Inspection on 12/06/07 for Abbey Place Care Home Trading As Southern Cross Healthcare

This inspection was carried out on 12th June 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 Place Care Home Trading As... 08/06/09

Abbey Place Care Home Trading As... 14/08/06

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Tyndale Avenue

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Eastfield Residential Home

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

CARE HOMES FOR OLDER PEOPLE Abbey Place Care Home t/a Southern Cross Healthcare 90 Abbey Road Fartown Huddersfield West Yorkshire HD2 1BB Lead Inspector Karen Summers Key Unannounced Inspection 12th June 2007 09:00 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 Place Care Home t/a Southern Cross Healthcare DS0000065974.V335368.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 Place Care Home t/a Southern Cross Healthcare DS0000065974.V335368.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbey Place Care Home t/a Southern Cross Healthcare 90 Abbey Road Fartown Huddersfield West Yorkshire HD2 1BB 01484 469946 01484 423399 Address 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) www.southerncrosshealthcare.co.uk Ashbourne (Eton) Limited Mr Alan Firth Care Home 78 Category(ies) of Dementia - over 65 years of age (78), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (10) Abbey Place Care Home t/a Southern Cross Healthcare DS0000065974.V335368.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. House 3 to accommodate one named person (MD category) under 60 years of age. House 1 and 2 to accommodate 38 DE(E) personal care only House 3 and 4 to accommodate 40 DE(E), 10 MD(E) The two bedrooms, which are due for completion in February 2006, are not used to house service users until the Commission for Social Care Inspection has inspected them. 14th August 2006. Date of last inspection Brief Description of the Service: Abbey place provides accommodation for up to seventy-eight older people in a purpose built nursing home located in the Fartown area of Huddersfield, approximately one mile from the town centre. The home comprises of three separate units, an administration area and a basement containing the kitchen, laundry and storage areas. The home has a separate activities/hairdressing area. House 1and 2 provides accommodation and personal care for older people with dementia. House 3 provides accommodation and nursing care for twenty older people with dementia and up to ten older people who have a history of mental illness. House 4 provides accommodation and nursing care for twenty older people with dementia. There are ample parking spaces and there are well-maintained gardens around the houses. The provider informed the Commission for Social Care Inspection on 5/07/06 that fees range from £341.46 to £535.68 per week. Additional charges include hairdressing, private chiropody, newspapers, and toiletries. Information about the home and the services provided are available from the home in the statement of purpose and service user’s guide. People can also see a copy of the inspection report at the home. Abbey Place Care Home t/a Southern Cross Healthcare DS0000065974.V335368.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report refers to a key inspection, which included an unannounced visit to the home on the 11th and 12th June 2007, which took 10 hours. Mr Alan Firth manager was present throughout the visit, and Mr Richard Lake Project manager, was there on the first day of the visit. Two inspectors visited the home, and during the visit they spoke to people who live there, and a number of staff. The inspectors read care records, staff recruitment records, training records, and staff supervision records and also had a tour of the home. To reflect the views of those who use the service, satisfaction surveys were sent to 12 people living at the home, of which 2 were returned, 12 relatives/ advocate/ friends, 7 of which were returned, also to local doctors and health care workers (Social workers, community nurses), none of which were returned by the time of the inspection. Evidence used in the inspection process includes information supplied by the manager, at the request of CSCI, about people who live at the home, staff who work there and how the home is run. Notifications received since the last inspection about incidents at the home have also been taken into account. The inspectors would like to thank those who contributed to the inspection, and also thank Mr Firth, the staff and people who use the service, for their time and hospitality on the days of visits. What the service does well: What has improved since the last inspection? Abbey Place Care Home t/a Southern Cross Healthcare DS0000065974.V335368.R01.S.doc Version 5.2 Page 6 Care plans now include risk assessments and there is evidence that they are reviewed. The home employs a full time and part time activities people and they record the information in relation to the individuals social and community involvement. Satisfactory records are held in relation to medication and stock balances are maintained. The decorative condition of the home has been improved. There are sufficient numbers and skill mix of staff on duty to meet peoples’ needs. 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 Place Care Home t/a Southern Cross Healthcare DS0000065974.V335368.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 Place Care Home t/a Southern Cross Healthcare DS0000065974.V335368.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): 3. Standard 6 – the home does not take people who require intermediate care. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. People are properly assessed before moving into the home with the assurance that their needs will be met. EVIDENCE: This home does not provide intermediate care. The records of six people living at the home were examined and contained evidence of pre admission assessments carried out by a senior member of staff. A copy of a Community Care Assessment carried out by the multi disciplinary team (this may consist of a social worker, nurse, doctor, physiotherapist etc), was also seen. Responses in surveys from relatives indicated that family members are able to visit the home prior to admission in order to make an informed choice about whether Abbey Place is suitable to meet their relative’s needs. Due to the mental health needs of the people living at Abbey Place, they are generally not able to visit prior to moving in. Abbey Place Care Home t/a Southern Cross Healthcare DS0000065974.V335368.R01.S.doc Version 5.2 Page 9 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 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. The level of care people need, which includes their health, personal and social care needs are clearly highlighted within their care plan. People are treated with respect. EVIDENCE: The care plans of six people living at the home were examined, two from each house. These were generally clear documents, which included risk assessments regarding tissue viability, falls, mobility, nutritional status and continence. The daily records examined had an adequate amount of detail recorded, which gave an indication of the level of support and care delivered on a daily basis. These were variable in standard, and could be developed further. Staff also need to ensure that every entry in records is dated and signed so that it is clear who provided what care and support on each day. The people living at the home on the day of this visit, looked well cared for, comfortable and relaxed. People responded well to the staff and it was evident from observing Abbey Place Care Home t/a Southern Cross Healthcare DS0000065974.V335368.R01.S.doc Version 5.2 Page 10 staff interaction with people living in the home that they knew each individual’s likes, dislikes and needs. Feedback from people living in the home spoken to on the day of this visit was positive. People said that staff were kind and you can have a laugh and a joke. One person said that the standard of nursing care was excellent. The healthcare needs of people are met, evidence was seen of involvement from doctors, optician, dentist and other healthcare professionals where needed. The medication of the six people whose care records were looked at were examined. All were found to tally with the records held. Records were clear, and medication was stored correctly. Systems are in place to ensure safe administration of medication. A staff signatory list is in place so it is easy to identify who has given out medication. During this visit staff were observed to maintain the privacy and dignity of people. Staff approached and spoke to people in an appropriate manner. The atmosphere in all the houses was calm and relaxed with friendly staff, and going about their work in a competent manner. Families are included in reviews of the care provided for their relative and evidence was seen in the care records looked at. One comment included “I am quite happy with every aspect of my father’s care. I feel the entire staff are doing their very best to sort him out”. Abbey Place Care Home t/a Southern Cross Healthcare DS0000065974.V335368.R01.S.doc Version 5.2 Page 11 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 – 15 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People living in the home are able to maintain contact with their family and friends, and staff assist people in having a choice in most things they do. Meals are varied and nutritious. The lifestyle at the home appears to satisfy the needs of the people living there, and encourages the involvement of family and friends. EVIDENCE: The home has a full time activities person 40 hours a week and an assistant who is employed 15 hours a week. The services offered to people ensure that they can get involved in activities and events that match their preferences, and this satisfies their social, cultural, religious and recreational interests and needs. The records examined, although still being developed were comprehensive and individualised. During the visit individual people were seen to be participating in various activities including listening to the radio, looking at newspapers and receiving visitors, watching television, having a singalong and doing art work. Abbey Place Care Home t/a Southern Cross Healthcare DS0000065974.V335368.R01.S.doc Version 5.2 Page 12 Staff spoken to said that other activities included playing dominoes, quizzes, and arts and crafts. A group of people living in one of the houses spoke about various sporting events they had enjoyed on television and about going out shopping and for walks with staff. Staff said that religious services are held each month and people are invited to attend. Magazines can be purchased, and the home has a selection of books, including talking/ large print books for those people with a visual impairment. The activities person has also developed sensory areas within the home where people were seen to be enjoying the distractions and stimulation. The care documentation also recorded evidence to suggest that choices are promoted as to what time people get up, go to bed and what they eat. The company is introducing new menus and the staff are in the process of introducing these. They looked varied and nutritious. Specialised diets were seen to be catered for and at this time include someone with coeliac disease requiring a gluten free diet. Birthdays are celebrated and some people choose to invite their family and have a party at the home, which is usually held in the premises of the shop. Abbey Place Care Home t/a Southern Cross Healthcare DS0000065974.V335368.R01.S.doc Version 5.2 Page 13 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 & 18 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The home has a complaints policy, and people who use the service and their relatives are confident appropriate action will be taken to address any issues. Staff receive training in the protection of vulnerable adults, which helps to protect the people from harm. EVIDENCE: The home has a complaints procedure, which was displayed in the main reception of the home, and the manager said that each person is given a copy of the procedure on admission. Six out of seven relative surveys received confirmed that they were aware of the complaints procedure and the seventh person could not remember. Both surveys from people who live at the home said that they knew who to complain to. A relative who was spoken with said that the Alan the managers’ door was always open and he would go and see him. Policies and procedures were seen relating to the protection of people from abuse. Staff confirmed that they have had a copy of the whistle blowing policy, as well as having had training in the protection of vulnerable adults as part of their induction and have annual updates. Evidence was also seen that all staff had attended adult protection training. Three staff spoken to gave good responses to questions asked by the inspector on this subject. Abbey Place Care Home t/a Southern Cross Healthcare DS0000065974.V335368.R01.S.doc Version 5.2 Page 14 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 & 26 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. People live in a clean, and a safe environment, where the home is decorated to reflect the needs of people suffering from dementia. EVIDENCE: As part of the inspection a tour of the home was conducted which included the gardens, communal areas, a number of peoples bedrooms, and the laundry. Since the last inspection the home has undergone a redecorated programme. In the part of the home where people who have dementia live, and to assist those people to be orientated to their room, bedroom doors have letterboxes and doorknockers to resemble a front door and street lamps along some of the corridors. The walls also have imitation brickwork, which gives the feeling that you are walking along a street. In house four, the first floor corridor carpet that has been down since the home opened is showing signs of wear and should be replaced. Abbey Place Care Home t/a Southern Cross Healthcare DS0000065974.V335368.R01.S.doc Version 5.2 Page 15 A number of external windows were showing signs of wear and should be redecorated. The flowerbeds and grounds at the back of house 3 and 4 were in need of weeding and were looking overgrown. The home presently has a gardener 20hours a week, and the inspector would recommend that the hours be reviewed to ensure that the work is kept up to. People who live at the home commented in their surveys that the home was usually clean and odour free. At the time of the visit the home was clean, however there were odours in a number of areas, which soon disappeared. On the second day of the visit there were no unpleasant odour. Abbey Place Care Home t/a Southern Cross Healthcare DS0000065974.V335368.R01.S.doc Version 5.2 Page 16 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 – 30 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. There are sufficient numbers of staff to meet peoples’ needs. Staff receive training to assist them to carry out their responsibilities. Thorough recruitment procedures are followed in respect of all potential employees. EVIDENCE: The staff duty rotas were looked at, and staffing levels and skill mix were sufficient to meet the number and needs of people living there. Surveys received from people who live at the home commented that there is usually enough staff on duty. One of the relatives commented that they thought that the home should increase the number of staff, particularly at weekends. People commented, “Everybody is very friendly.” “The staff do a wonderful job in very difficult circumstances.” “I feel very happy that my sister is well cared for in Abbey Place Care Home.” They were also asked if the service meets the different needs of people (considering race, ethnicity, age, disability etc) One person said usually and six said always. One person said, “We think so. I find them all very friendly and caring towards people.” Staff receive induction training and records of this were seen for four members of staff. Abbey Place Care Home t/a Southern Cross Healthcare DS0000065974.V335368.R01.S.doc Version 5.2 Page 17 Training records were also inspected, and all staff had attended mandatory courses, and training to care for the people in there care. The recruitment records of four members of staff were checked and all were found to contain the required checks and documentation. Abbey Place Care Home t/a Southern Cross Healthcare DS0000065974.V335368.R01.S.doc Version 5.2 Page 18 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, 33, 35 & 38 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. The home is run in the best interests of people who live there. Peoples’ financial interests are safeguarded. The health, safety and welfare of people living and working at the home are promoted. EVIDENCE: Mr Alan Firth the manager of the home is a qualified nurse and has a number of year experience in the care of older people. He is presently taking a registered managers award and plans to complete the training by the end of the year. The Operations manager on behalf of the company visits the home monthly and the purpose of the visit is to ensure that the home is meeting its objectives. Abbey Place Care Home t/a Southern Cross Healthcare DS0000065974.V335368.R01.S.doc Version 5.2 Page 19 The manager also completes monthly audits of the home, and copies of these reports are sent to the CSCI. The areas audited included, presentation of the home and exterior grounds, enquiries made by new people who may use the service, medication, care documentation, complaints and accidents, staff training, finance and maintenance etc. Relatives meetings are held on a regular basis, and the last one which was held on the 31st May 07, ten people attended. Minutes of the meeting showed that the agenda included; environmental issues, activities, laundry, clothing, and the cream tea fund raising event which was held on the 10th June 07. A person from the Alzheimer’s society was also invited to give a talk. The minutes showed that there was positive feedback on the issues that were discussed. Evidence was seen that staff have received training in moving and handling, fire prevention and health and safety. Supervision records were also looked at and the records showed that supervision had commenced. Staff that were spoken to during the visit also confirmed this. Small amounts of personal monies are kept on behalf of people living at the home. Four of which were checked, and the monies were correct. Abbey Place Care Home t/a Southern Cross Healthcare DS0000065974.V335368.R01.S.doc Version 5.2 Page 20 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 3 Abbey Place Care Home t/a Southern Cross Healthcare DS0000065974.V335368.R01.S.doc Version 5.2 Page 21 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. OP7 OP19 OP19 OP19 OP31 OP36 Refer to Standard Good Practice Recommendations Staff should ensure that care records are dated and signed to show who has written the entry. The first floor corridor carpet that has been down since the home opened is showing signs of wear and should be replaced. The gardens should be kept tidy and weed free. A number of external windows were showing signs of wear and should be redecorated. The manager should complete the registered managers award. Staff should receive regular supervisory practice 6 times a year. Abbey Place Care Home t/a Southern Cross Healthcare DS0000065974.V335368.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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 Place Care Home t/a Southern Cross Healthcare DS0000065974.V335368.R01.S.doc Version 5.2 Page 23 - 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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