Inspection on 19/10/05 for Abbey Lodge Care Home

This inspection was carried out on 19th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 13/06/06

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 Unannounced Inspection 09:30 19 and 20th October 2005 th 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.V256793.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 Lodge Care Home DS0000044443.V256793.R01.S.doc Version 5.0 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) 01652 653414 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.V256793.R01.S.doc Version 5.0 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. 10th August 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.V256793.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out in 10.5 hours over a day and a half. . Discussions were held with the area and registered manager, two care staff and service users where possible. Policies, procedures and records were examined. Some parts of the premises were looked at mostly service users bedrooms, bathrooms and lounges. What the service does well: What has improved since the last inspection? Progress has been made on redecoration and refurbishment of the home. The manager has started the professional qualification that a registered manager needs to do the job. Abbey Lodge Care Home DS0000044443.V256793.R01.S.doc Version 5.0 Page 6 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.V256793.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Abbey Lodge Care Home DS0000044443.V256793.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Some of the pre admission information gathered is valuable. In order to ensure that the care needs of people moving into the home can be met a full and comprehensive assessment must be completed and recorded. EVIDENCE: A recommendation was made at the last inspection in August 2005 that the registered manager should complete pre admission assessments before accepting a service user into the home. In September 2005 a relative raised concerns that their relation had been admitted to the home following assessment by the social services and the homes manager and within twenty four hours had to be moved again because the home could not meet his needs. The manager explained that she had completed an assessment six days prior to the admission date and felt that the service user had either deteriorated in the meantime or that she had not been provided with accurate information. The pre assessment in relation to this case was examined and found to be incomplete in a number of key aspects. Two out of three pre- assessments examined were not completed fully and did not contain enough detail to enable judgements to be made as to whether or not the needs of the individual could Abbey Lodge Care Home DS0000044443.V256793.R01.S.doc Version 5.0 Page 9 be met by the service. The area manager is arranging for the registered manager to have needs assessment training. Abbey Lodge Care Home DS0000044443.V256793.R01.S.doc Version 5.0 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 and 9 The needs of service users are identified and arrangements are in place to ensure that their health 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: Service users health, personal and social care needs are detailed in the care plan. The plan is reviewed monthly by the manager or as changing needs dictate and a further six monthly review is held with family members and other professionals are invited. The plans are not signed by the service user where possible or their representatives. The area manager advised that they are going to change the care plan document to one that is more user friendly. Discussed the advantages of “outcomes based” care planning developed from the care management plan provided by the social services and the homes own pre admission assessment. Staff reports daily the care given to service users and any significant changes in their needs that may require further interventions. Abbey Lodge Care Home DS0000044443.V256793.R01.S.doc Version 5.0 Page 11 Service users have access to the primary health care team and the Community nurse was seen visiting the home. There have been meetings arranged with the community nurses to resolve the issues raised in the last inspection report and on going monitoring of the situation is in place. A couple of service users are able to part self medicate following a risk assessment. At the last inspection in August a number of issues were raised and a requirement made relating to the safe storage and administration of medicines. In September a community pharmacist visited the home and raised similar concerns with the Commission for Social Care inspection. Since then all of the requirements have been actioned and staff are receiving additional training. Staff spoken to confirmed this and said that the training had helped to clarify the procedures. The manager said that they are looking to replace the current monitored dosage system for a simpler system. A new controlled drugs cupboard has been provided. Abbey Lodge Care Home DS0000044443.V256793.R01.S.doc Version 5.0 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 Activities are well organised and provide stimulation and interest for people living in the home. Meals are nutritious and offer a varied diet. EVIDENCE: There is an activities assessment completed on each service user to establish the type of activities people prefer. There is a daily activity arranged e.g. Board games, bingo, skittles and “movie afternoons”. Clergy from Selby Abbey visit to give communion and other clergy will visit if requested. Service users and their families are surveyed through “satisfaction questionnaires” on various aspects of the service delivered including activities, food, and rising and retiring times. Friends and family are encouraged to visit at any reasonable time. The manager said that the home receives a lot of visitors. Staff spoken to were able to give numerous examples of how service users were helped to make choices about how they live their lives. Menus examined showed a choice of food at all mealtimes and staff were heard giving service users choices about what they would like to eat. Breakfast and lunch was observed. Service users came to the dining room for breakfast as and when they were ready and were given individual attention. Lunchtime was more of a communal arrangement, which seemed relaxed with good-humoured Abbey Lodge Care Home DS0000044443.V256793.R01.S.doc Version 5.0 Page 13 banter being exchanged. Service users can eat alone in their room if they prefer. Mealtimes are flexible to suit the needs of individuals and the group. Service users spoken to say that they liked the food. Abbey Lodge Care Home DS0000044443.V256793.R01.S.doc Version 5.0 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 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 displayed is from the staff procedural manual and not suitable for service users /representatives. The service user guide reflects the procedure that applied under the previous ownership of the home and is no longer valid. Two complaints have been received by the CSCI since the home was inspected in August alleging poor practice. The home was asked to investigate the first one and provide the CSCI with its findings. Following this investigation different arrangements and more staff training was provided to improve practice. Both of these complaints are detailed earlier in this report. The manager said that she hasn’t received any complaints. 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.V256793.R01.S.doc Version 5.0 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): 19,22,23,25,and 26. Abbey Lodge provides service users with a clean comfortable home. EVIDENCE: Since the last inspection improvements have continued to be made to improve the environment. A new carpet has been fitted to the entrance hall and non slip flooring fitted to two bedrooms. Two bedrooms have been redecorated and a first floor bathroom and ground floor toilet are under refurbishment to meet requirements made at the last inspection. Three new armchairs have been ordered and there are plans to redecorate more bedrooms soon. On first entering the home there was a smell of urine, this was located in the dining room, which is sited just off the entrance hall. A tour around the remainder of the home showed it to be clean and free from offensive odours. The home is decorated to a satisfactory standard and comfortably furnished. There are some difficulties with the central heating system, which has resulted in secondary heating having to be used. It has been agreed with the area manager that in order to protect service users from harm that if additional heaters are used they will be secured to the wall and guarded. Secondary Abbey Lodge Care Home DS0000044443.V256793.R01.S.doc Version 5.0 Page 16 heating was not in use at the time of this inspection. Room temperatures taken were satisfactory and service users said they were warm enough. It has not been possible to fit thermostatic controls to some bedroom radiators to allow service users to control the temperature in their bedrooms. The area manager explained that because the heating system is so old the thermostatic controls are a different measurement and cant be fitted. The solution would be to either replace the radiators or install a whole new heating system. A quote for this work is with the proprietor and a decision is yet to be made. A number of the requirements made at the last inspection have been actioned however the following remain outstanding. • Regulation of water temperatures and design solutions to control; • Risk of Legionella • Risks from hot water/surfaces (i.e. temperatures close to 43C) Water is still being delivered too hot, a reading taken from a bath exceeded 67C. Some of the problems associated with the unpredictable hot water temperatures are thought to be associated with the ageing heating system. The valve on the bath was adjusted immediately to ensure delivery of hot water at a safe temperature. Nothing further has been done to minimise the risk of Legionella. Abbey Lodge Care Home DS0000044443.V256793.R01.S.doc Version 5.0 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): 28,29 and 30 Service users benefit from an appropriately trained staff group. EVIDENCE: Two of these standards were assessed at the last inspection and requirements made to improve the recruitment practices to minimise the risk of employing unsuitable people. There has been no new staff recruited since the last inspection and therefore no evidence available to check that best practice is now in place. The manger said that at the next recruitment she would verify that references are authentic. A requirement was made that staff Criminal Record Bureau checks must be kept at the home for all newly recruited staff until after the next inspection takes place. The area manager explained that the proprietor refuses to provide the home with the Criminal Records Bureau reference obtained for staff. Because of the confidential nature of these references the proprietor felt they must be kept at the organisations head office and that inspectors could visit there to inspect them. Consideration should be given to keeping a record of the dates CRB’s were sought and issued and the record to be kept in the home, this would provide sufficient evidence of best practice. Staff spoken to and staff files examined confirmed that both mandatory and specialist training is provided. Staff said that the training provided was good and helped them to provide a quality service. At the time of this inspection Abbey Lodge Care Home DS0000044443.V256793.R01.S.doc Version 5.0 Page 18 First Aid and medication training was being provided. Only one member of care staff has achieved National Vocational Qualification level 2 with one staff undertaking it and another three waiting to start December/January. One member of staff is waiting to start NVQ level 3. Abbey Lodge Care Home DS0000044443.V256793.R01.S.doc Version 5.0 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 Some aspects of the management of the home have the potential to place service users at risk of harm or injury. EVIDENCE: The manager has achieved NVQ level 2 and commenced the Registered Managers Award in September 2005. 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. Abbey Lodge Care Home DS0000044443.V256793.R01.S.doc Version 5.0 Page 20 There are robust procedures in place to minimise the risk of financial abuse where the home is holding money on behalf of a small number of service users. Records examined showed that a record is kept of each financial transaction supported by receipts. Monies are stored securely. There are a range of policies and procedures covering health and safety topics designed to ensure the health, safety and well being of service users and staff. A number of the requirements made at the last inspection have been actioned however the following remain outstanding. •Up to date fire alarm and emergency lighting certificate – The manager said that an electrician had visited and work is required to be carried out before a certificate can be issued. The report has been sent to the proprietor. • Gas boiler – The manager said that the work required had been carried out but the certificate of safety could not be found. Seven staff fire training records examined showed that only one person had received any fire training in the last six months. This is unacceptable and puts service users and staff at risk. North Yorkshire fire authority advises the following training for staff in care homes; • Within the first month of employment two periods of instruction • Staff on day duty six monthly • Staff on night duty three monthly Refer North Yorkshire Fire and Rescue Log Book. An immediate requirement was issued on the day to make arrangements for all staff to receive training within seven days. Abbey Lodge Care Home DS0000044443.V256793.R01.S.doc Version 5.0 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 1 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 x 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 2 17 X 18 3 3 x x 3 3 x 1 3 STAFFING Standard No Score 27 x 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 1 Abbey Lodge Care Home DS0000044443.V256793.R01.S.doc Version 5.0 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 OP3 Regulation 14 Requirement Timescale for action 20/10/05 2 OP16 22,5 The needs of the prospective service user must be fully assessed and the registered person must confirm in writing to the service user that the home is suitable for the purposes of meeting the service users needs before admission is arranged. A clear accessible complaints 30/11/05 procedure must be made available to each service user/representative. A summary of the procedure must be included in the Service User Guide. Abbey Lodge Care Home DS0000044443.V256793.R01.S.doc Version 5.0 Page 23 3 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 and 30.09. 05 not met) The provider must forward to the Commission proposals to meet this overdue requirement. Hot water temperatures must be 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 and 10.08.05 not met) This was also subject to an immediate requirement at the last inspection. The provider must forward to the Commission proposals to meet this overdue requirement Procedures must be introduced and maintained to ensure the risk of Legionella is managed and recorded in the home. (Timescale of 31.05.05 and 10.08.05 not met) The provider must forward to the Commission proposals to meet 30/11/05 this overdue requirement 4 OP38 13,23 A copy of the up to date fire alarm and emergency lighting equipment must be provided. (Timescale of 15.09.05 not met) The gas safety certificate relating to the Andrews gas boiler must be provided to the Commission 30/11/05 5 OP38 13,23 Staff fire training must be kept up to date in accordance with DS0000044443.V256793.R01.S.doc Version 5.0 Page 24 Abbey Lodge Care Home North Yorkshire Fire Authority (Timescale of 15.09.05 not met) 26/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP7 OP26 OP29 Good Practice Recommendations Service user plans should be signed by the service user whenever capable and/or representative (if any). Measures should be employed to eliminate the smell of urine in the dining room. A record of the of the dates that CRB’s are sought and issued for staff should be kept in the home to provide evidence of good recruitment practices. Abbey Lodge Care Home DS0000044443.V256793.R01.S.doc Version 5.0 Page 25 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. Extracts may not be used or reproduced without the express permission of CSCI Abbey Lodge Care Home DS0000044443.V256793.R01.S.doc Version 5.0 Page 26 - 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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