Inspection on 08/04/08 for Abbey Park

This inspection was carried out on 8th April 2008.

CSCI found this care home to be providing an Adequate service.

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 Park 02/04/09

Abbey Park 27/04/07

Abbey Park 11/05/06

Abbey Park 06/10/05

Abbey Park 27/04/05

Abbey Park 27/09/04

Abbey Park 06/04/04

Abbey Park 02/12/03

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Abbey Park 49-51 Park Road Moseley Birmingham West Midlands B13 8AH Lead Inspector Brenda O’Neill Key Unannounced Inspection 8th April 2008 09:20 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 Park DS0000017004.V361776.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 Park DS0000017004.V361776.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbey Park Address 49-51 Park Road Moseley Birmingham West Midlands B13 8AH 0121 442 4376 0121 449 1300 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) Mr M Salim Mr M Mughal Mrs Patrica Bannister Care Home 28 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (28) of places Abbey Park DS0000017004.V361776.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The home is registered to accommodate a maximum of 28 people for reasons of old age, of which 6 for the category of DE(E). Three named people, who were under 65 years of age at the time of admission can be accommodated and cared for in this Home for reason of physical disability or mental disorder, 25 OP, 2 PD and 1 MD. That the Registered Manager obtains NVQ 4 in Care and Management and the Registered Managers Award or equivalent by September 2006. That the Registered Provider provides consultancy support until January 2006 specifically in setting up quality assurance tools in the home and providing support about staff management. 27th April 2007 Date of last inspection Brief Description of the Service: Abbey Park is a home registered for 28 older people and has both single and shared bedroom accommodation. It is situated in the Moseley area of Birmingham in a residential street within a ten-minute walk of Cannon Hill Park. Within walking distance there is access to bus services that will take you to the centre of Birmingham or to Acocks Green or, on another route to Birmingham and to Druids Heath. The home is an adapted building over three floors. The third floor is accessed by a stair lift and there is a passenger lift to the second floor. The home has three lounges and two dining areas. One of the dining areas is reserved for service users that smoke. There is an assisted bathing facility on the ground floor and an assisted shower on the first floor. The home has a large accessible enclosed garden to the rear of the property. The home has a ramped access at the front of the house but this is not the main access to the building and there is ramped access at the rear of the building. A small amount of car parking is available at the side of the home. The range of fees charged at the home was not included in the service user guide. Abbey Park DS0000017004.V361776.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use the service experience adequate outcomes. This key inspection was carried out by one inspector over one day in April 2008. During the course of the inspection a partial tour of the premises was undertaken and the care for three of the people who live in the home was looked into. This included looking at their care files and other documentation, observing practice in the home and speaking to the individuals. The files for two staff were sampled, as well as other care and health and safety documentation. The manager and two members of staff were spoken with. Prior to the inspection the manager had completed and returned an Annual Quality Assurance Assessment (AQAA) which gave some additional information about the home. Questionnaires were sent out to six of the people living in the home and the manager distributed six to relatives. The home had not had any complaints since the last key inspection. Some concerns had been raised with the Commission just before the inspection by a relative of one of the people who had been living in the home. He was concerned that the home had refused to take back his relative after an admission to hospital. The home had raised concerns with Social care and Health that they could not meet this individual’s needs prior to him going into hospital. They did not take him back as it was felt to be in the best interests of the individual, the other people living at the home and the staff. What the service does well: The home had a very relaxed atmosphere and it was very evident that staff had very good, friendly relationships with the people living in the home. The people living in the home described staff as ‘great’ and ‘smashing’. Medication management at the home was good and ensured the people living in the home received their medication as prescribed. Visits by health care professionals were recorded on separate sheets so they were easy to track and they did cross reference to the daily records. The records indicated that when staff identified any health care issues these were then followed up and monitored. Two of the people living in the home that were spoken with were very happy with arrangements in the home for meeting their health care needs. They spoke about seeing the doctor, having their toe nails cut and seeing the Abbey Park DS0000017004.V361776.R01.S.doc Version 5.2 Page 6 optician. One of them commented she had ‘improved’ physically since being in the home. There did not appear to be any restrictions on visiting within reasonable hours. There was evidence on the daily records and activity records of frequent visitors to the home. Conversations with the people living in the home and the records seen indicated that they were encouraged to exercise choice and control over their lives in such things as choosing what they did during the day, what to wear, when to get up and go to bed and what to eat. All the people living at the home who were spoken to on the day of the inspection were very happy with the meals being served. The menus were varied and nutritious and choices were offered at all meals. The people living at the home were very comfortable in the presence of the staff and the manager which would give them the confidence to raise any issues they may have. Speaking with people living in the home they said they would not have any problems speaking to the manager with any issues that may arise. Comments received included ‘anything on my mind I can go and discuss with Pat’ and ‘if I have any problem I can always have a chat with Pat the manager.’ Staffing levels were appropriate for the needs and numbers of the people living in the home. Some of the staff had worked at the home for a considerable amount of time which was good for the continuity of care of the people living in the home. The manager ensured the smooth running of the home in a competent manner and in the best interests of the people living in the home. What has improved since the last inspection? The manager was obtaining a copy of the social workers’ pre admission assessments for the individuals being admitted to the home. This ensured they had as much information as possible about the needs of the people being admitted. The home had purchased some sit on scales enabling them to weigh all the people living in the home and monitor any significant weight loss or gain that may need to be followed up. Some staff training had taken place since the last inspection in food hygiene, first aid, manual handling, fire and dementia care for some of the staff. This ensured those staff worked safely with the people living in the home. Abbey Park DS0000017004.V361776.R01.S.doc Version 5.2 Page 7 There had been some new furnishings purchased for the home such as arms chairs, wardrobes and bedside lockers enhancing the comfort of the people living in the home. Regular fire drills were taking place ensuring the people living in the home were safe guarded. 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 Park DS0000017004.V361776.R01.S.doc Version 5.2 Page 8 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 Park DS0000017004.V361776.R01.S.doc Version 5.2 Page 9 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): 1, 2 and 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There was information available for people wanting to go and live in the home but this needed to be updated to ensure it included all the current information about the home. The assessment process for the people wanting to live in the home ensured their needs were known to staff before admission. EVIDENCE: The home had a service user guide that had had some hand written amendments made as the service had changed. The document had been in place for a considerable amount of time and it was recommended that it was fully reviewed and retyped and that the range of fees charged at the home was included. This would ensure that people wanting to move into the home had all the relevant up to date information to help them decide if the home could meet their needs. Abbey Park DS0000017004.V361776.R01.S.doc Version 5.2 Page 10 The pre admission procedure for two people who had been admitted to the home since the last inspection was checked. This had improved. The home had obtained copies of the social worker’s assessments prior to the people being admitted to the home. These included some good detail about the individuals’ needs, their family history and why they required residential care. The manager had also undertaken an assessment which covered all the required areas including, hygiene and dressing, communication, mobility and memory impairment. It was recommended that the manager included the date and venue of the assessment so that it could be determined if they had been undertaken prior to admission. This was of particular importance for anyone admitted to the home who was a private payer and there was no social work involvement. This would evidence that a full assessment had been undertaken prior to admission so that an informed decision could be made as to whether the home could meet the person’s needs. Both of the files for the two people admitted to the home included copies of contracts with the home. These included the terms and conditions of residence at the home, the room to be occupied, the fees charged and who was responsible for paying them. Abbey Park DS0000017004.V361776.R01.S.doc Version 5.2 Page 11 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): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The care plans did not detail how all the individual needs of the people living in the home were to be met and strategies for managing risks were not always clearly identified. Health care needs were being identified and followed up. The medication system was generally well managed and safe. EVIDENCE: The care plans for three of the people living in the home were sampled. Two for people recently admitted to the home and the other one for a person who had lived at the home for a considerable amount of time. These varied considerably in detail. The manager was very clear about the needs of the individuals and how they were met by staff but these were not always adequately detailed in the care plans. It was also noted that some of the needs identified in the assessments had not been taken forward into the care plans. Care plans did have some good detail in some areas but did not cover all aspects of the individuals’ lives and how staff were to meet identified needs Abbey Park DS0000017004.V361776.R01.S.doc Version 5.2 Page 12 was not always included. It was difficult to evidence what the abilities of the individuals were in some instances for example ‘able to do a lot for himself’ but did not detail what. In some instances incorrect information was included for example, ‘encourage to clean dentures’. The assessment for this person stated that his dentures had been lost prior to admission and he had not had a new set at the time of the inspection. Also a care plan for becoming isolated included ‘welcome regular visits from family’ this person had no known family.’ The care plan for another person was better detailed for example it included some details of the individual’s abilities and preferences as to her daily routine and how staff were to help her maintain this. This individual had been diagnosed with dementia and there was little in her care plan in relation to this apart from ‘will wander’ but little about how staff were to manage this. The person was seen and spoken with and was clearly confused, agitated and trying to get out of the home. Staff appeared to be managing her behaviour quite well but there needed to be a specific management plan in the care plan for this so that staff managed the behaviour consistently. The homes assessment for the individual stated ‘can become aggressive if she is stopped from wandering or doing something she decides to do. Divert her attention onto something else.’ This had not been brought forward to the care plan and there was no detail anywhere about what staff were to divert her to. The care plan for a person who had been at the home for a considerable amount of time gave some good details of the individuals continence needs but the personal hygiene and dressing care plan was a pre printed sheet with very little detail of individual specific needs. There was a care plan for this person’s confusion which gave some good detail of how staff were to reassure and communicate with her. There was also a good care plan in place for a health care need that detailed how staff were to manage this. There were risk assessments and corresponding management plans in place for some of the identified risks on the files sampled. These varied in detail. There was a good management plan in place for the poor mobility of one of the individuals which detailed the use of a handling belt. The other two files also included manual handling risk assessments but one of these was not fully completed and the other stated one carer was to assist with tasks such as bathing and toileting but the methods of handling were not detailed. All the files included tissue viability assessments that highlighted if people were prone to pressure sores. There were some good details on one of the care plans for mobility about how staff were to manage the pressure areas of the individual both during the day and at night. This described the use of equipment and this was seen being used during the inspection. It was strongly recommended that care plans for pressure management were detailed separately to ensure staff were aware of why the details were there. Only two of the files sampled included nutritional assessments. The manager stated she had forgotten to do the other one as the person was quite new however there were no concerns with the individual’s diet. Abbey Park DS0000017004.V361776.R01.S.doc Version 5.2 Page 13 There were some personal risk assessments in place however these did not cover all the risks that had been highlighted on the individuals’ assessments. For example one of the assessments commented on the challenging behaviour of the individual. This had not been risk assessed and there was no management plan in place for staff to follow to ensure the behaviour was managed appropriately. One of the individuals was prone to falls but there was no risk assessment in place for this. There was a risk assessment that stated ‘keep frame close’ however this was not directly related to the risk of falls and the person did not use a frame. When speaking to the manager about the strategies in place for this person falling she stated staff were always at hand when the person was moving around. This was evidenced during the inspection. The manager needed to ensure that all the identified risks for the people living in the home had management plans in place for staff to follow. This would ensure that staff managed risks consistently and that individuals were not put at unnecessary risk. Visits by health care professionals were recorded on separate sheets so they were easy to track and they did cross reference to the daily records. The records indicated that when staff identified any health care issues these were then followed up and monitored. There was evidence of visits from G.Ps, district nurses, people being admitted to hospital when necessary and check ups by dentists and opticians. The assessment for one of the individuals indicated he had lost his dentures and would need to see a dentist. There was no evidence that this had been followed. The manager stated she had followed this up and was waiting for an appointment. It was recommended that when the manager speaks to health care professionals about visits to the home this is recorded to ensure there is evidence that all health care needs are followed up. The home had purchased some sit on scales since the last inspection. This enabled the staff to weigh all the people living in the home on a regular basis and records of this were seen. Two of the people living in the home were very happy with arrangements in the home for meeting their health care needs. They spoke about seeing the doctor, having their toe nails cut and seeing the optician. One of them commented she had ‘improved’ physically since being in the home. The system in place for administering medication had not changed and was generally well managed. Only senior staff administered medication and all had undertaken appropriate training. The medication for three of the people living in the home was audited. At the time of the last inspection some discrepancies were noted where the amounts of medication remaining in the home did not correspond with the amount that had been delivered to the home and what had been administered. At the time of this inspection only one very minor discrepancy was found. The manager stated she had been auditing the tablets Abbey Park DS0000017004.V361776.R01.S.doc Version 5.2 Page 14 on a regular basis before and after medication rounds however she was not keeping records of this. It was noted that some of the MAR (medication administration records) charts had been hand written. Some of these did not include the frequency of the administration of the tablets. This needed to be included so that staff could cross reference this to the boxes or blister packs to ensure they were administering correctly. It was also strongly recommended that any hand written MAR charts were verified as being correct by two staff. No controlled medication was being administered at the time of the inspection and none of the people living in the home administered their own medication. The people living in the home had their rights to privacy and dignity upheld. Staff addressed them appropriately and by the name of their choice. The people living in the home could spend time privately in their rooms if they wished without being disturbed. Bedroom doors were lockable and people were able to have keys if they wished and all double rooms had adequate screening. The manager told us how she been approached by a television programme to have some filming done in the home. She had declined this offer, despite that it would have been very good for marketing the home, she felt it would compromise the dignity of some of the people living in the home particularly those with dementia who were unable to give their consent to this. Abbey Park DS0000017004.V361776.R01.S.doc Version 5.2 Page 15 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): 12, 13, 14 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There were no rigid rules or routines in the home. There were some activities available for people to take part in if they wished but it could not be shown that these met the needs of all the people living in the home. The arrangements for visiting the home enabled visitors to come at any reasonable hour. The catering arrangements at the home met the needs of the people living there. EVIDENCE: The home had a very relaxed atmosphere throughout the course of the inspection. The interactions between the staff and the people living in the home were very friendly and there was a lot of laughter. There were no rigid rules or routines in the home. People were seen to wander freely around the home, spend time in the smoking room, in their bedrooms and in the lounges. All the people living in the home that were spoken with seemed very content and satisfied with the service they were receiving. One of them spoke about her son arranging for her to go to a day centre but she did not like it and had chosen not to go that day. This had not been an issue with the staff. Abbey Park DS0000017004.V361776.R01.S.doc Version 5.2 Page 16 There were no care plans in place for meeting the social needs of the people living in the home. It was therefore difficult to assess if individuals’ social needs were being met particularly for those who were unable to say what they liked doing. There was a daily activity programme in place on the files sampled which included such things as chair aerobics, drawing, reminiscence and skittles but this was the same for everyone. The manager needed to ensure that the interests of the people living in the home were discussed with individuals or their relatives/representatives. Care plans needed to be in place to show how individual social care needs were to be met by staff. The abilities of the individuals living in the home varied considerably and this would have a direct bearing on what they were able to do. Some were able to initiate their own activities others were totally reliant on staff for any stimulation. There were individual activity records for each of the people living in the home. These detailed such things as watching films, having visitors, talking to staff and skittles but there was little variety and there was no indication if other activities had been offered and refused. Speaking to two of the people living in the home they indicated they were able to facilitate their own activities and spent a lot of time together chatting. One also did a lot of puzzles such as word searches. They did not indicate there were many activities facilitated by staff. There did not appear to be any restrictions on visiting within reasonable hours. There was evidence on the daily records and activity records of frequent visitors to the home. The people living in the home that were spoken with indicated they went out with their relatives when they wanted to. There was no indication on the records seen that staff took individuals out. Conversations with the people living in the home and the records seen indicated that they were encouraged to exercise choice and control over their lives in such things as choosing what they did during the day, what to wear, when to get up and go to bed and what to eat. As at the last inspection individuals had been encouraged to personalise their rooms to their choosing and personal effects were seen in all the bedrooms sampled during the course of the inspection. All the people living at the home who were spoken to on the day of the inspection were very happy with the meals being served. The inspector had lunch with the people living in the home. The meal was well cooked and presented. The majority of the people that were having lunch enjoyed their meal very much and there was little waste. One of the people living in the home described the cook as ‘wonderful’. Choices were available for both courses and individuals had been asked prior to the meal being served what they wanted. Staff were available to offer assistance as required during the course of the meal. Abbey Park DS0000017004.V361776.R01.S.doc Version 5.2 Page 17 Records of the food being served to the people living in the home were being kept and these showed that there was a good variety of meals on offer and that the menus were generally followed. There was evidence that individuals had cooked breakfasts if they wished which included such things as, bacon and egg, bacon sandwiches and egg on toast. It was recommended that the records of food also included the vegetables that were being served to show that a variety was being offered. The manager stated that if anyone asked for something different the owner of the home ensured this was purchased. For example there was one individual who was having a short stay at the home and wanted a particular brand of cornflakes and coffee. These had been purchased for him. Abbey Park DS0000017004.V361776.R01.S.doc Version 5.2 Page 18 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): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is an appropriate complaints procedure for the home and the people living there were listened to. It could not be evidenced that the staff working at the home had received the appropriate training to ensure the people living there were safeguarded. EVIDENCE: The complaints procedure had been seen at previous inspections therefore was not viewed at this visit. All the people living at the home received a copy of the complaints procedure in the service user guide. The people living at the home were very comfortable in the presence of the staff and the manager which would give them the confidence to raise any issues they may have. Speaking with people living in the home they said they would not have any problems speaking to the manager with any issues that may arise. Comments received included ‘anything on my mind I can go and discuss with Pat’ and ‘if I have any problem I can always have a chat with Pat the manager.’ The home had not received any complaints since the last inspection. Some concerns had been raised with the Commission just before the inspection by a relative of one of the people who had been living in the home. He was concerned that the home had refused to take back his relative after an admission to hospital. The home had raised concerns with Social care and Health that they could not meet this individual’s needs prior to him going into Abbey Park DS0000017004.V361776.R01.S.doc Version 5.2 Page 19 hospital. They did not take him back as it was felt to be in the best interests of the individual, the other people living at the home and the staff. Social care and Health had also been consulted about this decision and had also contacted the hospital to say the individual should not return to the home. Prior to the inspection some information was passed to the Commission about one of the people living there being physically aggressive to the other people living in the home. It appeared, at that time, that the Commission had not been notified about this. This issue was discussed with the manager. She stated this individual was challenging but had not hit any of the people living in the home but had hit a member of staff. She also stated that a Regulation 37 notification had been sent to the Commission detailing this and that Social care and Health had been notified. The original notification was evident in the home detailing what had happened and who had been notified. The manager was well aware of her responsibilities under the safeguarding procedures. There were policies and procedures on site for adult protection and the manager had obtained a copy of the multi agency guidelines for adult protection. Part of the home’s procedure included a checklist for staff to follow if abuse was suspected and this stated ‘investigate in a robust manner’, which is contradictory to the multi agency guidelines, which needed to be followed in the suspicion of abuse. This checklist needed to be removed from the policies. This remains outstanding from the last two inspections. At the time of the last inspection there was evidence on site that some of the staff had been trained in adult protection issues and a recommendation was made that this was updated so that they were aware of the most recent procedures for reporting any suspicions or allegations of abuse. At the time of this inspection there was no evidence that staff had received this training and the topic was not included on the training matrix for the home. Abbey Park DS0000017004.V361776.R01.S.doc Version 5.2 Page 20 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): 19, 20, 21, 24 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was generally well maintained and safe and provided the people living there with a comfortable and homely environment in which to live. Some redecoration was required to ensure the home was kept to an acceptable standard for the people living there. EVIDENCE: There had been no changes to the layout of the home since the last inspection. The home was found to be generally comfortable and safe. The people living in the home appeared happy with the environment. There were some areas throughout the home that were in need of redecoration, for example, the top floor corridor and corridor outside the kitchen. New flooring had been fitted in some of the corridors. Abbey Park DS0000017004.V361776.R01.S.doc Version 5.2 Page 21 The home had adequate communal space with three lounges and one dining room. One of the lounges was a designated smoking area. Two of the lounges had had new large screen televisions since the last inspection. The dining room was quite small but some of the people living at the home chose to eat in the lounges. Two of the lounges had had new chairs since the last inspection. The dining room and smoking room were in need of redecoration. There were adequate numbers of toilet, bathing and shower facilities throughout the home. Not all of these were viewed at this inspection. One of the bathrooms had a hoist and the shower was floor level, both of these rooms allowed for assistance from staff. Some of the bedrooms also had en-suite facilities. Bedrooms in the home were a mix of singles and doubles, varied in size and some had en-suite facilities. The bedrooms of the people being case tracked were seen during the inspection. As at the last inspection not all the required furnishings were available in all the rooms, for example, two chairs. The manager needed to audit all the rooms against the National Minimum Standards and discuss with the people living there their requirements. It was also noted that some of the bedroom chairs were heavily stained and worn and needed to be replaced. All the bedrooms seen had been personalised to the occupants choosing. Some of the bedrooms had had new wardrobes and lockable bedside cupboards. The laundry and kitchen were not inspected during this inspection. The areas of the home that were seen were clean and fresh. Abbey Park DS0000017004.V361776.R01.S.doc Version 5.2 Page 22 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): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Adequate staffing levels were maintained to enable the needs of the people living at the home to be met. Arrangements for staff induction and ongoing training needed to be improved to ensure staff were able to deliver adequate and appropriate care. Recruitment procedures were robust and protected the people living in the home. EVIDENCE: There had been some staff turnover at the home since the last inspection but they were fully staffed at the time of the inspection. Some of the staff had worked at the home for a considerable amount of time which was good for the continuity of care of the people living in the home. Staffing levels were appropriate for the numbers and needs of the people living in the home at the time. There were three care staff on during the waking day and two at night. The manager’s hours were supernumery to the care rota and the home also employed catering and domestic staff. The interactions between the staff and the people living in the home throughout the course of the inspection were very good. The people living in the home described staff as ‘great’ and ‘smashing’. Abbey Park DS0000017004.V361776.R01.S.doc Version 5.2 Page 23 The recruitment files for two new staff were sampled. All the required documentation was in place and it was evident all the required checks had been undertaken prior to new staff starting work at the home. Induction training at the time of this inspection was just a checklist of topics. At the time of the last inspection new staff were completing the Skills for Care Induction. The manager stated that at that time staff were doing this off site but this had not continued. The manager was advised she needed to ensure all new staff received induction training in line with the specifications laid down by Skills for Care unless they could evidence they had already completed this. The home had a training matrix and this showed that well over 50 of staff were trained to NVQ level 2 or the equivalent. As previously stated there was no evidence on the matrix that staff had undertaken training in adult protection issues and this needed to be addressed. The matrix also indicated that there were some shortfalls for some of the staff in relation to fire, manual handling, first aid, health and safety and infection control. The matrix did show that some training had taken place since the last inspection in food hygiene, first aid, manual handling, fire and dementia care for some of the staff. Abbey Park DS0000017004.V361776.R01.S.doc Version 5.2 Page 24 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): 31, 32, 33, 35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager ensured the smooth running of the home in a competent manner and in the best interests of the people living in the home. The home needed to have in place a formal system for monitoring the quality of the service offered based on seeking the views of the people that live there with a view to continuous improvement. EVIDENCE: The manager had worked at the home for a considerable amount of time and was appropriately qualified. Throughout the course of the inspection she demonstrated a very good knowledge of the needs of the people living in the home. She had a very good relationship with the proprietor and stated he was very supportive and a regular visitor to the home. Abbey Park DS0000017004.V361776.R01.S.doc Version 5.2 Page 25 The people living in the home were very comfortable in the presence of the manager and could speak to her at any time. One of the staff members spoken with said the manager was very good and supportive. It was evident throughout the inspection that the manager’s relationships with staff were good. As at the last inspection the manager was very complimentary about her staff team and stated they work well together and were very aware of their responsibilities. Good relationships within the staff team were evident. The home was run with an open and inclusive atmosphere and there was a very friendly and relaxed atmosphere. There had not been any progress with implementing a formal quality monitoring system in the home. The people living in the home were issued with satisfaction surveys every few months and there were staff meetings. The manager also undertook audits within home, for example, medication audits and health and safety audits. However there was no way of analysing the information gathered and drawing up a yearly development plan for the home with the aim of continually improving the service. There had been no changes to the system in place for managing money on behalf of the people living in the home where necessary. A specific account had been set up by the proprietor for some personal allowances to be paid into where there was no other option. The proprietor then drew the money and passed it over to the manager. All these people had individual books where this was recorded. One of these was sampled and the records were appropriate. Other people living in the home also had some personal allowance managed by the home which was deposited with the manager by their relatives. These people also had individual books that detailed all income and expenditure two of these were also sampled. There were receipts available for all expenditure and two staff signed for any expenditure. The balances of the money held were correct. Where possible the people living in the home were asked to sign for any cash they were given. One of the people living in the home continued to manage his own finances. Although the provider was a frequent visitor to the home there was little evidence that he was making any unannounced visits to the home to oversee the management/conduct of the home. It is an ongoing requirement that these visits take place and that the proprietor inspects the environment, samples administration and speaks to the people living in the home and then prepares a report on the outcome of the visit. Only one report had been sent to the Commission since the last inspection. Health and safety in the home were well managed. The in house checks on the fire system were up to date and there had been a recent fire drill. It was recommended that the manager kept a list of staff who were present for the fire drill to ensure they were all covered over a period of time. There was Abbey Park DS0000017004.V361776.R01.S.doc Version 5.2 Page 26 evidence on site that the equipment used in the home was regularly serviced and the water system was checked for the prevention of legionella. The only issues raised during this inspection were, some remedial works had been identified for the lift on the recent service and the Commission must be notified when this has been completed. Also some staff still required training in safe working practices. Accident and incident recording and reporting were appropriate. Abbey Park DS0000017004.V361776.R01.S.doc Version 5.2 Page 27 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 2 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 3 3 X X 2 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X X X X 2 Abbey Park DS0000017004.V361776.R01.S.doc Version 5.2 Page 28 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 All people living in the home must have care plans that clearly detail how all their needs in respect of health and welfare are to be met by staff. Care plans must include individual abilities, likes, and dislikes, preferences and their preferred daily routines This will ensure that people living in the home receive individual care that meets their needs. (Outstanding since 01/07/06) Manual handling risk assessments must be fully completed for the people living in the home. The assessments must specifically detail any handling methods to be used. This will ensure the safety of the people living in the home. All people living in the home must have personal risk assessments that detail how any DS0000017004.V361776.R01.S.doc Timescale for action 01/06/08 2. OP7 13(5) 01/06/08 3. OP7 13(4) 20/05/08 Abbey Park Version 5.2 Page 29 identified risks are to be minimised by staff. (Outstanding since 31/05/07) There must be individual management plans in place for staff to follow for any challenging behaviour. This will ensure the safety of the people living in the home. 4. OP18 13(6) All staff must receive training in adult protection issues. This will ensure the people living in the home are safe guarded. The registered person must ensure that: New staff complete induction training in line with the specifications laid down by Skills for Care All staff have completed the appropriate training in safe working practices. (Outstanding since 01/07/07) This will ensure the safety of the people living at the home. Evidence must be forwarded to the Commission that the remedial works identified on the lift service have been undertaken. This will ensure that the people living in the home are not put at risk. 31/07/08 5. OP30 18(1)(a) 31/07/08 6. OP38 13(4) 01/06/08 Abbey Park DS0000017004.V361776.R01.S.doc Version 5.2 Page 30 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 OP1 Good Practice Recommendations It is recommended that the service user guide is reviewed and updated and that the range of fees is included. This will ensure people have all the relevant information to help them decide if the home can meet their needs. The home’s preadmission assessment should include details of where and when the assessment was completed to evidence that it was undertaken prior to the individual being admitted to the home. All the people living in the home should have nutritional assessments undertaken to ensure any issues that need to be monitored are highlighted. Pressure management plans should be separate from other management plans so that it is clear to staff what the instructions are for. Hand written MAR charts should include the administration details of the medication and be verified as correct by two staff This will ensure the people living in the home are safeguarded. The manager should keep records of the drug audits undertaken as evidence that staff are competent to administer medication. All the people living in the home should have care plans in place that detail their social care needs and how these are to be met by staff. This will ensure they receive person centred care. Recording of activities should be reviewed so that it can be evidenced when people living in the home have refused an activity and if an alternative was offered. The records of food served should include the vegetables to evidence that the people living in the home are receiving a varied and nutritious diet. The adult protection procedures in the home should be amended to ensure they comply with the multi agency guidelines. This will ensure people living at the home are safeguarded. All others of the home should be reasonable decorated to ensure they are kept to an acceptable standard for the people living in the home. Not all the bedrooms had all the furniture and fittings DS0000017004.V361776.R01.S.doc Version 5.2 Page 31 2. OP3 3. 4. 5. OP8 OP8 OP9 6. 7. OP9 OP12 8. 9. 10. OP12 OP15 OP18 11. 12. OP19 OP24 Abbey Park detailed in the National Minimum Standards. This should be discussed with the residents to ensure the furnishings meet with their needs. 13. 14. OP24 OP33 Any worn or heavily stained bedroom chairs should be removed and replaced. This will ensure the people living in the home have acceptable furnishings in their rooms. The home must have a system in place for monitoring the quality of the service offered based on seeking the views of the people living in the home with a view to continuous improvement. This will ensure the service offered in the home is kept to an acceptable standard for the people living there. The responsible individual for the home must visit the home unannounced at least monthly and prepare a report about the conduct of the home. These reports must be made available for inspection. This will ensure people living in the home know someone is overseeing the management of the home. The names of staff present during a fire drill should be recorded to ensure the manager can easily identify that all staff are covered over a period of time. 15. OP33 16. OP38 Abbey Park DS0000017004.V361776.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 Park DS0000017004.V361776.R01.S.doc Version 5.2 Page 33 - 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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