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Inspection on 30/11/05 for Abbeycroft Care and Nursing Home

Also see our care home review for Abbeycroft Care and Nursing Home for more information

This inspection was carried out on 30th November 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

What has improved since the last inspection?

The registered manager had made some audits upon the plans of care. This should continue. The review had improved the quality of the plans and ensured they were up to date. The last respects of resident`s wishes regarding death and dying had been recorded to fully take account of their wishes at this difficult time.

What the care home could do better:

Plans of care did not show resident or their families involvement. The care plans are reviewed upon a regular basis and the registered manager thought the original plans had been replaced. A system must be devised to ensure a resident`s involvement in the development of the plans can be verified. Residents or their families, where possible, must be involved in the development of the plans to fully take into account their wishes. Quality assurance systems must include the views of stakeholders. When the views of residents, families and stakeholders have been obtained the views must be published. When the quality assurance systems fully obtain the views of all the standard will be met.

CARE HOMES FOR OLDER PEOPLE Abbeycroft Care and Nursing Home Burnley Road Loveclough Rossendale Lancashire BB4 8QL Lead Inspector Mr Graham Oldham Unannounced Inspection 09:30 1 December 2005 st 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 Abbeycroft Care and Nursing Home DS0000056843.V254999.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. Abbeycroft Care and Nursing Home DS0000056843.V254999.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Abbeycroft Care and Nursing Home Address Burnley Road Loveclough Rossendale Lancashire BB4 8QL 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) Regency Healthcare Limited Mrs Susan Grayston Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37), Physical disability (37) of places Abbeycroft Care and Nursing Home DS0000056843.V254999.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 37 service users to include up to 37 service users requiring nursing care who fall into the category of OP (over 65 years) Up to 37 service users requiring nursing care who fall into the category of PD(E) Date of last inspection 7th July 2005 Brief Description of the Service: Abbeycroft is registered to provide personal and nursing care for up to 37 older people. The home is purpose built within its own grounds. The home is located in a semi-rural position close to a local bus route with easy access to Burnley or Rawtenstall. There are extensive views over the countryside. There is a car park to the front of the property and the gardens are accessible to residents. Accommodation is provided in single and twin-bedded rooms on three floors. Communal space is available on each floor. There is a dedicated smoking area and a new conservatory was nearing completion. Abbeycroft Care and Nursing Home DS0000056843.V254999.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 1st December 2005. Much of the information gained was obtained from talking to residents and staff members. The views of residents were obtained on a variety of topics. Two residents were case tracked. One resident was able to give the inspector information the other resident was unable to and therefore staff were questioned in depth to determine care given was as detailed in the plan of care. Case tracking gave the inspector an overall view of the specific care for the individual resident by checking the plans of care, other documentation and talking to residents and staff. Two staff members were talked to about care issues. Some of the views have been reported collectively with specific comments contained within the body of the report. The inspector took detailed notes during the inspection, which have been retained as evidence. Staff were directly and indirectly observed carrying out their tasks and interacting with residents. Paperwork examined included plans of care, assessment documentation, policies and procedures or documents relevant to each standard. A tour of the building and grounds was conducted. What the service does well: The home is undergoing some upgrading. There was a new conservatory nearing completion and some rooms had been decorated. The environment was being improved to provide better facilities for residents. The home was prepared to take risks and allow residents to go out upon their own. One resident case tracked went out every day and said, “I came here from another home. I just wanted to get out. You could not do anything. I go out more or less every day – take the bus to town, go shopping or for a drink. You can more or less do what you want”. Residents were allowed, where possible, to retain some independent living. The health and safety of residents was protected at the home. The assessment of residents was good and ensured residents needs could be met at the home. One visitor said, “there are no problems with visiting, we come when we want. The home is good”. One resident case tracked said, “my visitors come anytime. There are no fixed hours for visiting”. Visiting at the home was promoted for the benefit of residents. Abbeycroft Care and Nursing Home DS0000056843.V254999.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? 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. Abbeycroft Care and Nursing Home DS0000056843.V254999.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 Abbeycroft Care and Nursing Home DS0000056843.V254999.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 Each prospective resident was assessed prior to admission to ensure their needs could be met at the home. EVIDENCE: Two plans of care were examined during the case tracking process. Plans of care contained a social services and the homes own assessment documentation. The assessment of residents was thorough and met the requirements of the Commission for Social Care Inspection (CSCI). The assessment documentation gave staff the knowledge they needed to care for residents. Abbeycroft Care and Nursing Home DS0000056843.V254999.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 10 Plans of care had been developed for staff to deliver care. Resident’s health care needs were met by attending specialists. Staff maintained Resident’s privacy and dignity. EVIDENCE: Two plans of care were examined during the case tracking process. Several more care plans were examined to determine if residents had been involved in developing the plans. Plans of care contained good information for each resident’s health and social needs. Plans of care had been reviewed on a regular basis. Information supplied by one resident and details supplied by staff members matched the care written in the plans. The resident case tracked was aware of a plan but said, “I don’t want to bother with it”. Plans of care had been developed with sufficient detail to enable staff to care for residents. Plans of care contained evidence residents attended health care specialists. Staff questioned were able to identify the health care specialists the two residents case tracked attended. The resident case tracked said, “I attend the Abbeycroft Care and Nursing Home DS0000056843.V254999.R01.S.doc Version 5.0 Page 10 chiropodist and see the optician at the home”. Residents attended specialists to enable their health care needs to be met. One resident case tracked thought privacy and dignity was maintained. The resident said, “I don’t need much care but they look after my wife who has more care needs. They look after her well and always close the doors and deal with her privacy very well. They are very confidential about us”. Staff were directly and indirectly observed carrying out tasks of a personal nature in a way to preserve the dignity of residents. The attitude of staff made residents feel comfortable with personal care. Abbeycroft Care and Nursing Home DS0000056843.V254999.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 13 Leisure activities were provided in a suitable format for residents. Visiting was unrestricted. EVIDENCE: One resident involved in the case tracking process said, “I like to go out during the day and am going to town when we have finished talking. I like to do my own thing during the day but join in some of the activities like parties. I like to watch television”. There was a planned series of activities and there had been a party and good as new sale recently. There was a table with items from the past, which was used as remembrance therapy. Leisure activities were provided to help residents live a fulfilling life. Visiting was unrestricted to allow residents to maintain their social contacts. Abbeycroft Care and Nursing Home DS0000056843.V254999.R01.S.doc Version 5.0 Page 12 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): No standards were inspected in this section of the NMS. Core standards were met at the last inspection. EVIDENCE: No complaints or abuse allegations had been made to the CSCI since the last inspection. Abbeycroft Care and Nursing Home DS0000056843.V254999.R01.S.doc Version 5.0 Page 13 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 - 25 The home was warm, clean and comfortable. Furnishings and equipment was domestic in style and met residents needs and individual tastes. Suitable equipment such as hand rails or disability equipment had been provided where necessary. Toilets and bathrooms were of a type that met residents needs. Shared space was provided to give a variety of activities and uses for residents. EVIDENCE: The inspector conducted a tour of the home during the inspection process. All communal areas and most bedrooms were inspected. Rooms had been individualised to resident’s tastes. Comments from the resident case tracked included, “I share this room with my wife. There is plenty of room and we have our own things. The television is ours. The home is kept clean”. There was a planned maintenance programme and the home was decorated to a high standard. Equipment was observed for residents with mobility problems such as wheelchairs, walking frames, grab rails and hoisting equipment. Bathrooms had suitable adaptations. Equipment for pressure relief was observed during Abbeycroft Care and Nursing Home DS0000056843.V254999.R01.S.doc Version 5.0 Page 14 the tour. Other residents said they were satisfied with communal and private space. Rooms were observed to be clean, tidy and contain sufficient equipment to provide residents with a comfortable environment. Abbeycroft Care and Nursing Home DS0000056843.V254999.R01.S.doc Version 5.0 Page 15 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): 28 More than 50 of staff had achieved NVQ qualifications. EVIDENCE: The registered manager had an organisational training profile. The registered manager counted the number of staff, who held NVQ2 qualifications and said, “66 of staff are now qualified”. One staff member questioned was an overseas nurse and said, “I received induction training when I came here. I have since taken food hygiene and manual handling training. When I first came here I was very nervous but the staff have been very supportive”. Another staff member said, “I completed a recognised induction here but completed my foundation training when I worked in domiciliary care. I am starting my NVQ and have taken training in fire awareness, moving and handling, food hygiene, health and safety and infection control”. Training given at the home enabled staff to gain knowledge to meet the needs of residents. Abbeycroft Care and Nursing Home DS0000056843.V254999.R01.S.doc Version 5.0 Page 16 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): 31, 33, 35 and 38 The registered manager was qualified and had the experience to perform her role. Quality assurance systems had been partially developed. The financial affairs of residents were competently handled. Health and safety was promoted and protected. EVIDENCE: The registered manager was a qualified nurse maintained upon the Nursing and Midwifery Councils register. The registered manager had completed the Registered Managers Award and taken training in risk assessment since the last inspection. The registered manager was an NVQ assessor. The registered manager updated her knowledge to better perform her role. The registered manager said, “we handle the finances of four residents”. The system was explained to the inspector who examined the records. The system used prevented staff from handling any money individually. There was a safe for holding valuables. The financial procedures protected residents from possible financial abuse. Abbeycroft Care and Nursing Home DS0000056843.V254999.R01.S.doc Version 5.0 Page 17 There was an up to date business plan. The registered manager had conducted quality assurance questionnaires for residents and student nurses. The views of stakeholders need to be gained and the results published. When this has been completed the standard will be met and the registered manager will be able to respond to the changing expectations of residents and stakeholders. Certification was observed for gas and electrical appliances and installations. Fire and call alarm systems had been maintained. The registered manager had undertaken environmental risk assessments. There was a health and safety policy and procedures. Information on health and safety legislation was available. Health and safety notices were located were staff could access them. The registered manager had a training profile for the home and was able to demonstrate staff had undertaken training in health and safety topics. Two staff members told the inspector they had undertaken some health and safety training. The health and safety of residents and staff was protected at the home. Abbeycroft Care and Nursing Home DS0000056843.V254999.R01.S.doc Version 5.0 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 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 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 3 3 3 3 3 3 X STAFFING Standard No Score 27 X 28 4 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Abbeycroft Care and Nursing Home DS0000056843.V254999.R01.S.doc Version 5.0 Page 19 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 The registered manager must, where possible, develop plans of care with residents or their family members. Timescale for action 31/01/06 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 Refer to Standard OP33 OP33 Good Practice Recommendations The registered manager should ensure the views of stakeholders are gained for quality assurance purposes. The registered manager should publish the results of quality assurance questionnaires when they have been obtained. Abbeycroft Care and Nursing Home DS0000056843.V254999.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB 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 Abbeycroft Care and Nursing Home DS0000056843.V254999.R01.S.doc Version 5.0 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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