Inspection on 01/09/05 for Abbeydale

This inspection was carried out on 1st September 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Abbeydale 16/05/07

Abbeydale 13/12/05

Abbeydale 07/02/05

Abbeydale 16/09/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Abbeydale Grove Road Ilkley Leeds LS29 9QE Lead Inspector Nadia Jejna Unannounced From 10:00 on 1 September 2005 st The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Abbeydale J52 S1237 Abbeydale V242068 010905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Abbeydale Address Grove Road Ilkley Leeds LS29 9QE 01943 603074 01943 608077 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Robert Dey Pamela Denman Care Home 36 Category(ies) of Older people (34) registration, with number Dementia (4) of places Abbeydale J52 S1237 Abbeydale V242068 010905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 7th Februaury 2005. Brief Description of the Service: Abbeydale is large, period, detached, stone built property, which has been extended in line with the character of the building. It stands in its own grounds and has the benefit of car parking areas, well-maintained gardens and a sun terrace, which is accessible by stairs or ramp. Abbeydale is in a quiet residential area. The home is within walking distance of the town centre and shops. It is close to local bus routes and is within easy reach of a railway station and the main roads to Leeds, Bradford and Skipton. The home provides care for up to 36 residents of both sexes over the age of 65. They may take up to 4 residents with dementia over the age of 65. Nursing care is not provided. The home is tastefully decorated and furnished to a very high standard. Accommodation is provided over three floors in 28 single bedrooms and 3 double rooms. There are three lounge areas and a large dining room. A shaft lift allows access to all floors and there is a stair lift connecting the ground and first floor. Abbeydale J52 S1237 Abbeydale V242068 010905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Over an inspection year from April until March, care homes have a minimum of two inspections a year; these may be announced or unannounced. The last inspection was announced and took place on the 7th February 2005. This inspection was unannounced. The people who live in the home prefer the term residents, and this is the term that will be used throughout this report. The purpose of this inspection was to monitor the home’s progress and to assess whether the care given to residents meets minimum standards. During the inspection records were examined and care staff were seen carrying out their work. Discussions were held with members of staff, the manager, the providers, residents and visitors. Comment cards/questionnaires were left for residents and visitors so that they can share their views of the home with the CSCI. Six resident survey cards and four from relatives had been returned when this report was written. This inspection started at 10:00am and ended at 4:00pm. Because the manager was not present, verbal feedback from the inspection was given to her on 16th September 2005. What the service does well: Care is provided in a clean, tidy, well-maintained home, which has been furnished and decorated to a very high standard. The home owners are ‘hands on’ and very involved with the day-to-day running of the home. They work closely with the manager and staff and have established good relationships with the residents and their relatives. There are systems in place to make sure that a consistently high standard of care is given. This includes care plans that give a clear picture of the resident and how to meet their needs, communication systems, regular training for staff, formal staff supervision, monthly residents meetings and regular surveys. There is a programme of planned activities and ample provision of books, videos, DVD’s, jigsaws, CD’s and board games. Two of the lounges have wide screen TV’s and video or DVD players and one of these TV’s is connected to satellite TV. The home has a mini bus and there are regular trips. Residents said they were happy living in the home and that they were more than satisfied with the care given to them. They said that staff were polite and respected their privacy. Interactions between staff, residents and visitors were seen to be polite, respectful and friendly. Resident survey cards confirmed these views. Abbeydale J52 S1237 Abbeydale V242068 010905 Stage 4.doc Version 1.40 Page 6 Comments received on the relatives and visitors survey cards showed that they were satisfied with the care given and that they were kept informed of important matters and changes. Other comments made were ‘ wonderful care and support from every member of the staff and management’, ‘ impressed by the overall care provided by the owners and staff’. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Abbeydale J52 S1237 Abbeydale V242068 010905 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Abbeydale J52 S1237 Abbeydale V242068 010905 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3 and 5. Standard 6 is not applicable to this home. Residents and their relatives are given the information needed to help them make an informed choice about the home. The admission process is good and includes introductory visits. EVIDENCE: Copies of the Statement of Purpose and Service User Guide are available in the reception area. Copies of the last two inspection reports are displayed on the residents’ notice board. Prospective residents and their relatives are given copies of the homes brochure. They are encouraged to visit the home and spend time with residents and staff. The relative of a resident recently admitted to the home said that they had been to look around the home and given all the information needed to make a decision on behalf of their relative. They said that the manager had visited their relative to carry out a pre admission assessment. A copy was in the care plan. This provided a clear picture of the residents needs and confirmed that the home would be able to meet them. Abbeydale J52 S1237 Abbeydale V242068 010905 Stage 4.doc Version 1.40 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 and 10. The health care needs of residents are met and care plans provide clear and detailed instructions for staff to follow. Residents are treated with respect and their privacy is upheld. EVIDENCE: Three care plans were seen. These showed that resident’s needs had been assessed, identified and appropriate care plans put in place. A detailed assessment is carried out within the first few days of moving into the home. This gives a very clear picture of the person at the centre of the care plan. When feedback was given to the manager she said that she had identified where further improvements could be made to the care plans and make them more person centred. Appropriate health assessments are carried out. These include moving and handling, nutrition and risk of developing pressure sores. If any risks are identified staff request the input of appropriate specialist advice via the GP (General Practioner) and district nurses. Residents and visitors said that they are involved with care planning on admission and that they are invited to annual reviews. One visitor said the care Abbeydale J52 S1237 Abbeydale V242068 010905 Stage 4.doc Version 1.40 Page 10 her relative received in the home was fabulous. They had received a letter inviting them to arrange a date for a care plan review, which they had done that morning. Visitors said that staff kept them well informed about changes in their relatives condition and needs. They said that all knew and understood residents needs and this gave them confidence in the home and the care being given. The senior carer had an in depth conversation with some relatives and it was clear that she had a good understanding of their relatives needs and what had been happening. Residents said that staff were polite and always respected their privacy. Interactions between staff, residents and visitors were seen to be polite, respectful and friendly. The home uses the Nomad pre dispensed system for administering medication. The senior in charge was checking the repeat prescriptions and new MAR’s (Medication Administration Records). She described the process of ordering repeat prescriptions, which was a robust and safe procedure. Medications are given to residents by senior carers who have completed certificated training. Abbeydale J52 S1237 Abbeydale V242068 010905 Stage 4.doc Version 1.40 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 15. Residents are encouraged to participate in social and leisure activities, to maintain links with their friends and family and to exercise choice and control over their lives. EVIDENCE: Resident’s social and recreational interests and preferences are recorded in detail in the care plans. These provide good detailed information about their life history and what they used to enjoy doing. There are regular planned activities in the home, which include quizzes, bingo and video/DVD sessions. The home has it’s own minibus and has employed a driver who will take residents out on trips. Before lunch a group of residents went out for a drive that took about an hour and a half. They said that they enjoyed these runs as much as the longer trips when they would stop somewhere to shop or for a meal. The senior carer in charge said that trips have been organised to the theatre as well as to places of interest. Information about planned events in the home, local transport, taxis, local events was displayed on the residents’ notice board by the dining room. The lounges are provided with ample supplies of books, videos, DVD’s, jigsaws, CD’s and board games. Two of the lounges have wide screen TV’s and video or DVD players and one of these TV’s is connected to satellite TV. Abbeydale J52 S1237 Abbeydale V242068 010905 Stage 4.doc Version 1.40 Page 12 Residents said that they decide what their daily routine will be, where they will spend their time and whether or not they join in with planned activities. They said that the staff are very supportive in helping them to do this. Residents are offered the choice of having their meals in the dining room, their own room or one of the lounge areas. Sherry and fruit juices are offered half an hour before the meal is served. Residents said that the food was very good and that there was a good choice of meals and alternatives. Abbeydale J52 S1237 Abbeydale V242068 010905 Stage 4.doc Version 1.40 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 standard(s) 16. There is a clear complaints procedure which residents are aware of. They were confident that any concerns would be dealt with properly. EVIDENCE: The complaints procedure is displayed in the entrance hall and included in the information given to residents. A record of all complaints made is kept. It is the homes policy that all concerns raised by residents are dealt with through the complaints procedure and that they are responded to appropriately. The complaints record book showed that no complaints have been received since the last inspection in march 2005. Residents said that they were very satisfied with the care and services provided, they felt safe and they were confident any issues would be dealt with. Abbeydale J52 S1237 Abbeydale V242068 010905 Stage 4.doc Version 1.40 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 standard(s) 19, 20, 21, 24, 25 and 26. Residents live a clean, tidy, safe and well maintained home which is suitable for their needs. EVIDENCE: The home is decorated and furnished to a very high standard. It was clean, tidy and well maintained. The provider makes sure that regular checks are carried out on all hot water outlets and records are kept. The grounds, garden and patio areas are well maintained, colourful and equipped with garden furniture to enable service users to sit outside and enjoy the views. The provider said that the gardens have won the Ilkley and the regional Yorkshire ‘in bloom’ contest. Residents said how much they enjoyed looking at and sitting out in the gardens. There are three lounge areas and a dining room. These are set out as quiet reading areas and an area where residents can watch TV or listen to music. These areas have been equipped and furnished to a high standard, while still providing comfortable, relaxing sitting areas for the residents. Abbeydale J52 S1237 Abbeydale V242068 010905 Stage 4.doc Version 1.40 Page 15 The bedrooms are spacious and some have an added area that can be used as a sitting room. The extra space and comfort achieved with this arrangement is valued and appreciated by residents. The rooms are furnished and decorated to a high standard and residents are able to bring their own belongings and make the rooms ‘theirs’. All rooms have low-level opening windows providing views of the grounds. The bedrooms on the ground floor of the extension, facing Grove Road, have French-doors, which open out, onto a paved patio area. Most of the rooms have en suite facilities, which includes a shower. There is ample provision of communal toilets and assisted bathing facilities on each floor. There is a well equipped hairdressers on the ground floor. The laundry is on the ground floor. Residents’ clothes looked well laundered and neatly pressed. They said that the service was prompt and efficient. Abbeydale J52 S1237 Abbeydale V242068 010905 Stage 4.doc Version 1.40 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, and 30. The home makes sure that there are enough staff are on duty to meet the needs of residents. Appropriate training is given to staff. EVIDENCE: Staffing levels were appropriate to the needs of residents. The NVQ training programme is ongoing. At least three staff now have NVQ 2. Some have almost completed level 3. The staff showed a positive and enthusiastic approach to training as many are hoping to enrol on NVQ training in the near future. Staff said that they all had all completed a carers’ foundation course via a local college. The manager said that this course included topics such as food hygiene awareness, infection control and health and safety. Most staff have completed training in first aid awareness and all receive regular updates on fire safety and moving and handling. The manager and her deputy have recently attended training on dementia care and they are planning how to share this with staff. Abbeydale J52 S1237 Abbeydale V242068 010905 Stage 4.doc Version 1.40 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32 and 36. Residents are able to contribute to the running of the home by being consulted about their views and opinions of the service provided by the home. EVIDENCE: Monthly residents meetings are held and relatives are invited to attend if they want to. The minutes of these meetings are displayed on the residents’ notice board. These showed that any concerns, comments and suggestions that residents have are discussed and dealt with. Residents and visitors said that all staff, the manager and the providers are approachable at any time. Some appreciated the ‘hands on’ approach of the providers. They said it reassured them and gave them confidence that standards in the home were being monitored. Staff meetings have been held monthly and records are kept. This is very good practice. But the manager said that staff find it difficult to attend every meeting and it was suggested that the frequency of these meetings would be reduced to two or three monthly. Staff said that they were kept well informed Abbeydale J52 S1237 Abbeydale V242068 010905 Stage 4.doc Version 1.40 Page 18 of changes during shift handovers and that these sessions were often used to discuss ideas and concerns. Staff said that they receive formal supervision every two months and six monthly appraisals. They said that the supervision sessions provided them with training and updates on different topics such as fire safety and abuse awareness. They also said that any training needs or other issues would be identified and discussed. Abbeydale J52 S1237 Abbeydale V242068 010905 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x 4 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION 4 4 4 x x 4 4 4 STAFFING Standard No Score 27 3 28 2 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 4 x x x 4 x x x 4 x x Abbeydale J52 S1237 Abbeydale V242068 010905 Stage 4.doc Version 1.40 Page 20 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 28 31 Good Practice Recommendations The registered person should make sure that at least 50 of care staff are qualified to NVQ level 2 by 31 December 2005. The manager should forward confirmation that they have successfully completed the registered managers award to the CSCI when avialble. (This standard was not assessed and the recommendation has been carried forward.) Abbeydale J52 S1237 Abbeydale V242068 010905 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection Aire House Town Street Rodley LS13 1HP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Abbeydale J52 S1237 Abbeydale V242068 010905 Stage 4.doc Version 1.40 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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