CARE HOMES FOR OLDER PEOPLE
Abbey Road [53] 53 Abbey Road Newbury Park Ilford Essex IG2 7LZ Lead Inspector
Helen Fontaine Unannounced Inspection 02 November 2005 10:00 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 Road [53] DS0000025946.V261861.R01.S.doc Version 5.0 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 Road [53] DS0000025946.V261861.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Abbey Road [53] Address 53 Abbey Road Newbury Park Ilford Essex IG2 7LZ 0208 518 6757 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) Servite Houses Limited Nova Ann O`Sullivan Care Home 18 Category(ies) of Dementia - over 65 years of age (18), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (18) Abbey Road [53] DS0000025946.V261861.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 27th June 2005 Brief Description of the Service: 53 Abbey Road is an 18-place care home with nursing for older people, who have dementia or mental health problems. Servite Houses Ltd, a national charity that provides similar homes across England, operates it. The home has a contract with the local Primary Care Trust, so only accepts referrals from that source. The home is purpose built and is situated in a residential area of Newbury Park, close to tube and bus routes. The accommodation is spread over two floors, with nine single, en-suite, bedrooms, bathrooms and toilets on each floor. There is a passenger lift and all parts of the building have full disabled access. There is a lounge/dining area on each floor, with an additional lounge on the ground floor, through which a well maintained garden is accessed. Nursing and personal care are provided on a 24-hour basis and specialist health needs are met by visiting professionals. There are currently 15 people living in the home. Abbey Road [53] DS0000025946.V261861.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This Unannounced Inspection of Abbey Road took place over four hours and was carried out as part of the yearly inspection programme. This was the second statutory inspection visit in the inspection programme for 2005/6. Over the course of the two visits, all core standards have now been assessed. One Requirement was set at the previous inspection and the registered person has complied with all of the required action. The Inspector looked around all parts of the building and a number of records were inspected. A number of Service Users, a family member and a member of staff were spoken to. The assistance of the Manager during the inspection was very much appreciated. What the service does well: What has improved since the last inspection? What they could do better:
It was noticed during the inspection and the tour of the building that a number of fire doors were wedged open. The home does need to make sure that all Abbey Road [53] DS0000025946.V261861.R01.S.doc Version 5.0 Page 6 fire regulations are adhered to and where any door that needs to be open, the appropriate equipment is used. 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. Abbey Road [53] DS0000025946.V261861.R01.S.doc Version 5.0 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 Road [53] DS0000025946.V261861.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Service Users needs are assessed by the home, prior to them moving in and Care Plans are developed to meet all needs. EVIDENCE: The home has had a number of Service Users move into the home recently, due to the closure of a long stay hospital ward. The Manager undertook all the assessments for prospective Service Users and the assessment looked at was one of the newest Residents to the home. On the front of the assessment was a photo of the Service User and then an inventory of the belongings bought into the home. There was a sheet with basic details, with next of kin, GP and Religion. This particular Service User was Jewish and the issues over food and diet had been explored to establish if they needed a special diet. The next section was headed Personal Care, covering some eleven areas such as ability to wash, step into a bath and put on shoes. Then there was a blank section at the end of each section, for additional needs to be included. Other sections covered: communication, mobility, personal safety, risks, medical history, medication and mental health. The assessment also covered other areas, diet, weight, food and meals, dental and foot care and daily living and
Abbey Road [53] DS0000025946.V261861.R01.S.doc Version 5.0 Page 9 social activities. There was a whole section on mental health assessment, which was divided up into further headings. Due to the comprehensiveness of assessments, the home is able to establish that they are able to meet the Service Users needs and inform family and representatives of the outcome. Abbey Road [53] DS0000025946.V261861.R01.S.doc Version 5.0 Page 10 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 9 The home’s documentation demonstrated they meet assessed needs. Service Users’ health, personal and social care needs are set out in individual plans of care, which are reviewed. None of the Service Users are responsible for their medication and are protected by the home’s policies, practices and procedures. EVIDENCE: The file with Care Plans for two of the Service Users were looked at and a member of staff spoken to. The Care Plan had emergency contact details, summary of needs, life history and favourite things. There was a tick box area of assessed needs to be covered by the care plan and then the care plan had sections for more in-depth information. The care plan covered the areas that the pre-assessment form covered and each section was divided into two, Service to be provided and Objectives. The file had a communication assessment; the hospital ward had done this on the day of admission to the home. Another area covered on the file was weight chart and the manager said that some Service Users are weighed weekly, fortnightly or monthly, depending on individual assessed needs. The
Abbey Road [53] DS0000025946.V261861.R01.S.doc Version 5.0 Page 11 file identified risks, including hazards, degree of risk and plan of activity to reduce the risk. One file of a Service User fairly new to the home was admitted to the home as a long stay hospital ward was closing. This Service User needed full nursing care with their meals in liquid form. The member of staff spoken to, said that the Care Plans informed them of the Service Users needs very clearly and were easy for them access when they needed to. The Medication Administration Records (MAR sheets) were looked at during the inspection and all the sheets were appropriately signed. The home is in the process of dividing the medication into a trolley for upstairs and one for downstairs. Abbey Road [53] DS0000025946.V261861.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 and 15 The home matches the Service Users’ expectations and preferences and maintains contact with family and friends. Service Users receive a good wholesome diet that gives them choices in surroundings that are suitable. EVIDENCE: During the inspection a number of visitors were observed coming and going from the home. One family member spoken to said that their relatives were very well looked after and they visited frequently. The home has Residents meetings and also has Relatives meetings; this is especially helpful for new Service Users where the relatives are anxious. One Service User’s file looked at documented their cultural needs, including that the home had explored and offered a special diet, but this was found not to be necessary. The home has had a number of outings and events in the home, with activities being 1:1, because of the frailty of the Residents. The kitchen staff now does theme days and the most recent was a high tea and they had a barbeque during the summer. The home had planned a
Abbey Road [53] DS0000025946.V261861.R01.S.doc Version 5.0 Page 13 sausage and baked potatoes for the 5th November, with some of the Residents attending a firework display. One Service User, who had attended outpatients at the local hospital for a long time, had been invited to a staff’s leaving party. The Manager was observed to check the time of the event and confirm their attendance, making sure if the Service User needed a member of staff for support. The Manager said the Resident was very excited about the prospect of attending the leaving party. The kitchen was seen during the tour of the building and the fridges, freezers and store cupboards were observed to be very well stocked. The cook had been working at the home for some years and their routine well established. Service users spoken to said they very much liked the food and they were well fed. One Service User did not want the food on the menu and had asked for an alternative, after lunch the Resident said that their meal was very nice and she was given the alternative. Some of the Service Users had their meals in the dining room, while other had them in their rooms, in accordance with individual choice. Abbey Road [53] DS0000025946.V261861.R01.S.doc Version 5.0 Page 14 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The home protects Service Users’ rights and protects them from abuse. The Service Users are confident that their complaints will be listened to and are protected from abuse by the policies and practices of the home. EVIDENCE: The complaints book was looked at during the inspection and there were only two complaints this year. One Service User had complained about the Manager and the home arranged for the Area Manager to investigate the complaint. This was done very quickly and it was found that the Service User was unwell. The home had the Consultant to visit and the Service User’s psychiatric medication was altered. A staff member spoken to during the inspection said that all complaints and concerns would be looked into straight away. The member of staff even though they were an agency worker, was aware of the homes policies and procedures for Adult Abuse. A Service User spoken to when asked about any concerns was very clear that anything they were worried about would be dealt with straight away. The Service User felt safe and very happy living in the home. Abbey Road [53] DS0000025946.V261861.R01.S.doc Version 5.0 Page 15 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24 and 26 Service Users live in a safe, well maintained, clean, pleasant and hygienic environment. Residents have access to safe and comfortable indoor and outdoor facilities. Each Service User has their own comfortable bedroom, with their own possessions. EVIDENCE: During the inspection a tour of the building was made with the Manager and then the inspector visited Service Users in their rooms, with their permission. The home was seen to be safe with appropriate equipment for moving and handling and the home was clean and hygienic. The home had a lounge on both floors and a lift for Service Users to access all areas of the home. Outside there was a garden and during the summer months, the Service Users were able to access this. The Inspector visited Service Users in their rooms and each room was furnished individually. The Residents have their own possessions around them, friends and relatives when visiting tend to see the Residents in their rooms.
Abbey Road [53] DS0000025946.V261861.R01.S.doc Version 5.0 Page 16 The Manager said that it had been sometime since the home was re-decorated and they are planning this to be done soon. There are currently plans for carpets to be replaced as the Manager feels the home needs freshening up. The home has had a number of new Service Users move in and in the office upstairs, possessions of clothing were being labelled. The Manager said they like to get everything labelled as quickly as possible, so that nothing gets lost. Abbey Road [53] DS0000025946.V261861.R01.S.doc Version 5.0 Page 17 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29 and 30 Service Users are supported by the home’s recruitment policies and practices and by staff that are trained and competent. EVIDENCE: The staff files were looked at and one of the files was of the newest member of staff. The file had two references and a record of the Criminal Records Bureau check (CRB), along with other information such as identification. The Manager had new staff training portfolio format, which when completed would cover any new staff induction. The Manager said that all new staff has a day corporate induction, as well as the induction organised in the home. Staff training for a member of staff working in the home for sometime covered, nutrition in the elderly, COSHH, food hygiene, health and safety awareness, first aid, manual handling, foundation in dementia care. Abbey Road [53] DS0000025946.V261861.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35 and 38 The home safeguards the finances of the Service Users, but the safety and welfare of the Residents is being compromised by the fire doors being wedged open. EVIDENCE: During the inspection the issue of the Service Users finances were looked at and as most of the Service Users are placed by the Health Authority fees are generally not an issue for the Residents. Some of the Service Users finances are looked after by the families or next of kin and others look after their own. The Provider has a finance officer that deals with the issue of Service Users money, the home only having a maximum of £50 for each Resident. Each Resident has an envelope kept at the home and all transactions in or out are written on the envelope and signed by two staff- these were appropriate. Abbey Road [53] DS0000025946.V261861.R01.S.doc Version 5.0 Page 19 During the tour of the home, it was observed that a number of fire doors were wedged open. The home does need to make sure that it does not put the Service Users at risk and that all fire regulation are adhered to. Abbey Road [53] DS0000025946.V261861.R01.S.doc Version 5.0 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 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X X 3 X 3 STAFFING Standard No Score 27 X 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X 1 Abbey Road [53] DS0000025946.V261861.R01.S.doc Version 5.0 Page 21 No Are there any outstanding requirements from the last inspection? 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 OP38 Regulation 23 Timescale for action The Registered Person must take 30/11/05 adequate precautions against the risk of fire, and ensure fire doors are not being wedged open. Requirement RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Abbey Road [53] DS0000025946.V261861.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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