Inspection on 25/10/06 for Abbey Lodge Residential Care Home

This inspection was carried out on 25th October 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 Lodge Residential Care Home 11/09/07

Abbey Lodge Residential Care Home 23/01/07

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 Mr Ian Harris Key Unannounced Inspection 25th October 2006 08:00 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.V297466.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.V297466.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) 0121 472 1044 Mr Vijay Odedra Mr Arjan Bhoja Odedra, Mrs Shanta Arjan Odedra, Jasvinder Takhar, Daljit Takhar Vacant 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.V297466.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 Brief Description of the Service: Abbey Lodge is a large detached house that has been extended to provide accommodation 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 bedrooms and 23 single bedrooms, 13 of which have 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 £336 to £400 per week Abbey Lodge Residential Care Home DS0000066038.V297466.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced key inspection and took place over 6 hours in the presence of the Acting Care Manager and some of the time with the Proprietor. During the inspection a tour of the premises took place and staff and care records were inspected. Also staff rotas and general records regarding the maintenance of the home were checked and the last reports of the Fire Prevention Officer and Environmental Health Officer were considered. 3 members of staff and 6 residents and 1 relative were spoken to. What the service does well: What has improved since the last inspection? There has been considerable improvements made to the home and the care provided since the change of ownership these include, three new bedrooms with en-suite have been provided in order to reduce the number of double Abbey Lodge Residential Care Home DS0000066038.V297466.R01.S.doc Version 5.2 Page 6 bedrooms. Four bedrooms have been redecorated, refurbished and fitted with new floor covering. New floor covering has been fitted to the hall, and ground floor corridors. The office has been extended, redecorated and new floor covering fitted. In addition to this the home has introduce new residents’ files and care plans. The Acting Care Manager and proprietor are to be commended on the progress made in such a short time. 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.V297466.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.V297466.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): This judgement has been made using available evidence including a visit to this service. 1, 3 and 6 the Quality in these outcome areas good. The home has a Statement of Purpose and a Service users Guide. The home has a satisfactory admissions procedure ensuring the individual needs of the residents are fully met. The home does not provide intermediate care they only provide short stay and introductory stays when the home has a vacancy. EVIDENCE: The home has a good Statement of purpose and a Service Users Guide. All the residents who are funded by the Local Authority undergo a full multidisciplinary assessment prior to admission. The residents’ who are self funding are assessed by the Care Manager, using the homes assessment forms. Copies of the assessment, Care Plan and Reviews are on the residents’ files. The Six residents files and care plans inspected contained pre admission Abbey Lodge Residential Care Home DS0000066038.V297466.R01.S.doc Version 5.2 Page 9 assessments of the persons needs, both from assessments by the home’s staff and other relevant professionals. Observations and discussions with residents, the Acting Care Manager and staff on duty indicated that the home continues to meet the individual needs of the elderly people living at the home in a satisfactory and sensitive manner. Abbey Lodge Residential Care Home DS0000066038.V297466.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): This judgement has been made using available evidence including a visit to this service. 7,8,9, and 10 the Quality in these outcome areas is good. Each resident has a individual care plan that is reviewed on a monthly basis. The home has good contact with local G.P. s. local hospitals and paramedical services, which ensures that resident’s health needs are met. The systems for the administration of medication are good with clear and comprehensive recording arrangements being in place to ensure resident’s medication needs are met. EVIDENCE: The home provides a Care Plan for each individual resident based on the initial assessment. The Care Plans are drawn up by the Care Staff in consultation with the resident and their family. There was evidence on the files to show the care Plans are being carried out and reviewed on a monthly basis. However it was noted that some of them lack a detail. It was evident during the inspection from looking at records, inspecting the facilities, observation of care given and chatting to staff and residents that individual health, and personal needs were Abbey Lodge Residential Care Home DS0000066038.V297466.R01.S.doc Version 5.2 Page 11 being met. Residents were being treated with respect, staff were working sensitively in meeting individual needs, and the residents looked comfortable and well cared for. The home is well supported by local G. P. s. and all of the paramedical services. Wherever possible, the residents are encouraged to retain their own G. P s, Opticians, and Dentists. It was noted that if the resident has moved out of their area the Care Manager ensures that, these services are provided by local practitioners. A number of residents stated that the staff arrange hospital visits and G.P. visit and that they feel that their health is much better since coming into the home. Medication is administered by means of a Boots monitored dosage system. The system appears to be working very well. The home receives good support from the Boots pharmacist. All Senior Staff have been trained to use the system before they are allowed to administer medication and have completed the Safe Handling of Medication training course. The home has good policies and procedures, regarding the administration, storage and recording of medication. Consultation with health care and social care professionals is carried out within the resident’s bedrooms. Visitors are able to meet residents in their bedrooms or the conservatory on the ground floor, which offers that privacy when not being used. It was observed that residents’ were being treated with respect and staff are working both professionally and sensitively in meeting individual needs. Those residents spoken to were complimentary regarding the quality of their lives and the care they are receiving at the home. Abbey Lodge Residential Care Home DS0000066038.V297466.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): This judgement has been made using available evidence including a visit to this service. 12,13,14, and 15 the Quality in these outcome areas is adequate. The home does not provide a good programme of social activities and outings, which are designed to meet the resident’s capabilities. The Care Manager and staff encourage family and friends to maintain good contact with their relatives at the home. The meals in the home are good offering both choice and variety and also catering for special dietary needs. EVIDENCE: The routines and activities within the home are flexible and are built around the needs of the residents. The home does not have a staff member designated to organise social and leisure activities and who identified interests that the residents wish to pursue. However there was evidence to show staff do consult with the residents regarding the choice of meals through residents/ relatives meetings, the Acting Care Manager and key-workers. It was noted that there is little in the way of entertainment and activities provided within the home and no outings or trips have been arranged throughout the summer months. Staff at the home, encourage regular contact between residents’ and their relatives by inviting them to parties, fetes, outings and celebrations. Abbey Lodge Residential Care Home DS0000066038.V297466.R01.S.doc Version 5.2 Page 13 All residents’ comments were very complimentary about the standard and choice of food provided. However there have been requests made to vary the teatime menus to provide an alternative to a selection of sandwiches. It was noted that the menu for the main meal of the day is changed to incorporate seasonal changes. Several residents told the Inspector that the food was nice, tasty and well prepared. The kitchen is well equipped, kept clean and tidy. The catering staff are trained in food safety and hygiene matters. Abbey Lodge Residential Care Home DS0000066038.V297466.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): This judgement has been made using available evidence including a visit to this service. 16 and 18 the Quality in these outcome areas is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints procedure and there is evidence that residents’ and their families feel that their views are listened to and acted upon The home has good policies and procedures regarding protection from abuse, which includes a whistle blowing policy. EVIDENCE: The home has a satisfactory comprehensive complaints procedure. The residents and relatives are made aware of the procedure through the statement of their terms and conditions of residence, the service users guide, which a is issued on admission to the home. A copy is also placed in the reception hall. The home has a complaints book in which all complaints are recorded. It was noted that the home has not received any formal complaints since the last inspection all minor complaints are dealt with appropriately and quickly. The home has not had to report any vulnerable adult issues The home has good policies and procedures regarding Restraint, dealing with Aggressive Behaviour and Prevention of Abuse, which, includes a WhistleBlowing policy. These issues are also covered in internal and N.V.Q. training, which all care Staff is undergoing. Abbey Lodge Residential Care Home DS0000066038.V297466.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. JUDGEMENT – we looked at outcomes for the following standard(s): This judgement has been made using available evidence including a visit to this service. 19 and 26 the Quality in these outcome areas is adequate. The standard of the environment within the home has improved and is now good providing the residents with a comfortable, homely and safe place to live. The home was found to be clean tidy and free of unpleasant odour. EVIDENCE: The home is long established and has undergone alterations over the years in order to provide appropriate accommodation for 25 older people. All the bedrooms are of good size 13 with en-suite facilities. The home is maintained to a good standard. Considerable amount of work has taken place within the home since the change of ownership. Three new bedrooms with en-suite have been provided in order to reduce the number of double bedrooms. Four bedrooms have been redecorated, refurbished and fitted with new floor Abbey Lodge Residential Care Home DS0000066038.V297466.R01.S.doc Version 5.2 Page 16 covering. New floor covering has been fitted to the hall, and ground floor corridors. The office has been extended, redecorated and new floor covering fitted. The general appearance of the internal environment is good but the rooms on the first floor are in need of redecoration and refurbishment and a rolling programme of redecoration and refurbishment should be introduced to modernise and improve the environment. The floor covering in the dining room, and lounges and first floor corridor should be replaced and the new ensuites in the new bedrooms are fitted with a mirror, cabinet for toiletries and safety rails around the toilet. It is recommended that the unused bathroom on the first floor be converted into a walk in shower room for less able residents. The home was found to be clean tidy and free from odour. The home has good policies and procedures regarding infection control and the staff have received training in food hygiene and Infection Control. From observations and discussions with staff they appeared to be conscious of the dangers of cross infection. Abbey Lodge Residential Care Home DS0000066038.V297466.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. JUDGEMENT – we looked at outcomes for the following standard(s): This judgement has been made using available evidence including a visit to this service. 27, 28, 29 and 30 Quality in these outcome areas is adequate. The The The The home is staffed with adequate numbers and skill mix of staff. staff have a very good understanding of the residents support needs. home has good policies and procedures regarding the recruitment of staff. manager has introduced a good staff-training programme. EVIDENCE: The inspection of staff rotas and discussions with staff and residents indicated that the home is adequately staffed. There is a good balance within the staff group, which includes experience, mature and younger staff who are embarking on a new career. It was noted that there have been minimal staff changes since the last inspection. However it was noted that as the numbers of residents increase and the dependency levels rise the staff are struggling to provide a good standard of care. Also it is noted that the staff have little time to provide social and leisure activities. In order to provide a good standard of care the care staff should be increased by 37 hours per week during the daytime. The home now operates an acceptable recruitment procedure since the new ownership and management has taken over. On inspecting the staff files, it was discovered that there was no evidence that C.R.B. checks have been Abbey Lodge Residential Care Home DS0000066038.V297466.R01.S.doc Version 5.2 Page 18 carried out on a number of staff. The Acting Care Manager is in the process of obtaining C.R.B. checks on all staff. All staff at the home are committed to developing their knowledge and skills through training and have regular opportunities to do so through external and internal training activities. The home has a programme of N.V.Q. training has now exceeded the minimum standard. Care staff have attended courses on Safe handling of medication, Dementia care, and Fire prevention, and Health and safety at work. There is a staff supervision system in place, however it was noted the staff are not receiving regular supervision meetings. Abbey Lodge Residential Care Home DS0000066038.V297466.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. JUDGEMENT – we looked at outcomes for the following standard(s): This judgement has been made using available evidence including a visit to this service 31, 33, 35 and 38 Quality in these outcome areas is adequate. The home is well managed, where service users interests and welfare is promoted. The home is operating a good system to assist residents with the safe handling and keeping of their personal finances and good records are being kept of all transactions made. The records inspected, were found to be well ordered and maintained. The home has good policies and procedures regarding Health and safety and meets the requirements of the Fire Officer and Environmental Health Officer, promoting the health, safety and welfare of the residents. EVIDENCE: Abbey Lodge Residential Care Home DS0000066038.V297466.R01.S.doc Version 5.2 Page 20 The home is without a Registered Care Manager however the home is well managed by an Acting Care Manager who is qualified in both practice and management and has considerable experience in caring for older people in residential homes There are clear lines of accountability within the home and the manager is very supportive of both staff and residents. It was noted the Acting care manager is very well supported by the proprietor. The home has a formal staff supervision system in place but it was noted that meetings are very infrequent. Observations made and discussions with residents’ and staff indicated that the Care Manager is very approachable and operates an open door policy. The staff and residents who could express themselves stated that they are happy to approach the Care Manager and staff with any problems they might have and were confident that they would be responded to. It was also noted that the home has a Quality Assurance system in place, which includes questionnaires to residents, visitors and relatives to obtain feedback on the quality of service. The feedback from the last issue of 13 questionnaires was generally very positive regarding the home and the care received however there were comments regarding the quality of some areas of the internal decoration, lack of social activities and the teatime menus. The routines and activities within the home are flexible and built around the needs of the residents. All the Financial records and administrative procedures within the home that were, inspected were found to be well ordered and maintained. The home has a good heath and safety policy and all staff are aware of their responsibilities regarding these issues and a number of staff have received training on these issues. All recommendations and requirements made at the last inspections of the Fire Prevention Officer and Environmental Health Officer have been actioned. All safety equipment is regularly checked and well maintained. Abbey Lodge Residential Care Home DS0000066038.V297466.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 2 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 3 Abbey Lodge Residential Care Home DS0000066038.V297466.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP12 Regulation 12 7& 17 Requirement The Registered Provider must ensure that staff are pro-active in positively encouraging the service users to take part in a range of social and leisure activities both indoor and outdoor of the Home. The activities must be varied in range and appropriate, and in accordance with the service users’ choice, preference and capacities, and displayed in the main lounge for service users’ information. The Home must maintain records of all activities enjoyed by the service users and must also be incorporated into the individual service users’ care plans. Timescale for action 01/12/06 2 3 OP27 OP29 18 19 The registered person must 01/12/06 ensure that the levels of care staff are reviewed and increased. The Registered Provider must 01/12/06 ensure that two written references are obtained before appointing a member of staff and POVA and CRB checks must also be carried out on all current and new members of staff; and DS0000066038.V297466.R01.S.doc Version 5.2 Page 23 Abbey Lodge Residential Care Home 4 AD31 8 5 OP7 15 6 OP30 18 7 OP19 23 8 OP19 23 that all staff files must have their current photographs and/or copies of their birth certificates. The Registered Provider must ensure that a registered manager is provided for the home. The registered person must ensure that all the residents care plans are reviewed and more detail aims and objectives recorded. The registered person must provide all staff with formal staff supervision meetings at least six times a year. The registered person must ensure that the new en-suites in the new bedrooms are fitted with a mirror, cabinet for toiletries and safety rails around the toilet. The registered person must ensure that new floor covering is fitted to the dining room, lounges and first floor corridor. 01/12/06 01/12/06 01/12/06 01/12/06 01/01/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP19 Good Practice Recommendations The registered person considers the provision of a walking shower room. Abbey Lodge Residential Care Home DS0000066038.V297466.R01.S.doc Version 5.2 Page 24 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. Extracts may not be used or reproduced without the express permission of CSCI Abbey Lodge Residential Care Home DS0000066038.V297466.R01.S.doc Version 5.2 Page 25 - 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. 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