Inspection on 11/09/07 for Abbey Lodge Residential Care Home

This inspection was carried out on 11th September 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 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 Residential Care Home 23/01/07

Abbey Lodge Residential Care Home 25/10/06

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Abbey Lodge Residential Care Home Cranmore Avenue Tettenhall Wolverhampton WV6 8PW Lead Inspector Joy Hoelzel Key Unannounced Inspection 10:30 11 September 2007 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 Residential Care Home DS0000066038.V346125.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 Residential Care Home DS0000066038.V346125.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbey Lodge Residential Care Home Address Cranmore Avenue Tettenhall Wolverhampton WV6 8PW 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) 01902 745181 F/P01902 745181 Mr Vijay Odedra Mr Arjan Bhoja Odedra, Mrs Shanta Arjan Odedra, Jasvinder Takhar, Daljit Takhar vacant post Care Home 25 Category(ies) of Dementia (7), Old age, not falling within any registration, with number other category (25) of places Abbey Lodge Residential Care Home DS0000066038.V346125.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The home should only accommodate up to 7 (seven) service users with mild dementia. The home must provide safe and secure gardens. Females 60 years and above and males 65 years and above Date of last inspection 23rd January 2007 Brief Description of the Service: Abbey Lodge is a large detached house that has been extended to provide accommodation and personal care for 25 older people. It is situated in a private residential area on the outskirts of Wolverhampton approximately 1.5 miles from Tettenhall village where the amenities include a post office, shops and a public house. The accommodation consist of one double bedroom and 23 single bedrooms, of which some benefit from en-suite facilities, two lounges, conservatory a dining room, laundry, kitchen, staff room and Registered Managers office. There is a car park at the front of the building and gardens and to the front and rear. The current fees range from £347.00 to £400.00 per week Information of the home and the provision of the service are available in the statement of purpose and service user guide, both documents have recently been revised and are readily available. Commission for Social Care Inspection Reports for this service are available from the provider or can be obtained from www.csci.org.uk Abbey Lodge Residential Care Home DS0000066038.V346125.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced key inspection took place over five and three quarter hours on Thursday 5th July 2007. It was conducted by one Commission for Social Care Inspection regulation inspector. Twenty four of the thirty eight National Minimum Standards for Care Homes for Older People were inspected as they are viewed as key standards for services. Twenty seven people are currently living at the home, and were observed to be accessing all areas of the home. The care provided for four people were examined in detail, relevant documents were inspected, discussions were held with people living at the home, visitors, members of staff and the manager. Observation was made of the various daily activities and a tour of the premises was conducted. An Annual Quality Assurance Assessment (AQAA) had been completed by the manager and submitted to CSCI prior to this inspection, offering a full overview of the home. On site surveys were distributed during the inspection and completed by people living, working and visiting the home. The comments received are included in this report. What the service does well: The home provides a comfortable environment in which to live. People commented that • • • • • We are looked after well by the staff, they are all lovely Friendly and very good service Care and patience with residents especially the people with dementia, prompt action when doctor needed. Food excellent Individual attention, meals good The cleanliness of the home is maintained to a high standard. Abbey Lodge Residential Care Home DS0000066038.V346125.R01.S.doc Version 5.2 Page 6 The care manager and staff demonstrated a good in-depth knowledge of the resident group and the conditions and dilemmas associated with the ageing process. 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. The summary of this inspection report can be made available in other formats on request. Abbey Lodge Residential Care Home DS0000066038.V346125.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 Residential Care Home DS0000066038.V346125.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. JUDGEMENT – we looked at outcomes for the following standard(s): OP 3,6 Quality in this outcome area is good. The home provides a Statement of Purpose that is specific to the individual home, and the resident group they care for. Admissions are not made to the home until a full needs assessment has been undertaken and only take place if the service is confident that the assessed needs of the prospective resident can be fully met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The statement of purpose and service user guides are available for the service and were supplied on request both documents and were reviewed in April 2007. Details of the current fee levels and what is included in the fees has not Abbey Lodge Residential Care Home DS0000066038.V346125.R01.S.doc Version 5.2 Page 9 been specified. This was discussed with the care manager who confirmed that the document would be revised to include this information. Three case files were selected for examination and included the file of the most recent person to move in, all contained an assessment by staff at the home prior to moving in. In addition there was information from other health authorities and social care departments. The Annual Quality Assurance Assessment (aqaa) completed by the manager stated • We provide good quality care in a warm, friendly and homely atmoshere, service users assessed prior to admission, individual care plans for each service user, reviews carried out monthly on all care plans The home does not offer an intermediate care service. Abbey Lodge Residential Care Home DS0000066038.V346125.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. JUDGEMENT – we looked at outcomes for the following standard(s): OP 7,8,9,10 Quality in this outcome area is adequate. Each individual has a care plan that includes basic information necessary to deliver the resident’s care but is not detailed and does not consistently reflect the care being delivered. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three care plans were selected for inspection and included people with differing care needs and varying lengths of stay at the home Each plan contained a full assessment of need based on the activities of daily living. Not all of the needs identified had a specific plan of care to detail the action needed by staff to ensure that the needs can be fully met. Abbey Lodge Residential Care Home DS0000066038.V346125.R01.S.doc Version 5.2 Page 11 One assessment identified a particular difficulty with maintaining continence and mobility. A specific plan had not been developed. The care plan of a person who has cognitive difficulties was looked at. Observation of staff practices evidenced that the specialised care needs of this person was being satisfactorily met. However the care plan did not accurately reflect the care being provided. It was not possible to engage this person fully in conversation but she was well dressed, clean, tidy and appeared quite happy in her surroundings. The daily reports by the care staff are informative and in sufficient detail to inform of the day-to-day activities of the individuals. Comments recorded in the ‘ what the home does well’ section of the on site surveys indicated – • Care and patience with residents especially with those with dementia, prompt action when a doctor is needed. Medication is administered using the monitored dose system with the additional use of bottles and boxes. Observation of the administration and records demonstrated the home’s practices meet the guidelines of the Royal Pharmaceutical Society. The care staff were observed to be assisting service users with personal care discreetly and in a manner which promotes a persons dignity. The people looked well cared for, well groomed and nourished. There was lots of chatter and discussions happening, it appeared that good relationships had been developed between the staff, visitors and residents. Abbey Lodge Residential Care Home DS0000066038.V346125.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. JUDGEMENT – we looked at outcomes for the following standard(s): OP 12,13,14,15 Quality in this outcome area is good. People who live at the home are involved in daytime activities of their own choice and according to their individual interests and capabilities. The meals are balanced and nutritional and cater for the dietary needs of the individuals using the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the morning of the inspection some people were watching TV, listening to music whilst others were reading the newspapers, or just sitting watching the happenings of the day. Activities are arranged by the care staff every afternoon and include card games, bingo and sing alongs. A daily programme has been developed and is displayed at the entrance to the home. Entertainers and musicians visit the home every month and various outings to places of interest are arranged. Abbey Lodge Residential Care Home DS0000066038.V346125.R01.S.doc Version 5.2 Page 13 There were lots of visitors during the day of the inspection all appeared to be very well at ease. All spoke very highly of the staff and that they were satisfied with the care provided. During the tour of the premises many of the private rooms were highly personalised, one person stated that they were very comfortable and having ‘bits around makes it feel like home’. People have the choice of where to take their meals but are encouraged to go to the dining area whenever possible. The dining rooms are well fitted and prepared in advance of the meals. Comments recorded in the’ what could be dome better’ section of the on site surveys completed by staff indicated that • More choice in food, different menu more variety in the food. People living in the home commented that they thought the food was – • • Very good. The meals were very good can’t remember what is on the menu but that it didn’t matter as the meals are always enjoyable. Staff were observed to be encouraging and assisting people with the midday meal in a discreet way showing patience and understanding of the individuals needs. Abbey Lodge Residential Care Home DS0000066038.V346125.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. JUDGEMENT – we looked at outcomes for the following standard(s): OP 16,18 Quality in this outcome area is good. Residents and others involved with the service say that they are happy with the service provision, feel safe and well supported by an organisation that has their protection and safety as a priority. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints procedure is included in the statement of purpose and service user guide and a copy is displayed on the notice board. One lady stated that if she had any problems or concerns about anything at the home she would ask to see the manager. Visitors confirmed that they are aware of the complaints procedure and would have no hesitation but to see the manager if they had any concerns. Any complaints received are logged and recorded in a bound book, together with the outcomes of any investigations The Wolverhampton safeguarding adult procedure is available for staff reference and the homes vulnerable adults policy was reviewed in April 2007. Abbey Lodge Residential Care Home DS0000066038.V346125.R01.S.doc Version 5.2 Page 15 The manager demonstrated a good knowledge of the procedures and described the action taken when a potential problem was identified. The home offers a facility for residents to deposit personal monies for safekeeping; records relating to this have been maintained and fully receipted. The manager was advised to have another person to witness the transactions and for regular audits to be conducted for checking the accuracy of the transactions. Abbey Lodge Residential Care Home DS0000066038.V346125.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): OP 19,22,26 Quality in this outcome area is good. The home provides a physical environment that is appropriate to the specific needs of the people who live there. The phased refurbishment programme will further improve the standard of living for the people in residence. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager discussed the phased refurbishment programme of the private and communal areas of the home. Some bedrooms are being supplied with en suite facilities, floor coverings are being replaced and a bathroom if being completely modernised to include a walk in shower. Abbey Lodge Residential Care Home DS0000066038.V346125.R01.S.doc Version 5.2 Page 17 During the tour of the premises many of the private bedrooms were personalised with the possessions of the occupant and were very individualised. Some beds have been fitted with bed rails following an assessment for maintaining a persons safety, protective bumpers are not provided. All areas of the home were clean and hygienic. People living in and visiting the home stated how satisfied they were with the accommodation. One person commented – • Very good here, the staff are marvellous and I love my room I like to keep it clean and tidy myself and will continue to do so while I am able. Staff demonstrated a good knowledge of infection control procedures. Hand wash facilities have been provided in all communal areas and at the point of the delivery of care. Visitors and staff who completed the’ what has improved in the last six months’ section of the on site survey indicated that – • The changes in the flooring and building work are generally improving the home. Abbey Lodge Residential Care Home DS0000066038.V346125.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): OP 27,28,29,30 Quality in this outcome area is good. There appear to be enough staff available to meet the needs of the people using the service, with the staffing structure based around delivering outcomes for the people using the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: General observations and discussion with staff confirmed that staffing numbers and skill mix enable a service provision, which meets the care needs of the people living at the home. Staff were observed to carry out their duties in an enthusiastic and professional manner. A rota is maintained to detail the staff on duty at any one time, with the manager stating that extra staff are arranged for peak periods if needed. Abbey Lodge Residential Care Home DS0000066038.V346125.R01.S.doc Version 5.2 Page 19 Staff personnel records examined showed they contained all the necessary information, which demonstrates potential staff are well screened before they are deemed suitable to start work at the home. Management systems and staff records relating to provision of training were found to be well organised and clearly presented. They showed evidence that staff had completed appropriate courses relevant to their level of training need in the core and specialist topic areas. Abbey Lodge Residential Care Home DS0000066038.V346125.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): OP 31,33,35,38 Quality in this outcome area is good. The care manager has a clear understanding of the key principles and focus of the service, is person centred in their approach, and leads and supports a strong staff team ensuring the provision of an increased quality of life for residents This judgement has been made using available evidence including a visit to this service. EVIDENCE: Susan Parry has been in the care manager’s position for eleven months and has yet to submit the formal application form for registering of manager of the Abbey Lodge Residential Care Home DS0000066038.V346125.R01.S.doc Version 5.2 Page 21 home. It was agreed that the completed application form would be submitted to Commission for Social Care Inspection registration department by the end of September. The AQAA indicates that Ms Parry plans to complete the Registered Managers Award by the end of the year. The home and office management were very well organised with the manager able to produce all documentation requested. People living and working at the home offered positive comments of the style of leadership and stated that the manager was ‘ very supportive, and approachable, and would have no hesitation but to ask to see her if there were any concerns’. The manager stated that there are numerous formal and informal opportunities for staff and service users to discuss any concerns or difficulties together with suggestions for improving the service. Quality assurance and monitoring of the home continues with bi -annual surveys and satisfaction questionnaires being audited and the findings acted upon. The home offers a facility for residents to deposit personal monies for safekeeping; records relating to this have been maintained and fully receipted. Weekly, monthly and annual testing of the equipment and premises are conducted with records kept. The fire risk assessment was last reviewed in May 2007. Abbey Lodge Residential Care Home DS0000066038.V346125.R01.S.doc Version 5.2 Page 22 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 X 3 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 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 2 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 2 X 3 X 3 X X 3 Abbey Lodge Residential Care Home DS0000066038.V346125.R01.S.doc Version 5.2 Page 23 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 OP7 Regulation 15(1) Requirement The care plan must be in sufficient detail to ensure that all care needs can be fully and effectively met. Risk assessments must be fully completed, with the findings recorded and the action needed to be taken to reduce the risk of a person being placed at harm The Registered Provider must ensure that a registered manager is provided for the care home. Previous requirement not met Timescale for action 30/10/07 2 OP8 12(1) 30/10/07 3 OP31 8 30/09/07 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 Lodge Residential Care Home DS0000066038.V346125.R01.S.doc Version 5.2 Page 24 1 2 OP7 OP22 When ever possible care plans should be developed, agreed and reviewed with the individual person and/or representative For the additional safety and comfort of people protective bumpers should be available with the use of bed rails. Abbey Lodge Residential Care Home DS0000066038.V346125.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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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