Inspection on 08/06/09 for Abbey Place Care Home Trading As Southern Cross Healthcare

This inspection was carried out on 8th June 2009.

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

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 Place Care Home Trading As... 12/06/07

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

Similar services:

Whiteley House

Tyndale Avenue

2-10 Norfolk Road

Bennfield House Nursing Home

Eastfield Residential Home

Sign Health

Springwood

Fairburn Mews

Extracts from inspection reports are licensed from CQC, this page was updated on 24/11/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Abbey Place Care Home Trading As Southern Cross Healthcare 90 Abbey Road Fartown Huddersfield West Yorkshire HD2 1BB Lead Inspector Karen Summers Key Unannounced Inspection 8th June 2009 08:55 DS0000065974.V375707.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Abbey Place Care Home Trading As Southern Cross Healthcare DS0000065974.V375707.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Abbey Place Care Home Trading As Southern Cross Healthcare DS0000065974.V375707.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbey Place Care Home Trading As 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 Post vacant 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 Trading As Southern Cross Healthcare DS0000065974.V375707.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. 11th August 2008 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. Houses 1and 2 (which are located in the same unit,) provide 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 8/06/09 that fees range from £431.20 to £578.00 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 Trading As Southern Cross Healthcare DS0000065974.V375707.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 one star. This means the people who use this service experience adequate quality outcomes. This report refers to an inspection, which included an unannounced visit by two inspectors on the 8th June 2009, commencing at 8.55am, and the length of the inspection was 7 hours. Following carrying out an annual review of Abby Place in June 2008, a random inspection was carried out on the 11th August 2008 and recommendations were made relating to people making choices, infection control, and movement and handling equipment. There were 57 people living at the home on the day of this visit. As part of the inspection in order to provide information to help us form judgments about the quality of the service, the manager was asked to complete an annual quality assessment (AQAA) document. This she did, and the document provided the Care Quality Commission (CQC) with a lot of information about the way the home is run, and what they hope to achieve in the future. To enable people who use the service to comment on the care it provides, we sent surveys to twenty people living at the home, eight of which were returned, fifteen to staff, nine were returned, and five to local doctors and health care workers (social workers, community nurses), none of which were returned. The comments in the surveys were positive about the standard of care provided by the staff at the home. We focused on the key standards and what the outcomes are for people living in the home, as well as matters, which were raised at the last inspection. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. We would like to thank all people who gave feedback about the home, and would like to thank the manager and staff for their co-operation on the day of the visit. Abbey Place Care Home Trading As Southern Cross Healthcare DS0000065974.V375707.R01.S.doc Version 5.2 Page 6 What the service does well: People are assessed prior to them moving into the home to ensure that their needs can be met, and are able to visit the home to establish whether or not it is the right place for them. People are also encouraged to maintain contact with their family and friends. And the services offered to people ensure that they can be involved in daily activities and events that match their preferences, and satisfies their social, cultural and religious interests and needs. As a tribute to the standard of food provided the home has received a four stars, “Very Good” award in association with Kirklees Council’s Health Choice Award. “Scores on the doors”. The award is a five star rating scheme providing information about the standards of hygiene and compliance with legislation in food premises within Kirklees. What has improved since the last inspection? What they could do better: Where appropriate the service user’s plan must include the guidelines for staff to follow in the care of medical conditions, and the action taken. For example when a person has lost weight should be recorded to ensure that their healthcare needs have been met. The daily record should also show that the needs of the person have been met, and if this has not been possible, an explanation as to why should be recorded. Staff must always only give the medication which has been prescribed by an appropriate health care professional. Medication must be stored at the appropriate temperatures. Abbey Place Care Home Trading As Southern Cross Healthcare DS0000065974.V375707.R01.S.doc Version 5.2 Page 7 This is to make sure that people are receiving their medication exactly as prescribed. Within the maintenance programme any worn furniture should be made good or replaced, and in the interest of infection control, all parts of the home should be kept clean and free from odours. A minimum of 50 of care staff should have a National Vocational Qualification, level 2 in care as qualified staff have a better understanding of peoples needs. All staff should have fire lectures every six months to ensure that they are kept up to date and aware of the procedures to follow in the event of a fire. . If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Abbey Place Care Home Trading As Southern Cross Healthcare DS0000065974.V375707.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 Place Care Home Trading As Southern Cross Healthcare DS0000065974.V375707.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3, the home does not provide intermediate care. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are assessed prior to them moving into the home to ensure that their needs can be met, and they are able to visit the home to establish whether or not it is the right place for them. EVIDENCE: This home does not provide intermediate care. A sample of records relating to people living at the home was examined including those of two people who had recently been admitted to the home. There was evidence that a thorough pre-admission assessment had been conducted, with input from the individuals’ family. Care Management assessments and care plans were also in place. Abbey Place Care Home Trading As Southern Cross Healthcare DS0000065974.V375707.R01.S.doc Version 5.2 Page 10 The information received from the manager prior to admission states that people and their relatives are invited to visit the home prior to admission and join them for morning coffee, lunch or afternoon tea. 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. From the eight surveys received from people living at Abbey Place four people said that they had received enough information to help them decide if the home was the right place for them prior to moving in. Two people said that they had not received enough information, one person did not know if they had received enough information or not, and one person did not make a comment. Abbey Place Care Home Trading As Southern Cross Healthcare DS0000065974.V375707.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7 – 10 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples’ personal needs are generally met however; the practice regarding medicine management does not always protect peoples’ well-being. EVIDENCE: When people were asked in the surveys, “What does the home do well?” One person said, “Care and attention.” Another said, “Looks after us well”, and a third person said, “I cannot think of anything it does not do well.” Five care plans that were examined all contained detailed information about how peoples’ needs should be met. Relevant risk assessments were in place in all most of the records examined, including falls, pressure care, nutrition and continence. Abbey Place Care Home Trading As Southern Cross Healthcare DS0000065974.V375707.R01.S.doc Version 5.2 Page 12 However we found areas where there were gaps which could lead to people not receiving the health care they need. Examples of these were:Whilst staff were correctly monitoring blood sugar levels, there was no information about what would be the normal range for the person and what action should be taken if the level was too high or too low. Peoples’ personal needs are generally met however, the practice regarding medicine management does not always protect peoples’ well-being. Evidence was seen to suggest that peoples’ weight is monitored monthly or more regularly where there had been an unacceptable weight loss, and that action had usually been taken. However, it was noted in one person’s notes that they have had a significant weight loss over a relatively short space of time, with no apparent action being taken to address this. Daily records are kept with information about how peoples needs have been met. However, it was not always apparent that their needs had been met as agreed in the care plan. For example, in two care plans it stated that showers should be offered regularly, at least two or three times a week. There was no evidence that a shower had been offered in the last week and records suggested that people had been helped to have a wash instead. The daily records should contain sufficient detail to demonstrate whether or not peoples needs have been met and if they haven’t been met and explanation should be recorded. These issues were discussed with the manager who agreed to take action to make sure people’s needs were fully met. People are supported to access the healthcare they need and there is evidence that advice is sought from the appropriate healthcare professionals and appointments are recorded in peoples’ notes. Input from the dietician, district nurse and GP was recorded to have taken place. We looked at four peoples’ medication records to see if staff were administering medication correctly we found:Most of the medicines tallied with the records kept although there was two discrepancies with tablets unaccounted for that could not be explained by the staff at the time. The home manager has been able to account for these satisfactorily since the inspection visit and has explained that the tablets were in fact accounted for in the returns record. A member of staff had given a higher dose of pain relief to an individual than was prescribed. The staff member explained that the prescribed dose was not sufficient to provide pain relief, however this information had not been passed Abbey Place Care Home Trading As Southern Cross Healthcare DS0000065974.V375707.R01.S.doc Version 5.2 Page 13 on to the appropriate person or recorded. The manager assured the inspectors that this would be looked into immediately. The temperature of the medication room on house 2 had been recorded twice daily, and on occasions the temperature had been 28°C. The temperature for the storage of medication should not exceed 26°C. Medication that should have been stored in the fridge was also found in the main medicine cabinet. The staff member transferred this to the medication fridge at the time. A number of preparations that must be discarded within a set period of time after opening were found not to have been labelled with the date of opening, and this was addressed at the time of the visit. It was noted that there was no guidance for staff about medication prescribed to be given ‘as required’ to help reduce agitation. It would be good practice to include information for staff so that they are clear about when and why this medication should be given. Although the staff training records showed that all staff who handle medication have received training, and this was confirmed by those staff spoken to. The evidence shows us that medication is not always correctly administered at Abbey Place and people could be at risk. Abbey Place Care Home Trading As Southern Cross Healthcare DS0000065974.V375707.R01.S.doc Version 5.2 Page 14 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12 – 15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this 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: Information from the home states that they “Employ an activities organiser who organises in house activities on a daily basis such as quizzes, sing-alongs, film afternoons and bingo/ dominoes. Outside activities include local walks in Huddersfield, Sunday Café, and trips out in the mini bus.” Other activities include, “Arm chair aerobics” and aromatherapy. 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. Abbey Place Care Home Trading As Southern Cross Healthcare DS0000065974.V375707.R01.S.doc Version 5.2 Page 15 The daily activities were displayed on the notice boards at the side of the lifts and the entrance to the home. The records examined, were comprehensive and individualised, and encouraged input from family and friends. We spoke with the activities co-ordinator, who was visiting on a day that she was not working at the home, and she was enthusiastic about her work and how she encourages people to be involved in the activities that take place. The manager said that the activities person had been asked to attend a meeting and unfortunately due to short notice the structured activities that were booked for that day were not taking place. Staff spoken to confirmed the variety of activities that take place, and one of the people who live there also said how they enjoyed the activities, and how there was usually something for them to do each day. The manager confirmed that religious services continue to be held each month and a person living there also said that people are invited to attend. The activities person has also developed sensory areas within the home where people are able to enjoy the distractions and stimulation. The information provided by the manager states, that the home offers a choice of food at meal time, provides three balanced meals each day and that relatives and friends are welcome to dine at the home when visiting. Staff said that they ask people their choice of meal for lunch during the morning, as this gives the chef an idea of what food to prepare. People are then shown alternatives of the plated meals to enable them to choose what they would like. Records were seen of the menus and evidence of the meals that people had chosen. As a tribute to the standard of food provided the home has received a four stars, “Very Good” award in association with Kirklees Council’s Health Choice Award. “Scores on the doors”. The award is a five star rating scheme providing information about the standards of hygiene and compliance with legislation in food premises within Kirklees. Two people who completed the survey said that they always liked the meals at the home; four people said that they usually did and two people said that they sometimes liked the meals. One of the people who commented that they usually liked the meals also said that the home takes care of their dietary needs well, as they have 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 Trading As Southern Cross Healthcare DS0000065974.V375707.R01.S.doc Version 5.2 Page 16 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this 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 on house 1, and the manager confirmed that each person is given a copy of the procedure on admission. The information provided by the manager states that there have been 14 complaints since the last inspection, none of which were upheld, and all of which had been responded to within 28 days as stated in the procedure. There was also evidence to suggest that the Operations Manager and the Manager audits the complaints monthly to try to improve the care for people living there. Seven out of eight people said that they knew how to make a complaint, and six people also said that there was someone that they could speak to informally if they were not happy. Abbey Place Care Home Trading As Southern Cross Healthcare DS0000065974.V375707.R01.S.doc Version 5.2 Page 17 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. There was evidence to suggest further staff were having update training on the day of the visit and the following day, and the manager said that she would ensure that all staff has had the training. Procedures were seen relating to the protection of people from abuse. The information provided by the manager also states that as part of the Company’s commitment towards the zero tolerance approach to abuse in care homes, a “Dignity in Care Champion” has been identified. This person will lead the zero tolerance approach to abuse, and will also be involved in relatives/ people who use the service meetings, and discuss privacy, dignity and choice; and feedback will actively be given to the manager in order to improve the service to people in their care. Abbey Place Care Home Trading As Southern Cross Healthcare DS0000065974.V375707.R01.S.doc Version 5.2 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a clean, and a safe environment, where the home is decorated to reflect peoples’ needs. EVIDENCE: As part of the inspection a tour of the home took place, which included the communal areas and a number of bedrooms. The environment is decorated with tactile boards and pictures of interest and a newly created pamper room which is said to be enjoyed several times a week. Abbey Place Care Home Trading As Southern Cross Healthcare DS0000065974.V375707.R01.S.doc Version 5.2 Page 19 Ongoing refurbishment continues to take place, and includes the replacement of the first floor corridor carpet in one of the homes, which was identified as needing replacing on a previous visit. However, during this visit we found a bedroom carpet was heavily stained and had cigarette burns on it, and one of the rooms had an unpleasant odour. The furniture in a bedroom was also worn and needed to be re-varnished or replaced, and a lounge that was being used by one person was not kept clean. We also discussed with the manager that some of the carpet joins were lifting and could become a potential trip hazard. Following the visit we were notified by the manager that these issues had been addressed, and the floor covering had been replaced in the room where there was an odour. The information received from the manager prior to inspection states that over the last year, “The decoration has improved the appearance of the home and encouraged a feeling of ownership within the staff from their units. The atmosphere within the home has increased immensely and is commented upon by visitors.” Six people who commented in the surveys said that the home is always fresh and clean, and two people said that it usually was. One person said in the survey when asked, “What could the home do better?” said, “Improve the return of laundry, and the correct laundry.” When asked, “What could the home do better?” One person said, “Install a bar.” Staff said that the home is always clean and well decorated. At the previous inspection a number of external windows were showing signs of wear. These have now been redecorated. The flowerbeds and grounds at the back of house 3 and 4 were also in need of weeding and were looking overgrown at the last visit. The handyman/gardener was gardening at the time of this visit, and was being observed by one of the people living at the home. Banter was heard to be exchanged between the two people. Abbey Place Care Home Trading As Southern Cross Healthcare DS0000065974.V375707.R01.S.doc Version 5.2 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27 – 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are sufficient numbers of staff to meet peoples’ needs. Staff receive training to assist them to carry out their responsibilities. People are supported and protected by the home’s recruitment practices. EVIDENCE: The duty rota confirmed there are sufficient staff on duty to care for the number of people living at the home, and the manager confirmed this. Surveys received from people who live at the home commented that there is usually enough staff available when they need them. Care practice observed during this visit, and the relationship between staff and people being cared for was positive. A sample of recruitment records was inspected and they contained the required information and employment checks. These checks are necessary to help protect people from potentially unsuitable staff. Abbey Place Care Home Trading As Southern Cross Healthcare DS0000065974.V375707.R01.S.doc Version 5.2 Page 21 There was also evidence in the staff records and staff confirmed that they had induction training when they came to work at the home, which provides them with the knowledge and skill to look after people in their care. When staff were asked, “What does the home do well?” One said, “Give employees regular training.” Qualified nurses are on duty twenty four hours a day. Forty six percent of care staff have an NVQ (National Vocational Qualification) level two or above in care, and a further five staff are either doing, or soon to be enrolled on the course. Qualified staff have a better understanding of peoples needs. Abbey Place Care Home Trading As Southern Cross Healthcare DS0000065974.V375707.R01.S.doc Version 5.2 Page 22 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, & 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is generally run in the best interests of people who live there. EVIDENCE: The information provided prior to inspection states that, “The Manager is an experience Registered Nurse and has worked with older people with dementia for the past four years. The home Manager has level four in Management and Health Care through Leeds University and has completed her Registered Managers Award.” Abbey Place Care Home Trading As Southern Cross Healthcare DS0000065974.V375707.R01.S.doc Version 5.2 Page 23 When staff were asked in their survey, “What does the home do well?” One person said, “At present the home has an excellent manager who is taking us forward on every level. I have seen a real improvement, one I thought impossible, in the service we provide for the first time since I’ve worked here. It is starting to feel like home.” Another person said, “The manager informs us of regular updates. Good communication. High standard of care delivery.” The information provided by the manager also states that she has a daily walk round each unit and is actively involved in the care planning of people who live there. The manager said that the Operations Manager supports the manager in her role, and this was confirmed with this manager who was there at the time of our visit. As part of the inspection in order to provide information to help us form judgments about the quality of the service, the manager was asked to complete an annual quality assessment (AQAA) document. This she did, and the document provided the Care Quality Commission (CQC) with a lot of information about the way the home is run, and what they hope to achieve in the future. The Operations Manager was said to visit monthly and write reports on the conduct and quality assurance audits of the home, and there was evidence of this in the documentation inspected. The areas audited included, presentation of the home and exterior grounds, medication, care documentation, complaints and accidents, staff training, finance and maintenance etc. The manager has recommenced the relatives meetings, and said that every Sunday between 2pm and 4pm meetings take place in the Café in the centre of the grounds. People and staff said that this was quality time that people have together where drinks and biscuits are provided, and they also have a sing a long. This also helps the manager to keep up to date with peoples views about Abbey Place. The Annual Quality Assurance Assessment states the maintenance and service records are in order. The fire safety procedures were in place and this showed equipment was maintained and staff have received the appropriated training. However we found the fire and moving and handling training had not been updated. The Operations Manager provided this information following the visit and assured us that training had been arranged for any outstanding movement and handling training and fire lectures. The home has an in house movement and handling trainer. Records showed that supervisions had commenced and staff confirmed this. Small amounts of personal monies are kept on behalf of people living at the home; unfortunately the computer network was seen to have stopped working therefore this standard was not inspected at the time of this visit. The Abbey Place Care Home Trading As Southern Cross Healthcare DS0000065974.V375707.R01.S.doc Version 5.2 Page 24 information received from the manager confirmed that monthly audits of the financial records take place. Abbey Place Care Home Trading As Southern Cross Healthcare DS0000065974.V375707.R01.S.doc Version 5.2 Page 25 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 2 8 2 9 2 10 3 11 3 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 2 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X 3 X 2 Abbey Place Care Home Trading As Southern Cross Healthcare DS0000065974.V375707.R01.S.doc Version 5.2 Page 26 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 OP7 Regulation 15.-(1) Requirement To make sure peoples health care needs are always met. Peoples care plans must contain the necessary information to enable the staff to meet their health care needs. Staff must always only give the medication which has been prescribed by an appropriate health care professional. Medication must be stored at the appropriate temperatures. This is to make sure that people are receiving their medication exactly as prescribed. Timescale for action 22/07/09 2. OP9 13.-(2) 22/07/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000065974.V375707.R01.S.doc Version 5.2 Page 27 Abbey Place Care Home Trading As Southern Cross Healthcare 1. OP7 The daily record should show that the needs of the person have been met, and if this has not been possible, an explanation as to why should be recorded. The action taken when a person has lost weight should be recorded to ensure that their healthcare needs have been met. Steps should be taken to ensure that medication is not stored above 26°C as per manufacturer’s instructions. Guidance should be available for staff when “as required” medication is to be given. 2. 3. OP8 OP8 4. 5. 6. OP19 OP26 OP28 7. OP38 Within the maintenance programme any worn furniture should be made good or replaced. In the interest of infection control, all parts of the home should be kept clean and free from odours. A minimum of 50 of care staff should have a National Vocational Qualification level 2 in care or an equivalent qualification as qualified staff have a better understanding of peoples needs. Ensure that all staff have fire lectures and drills every six months, (and that they are recorded,) to ensure that they are kept up to date and aware of the procedures to follow in the event of a fire. Abbey Place Care Home Trading As Southern Cross Healthcare DS0000065974.V375707.R01.S.doc Version 5.2 Page 28 Care Quality Commission Yorkshire & Humberside Region Citygate Gallowgate Tyne and Wear NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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