Inspection on 26/01/07 for Abbeycroft Residential Care Home

This inspection was carried out on 26th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 17/05/07

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 Mark Sims Unannounced Inspection 26th January 2007 10:30 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.V319357.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.V319357.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.V319357.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 5th December 2005 Brief Description of the Service: Abbeycroft is a care home that is registered for twenty service users within the category of older persons and varying levels of dementia. The home is situated in Woolston, a quiet area of Southampton. The home offers accommodation with eighteen single and one double room. On the ground floor of the home there is a lounge, dining room, kitchen and several bathrooms and toilets. On the first floor is a range of service user bedrooms and facilities for bathing and personal needs. The front of the property is accessed via a drive, which provides parking for visitors and staff of the home. The home is surrounded by a nicely maintained garden that facilitates access for service users wishing to use this area. The home is close to local shops and a short journey away from the city of Southampton. The fees for accommodation at the home range from £360 per week to £450 per week. Abbeycroft Residential Care Home DS0000041730.V319357.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the first ‘Key Inspection’ for Abbeycroft Residential Home, a ‘Key Inspection’ being part of the new inspection programme, which measures the service against the core and/or key National Minimum Standards. The fieldwork visits, the actual visits to the site of the home, were conducted over one day, where in addition to any paperwork that required reviewing the inspector met with service users, relatives and staff and undertook a tour of the premises to gauge its fitness for purpose. The inspection process also involved far more pre fieldwork visit activity, with the inspector gathering information from a variety of professional sources, the Commission’s database, pre-inspection information provided by the service and linking with previous inspectors who have visited the home. The new process is intended to reflect the service delivered at Abbeycroft Residential Home over a period of time as opposed to a snapshot in time. What the service does well: What has improved since the last inspection? What they could do better: The following is an indication of the areas where the service could perform better: Abbeycroft Residential Care Home DS0000041730.V319357.R01.S.doc Version 5.2 Page 6 • • • • • • • • The home’s service users’ guide is being revised and a new copy was not available for inspection. Risk assessments require reviewing. Medication management and storage. Environmental issues (odours, dust, etc.) Training records were not readily available during the inspection. Formalised quality auditing. Supervision. Portable Appliance testing. 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.V319357.R01.S.doc Version 5.2 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 Residential Care Home DS0000041730.V319357.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Standard 1: The statement of purpose and service users’ guide were being updated and were not available for inspection, a judgement on their suitability therefore could not be made. Standard 3: Assessment documents were available, however the content was not always being appropriately incorporated into the service users’ care planning package. Standard 6: The service does not provide an intermediate care facility. EVIDENCE: Statement of Purpose: The management failed to produce an up to date copy of the service users’ guide when requested. Abbeycroft Residential Care Home DS0000041730.V319357.R01.S.doc Version 5.2 Page 9 During discussions with the manager it was established that the service users’ guide was not easily or readily accessible, the stated reason being that the document was being reviewed and updated. A copy of this document was request by the inspector, the manager agreeing to forward the revised forms to the Commission for information, before the report was completed. However, the Commission never received the revised documentation and therefore the inspector has no option but to consider the home’s compliance with this particular standard to be inadequate. Assessments: The evidence indicates that assessments are undertaken prior to admission, with files containing either assessments completed by the management or professional sources. • Three pre-admission assessments were reviewed, during the casetracking process (a review methodology used by the Commission’s inspectors during visits), when care plans were scrutinised as part of the fieldwork visit. The care plans of four service users were reviewed in total, with three found to contain completed assessment, which address the principle’s set out in Standard 3 of the National Minimum Standards for Older People. Two containing professional assessment documentation, the placement summaries provided by the local authority care managers, which describe the person’s needs, etc. and reasons for admission, the third being an in house assessment undertaken by the manager, which gauged the person’s abilities, needs and wishes prior to admission. However, it was also noted that whilst information is being appropriately gathered or obtained via the assessment process, this is not always being effectively transferred onto the resident’s care plan, which was discussed with the manager during the visit. • In conversation with service users and their families it was established that people’s recall, of having been visited prior to admission was limited, however, two service users relatives did discuss how they had families had supported their next of kin in finding the home and had ensured it would meet their needs before they moved in. The latter statement was also supported by a remark made via the Commission comment card process, which invites service users to comment on the quality of the care provided, a service user writing: ‘my daughter found out all about the home for me’. • Abbeycroft Residential Care Home DS0000041730.V319357.R01.S.doc Version 5.2 Page 10 • In total seven service users responded via the comment card process to the Commission, in the build up to the fieldwork visit, all seven ticking ‘yes’ in response to the question ‘ did you receive enough information about this home before you moved in so you could decide if it was the right place for you’. One person adding ‘I visited the home for one afternoon and met all the staff and residents’. • The dataset, a pre-visit tool used by the Commission to gather information, also confirms that the home has a policy on the specific area of ‘Emergency Admission’, although no indication of when this was last updated was available. Abbeycroft Residential Care Home DS0000041730.V319357.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Standard 7: The home’s care planning process provides inadequate guidance to staff around the service users’ rights to take risks and how these are to be met. Standard 8: The health and social care support needs of the clients are well managed internally and are clearly meeting people’s needs. Standard 9: The home’s medication system is not being appropriately and efficiently managed. Standard 10: The rights of the service users to be treated with respect and dignity are being appropriately promoted by the practices of the home. EVIDENCE: Service User Plans: The evidence indicates that the home’s care planning process is not being used appropriately and do not reflected adequately the right’s of service users to take risks within a safe and managed environment. Abbeycroft Residential Care Home DS0000041730.V319357.R01.S.doc Version 5.2 Page 12 • Four service users plans were reviewed and found to include: 1. 2. 3. 4. 5. 6. Admission information Assessment information Care plans, based on an Activities of Daily Living Model Risk Assessments Information relating to Next of Kin contacts Photograph of service user • The care-planning element of the service users plans were noted to be a little repetitive, with keyworkers utilising similar phrases to describe how care should be delivered, although generally the content was sufficiently informative to enable carers to identify and meet the service users needs. A statement supported by the remarks of the service users, with five of the seven service users to respond ticking ‘always’ in reply to the question ‘do you receive the care and support you need’, the remaining two responding ‘usually’ to the same question. At the last inspection, undertaken on 05th December 2005, the manager was required to ‘Develop service user plans to include specific information and incorporate risk assessments into the service user plan’. Whilst efforts have been made to improve the care-planning process and content of the plans, the inspector’s finding suggest there is still room for some improvement, with a far more individualised and client centred approach needed when developing and writing up care plans. • • • Risk Assessments: The evidence indicates that further work is required on developing appropriate risk assessment documentation. • As indicated above concerns persist over the use of the home’s risk assessment documentation, previous inspectors raising requirements around the need to ‘Undertake risk assessments for the home and for the homes staff. Implement suitable controls for identified risks’ and ‘Develop service user plans to include specific information and incorporate risk assessments into the service user plan’. The risk assessment tools introduced by the current manager are simple and straightforward risk assessment apparatus, however, the inexperience of the manager and the lack of awareness within her staff team, means these tools are being inappropriately used and that significant areas of risk or restraint are not being effectively assessed and planned for, i.e. the locking of the front door to prevent road accidents, falls/injuries, disorientation, etc. Abbeycroft Residential Care Home DS0000041730.V319357.R01.S.doc Version 5.2 Page 13 The need to work on managing and identifying risks was discussed during the fieldwork visit, as was the need to develop specific risk assessment tools like ‘moving and handling assessments’, which are designed to assess the risks associated to a specific practice and which were noted to be missing on service users files/plans. Health Care Supported: The evidence indicates that clients’ health care needs are well managed at Abbeycroft. • The care plans, as listed above, do not contain information relating to health care professionals visits, this information being documented within a specifically created and individualised record. These files included evidence of the treatment plans being followed, rereferrals or follow up appointments to professionals and input from specialist services like psychiatry. Health and social care professionals generally indicated that they felt people were happy with the service provided to service users. A view shared by three relatives who indicated, via the relatives comment cards that they were ‘satisfied’ with the overall care provided at the home. • Six service users, who responded via the comment card process, also indicated they were happy with the level of support they received in accessing appropriate health and social care services, all six ticking ‘yes’ in response to the question: ‘do you receive the medical support you need’, the seventh service user responded ‘usually’ to the same question. • • Medication Management: Whilst the information gathered is positive in respect of the health and social care elements of the residents care, the evidence gathered on the homes’ management of service users medications found there to be some room for improvement, namely consideration on the home’s storage facility for controlled medications and general approach to storing bulk medicines. • During the fieldwork visit the inspector scrutinised the home’s medication system and whilst most elements of its management were found to be appropriate: Checked in on receipt from pharmacist Correct disposal Individually held and/or stored medications Monitoring of medication fridge temperatures Availability of medication policies and guidance DS0000041730.V319357.R01.S.doc Version 5.2 Page 14 • • • • • Abbeycroft Residential Care Home • • Staff training Medication administration records. The current arrangements for storing controlled substances does not comply with the guidance set out within the ‘Safe Custody Regulations’ and consideration should be given to updating the present system, should or when the medication storage cabinets are upgraded. • This is only a recommendation within a care home, as the regulations quoted are designed for hospital and nursing based environments. The inspector also found several bags of medications, left unattended and unsecured in a bathroom, during the tour of the premise, which was brought to the managers attention. • All medication regardless of whether or not they are awaiting return to the pharmacy or storing by staff, etc., must be properly and safely secured at all times. Observations from the fieldwork visit day also suggest that service users receive their medications appropriately, adding further wait to the assumption that the problem is clerical in nature. The dataset also establishes that the home has a medication policy/procedure available, although as identified previously no dates for implementation or updated were included within the dataset. During conversations with staff it was established that medications training has been completed, although it is unclear exactly how many staff this included and what the timescales had been for completion, the manager failing to supply training information with the dataset, despite being asked, again, for this information during the fieldwork visit. • • • Dignity and respect: Respect & Dignity: The evidence indicates that privacy and the promotion of dignity for the service users is generally satisfactory. • The tour of the premises highlighted that the home has reasonably good communal facilities, which can be utilised by the service users when entertaining in private. 1. Main lounge 2. Dining Room 3. Quiet/smoking (occasional) lounge/conservatory Each of the above was seen to be in use at some point during the fieldwork visit. Abbeycroft Residential Care Home DS0000041730.V319357.R01.S.doc Version 5.2 Page 15 • The comment cards of the three relatives are also supportive of the arrangements made for conducting visits in private, all three ticking ‘yes’ in response to the question ‘can you visit your relative/friend in private’. Service users were observed participating in self-directed activities. A taxi driver, who took the inspector to the home, discussed being called to take a resident to the library and day-centres. The resident in question located during the visit and interviewed, the person confirming he undertakes trips out regularly. The service user also discussed his love of art and how staff support him in his artistic endeavours by assisting him to display his work around his bedroom. • • • • A service user is supported in keeping his dog, which staff walk regularly. However, despite the good work witnessed a couple of issues do undermine the home’s support for clients dignity, choice, etc, one issue being the failure to properly screen/obscure the door leading to the shower, which could lead to people showering or their shape, etc being clearly visible and secondly the urine odour, which permeates around the home and must be addressed. Abbeycroft Residential Care Home DS0000041730.V319357.R01.S.doc Version 5.2 Page 16 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standard 12: The service users enjoy a varied, if somewhat limited social activities programme, which appears to meet their needs and preferences. Standard 13: The visiting arrangements at the home meet the needs of both the residents and their relatives and good community links are maintained. Standard 14: The service users are helped to exercise choice and control over their lives. Standard 15: The meals are nutritionally well balanced and appetising. The menu’s varied and appealing. EVIDENCE: Activities and stimulation: The evidence indicates that all service users are afforded the opportunity to participate within activities and entertainments, although it is felt these are a little limited at times: • The dataset, did not include details of the activities available generally to the clients’, however, during the fieldwork visit and form comments DS0000041730.V319357.R01.S.doc Version 5.2 Page 17 Abbeycroft Residential Care Home made by service users it would appear as though the activities and entertainments at the home include: 1. 2. 3. 4. 5. 6. 7. • Music Quiz and games Sing-a-longs Bingo Visiting entertainers Library outings Access to day centres During the fieldwork visit the inspector observed a group of people listening to a visiting musical entertainer, which appeared to be enjoyed by those participating in the activity and those watching, judging by the banter and interaction. Conversations with several service users established that outings are always enjoyable occasions, although not frequent enough for some residents, most outings or trips undertaken by/with relatives and/or friends. Feedback via the comment cards indicates that generally people find the activities arranged at the home satisfactory, with four out the seven respondent ticking ‘always’ when asked if ‘are there activities arranged by the home that you can take part in’, the remaining three ticking ‘usually’ in response to the same question. People also added comments such as: ‘I like the activities they are very stimulating, quizzes, music, bingo, etc’. • • • However, a failure to keep good records of the activities undertaken coupled with the manager’s failure to forward to the Commission documents request initially via the dataset and then during the fieldwork visit, does undermine the inspector’s ability to evidence satisfactorily that activities are sufficient. Visiting: The evidence indicates that the visiting arrangements at the home met both the service users and/or their relatives/visitors needs: • The previous inspector recorded within her report that ‘the home has a visiting policy, which welcomes visitors at all reasonable times. Service users are able to see visitors either in private in their rooms or elsewhere in the home or gardens.’ This comment was supported by the visiting inspectors observations, with family members and friends observed arriving at and leaving regularly throughout the day. Abbeycroft Residential Care Home DS0000041730.V319357.R01.S.doc Version 5.2 Page 18 • Comments made via the relative comment cards indicate that people generally find visiting arrangements satisfactory, all three comment cards ticked ‘yes’ in response to the question ‘do staff welcome you in the home at any time’. The service users also acknowledged the flexibility of the visiting arrangements and stated that they could entertain their families/friends in a variety of locations, dining room, lounge or their bedrooms, which supports the previous inspectors findings. On arrival and departure from the home visitors are expected to sign the visitors book, this providing a degree of security and keeping track of the people in the home in the event of fire, etc. However, the log also provides evidence of the visitors to the home and the type of people undertaking the visits, relatives, friends or professionals. Examination of the home’s log demonstrated that not all visitors sign in, although where people had the picture created was of a mixed social and professional visitor group, improved use of the log would of course provide a far better view of the people visiting the home. • • • One issue which was brought to the Commission’s attention in the build up to the visit, was a concern with regards to staff appearing to sit in service users communal areas chatting and eating and being on view smoking, which gives the impression of people being sat about and not interacting or caring for the service users. This practice was actually observed by the inspector during his visit and brought to the manager’s attention, although it was clear that staff were actually on official or agreed breaks, the practice of using facilities designated for service users means people can easily and readily interpret the actions/practice as one of disengagement from caring for residents and it has been suggested to the manager that alternative arrangements for breaks be sought. Choices: The evidence indicates that the home’s approach to supporting people exercise their rights to choice and self-determination are reasonable, as demonstrated throughout the report: 1. Comments from service users in the first two sections of the report 2. Comments from relatives in the first two sections of the report 3. Choice of where to entertain visitors, mentioned above Abbeycroft Residential Care Home DS0000041730.V319357.R01.S.doc Version 5.2 Page 19 In addition to the information already contained within the report the inspector also found that: • Feedback from the service users relatives, comment cards indicating that people are involved in decision-making if their relatives are unable to make-decisions themselves. Service user supported with accessing day services and local facilities. Comments on the service users comment cards, such as, that documented in relation to activities. Variety and choice of menu/meal. Individually personalised/furnished bedrooms. • • • • Meals and Menus: The evidence indicates that service users are receiving a well-balanced and varied diet that is meeting their needs: • Sample menus provided to the Commission prior to the fieldwork visits and information taken from the previous inspection reports indicate that menus are ‘varied and balanced’. Observations of the meals provided to the service users indicate that dinners are plated up according to the person’s known preference for size of meal and appetite and conversations with staff evidenced that they understand the particular eating habits of their clients. A conversation with the cook established that menus are specifically created with the likes and dislikes of the service users in mind, although seasonal influences were of course taken into account when preparing menus. Information relating to the mealtime choices of service users are understood to be collected by care staff, with a record of the person’s choice retained in the kitchen by the cooks for reference purposes. • Records checked during the visit indicate that information about the meals chosen and consumed by the clients are available and that fridges/freezers and meals are monitored to ensure food is stored and served at the correct temperature. Five of the service users to return completed comment cards indicated, ‘always’, in response to the question ‘do you like the meals at the home’, the remaining two responding ‘usually’ in response to the same question. • • • Abbeycroft Residential Care Home DS0000041730.V319357.R01.S.doc Version 5.2 Page 20 One person also making the additional comments: ‘I am catered for as I do not always like everything but always get a substitute when needed’. Abbeycroft Residential Care Home DS0000041730.V319357.R01.S.doc Version 5.2 Page 21 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Standard 16: Relatives and visitors are confident that complaints or concerns brought to the attention of the management are appropriately addressed. Standard 17: Efforts to protect service users from abuse/harm could be improved. EVIDENCE: Complaints & Concerns: The evidence indicates that generally the service users and/or their relatives are happy to raise concerns or complaints with the home and confident that the issues will be appropriately handled and addressed. • Four service user comment cards returned confirmed/ticked ‘always’ in response to the question ‘do you know how to make a complaint’. Three people indicated ‘usually’ in response to the same question, with two of the three adding: ‘the staff are very helpful in assisting me if I have a complaint problem’ and ‘I would approach a member of staff i.e. supervisor or manager’. • Two of the of the relative comment cards indicating that people know how to make a complaint, all three confirmed they have never needed to use the process. DS0000041730.V319357.R01.S.doc Version 5.2 Page 22 Abbeycroft Residential Care Home • Previous inspectors have recorded that: ‘neither the home nor the Commission for Social Care Inspection have received any complaints since the last inspection. The home had a complaints procedure, which a copy is given to all service users and their families. The home is currently updating the complaints procedure to include recent changes and details of the Commission for Social Care Inspection. A record of complaints are kept by the home, which had been a legal requirement at the last inspection’ • At this inspection it was determined that the home were continuing to manage complaints effectively, although no details of the home’s complaints process were included within the dataset. However, the dataset did included a summary of the home’s complaints activity over the last twelve months, which establishes that: 1. No complaints have been received in twelve months • • As mentioned previously the Commission were contacted in the build up to the inspection with regards to some concerns, although these were never formalised as a complaint and never brought to the home’s attention by the complainant for investigation/consideration under their own procedure. The findings of the inspection were that not all issues brought to the Commissions attention could be evidenced or substantiated. • One staff questionnaire, returned in the build up to the fieldwork visit, suggests staff have a good working knowledge of the complaints process, the staff member indicating that they would keep records of the complaint and pass the information on to the their manager. Protection: The evidence indicates that the service users welfare is being promoted and that the management and/or staff are seek to protect people from abuse. • The dataset indicates that adult protection policies and procedures are available to staff, although no mention is made of training and awareness sessions. When asked the manager could not produce evidence of the training completed by the staff and agreed to forward training information to the Abbeycroft Residential Care Home DS0000041730.V319357.R01.S.doc Version 5.2 Page 23 Commission in time for inclusion or consideration when drafting the report, this information has not been received. • The manager was able to produce evidence of places having been booked on a forthcoming training event, 26th February 2007, around adult protection, which she and her deputy manager are to attend. The course intended to enable the management team to train their own staff in protection matters, using a variety of learn and educational tools. • All new employees are required to complete a full induction programme, which addresses protection issues but which does not comply with the units defined by ‘Skills for Care’ under the new ‘Common Induction Standards’. In discussion with staff, whilst none specifically mentioned the abuse training, it was established that the manager provides access to skills development courses and vocational qualifications. As already mentioned within the body of the report, relatives feel the home is meeting the needs of their next of kin and no concerns regards their safety or wellbeing were identified. • • Abbeycroft Residential Care Home DS0000041730.V319357.R01.S.doc Version 5.2 Page 24 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Standards 19 & 26: The premises is generally well maintained, clean and tidy and a reasonably pleasant environment for the service users, although attention to the unpleasant odours is necessary. EVIDENCE: Environment: The evidence indicates that the service users are living within a reasonably well maintained, clean and tidy premises, which is meeting their needs. • The inspector was accompanied around the home by the manager, as he had not visited the home before and felt it important to familiarise himself with the layout of the property. Abbeycroft Residential Care Home DS0000041730.V319357.R01.S.doc Version 5.2 Page 25 The tour enabled the inspector to establish that generally the home is in a good state of repair and that the accommodation is largely single occupancy, although one shared room is retained. • During the tour the inspector noticed a couple of un-emptied containers/ashtrays left by staff, which should be removed from public or the service users view, this was brought to the manager’s attention, the manager stating she has discussed this with staff at meetings and has informed them she will impose a no smoking rule if they persist in leaving unsightly messes. The tour of the premises also highlighted the need for some general maintenance and refurbishment including: • 1. Carpets in corridors that require securing/relaying or replacing. 2. Wedges removing from beneath fire doors 3. Furniture in bedrooms, including corroded commodes that require replacing. 4. Emergency call pull cords in toilets/bathrooms that should be extended to the floor. 5. Portable Equipment Testing out of date and in need of completion. • The views of the service users and/or their relatives spoken with during the visit or completing comment cards were also largely praiseworthy of the service people commenting: ‘I’m happy here’. Cleanliness: The evidence indicates that the home is generally clean and tidy throughout. • Remarks on the cleanliness of the home would tend to indicate that the service users feel the standards of cleaning at Abbeycroft is good, all seven comment cards returned indicating ‘Always’ as their response to the question ‘is the home fresh and clean’. During the fieldwork visit the manager explained that the homes’ domestic staff member was absent due to illness, which could have explained both the malodour and cobwebs noted around the home, however, both issues will require addressing, the odour problem requiring a long term strategy for consistent management. The tour of the premises also enabled the inspector to establish that paper, towels and liquid soaps were located in each of the communal bathrooms and toilets. The last inspection report also established that ‘the home was found to be homely, clean and suitable for service users. The home has • • • Abbeycroft Residential Care Home DS0000041730.V319357.R01.S.doc Version 5.2 Page 26 implemented a suitable cleaning system into the home and this takes into account infection control procedures’. Abbeycroft Residential Care Home DS0000041730.V319357.R01.S.doc Version 5.2 Page 27 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): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Standard 27: Staffing levels are sufficient to meet the needs of the service users. Standard 28: The management team supplied insufficient information to support that they have achieved the target of 50 of the care staff trained to National Vocational Qualification (NVQ) level 2 or above. Standard 29: The recruitment and selection practices of the home are sufficiently robust to ensure that service users’ wellbeing and safety are promoted. Standard 30: In-house training and development opportunities for staff appear reasonable. EVIDENCE: Staffing: The evidence indicates that the home employs staff in sufficient numbers to meet the needs of service users. • The duty roster, seen during the fieldwork visit indicates that staff are deployed in sufficient numbers to meet the needs of the service users, with three care staff, the manager and catering staff available in the DS0000041730.V319357.R01.S.doc Version 5.2 Page 28 Abbeycroft Residential Care Home morning and three care staff and the manager (for part of the afternoon) in the afternoon, as witnessed during the field work visit. At night the duty roster indicates that staffing levels drop to two wakeful staff, with most residents understood to sleep fairly well. • The service users, who responded via the comment cards indicated that generally staffing levels are sufficient to meet their needs, with four people ticking ‘always’ and two ‘usually’ in response to the question: ‘are the staff available when you need them’, the remaining resident ticked ‘sometimes’. However, it was the opinion of one relative that staffing levels could be improved, the person stating ‘there is only the bare minimum on duty’, although the other two relatives to complete comment cards indicated they felt staffing levels were adequate. The latter statements supported by relatives spoken with during the fieldwork visit, who described the staff as ‘supportive, welcoming and available to discuss their next of kin’s care if required’. Training & Development: The evidence indicates that the training opportunities for the staff are reasonable, although the records maintained in respect of the courses completed require attention. • The manager failed to included details of the staff’s training achievements or plans for forthcoming training events within the dataset bundle requested prior to the fieldwork visit. The manager has also failed to supply the required information, post the fieldwork visit, despite the inspector requesting the information be forwarded to the Commission’s Southampton Office. • However, information gathered during the fieldwork visit does indicate that staff are accessing regular training courses, as evidenced via a copies of training certificates, kept on file by the manager, which included recently: • 1. Infection Control Training 17/05/06 2. First Aid 23/08/06 3. Fire Marshalling (certificates of confirmation not yet available). • The manager was also able to demonstrate that she had access to a wide variety of training videos, which she works through with the staff and as indicated earlier, was able to evidence that an adult protection (train the trainer) course was due to commence on the 26/02/07. Abbeycroft Residential Care Home DS0000041730.V319357.R01.S.doc Version 5.2 Page 29 • However, it was also evident that due to the lack of planning and auditing some courses required updating: 1. Food Hygiene 2. Moving and Handling 3. Adult protection for all staff • Two staff surveys returned to the commission, prior to the fieldwork visit, all establish that the staff believe they have access to sufficient training events. Both questionnaires ticked ‘yes’ in response to the question ‘does the home provide funding and time for you to receive relevant training’. • It was also clear, given the information gleaned from the manager and feedback from the staff, that they are also being well supported when accessing National Vocational Qualifications (NVQ), staff discussing accessing both level 2 and level 3 qualifications. Although the evidence establishing that currently the home is not meeting the 50 ratio recommended within the National Minimum Standards, the percentage rate presently being 38.4 , rising potentially to 84.6 when the six staff currently undertaking NVQ courses finish their training. Recruitment & Selection: The evidence indicates that the home’s recruitment and selection process is not being appropriately managed. • Previous inspection reports indicate that: staff recruitment, selection, supervision and retention all met the required standards, etc. However, at this visit significant short fallings were found in the home’s recruitment process, with three newly recruit staff discovered to have incomplete employment files. Missing or erroneous items from the files of these staff included: 1. 2. 3. 4. Photographic identification Documents establishing identification Reference from last employers Criminal Record Bureau (CRB) and Protection of Vulnerable Adults (POVA) Checks 5. An induction that does not comply with the Common induction Standards, as set out by ‘Skills for Care’. Abbeycroft Residential Care Home DS0000041730.V319357.R01.S.doc Version 5.2 Page 30 • Some records were available on the file, which suggests that appropriate recruitment tools are available to the management, they were just not being appropriately used during this visit: 1. Application forms 2. Health check forms 3. Interview Records. • In discussion with the manager it was stated that the provider held a number of the required documents, as he processes the CRB and POVA checks, this however, does not excuse the poor state of the home’s recruitment files. Information from the two staff questionnaires also indicates that a more robust recruitment process/tool is available to the management, both people indicating that on applying to the home for employment they submitted to: 1. 2. 3. 4. 5. Interview CRB & POVA checks Completed and Application Completed and Induction Were provided with a Job Description and Contract. • • The latter findings suggesting that clerical and or managerial errors are responsible for the shortfall discovered at this visit. Abbeycroft Residential Care Home DS0000041730.V319357.R01.S.doc Version 5.2 Page 31 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Standard 31: The manager possesses a relevant care qualifications and is gaining experience as a leader, however, to date she has not completed her Registered Managers Award, although she is hopeful of completing the requisite units shortly and her time management or target setting requires work. Standard 33: The home is run in the best interests of the service users, although the manager needs to formalise most processes. Standard 35: The financial interests of the service users are managed by relatives, advocates or professional resources. Standard 38: Some work is required to ensure the safety and wellbeing of the service users is always maintained Abbeycroft Residential Care Home DS0000041730.V319357.R01.S.doc Version 5.2 Page 32 EVIDENCE: Management: The evidence indicates that whilst the manager is growing in experience and confidence, she needs to focus on achieving her targets and managing her time. • Prior to the fieldwork visit an pre-inspection questionnaire was sent to the home, requesting certain information from the manager to aid the inspection process. However, the information returned to the Commission was scant, which the manager, explained was due to her being absent, however, information requested during the fieldwork visit was also never provided to the inspector, which raises questions over the managers time management and organisational skills. • The above experiences coupled with the poorly maintained staffing records (recruitment and selection), medication concerns and failure to provide maintain adequate supervision sessions for staff (again explained as due to sickness), suggest the manager needs to apply herself to organising and structuring her working practices. On a more positive note the manager was described by both the service users, staff and relatives as an approachable and supportive person, ‘someone you can talk to about anything’. It was also evident from her attempts to address issues with staff, i.e. smoking and leaving full ashtrays outside on show, etc, that she is prepared to tackle difficult issues. However, as the staff continue to smoke in full view of the clients and the ashtrays remain full and on view, her approach perhaps should be toughened up slightly. Quality Assurance: The evidence indicates that both formal and informal quality auditing are used at Abbeycroft. • At previous inspections it has been reported that: ‘The home occasionally holds service user meetings and on a daily basis service users are spoken with to see if there are any issues, meetings held had not been documented. Service users confirmed that staff act on their wishes and this was evidenced through menus, activities and how care is provided in the home. • • Abbeycroft Residential Care Home DS0000041730.V319357.R01.S.doc Version 5.2 Page 33 The home has started to seek the views of service users, visitors and professional agencies informally, however, these are not documented. Service users spoken with confirmed that their views are listened to and that the home acts on their concerns’. This inspection process has established that the service users continue to feel their views are listened to and that staff continue to respond to people’s requests, etc. The comment cards of the seven service users all ticked ‘yes’ in response to the question: ‘do the staff listen and act on what you say’. However, it is less clear as to whether or not resident’s meets are continuing or if these are fully and appropriately minuted, given the recent sickness or absence of the manager it is likely that these events have also slipped and will require re-scheduling and planning. • The surveying of service users, their relatives, etc. as mentioned by the previous inspector, would also appear to have slipped in the manager’s absence and the process of seeking people’s views through questionnaires, etc. will require attention/addressing. Staff meetings, as indicated above, are still in hand and the manager did have minutes available to support the work undertaken with the staff in ensuring issues, effecting the home, are discussed. However, individual supervisions, as also mentioned above, are not being undertaken regularly and a schedule or plan for the delivery of these events/sessions will need to be developed. • Informal contacts or meetings with service users and their families do occur on a daily basis and the manager is considered an approachable and affable person, who listens and supports, however, informal processes do not provide outcomes that can be measured or audited and it is important that the manager addresses the long-term issues. • Service users’ monies: The evidence indicates that service users have access to funds as they wish. • It is the policy/practice of the home not to become involved in the management or storage of service users monies. A statement supported by the findings of the previous inspector who reported: ‘The home does not manage any of the service users money, service users are encouraged to manage their own money where possible Abbeycroft Residential Care Home DS0000041730.V319357.R01.S.doc Version 5.2 Page 34 and families or appointees manage money for those service users who cannot manage their own money’. • This information should be included within the home ‘statement of purpose’ and ‘service users guide’ information, however, the manager has not forwarded the revised documents to the Commission as agreed and this therefore has not been verified. Health & Safety: The evidence indicates that the health and safety of the service users and staff is generally being well managed. • No immediate health and safety concerns were identified with regards to the fabric of the premises during the tour of the property. However, Portable Appliance Tests (PATs), were considerable out of date and in need of attention. • • The dataset establishes that full health and safety policies/guidance documents are made available to the staff. Health and safety training has clearly been made available to staff in the form of infection control and first aid courses, however, moving and handling and food hygiene training needs updating or dates of completion documenting accurately. Access to paper towels and liquid soaps within bathrooms & toilets are indicators of attention to infection control, as is the availability of a specific infection control policy, as listed within the dataset and the training opportunities, as mentioned, however, call bell pull cords need extending to the ground and not tying up as is presently the situation. At the last inspection the inspector noted that: ‘The home has undertaken some basic risk assessments, however, these need further developing and documenting to include any controls that may be necessary for any identified risks. The home has implemented some controls for identified risks including radiators, hot water, chemicals, and window restrictors. The home is to review its current risk assessments and implement risk assessments for any further identifiable risks. At this inspection, as mentioned previously, work is still required on the home’s approach to both general risk assessment and individual risk assessment, the loose and puckered carpets a classic example, which possess a generic risk but which has neither been addressed nor identified as a potential hazards to service users, visitors or staff. • • Abbeycroft Residential Care Home DS0000041730.V319357.R01.S.doc Version 5.2 Page 35 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 2 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 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Abbeycroft Residential Care Home DS0000041730.V319357.R01.S.doc Version 5.2 Page 36 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 OP1 Regulation Requirement Timescale for action 23/03/07 2. OP7 Regulation The manager must provide to 4 the Commission a copy of the revised statement of purpose, discussed at the inspection. Regulation The manager must review the 13 home’s approach to risk assessment, ensuring all potential risks are identified/considered and addressed via a management plan. This requirement remains outstanding from the last inspection. The manager must take steps to ensure medications are appropriately stored and secured at all times. The staff must receive up to date and current training around adult protection and reporting criteria. The manager must give consideration to the issues identified within the body of this report, carpets, commodes, pull cords, etc, which require attention. The manager must ensure DS0000041730.V319357.R01.S.doc 23/03/07 3 OP9 Regulation 13 Regulation 18 Regulation 23 23/03/07 4 5 OP18 OP19 23/04/07 23/05/07 6 OP26 Regulation 23/03/07 Page 37 Abbeycroft Residential Care Home Version 5.2 13 7 OP28 Regulation 18 8 OP29 Regulation 19 8 OP30 Regulation 18 9 OP38 Regulation 23 efforts to address the urine odour, noticeable around the home. The manager must take steps to ensure the home reaches and maintains the 50 ratio of staff trained to NVQ level 2 or equivalent. The manager must make efforts to improve the home’s recruitment and selection process, addressing those issues identified within the report. The manager must forward to the Commission evidence of the training completed by staff within the last 12 months and plans for the training of staff for the forthcoming year. The manager must arrange for all portable appliances to be tested. 23/06/07 23/03/07 23/03/07 23/03/07 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 3 Refer to Standard OP9 OP33 OP33 OP36 Good Practice Recommendations The management should consider upgrading the current controlled drugs cabinet, ensuring it complies with the safe custody regulations. The manager should seek to formalise the homes quality auditing processes. The manager should establish a schedule for the delivery of regular staff supervision. Abbeycroft Residential Care Home DS0000041730.V319357.R01.S.doc Version 5.2 Page 38 Commission for Social Care Inspection Southampton, Portsmouth and Isle of Wight 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. Extracts may not be used or reproduced without the express permission of CSCI Abbeycroft Residential Care Home DS0000041730.V319357.R01.S.doc Version 5.2 Page 39 - 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. 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