CARE HOMES FOR OLDER PEOPLE
Abbeycroft Residential Care Home 147 Swift Road Woolston Southampton Hampshire SO19 9ES Lead Inspector
Lorraine Parton Unannounced Inspection 5th December 2005 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Abbeycroft Residential Care Home DS0000041730.V259684.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Abbeycroft Residential Care Home DS0000041730.V259684.R01.S.doc Version 5.0 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.V259684.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 25th July 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. Abbeycroft Residential Care Home DS0000041730.V259684.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The second inspection of the inspection year took place over 4 hours and the purpose was to ensure compliance with previous legal requirements brought to the homes attention at the first inspection in July 2005 and to complete the inspection process for the year. The inspector audited 11 standards and reassessed 6 standards, in which the inspector had raised requirements at the last inspection. All key standards have now been assessed throughout the year. The inspection involved a walk around the home and an audit of some of the homes documentation. The registered manager, who was found to be professional, highly motivated and knowledgeable about the service users, assisted the inspector. Much of the inspection was spent talking to the service users who clearly displayed their involvement in the home. Service users spoken to advised the inspector that they enjoy living at the home and that the homes staffs are ‘lovely’, ‘kind and caring’ and ‘fun’. Several service users commented on how nice the home is and that they liked the decoration of the home, which they had been involved in. Staff spoken to stated that they enjoyed working in the home and that they found the manager approachable and open to their views about the home. Staff stated that they work as a team and that moral within the home is very good. The inspector had the opportunity to speak to one visitor to the home, who confirmed that they are always made welcome and that the home’s staff provide very good care for their relative. What the service does well:
The home is benefiting from a new manager and with the improvements in the environment and the general atmosphere of the home. The home was welcoming and all staff were found to be positive about the home and the manager. The home provides a homely and welcoming environment that enables service users to access all areas of the home and garden. All service user rooms are personalised and service users are encouraged to have their own personal possessions in their rooms. Abbeycroft Residential Care Home DS0000041730.V259684.R01.S.doc Version 5.0 Page 6 Service users are able to participate in the home as they wish, several service users help around the home and this includes in the kitchen and dining room. Service users spoken to advised the inspector that the homes staff provide an excellent service and comments received included “nothing is too much trouble” and “ the staff are very caring and respectful”. The inspector witnessed staff interactions with service users and noted the obvious good relationships that were in place. Service users confirmed that the homes staff involve them in the running of the home and that they are asked what they want and do their best to provide it. Staff spoken to displayed a commitment to providing a high standard of care and support to the service users living at the home. All staff displayed an understanding of service user needs. Staff advised the inspector that they work well as a team and that they are supported at all times by the home. What has improved since the last inspection? What they could do better:
Although the home has started to review the service user plans they remain basic and not including all relevant areas of care. The home is required to review and develop service user plans, which must include the service user individual risk assessments. Abbeycroft Residential Care Home DS0000041730.V259684.R01.S.doc Version 5.0 Page 7 The home has not undertaken risk assessments, although all major controls for identifiable risk are in place. The registered manager has sought the advice and guidance of a health and safety trainer, who is going to assist her with these in the near future. A requirement has been made. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Abbeycroft Residential Care Home DS0000041730.V259684.R01.S.doc Version 5.0 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.V259684.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 The home does not provide accommodation for service users requiring intermediate care. EVIDENCE: Previous inspections indicate the remaining standards have been met and therefore were not reassessed during the inspection. Abbeycroft Residential Care Home DS0000041730.V259684.R01.S.doc Version 5.0 Page 10 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9 Service users plans were basic and need developing. Medication practices are safe. EVIDENCE: Three service user plans were audited by the inspector, and noted that whilst some review had taken place they remained basic. Some areas of care had not been included or actioned. Identified areas of need that had been included were mental health, moving and handling, falls and behaviour. Furthermore no risk assessments have been undertaken for service users specific issues or risks. A further requirement has been made. The home has a medication policy and procedures, which include the requirements for administration, storage and recording of receipt and returned medication. No issues were identified during the inspection. The home operates a monitored dosage system that is provided by the local pharmacist who visits the home to monitor the medication on a regular basis. Three staff have completed a diploma in medication administration. All staff undertake medication training prior to been able to administer medication and this
Abbeycroft Residential Care Home DS0000041730.V259684.R01.S.doc Version 5.0 Page 11 training is provided by the local pharmacists. The home has information available for staff regarding the medication in the home. Abbeycroft Residential Care Home DS0000041730.V259684.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): NONE EVIDENCE: Previous inspections indicate the above standards have been met and therefore were not reassessed during the inspection. Abbeycroft Residential Care Home DS0000041730.V259684.R01.S.doc Version 5.0 Page 13 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None EVIDENCE: Previous inspections indicate the above standards have been met and therefore were not reassessed during the inspection. Abbeycroft Residential Care Home DS0000041730.V259684.R01.S.doc Version 5.0 Page 14 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 The home has not documented its risk assessments, however, there appears to be adequate controls in place. The home is clean, well maintained and provides a homely environment for service users. EVIDENCE: The inspector undertook a walk around the home and identified no issues in the rooms that were entered. The home was found to be homely, clean and suitable for service users. The home has implemented a suitable cleaning system into the home and this takes into account infection control procedures. Several damaged carpets had been replaced and many rooms had been redecorated since the last inspection. The home has not documented its risk assessments fully. The registered manager advised the inspector that a health and safety advisor is assisting
Abbeycroft Residential Care Home DS0000041730.V259684.R01.S.doc Version 5.0 Page 15 with this process and it is envisaged these will be completed by the end of January 2006. The home appears to have implemented suitable controls for identifiable risks including window restrictors that had been required at the last inspection. The home is required to document risk assessments and implement suitable controls. The home must consider moving and handling and where necessary involve the appropriate health care professions with their assessments. Abbeycroft Residential Care Home DS0000041730.V259684.R01.S.doc Version 5.0 Page 16 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None EVIDENCE: Previous inspections indicate the above standards have been met and therefore were not reassessed during the inspection. Abbeycroft Residential Care Home DS0000041730.V259684.R01.S.doc Version 5.0 Page 17 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 38 Service users live in a well managed home that is run for their benefit. Service users are consulted about the running of the home. The home safe guards service users monies. All staff are supervised and appraised within their jobs. Service users and staff are protected by good practices, however, these need further development. EVIDENCE: Service users spoke positively about the home and the care they received. Service users confirmed that the manager is available in the home almost every day and that the home’s staff seek their views about the service it
Abbeycroft Residential Care Home DS0000041730.V259684.R01.S.doc Version 5.0 Page 18 provides. Both service users and the homes staff confirmed that the home is managed effectively and that the registered manager is excellent, and staff run the home for service users benefits. Staff advised the inspector that they are kept informed of any changes and that they are able to express their views openly. The home occasionally holds service user meetings and on a daily basis service users are spoken with to see if there are any issues. The 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. Service users are able to participate within the home and several service users help around their home as they wish. The home has started to seek the views of service users, visitors and professional agencies informally, however, these are not documented. Service users spoken to confirmed that their views are listened to and that the home acts on their concerns. The home does not manage any service users money. The registered manager undertakes regular staff supervisions, which were documented. Staff confirmed that they have regular staff meetings, which are open and the manager listens to their opinions and views about the service they provide. 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. Abbeycroft Residential Care Home DS0000041730.V259684.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 2 X X X X X X 3 STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 X 2 Abbeycroft Residential Care Home DS0000041730.V259684.R01.S.doc Version 5.0 Page 20 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 OP7 Regulation 15(2) Requirement Develop service user plans to include specific information and incorporate risk assessments into the service user plan. This remains outstanding from the last inspection. Undertake risk assessments for the home and for the homes staff. Implement suitable controls for identified risks. This remains outstanding from the last inspection. Timescale for action 28/02/06 2 OP38 13(4) 28/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Abbeycroft Residential Care Home DS0000041730.V259684.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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