Inspection on 17/05/07 for Abbeycroft Residential Care Home

This inspection was carried out on 17th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Abbeycroft Residential Care Home 10/03/09

Abbeycroft Residential Care Home 28/05/08

Abbeycroft Residential Care Home 26/11/07

Abbeycroft Residential Care Home 26/01/07

Abbeycroft Residential Care Home 05/12/05

Abbeycroft Residential Care Home 25/07/05

Abbeycroft Residential Care Home 02/11/04

Abbeycroft Residential Care Home 22/06/04

Abbeycroft Residential Care Home 18/02/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Abbeycroft Residential Care Home 147 Swift Road Woolston Southampton Hampshire SO19 9ES Lead Inspector Neil Kingman Unannounced Inspection 17 May 2007 09:45 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 Residential Care Home DS0000041730.V335843.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Abbeycroft Residential Care Home DS0000041730.V335843.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbeycroft Residential Care Home Address 147 Swift Road Woolston Southampton Hampshire SO19 9ES 023 8042 0820 023 8057 94444 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) Abbeycroft Care Limited Mrs Paula C Blake Care Home 20 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (20) of places Abbeycroft Residential Care Home DS0000041730.V335843.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To accommodate two named service users under the age of 65 years. Date of last inspection 26 January 2007 Brief Description of the Service: Abbeycroft is a home providing care and accommodation for up to 20 older people with age related mental health problems and illness associated with dementia. It is one of a number of homes in the Abbeycroft Care Ltd group. The home is situated in Swift Road Woolston about a ¾ mile from the local shops and about the same distance from Weston Shore. All but one of the rooms are for single occupancy and arranged over two floors. Access to the first floor is via a stair lift. Communal areas consist of a lounge, separate dining room and a conservatory. There is a toilet and shower facility on the first floor, and two bathrooms and several toilets on the ground floor. There is a driveway and car park to the front, from which there is level access into the home via the front door. The home is surrounded by gardens with seating areas, accessible to residents via ramps. The home provides 24 hours staffing. Weekly fees range between £350 and £450. The manager states that a copy of the home’s service user’s guide is provided to all residents or their representatives where applicable. Abbeycroft Residential Care Home DS0000041730.V335843.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report details the results of an evaluation of the quality of the service provided by Abbeycroft Residential Care Home and brings together accumulated evidence of activity in the home since the last key inspection on 26 January 2007. It also focuses on the home’s response to the requirements identified at the last inspection. Part of the process has been to consult with people who use the service; including a GP who regularly visits the home. There were two responses to the visitors/relatives survey and five from people who use the service, two having been supported in their completion by the home’s manager. Included in the inspection was an unannounced site visit to Abbeycroft by an inspector on 17 May 2007. The registered manager Mrs Blake was on duty and available throughout the day. At the visit we had an opportunity to speak with staff on duty, two visiting relatives, several residents as a group and some individually. We also looked at a selection of records. Prior to the site visit the manager sent to the Commission a range of information about the service including an Annual Quality Assurance Assessment (referred to as the ‘assessment’ during the report). However, the assessment lacked essential detail in all areas, especially the key areas of what the service does well and what they could do better. What the service does well: An opportunity for the home to tell us how well it is delivering good outcomes for the people using the service was the assessment forwarded to the Commission as part of the inspection process. This was an opportunity missed as the assessment lacked detail in all the outcome groups, e.g., in the area of health and personal care the evidence is that the service delivers good care for people, managing risk areas well, accessing a range of healthcare professionals and improving its care planning process. There was no mention of any of these in the assessment. The same applies to staff training, which is kept up to date and ongoing, with the latest NVQ programme nearly completed, at which time there will be almost a 100 ratio of trained staff. The home’s assessment made no mention of meals, which according to the evidence is one of the home’s strengths. Abbeycroft Residential Care Home DS0000041730.V335843.R01.S.doc Version 5.2 Page 6 There was agreement from everyone spoken with that the manager and staff are kind, caring and always provide the care and support that people need. The building offers a comfortable and homely environment for the people who use the service and attention is paid to peoples’ choices and preferences. This is reflected in colour schemes and personal touches in bedrooms. What has improved since the last inspection? What they could do better: It can be seen from the report that the service has more strengths than weaknesses. However, the one area of weakness that is identified as having poor outcomes for people who use the service is the vetting of new care staff. Services must have a robust system, which ensures all newly appointed staff have been security checked to an acceptable level before they commence working in the home. Anything less places vulnerable people at risk of abuse. It has been discovered during this inspection that two members of the care staff have been working in the home for several months without, at least them having POVA First clearance. This is unacceptable practice and must not be repeated. At the time of producing this report the manager has confirmed in writing that immediate steps have been taken to address this issue and to ensure that it does not happen again. Two areas were identified where good practice could be improved: • Residents’ personal plans have shown improvement on those viewed at the last inspection but attention paid to providing more detail, as DS0000041730.V335843.R01.S.doc Version 5.2 Page 7 Abbeycroft Residential Care Home explained further in the report, would better evidence the good quality of care being provided by the manager and staff. • The home stores controlled drugs in a cash box that sits in the wooden medicines cabinet. It is a requirement in hospital and nursing based environments, but not in residential homes that controlled drugs should be stored in a metal cabinet fixed to the wall in a prescribed way. Clearly it would be good practice from a safety point of view for the home to adopt a similar practice. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Abbeycroft Residential Care Home DS0000041730.V335843.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 Abbeycroft Residential Care Home DS0000041730.V335843.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6 - People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who may use the service and their representatives have the information needed to choose a home, which will meet their needs. The manager ensures that their care needs will be met by undertaking a proper assessment prior to them moving into the home. The home does not provide dedicated accommodation for short-term intermediate care or specialised facilities for rehabilitation. EVIDENCE: Information At the last inspection a requirement was made for the manager to forward to the Commission a copy of the home’s revised statement of purpose as it, and the service user’s guide were not available in the home at the time. Copies of both documents have since been received at the Commission and were also available in the home for inspection during this site visit. Abbeycroft Residential Care Home DS0000041730.V335843.R01.S.doc Version 5.2 Page 10 The manager explained that she gives prospective residents and/or their representatives a copy of the service users guide, which she talks through with them. It happened that relatives of the resident newest to the home were visiting on the day of our inspection. They were able to confirm that they had sufficient information to help them make a decision about the home. Pre-admission assessment People should know that their needs will be met when they move into a home. An important part of ensuring this happens is the pre-admission assessment process. It had been noted at previous inspections of Abbeycroft that this standard had been met. During this site visit the manager described the home’s admissions process in general, and specifically in relation to the newest person to be admitted: • • • The manager, either alone or with the staff supervisor visits the person who may want to use the service either at their home address or hospital where applicable. The manager visited the most recently admitted resident at their home address and carried out a pre-admission assessment of needs, recording information on a form designed for the purpose. Prospective residents are encouraged to visit the home prior to admission, as was this individual, who was invited to view the home and take lunch with the other residents. A copy of the pre-admission assessment was available on the resident’s file. The home’s policy is to carry out pre-admission assessments on all prospective residents including those who are referred in emergency situations. Intermediate care People who live at Abbeycroft tend to be long term. The home does not provide dedicated accommodation for short-term intermediate care or specialised facilities for rehabilitation. However, respite care is provided if there is a room available. Abbeycroft Residential Care Home DS0000041730.V335843.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 - People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: Care planning – The home has a system of care planning with an individual personal plan for each resident. At the last inspection a requirement was made for the manager to review the home’s approach to risk assessment, ensuring all potential risks are identified/considered and addressed via a management plan. At this site visit we looked at a sample of four plans. The intention was to look at the outcomes for people who use the service in general by assessing all areas of care for those sampled. The sample included the newest admission to the home, this person having moved in the previous month, a person with an illness associated with Abbeycroft Residential Care Home DS0000041730.V335843.R01.S.doc Version 5.2 Page 12 dementia, a person who was largely self-caring and a person identified as being at risk of developing pressure sores. It was clear that some improvements had been made to residents’ files since the last inspection and the manager said she and key workers had worked hard to achieve the improvements. However, in discussions it was recognised that further basic improvement could be made, e.g., the manager described the action taken by staff to minimise risks for one person experiencing a number of falls. The action was clearly positive and successful. While there was a risk assessment in place it did not go so far as to record the success that staff had achieved, nor the action they had taken to achieve the success. On the positive side, the sampled care plans were noted to be well structured, to include: • • • • • A check list of information The person’s photograph A plan of care, which covered all areas of their daily lives Identified areas of risk with a summary of action to be taken by staff Aims/objectives and goals. In summary residents’ personal plans had been improved since the last inspection. However, the inclusion of more detail especially in risk assessments would better evidence the quality of care that is being given. Health and access to care services The manager confirmed, and records evidenced the regular contact with GPs, optician, dentist and chiropodist. People spoken with said that the home was very quick to contact a doctor if they needed one and to arrange the various checks with the dentist and optician where applicable. During the site visit we had an opportunity to speak at length with two visiting relatives who were very happy with the way the home took care of their relatives’ healthcare. They said the home kept them informed of all important matters affecting their relatives. Records showed and discussions with care staff confirmed that two residents were currently vulnerable to pressure sores. The manager and staff were very clear about what was required to ensure that pressure sores did not develop, i.e., suitable equipment and care practices. However, this is another area where considerable success is being achieved in terms of outcomes for people but further detail in care plans would better evidence the quality of care given. The manager said, that while people who use the service have a choice about their GP it really only applied to those who had formerly lived in the area, there being at least four health clinics with several GPs at each clinic. Other Abbeycroft Residential Care Home DS0000041730.V335843.R01.S.doc Version 5.2 Page 13 healthcare professionals visit the home on a regular basis and more specialist ones e.g., aromatherapy treatment and community psychiatric nurse are called upon as and when required. All the responses from surveys taken as part of the inspection process were very positive, indicating the home always provides the care support and medical support that residents need. The survey of visiting relatives indicated the home meets residents’ needs, supports them and keeps the relatives informed and updated. This was confirmed in discussions with visiting relatives during the site visit. Medication Medication is dispensed by means of a ‘Nomad’ system by staff who have completed training in medicines administration, and deemed competent by the manager. At the last inspection areas where the standard was found to have been met were staff training, administration, and recording of medicines. Shortfalls were identified in the arrangements for storing medicines, i.e., the inspector found several bags of medications, left unattended and unsecured in a bathroom. At this site visit all medicines were noted to be held securely and appropriate records maintained. However, the arrangements for storing controlled drugs had not been upgraded as recommended. According to best practice guidance, and compulsory in hospital and nursing based environments, controlled drugs should be stored in a metal cabinet fixed to the wall in a prescribed way. The manager confirmed that the provider was not prepared to upgrade the facility due to the cost implications. Privacy, dignity and respect Respecting people’s dignity and privacy is covered in the Common Induction Standards for new staff. On the day of the site visit time was taken to observe the interactions between staff and residents and to sit with residents in the communal areas. Staff were noted at all times to be respectful, very attentive and kind towards residents, calling them by their preferred names and knocking on doors before entering rooms. All residents and visiting relatives spoken with during the site visit were full of praise for the staff and their approach to care, and no concerns were raised. While rooms are able to have telephones people can use the home’s portable phone if privacy is required. Abbeycroft Residential Care Home DS0000041730.V335843.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 - People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use service are able to make choices about their life style and activities are offered to suit their individual needs and expectations. Friends and family are made to feel welcome and can visit at any time. Residents’ nutritional needs are satisfied with a varied and balanced diet of good quality food. EVIDENCE: Routines and activities – The home’s assessment describes what the service does well as, “We always offer social activities within the home, we also offer outside entertainment.” This description does not do justice to the efforts made by the manager and staff in the area of routines of daily living and activities, which according to the evidence are discussed at residents’ meetings. Not everyone is interested in taking part in the activities offered, which include, visiting musicians, gentle exercises organised by a visiting occupational therapist, bingo, quizzes, reminiscence and games organised by staff. Abbeycroft Residential Care Home DS0000041730.V335843.R01.S.doc Version 5.2 Page 15 One actively mobile individual expressed a preference for socialising with other residents, watching TV and walking around. Visitors to one person were very clear that their relative was a very private person and always had been, not given to socialising and taking part in organised activities. The home facilitates one resident’s keen interest in art. This person attends a day service that offers therapeutic activities, which suit their preferences. Residents described how the home makes a special effort to celebrate special occasions and staff assist them with craft based activities, e.g., making cards and decorations etc. Another enjoys pottering in the garden, planting and tending the flowers. This activity was witnessed during the site visit. One resident has a particular interest in storing their possessions brought with them into the home. A special effort has been made to extend the storage facilities in this individual’s room beyond that which one would normally expect to find. All responses to the care homes survey indicated there are always activities that they can take part in. The home receives a monthly visit from the local parish clergy and those who wish can take communion in the privacy of their rooms. Visiting arrangements – Friends and relatives are encouraged to visit the residents with their permission. Details of visiting arrangements can be found in the service user’s guide and are generally at all reasonable times, i.e., respect for mealtimes and times that people want to retire in the evenings. People can receive visitors in their own rooms or any of the communal areas. There is a conservatory, which is a quiet area affording some privacy. A resident who wished to talk with us in private during the site visit suggested this. Personal autonomy and choice – Residents were spoken with as a group in the lounge and some individually in private. Due to some cognitive impairment it was not possible to obtain informed views from everyone. However, the consensus from others was that they were given choices regarding routines in the home, e.g., times of rising, going to bed, activities, meals, personal care etc. The manager confirmed that everyone has either a family member or a social worker to support them independently of the home. She demonstrated a knowledge of the advocacy service, and how and when to use it. People are encouraged to bring with them pictures, ornaments and personal items for their room. During the tour of the building it was noted that some rooms were Abbeycroft Residential Care Home DS0000041730.V335843.R01.S.doc Version 5.2 Page 16 very well personalised, and reflected the residents’ individual tastes and preferences. The management of residents’ finances is covered later in the report but in a general sense they are encouraged to handle their own financial affairs for as long as they are able. This information is set out clearly in the service user’s guide. Meals and mealtimes – During the site visit we had an opportunity to observe residents over lunch. The atmosphere in the dining room was sociable and friendly and attracted all residents as a group. Staff were available to assist them as and when required. Food served looked appetising and was well presented, with a main dish and a choice of several alternatives. All residents spoken with made very complimentary remarks about the lunch. Menus are arranged over a two-week cycle and show food to be varied and appealing. The home does not currently have a dedicated cook but care staff take turns in producing the meals. This seems to work satisfactorily and there were no concerns raised from anyone. In fact all responses to the surveys indicated they always liked the meals. Drinks and light snacks were offered through the day between meals. The home’s kitchen is clean and bright. It has recently experienced an inspection from the Department of Environmental Health and the requirement to lay an impermeable flooring has been met. Abbeycroft Residential Care Home DS0000041730.V335843.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 - People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are able to express their concerns and have access to a robust, effective complaints procedure. While procedures for responding to suspicion or evidence of abuse are robust shortfalls in the home’s recruitment procedures place people at risk of abuse. EVIDENCE: Complaints The home has a policy and procedure for dealing with complaints, details of which are summarised in the service users guide given to all residents or their representatives. At the last inspection this standard was judged to have been met. At this inspection it was clear that people had confidence in raising concerns with the manager in the knowledge that they would be treated seriously and dealt with appropriately. The manager confirmed that no complaints had been made since the last inspection. All responses to the visiting relatives and service users surveys indicated they always knew how to make a complaint. During the site visit one visiting relative commented, “I certainly know how to make a complaint and wouldn’t hesitate if I had one.” Abbeycroft Residential Care Home DS0000041730.V335843.R01.S.doc Version 5.2 Page 18 Safeguarding adults – At the last inspection a requirement was made for staff to receive up to date and current training around the safeguarding of adults and reporting criteria. The safeguarding of vulnerable adults is covered in the NVQ training for staff, of which all care staff are now either qualified or undertaking the training. In addition, the manager and the supervisor have recently achieved a qualification in ‘Adult Protection Training the Trainers’. The manager and staff confirmed that specific Protection of Vulnerable Adults training has been arranged by the company’s training co-ordinator for the near future. Care staff spoken with were very clear about how to recognise abuse, what to do, and the importance of reporting issues of concern without delay through the home’s whistle-blowing procedure. The home has a clear Adult protection policy and procedure for staff to recognise and act upon signs of abuse. The policy follows locally agreed multiagency protocols as regards the reporting of incidents. This is important as it reflects the position of social services as the lead agency in all adult protection referrals. Despite the obvious improvements that have taken place since the last inspection two care assistants have been working in the home with vulnerable people without having had the required criminal record or Protection of Vulnerable Adults (POVA) checks. This is unacceptable as it places people at risk of abuse. Abbeycroft Residential Care Home DS0000041730.V335843.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 - People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The physical design and layout of the home enables residents to live in a safe, well-maintained and comfortable environment, which encourages independence. All areas of the home are kept clean, hygienic and there are no unpleasant odours. EVIDENCE: Environment – Abbeycroft has been a residential care home for older people in Woolston for many years and while not purpose built has been developed and adapted over the years to be suitable for its stated purpose of providing a safe, manageable and comfortable environment for the people who live there. The home is located in Swift Road, and is only a short distance from the local shops and the Weston Shore. Abbeycroft Residential Care Home DS0000041730.V335843.R01.S.doc Version 5.2 Page 20 All areas of the building are accessible to the people who live there, including the two garden areas outside. These are generally laid to lawn with patio areas with seating, flowerbeds, shrubs and trees. The manager said that the person who normally tends the garden had been committed recently to improvements within the building. This was reflected in the fact that the lawns needed cutting, the wooden garden furniture needed staining and there were weeds growing between paving slabs. The manager confirmed that the garden was next on the list of tasks. A stair lift affords access to the rooms on the first floor. The home is generally comfortable and homely, reasonably well furnished and decorated. There was evidence of continued improvements with the environmental requirements identified at the last inspection having been addressed. There are personalised signs on doors to assist people who may be confused with being able to identify their rooms. The same applied to bathrooms and toilets of which there are sufficient on both floors to meet peoples’ needs. The home employs a maintenance/handy man who deals with all maintenance issues as and when they occur. When residents’ rooms are vacated, they are redecorated in colours of their choice and new carpets laid where required. Since the last inspection commodes have been replaced where applicable. Residents spoken with during the inspection made positive comments about the environment, especially one whose room was very well personalised with artwork they had accomplished at a day service. Cleanliness It was noted that all areas of the home were clean, hygienic and free from unpleasant odours. The laundry room has wipe clean surfaces, and while the floor covering is impermeable the manager confirmed that it was due for replacement as it was showing signs of wear and tear. Machines are of the commercial type, suitable for coping with high volumes of washing at the correct temperatures. It was noted that a good deal of attention is paid to infection control with liquid soaps and paper towels sited in areas of communal hand washing, and antibacterial hand gels strategically sited around d the home. Abbeycroft Residential Care Home DS0000041730.V335843.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 - People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff in the home are deployed in sufficient numbers, are trained and given the necessary skills and experience to meet the needs of the people who live there and support the smooth running of the service. However, shortfalls in the home’s recruitment procedures place people who use the service at risk of abuse. EVIDENCE: Staffing levelsAt the last inspection this standard was judged to have been met and there has been no change to staffing arrangements since that time. The home employs 13 care staff, domestic and maintenance staff. Staff rosters showed and the manager confirmed that three care staff are deployed during the day and evening. The manager works in a supernumerary capacity. On the day of the site visit there were seventeen people resident in the home with three care staff on duty in the morning and four in the afternoon, with the manager supernumerary. Overnight there are two wakeful carers on duty. These staffing levels are considered adequate for the current needs and numbers of residents in the home. Abbeycroft Residential Care Home DS0000041730.V335843.R01.S.doc Version 5.2 Page 22 All five responses to the service users survey indicated there are always staff available when they need them. NVQ training – Records showed and the manager confirmed that currently five of the thirteen care staff have achieved the NVQ at levels 2 or 3. A further seven care workers are currently undertaking the training, and in fact have almost completed it. When they are qualified this standard will be met. Recruitment There have been no new staff recruited to the home since the last inspection when a requirement was made to improve the home’s recruitment and selection process. This referred to the fact that three newly recruited staff had incomplete employment files, and it was stated at the time that the provider held a number of the required documents, in particular the results of Criminal Record (CRB) and Protection of Vulnerable Adults (POVA First) checks. At this inspection it was noted that the manager had updated the home’s recruitment records to better evidence compliance with the relevant regulation and schedule. However, the manager still could not demonstrate that the required safety checks had been carried out on those three newly recruited staff. This is important as to bring staff into the home without, at least them having POVA First clearance places vulnerable people at risk of abuse. An immediate requirement form in respect of this matter was given to the manager at the end of the site visit. At the time of producing this report the manager has confirmed that two of the three staff referred to above have not had the required security clearance, due according to the manager, the system in place whereby the provider takes responsibility for sending off the appropriate forms and receiving the results of the checks. That said the registered manager has a responsibility to ensure that these checks are carried out and that staff do not commence work in the home until POVA First clearance has been given and satisfactory references have been received. Staff training – While there have been no new staff to undertake an induction programme the manager has now accessed the Common Induction Standards recommended by ‘Skills for Care’. She confirmed that all new staff would start the new programme. Abbeycroft Residential Care Home DS0000041730.V335843.R01.S.doc Version 5.2 Page 23 Significant improvements were noted. The home now has individual training records with a matrix, which records details of training achievements. This was available for inspection together with certificates of achievement and showed that training includes: Manual handling Food hygiene First aid Health and safety Medication Safeguarding vulnerable adults The manager said that the system of identifying training needs has been reviewed and will shortly be improved by having a centralised system overseen by the Company’s appointed training co-ordinator. Plans are in place for staff to attend dementia care and additional medication training via Southampton City College. Abbeycroft Residential Care Home DS0000041730.V335843.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 - People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management and administration of the home is based on openness and respect, and has some effective quality assurance systems developed by a qualified manager. However, people who use the service are put at risk by poorly managed recruitment of new staff. EVIDENCE: Management – The registered manager Mrs Paula Blake has been in post for nearly two years and prior to that was the deputy manager. She has many years experience of working at Abbeycroft. She has achieved the NVQ at levels 2, 3 and 4 in care and has confirmed that she has completed the training for the Registered Managers Award (RMA) and is awaiting final verification before receiving the Abbeycroft Residential Care Home DS0000041730.V335843.R01.S.doc Version 5.2 Page 25 certificate. In addition, she updates her knowledge, skills and competence with periodic training in care related subjects specific to the service provided by the home along with the care staff. It was clear that the manager has made significant improvements in responding to the requirements identified at the last inspection but this has been let down by poor management of staff recruitment as described earlier in the report. Quality assurance – There was evidence that the manager has paid attention to the recommendation at the last inspection to formalise the home’s quality assurance process and has made improvements to the following: • • • The views of visitors/relatives are sought with the introduction of questionnaires, which are readily available in the hall near to the visitors’ signing-in book. Residents’ feedback cards are used with those who have the cognitive ability to use them. Residents meetings have been formalised and minutes are taken of matters arising, which the manager uses to improve the service. Other areas that inform the home’s quality assurance are: • • • • Regular in-house care plan reviews. Regular staff meetings and supervision sessions. One-to-one communications with the residents and their visiting relatives. This was witnessed during the inspection. A statement of future plans for environmental improvements to the home. Residents’ monies – It is the policy/practice of the home not to become involved in the management or administration of residents’ finances other than to provide a facility to safeguard monies or valuable on request. The home’s service user’s guide makes reference to the policy. Staff supervision – In response to a recommendation at the last inspection the manager has attended a supervisors course and implemented a programme of formal staff supervision, which she and the home’s supervisor undertake with staff every six weeks. Documentary evidence was available for inspection. Staff spoken with during the site visit confirmed that regular staff meetings and formal supervision sessions were taking place. They said that communication was Abbeycroft Residential Care Home DS0000041730.V335843.R01.S.doc Version 5.2 Page 26 good, the home was well managed and apart from the usual ups and downs of everyday life staff morale was general high. Health and safety – The home has policies and procedures in place to ensure safe working practices in the home. A sample of records was viewed including accident records, fire alarm tests, health and safety risk assessments, electrical certificate and public liability insurance all of which were in good order. It was identified at the last inspection that Portable Appliance Tests (PATs), were considerably out of date and in need of attention. There was evidence that a test was scheduled to be carried out on 21 May 2007. Staff training records showed, and staff confirmed that statutory training is scheduled and updated in manual handling, first aid, health and safety, infection control and food hygiene. Abbeycroft Residential Care Home DS0000041730.V335843.R01.S.doc Version 5.2 Page 27 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 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x 3 3 x 3 Abbeycroft Residential Care Home DS0000041730.V335843.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP29 Regulation 19 • Requirement POVA First checks or Criminal Record Bureau disclosures on employees must be obtained before they start working in the home and having access to the people who use the service, so that they may be safeguarded from abuse. Evidence of checks and other information set out in Schedule 2 to the regulation must be available in the home for inspection by persons authorised Timescale for action 01/06/07 • Abbeycroft Residential Care Home DS0000041730.V335843.R01.S.doc Version 5.2 Page 29 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 OP7 Good Practice Recommendations People who use the service and staff would benefit from additional information being recorded on the care plans and risk assessments to ensure consistency of care and better evidence the quality of care provided. Upgrading the current controlled drugs cabinet would improve the arrangements for safe storage of medicines. 1. OP9 Abbeycroft Residential Care Home DS0000041730.V335843.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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