. Communal areas are comfortably furnished and decorated to a good standard. There are continuing difficulties with the aging heating system. Service users cannot control the radiator temperatures in their bedrooms. The area manager confirmed that thermostatic valves have been purchased. The delay in fitting them is due in part to waiting for some warm weather because the system will have to be shut down for a few days and an inability to secure the services of Abbey Lodge Care Home DS0000044443.V300152.R01.S.doc Version 5.2 Page 16 a plumber. The area manager thinks a plumber has been located and is being persistent in her efforts to get the work done. A first floor bathroom is out of use because the bath water is too hot. The hot water tap has been removed. A reading taken from a ground floor bath exceeded 60C. Similar issues were identified at the last two inspections. Some of the problems associated with the unpredictable hot water temperatures are thought to be associated with the ageing heating system. The area manager explained that the cost of replacing the system is prohibitive at this time. She adjusted the boiler temperature in the area closest to this bathroom to reduce the temperature of the bath water. Aids and adaptations are provided and regularly serviced. Staff spoken to were aware of the homes policy on infection control. Abbey Lodge Care Home DS0000044443.V300152.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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users benefit from a properly vetted and appropriately trained staff group. EVIDENCE: Comments received in the surveys show that staff are either always or usually available when needed. Staff were observed responding quickly and appropriately to requests from service users and spent time talking to them. Service users spoken to said that staff were always available to provide support The rota showed that there is enough staff on each shift. Staff spoken to felt that in general they had enough time to deliver a good service. The two staff files examined showed a satisfactory recruitment process making sure that only suitable people are employed. Comprehensive induction training is provided and staff spoken to said that the on going training programme is very good providing them with the skills and knowledge to meet service users needs. Staff said that they are able to identify their training needs in supervision sessions with the manager. Abbey Lodge Care Home DS0000044443.V300152.R01.S.doc Version 5.2 Page 18 The area manager has arranged some additional equality and diversity training to ensure that staff have a clearer understanding of the issues to take account of when providing a care service. 25 of the care staff have achieved National Vocational Qualification level 2. Staff spoken to considered morale to be high amongst the staff team. Agency staff are rarely used. Abbey Lodge Care Home DS0000044443.V300152.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 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Management arrangements promote good service delivery. EVIDENCE: At the time of this visit the manager was not available. Service users spoken to liked the manager. Residents meetings are arranged where ideas for improvements can be put forward. Staff spoken to confirmed that the manager supports them well in achieving good outcomes for service users. They have regular supervision and annual appraisal. There are robust procedures in place to minimise the risk of financial abuse when the home is holding money on behalf of service users. There are a range Abbey Lodge Care Home DS0000044443.V300152.R01.S.doc Version 5.2 Page 20 of policies and procedures covering health and safety topics designed to ensure the health, safety and well being of service users and staff Quality assurance and quality monitoring systems based on seeking the views of service users and their representatives are in place. Quality audits are done by the area manager and a report published. Findings inform the annual development plan for the home. The findings of the most recent audit are soon to be published in the Newsletter. Abbey Lodge Care Home DS0000044443.V300152.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 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 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 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 Lodge Care Home DS0000044443.V300152.R01.S.doc Version 5.2 Page 22 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 OP25 Regulation 23 Requirement Timescale for action 13/07/06 2. OP25 23 The registered person is required to fit individual thermostats to all radiators in service users rooms which do not have them. (Timescale of 31.05.05, 30.09. 05, 30/11/05 not met) The provider must forward to the Commission proposals to meet this overdue requirement. Hot water temperatures must be 13/07/06 regulated at the point of delivery close to 43 degrees centigrade. Arrangements must be made to protect service users from the risk of scalding on a daily basis. (Timescale of 21.01.05, 10.08.05 and 30/11/05 not met) This was also subject to an immediate requirement at the last two inspections. The hot water tap in the first floor bathroom must be replaced. The provider must forward to the Commission proposals to meet this overdue requirement Abbey Lodge Care Home DS0000044443.V300152.R01.S.doc Version 5.2 Page 23 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 Lodge Care Home DS0000044443.V300152.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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