Inspection on 27/06/05 for Abbey Road [53]

This inspection was carried out on 27th June 2005.

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 Road [53] 22/02/07

Abbey Road [53] 02/11/05

Abbey Road [53] 28/09/04

Abbey Road [53] 08/06/04

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Cherry Tree House

Ashwood House (Leyton)

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

CARE HOMES FOR OLDER PEOPLE Abbey Road (53) 53 Abbey Road Newbury Park Ilford Essex IG2 7LZ Lead Inspector Edi OFarrell Unannounced Inspection 27 June 2005 13:00 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 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) G55_S0000025946_Abbey Road_V235513_270605_Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Abbey Road (53) Address 53 Abbey Road, Newbury Park, Ilford, Essex IG2 7LZ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8518 6757 Servite Houses Ltd Nova Ann OSullivan CRH Care Home 18 Category(ies) of DE(E) Dementia - over 65 (18) registration, with number MD(E) Mental Disorder - over 65 (18) of places Abbey Road (53) G55_S0000025946_Abbey Road_V235513_270605_Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 28 September 2004 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. It is operated by Servite Houses Ltd, a national charity that provides similar homes across England. 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 accomodation is spread over two floors, with nine single, ensuite, bedrooms, bathrooms and toilets on each floor. There is a passenger lift, and all parts of the buidling 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) G55_S0000025946_Abbey Road_V235513_270605_Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This, unannounced, inspection took place on a weekday afternoon. The building was toured, both accompanied by staff and unaccompanied, including some bedrooms, with the permission of the service users. All the current residents were spoken to, along with two sets of visitors and some of the staff. Assessment and care planning records were examined, along with the daily records and accident book. A part of the meeting where the morning shift hands over information to the afternoon shift was attended. The manager was out at a meeting during the visit but was contacted by phone the following day to discuss the outcome of the inspection. She provided some additional information. Service users, staff, and visitors are thanked for their warm welcome, and input to the inspection. What the service does well: What has improved since the last inspection? The home has started arranging monthly outings for some of the service users. These have included visits to the theatre and garden centres. All nursing staff Abbey Road (53) G55_S0000025946_Abbey Road_V235513_270605_Stage 4.doc Version 1.40 Page 6 have been reminded of the importance of always signing when they give out medication. 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. Abbey Road (53) G55_S0000025946_Abbey Road_V235513_270605_Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Abbey Road (53) G55_S0000025946_Abbey Road_V235513_270605_Stage 4.doc Version 1.40 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 standard(s) 1, 3, 4 & 5 Prospective service users, and their representatives have the information they need in order to make an informed choice about moving into the home. Their needs are assessed by the home prior to them moving in, and care plans are developed to meet all needs. In practice it is relatives and representatives, such as advocates and health professionals who visit the home prior to admission, rather than the service user. EVIDENCE: The Statement of Purpose and the Service User Guide are both up-to-date, and available for service users, their relatives and representatives. The room that each service user occupies is included on their care plan. Nine care plans were examined, of which four were of people admitted since the last inspection. Three of these were people who transferred from another home that has closed. The service users were spoken to, and staff were observed carrying out their duties with them, as well as the daily log, and other records being examined. All these sources demonstrated that the home undertakes a very detailed assessment prior to service users moving into the home. This includes obtaining reports from other professionals where appropriate, for example from social workers, and consultants. This means that by the time Abbey Road (53) G55_S0000025946_Abbey Road_V235513_270605_Stage 4.doc Version 1.40 Page 9 the service user moves into the home a comprehensive care plan is in place. Once the service user has been living in the home for a few weeks a review is held, so that all parties may give their views on how the home is meeting the service user’s needs. Abbey Road (53) G55_S0000025946_Abbey Road_V235513_270605_Stage 4.doc Version 1.40 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 standard(s) 7, 8, 9, 10 & 11 Service users’ health, personal and social care needs are set out in individual plans of care, which are regularly reviewed, so as to ensure that all these needs are met. Service users, and their relatives, feel that they are treated with respect and their right to privacy is upheld. Some nurses are not always signing the charts when giving out medication, which means that it is not always clear if it has been given or not. Service users, and their relatives are assured that staff deal with dying and death in a respectful, caring, and sensitive manner. EVIDENCE: Nine care plans were examined, along with the daily logs, accident records and the duty rota. All service users were spoken to, along with two sets of relatives and some of the staff, who were also observed carrying out their duties. The home has an excellent assessment and care planning system in place. It focuses on the outcomes for service users, using the National Minimum Standards. It is very detailed and covers all aspects of care. There Abbey Road (53) G55_S0000025946_Abbey Road_V235513_270605_Stage 4.doc Version 1.40 Page 11 is evidence of regular review, and changes in the care plans where needs have changed, for example following a stay in hospital. The files also contain very detailed health histories, and how previous, and current, health conditions, such as epilepsy, diabetes, and strokes will affect the service user on a daily basis. The daily log records how needs are being met, and include information about the moods of service users, which is helpful to staff in knowing how to approach them. Regular monitoring of such things as weight and blood pressure are individualised, with the norm being monthly, but weekly or biweekly where necessary. Referrals to specialists, such as a dieticians or the tissue viability nurse are made promptly. Guidance from specialists, such as the speech and language therapist are included in the care plans, and displayed in service users’ bedrooms. This is particularly important where a service user has difficulty in swallowing and in verbal communication. The medication administration charts were checked, in particular to see if all omissions were being correctly recorded, as information in the daily log showed that one service user regularly refuses medication. In addition a Requirement had been set at the previous inspection that a robust monitoring system be developed and implemented. This matter was also discussed with the manager by phone on the day following this visit. The charts were, in the main, in order, but in nearly all of them there were one or two times where the nurse administering the medication had not signed that it had been given, nor put in a code to show why this might have been the case. This is Requirement 1 brought forward from the previous inspection. The manager has already written to all nurses about this aspect of care, reminding them that they have a responsibility under both the Care Standards Regulations, and their professional code of conduct to fully comply with the home’s procedure on the administration of medication. Service users, and their relatives, spoke highly of staff and the way that they carried out their duties. Staff were observed to be very caring, and respectful, during the visit, and the written records also took account of dignity and respect, for example, how individual service users preferred their intimate care needs to be met. Each of the nine care plans seen had a section on the wishes of service users, and/or their relatives, in the event of death. These were very sensitively written, and where necessary plans in relation to dying had been discussed with a medical practitioner, e.g. regarding invasive treatments. Abbey Road (53) G55_S0000025946_Abbey Road_V235513_270605_Stage 4.doc Version 1.40 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 standard(s) 12, 13, 14, 15 Service users’ lifestyles match their expectations and preferences, as far as is possible in a group living situation. They maintain contact with family and friends, and exercise as much choice and control over their lives as they wish. Service users receive a wholesome, appealing and balanced diet in pleasing surroundings at times convenient to them, and special diets and preferences are well catered for. EVIDENCE: Service users, and visiting relatives, were asked for their views, and nine care plans were examined. Staff were observed carrying out activities, and the records were checked. On the day following the visit the manager provided further information by phone. Some of the people living in the home are very physically and mentally disabled, which impacts greatly on their daily life, and could mean in some homes that only health and personal care needs receive attention. In this home this is not the case, and even where the level of disability is very severe there is attention to lifestyle and social needs. For example, one care plan included how to address the person to get the most attention, how to encourage communication, and how to work out their preferences, where not known. Abbey Road (53) G55_S0000025946_Abbey Road_V235513_270605_Stage 4.doc Version 1.40 Page 13 There is a weekly activity programme, which the care staff carry out with some of the service users, and since the last inspection monthly external events have been organised. These have included visits to the theatre and a local garden centre. The two sets of visitors to the home during the visit were enthusiastic about the service provided, and very complementary about the staff and management, as were the service users who could give a view. One said `they spoil me’, whilst another said `they couldn’t be better’. Other service users were either unable, or declined, to give their views, but observation of staff and examination of the records showed that staff work hard to ensure that service users’ quality of life is given a high priority. At the start of the visit some service users were still eating their lunch, it looked very appetising, and one relative said `I always want to eat the food when I see it’. The menu was discussed with the cook, who confirmed that, wherever possible, food is prepared from fresh. She was aware of which service users require special diets, such as diabetic, and of which type of food was suitable. One service user said that the kitchen staff were `very good, because if I don’t like something they give me an alternative’. The daily logs, and the handover provided further information about the home meeting dietary need. For example, where the main meal had been refused, sandwiches had been prepared, and where these had still been refused they were to be re-offered during the afternoon. Abbey Road (53) G55_S0000025946_Abbey Road_V235513_270605_Stage 4.doc Version 1.40 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 standard(s) 18 Service users are protected from abuse by the policies and procedures of the home, and the training that they provide to staff. EVIDENCE: Two Requirements had been brought forward at the previous inspection in relation to the home’s Adult Protection policy and procedure document. The Commission is satisfied that the correct changes have been made to this document and that staff have received appropriate training. Accident records were cross-referenced with the daily logs, and appropriate action has been taken where bruises or cuts have been noted. The financial records of service users were not checked on this visit. Abbey Road (53) G55_S0000025946_Abbey Road_V235513_270605_Stage 4.doc Version 1.40 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 standard(s) 19, 20, 21, 22, 23, 24, 25 & 26 Service users live in a pleasant, safe, and well-maintained home, where both the individual and communal space meets their needs. EVIDENCE: The home was toured, once accompanied by a staff member, and then alone. The outside of the building and the garden were also viewed. The home is well maintained and decorated. Some dents to woodwork were noted in some bedrooms but as these do not adversely affect the welfare of the service users no Requirement has been set. Furnishing and fittings are of a homely nature, and individual bedrooms include personal items. There are sufficient bathrooms and toilets to meet the needs of the service users and visitors. The communal space is also sufficient to meet the needs of the service users. The home was very clean and tidy and no offensive odours were noted during the visit. Abbey Road (53) G55_S0000025946_Abbey Road_V235513_270605_Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 & 28 The numbers and skill mix of staff meet service users’ needs, and they are in safe hands at all times. EVIDENCE: Service users and relatives were asked for their views, and staff were observed carrying out their duties. Some staff were asked about their work within the home, and records were examined. Staffing was discussed with the manager by phone the day following the visit. There was only one member of permanent staff on duty during the afternoon shift that the visit covered. The nurse in charge was an agency nurse, and the remaining carers were bank staff. Following discussion with staff, observation of them carrying out their duties, and discussion with the manager, the Commission is satisfied that this does not adversely affect the well being of service users. Bank staff work at the home on a regular basis, and the agency nurse had worked at the home previously. In the handover meeting she demonstrated knowledge of the needs of service users. As stated earlier in this report service users, and their relatives, were very complimentary about the staff team, and how they meet needs. During this visit staff were observed responding well to requests for additional help, and demonstrated a sound knowledge of the needs of each service user. Abbey Road (53) G55_S0000025946_Abbey Road_V235513_270605_Stage 4.doc Version 1.40 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32 & 33 Service users live in a home that is well run and managed in their best interests. EVIDENCE: The manager was not at the home during the inspection as she was attending a meeting outside of the home. Observations during the visit and examination of the records demonstrated that this is a very well run home, where the best interests and the needs of service users are put first. Dates for residents’ meetings, relatives’ meetings and supervisions were on notice boards, service users are regularly reviewed, staff reported enjoying working at the home, and service users, and relatives spoke highly of the service provided. Abbey Road (53) G55_S0000025946_Abbey Road_V235513_270605_Stage 4.doc Version 1.40 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 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 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 3 3 3 x x x x x Abbey Road (53) G55_S0000025946_Abbey Road_V235513_270605_Stage 4.doc Version 1.40 Page 19 Yes 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 OP9 Regulation 13(2) Requirement The registered persons are required to ensure that robust systems are developed and implemented ensuring that all medication is administered safely and recorded accurately. Previous timescale of 01/11/04 not met. Timescale for action 31/08/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Abbey Road (53) G55_S0000025946_Abbey Road_V235513_270605_Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection Ferguson House 113 Cranbrook Road Ilford Essex IG1 4PU National Enquiry Line: 0845 015 0120 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 Road (53) G55_S0000025946_Abbey Road_V235513_270605_Stage 4.doc Version 1.40 Page 21 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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