CARE HOMES FOR OLDER PEOPLE
Abbeydale Grove Road Ilkley West Yorkshire LS29 9QE Lead Inspector
Nadia Jejna Unannounced Inspection 13th December 2005 11:30 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 Abbeydale DS0000001237.V273519.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. Abbeydale DS0000001237.V273519.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Abbeydale Address Grove Road Ilkley West Yorkshire LS29 9QE 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) 01943 603074 01943 608077 Mr Robert Bramley Dey Mrs Catherine Elizabeth Dey Pamela Denman Care Home 36 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (4), Old age, not falling within any other of places category (32) Abbeydale DS0000001237.V273519.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The place for DE is specifically for the named service user Date of last inspection 1st September 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 DS0000001237.V273519.R01.S.doc Version 5.0 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 unannounced and took place on the 1st September 2005. This second inspection was unannounced. It started at 11:30am and ended at 4:15pm. 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 the manager, the providers, residents and visitors. Comment cards/questionnaires had been left after the last inspection for residents and visitors so that they can share their views of the home with the CSCI. Those that were returned were commented upon in the last report. None have been received since then. The people who live in the home prefer the term residents, and this is the term that will be used throughout this report. 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, DVDs, jigsaws, CDs and board games. Two of the lounges have widescreen televisions and video or DVD players and one of the televisions is connected to satellite TV. The home has a mini bus and there are regular trips out. 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. Regular residents/relatives meetings are held and twice yearly quality assurance surveys are carried out which involve residents in the running of the home. Abbeydale DS0000001237.V273519.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Abbeydale DS0000001237.V273519.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Abbeydale DS0000001237.V273519.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 3 and 5 were met during the last inspection. No further standards have been assessed. EVIDENCE: Abbeydale DS0000001237.V273519.R01.S.doc Version 5.0 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 Residents are protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: Policies and procedures around dealing with medication were in place. The manager also had a copy of the Royal Pharmaceutical Guidelines. Senior care staff are responsible for administering medications and all have received certificated training. The manager and a senior carer order repeat prescriptions that are received back into the home for checking and signing before sending them to the pharmacy. The home uses the NOMAD cassettes monitored dosage system. The cassettes are delivered weekly. Appropriate records of medicines received, in stock, given and returned to the pharmacy were seen. Controlled drugs are being used in the home. The manager was able to show that a controlled drugs register was being used. The stock levels were checked and found to be correct.
Abbeydale DS0000001237.V273519.R01.S.doc Version 5.0 Page 10 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 and 14. Residents’ choices are respected and contact with family and friends is encouraged. EVIDENCE: The home was preparing for the festive season and Christmas decorations were in the communal areas. Posters advertising activities and events in keeping with the season were seen. These included shopping trips, visits to view Christmas lights and visiting carol singers. There are regular planned activities in the home, which include quizzes, bingo and video/DVD sessions. The home has its own minibus and has employed a driver who will take residents out on trips. After lunch, a group of residents went out for a drive that took about an hour and a half. 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. It was seen that visitors were welcomed to the home at any time. Abbeydale DS0000001237.V273519.R01.S.doc Version 5.0 Page 11 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): 18 Residents feel safe living in the home. EVIDENCE: Copies of the home and local authority adult protection procedures were in place. The manager and her deputy have attended abuse and adult protection training and then cascaded it down to the staff via team meetings and staff supervision. Residents said that they felt safe living in the home. Staff said that they would not hesitate to report any actual or suspected abuse. Abbeydale DS0000001237.V273519.R01.S.doc Version 5.0 Page 12 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): Standards 19, 20, 21, 24, 25 and 26 were met during the last inspection. No further standards have been assessed. EVIDENCE: Abbeydale DS0000001237.V273519.R01.S.doc Version 5.0 Page 13 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): 29 Residents are protected by the home’s recruitment policies. EVIDENCE: Two staff files were reviewed in detail. These showed that: • Application forms had been completed. • Details of full employment history are requested. But there were no interview records to show that gaps in employment had been explored. • Two written references were received. • Enhanced Criminal Records Bureau (CRB) disclosures were in place along with Protection of Vulnerable Adults (POVA) checks. • Terms and conditions of employment had been issued. • Induction workbooks had been issued and started. It was clear that the manager is aware that new CRB disclosures must be requested for all new employees in order to check against the POVA list. Abbeydale DS0000001237.V273519.R01.S.doc Version 5.0 Page 14 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. The home is well managed and run in the best interests of the residents. EVIDENCE: The manager has successfully completed the registered managers award. Internal quality assurance systems are in place. These include regular audits carried out by the manager and sending out survey questionnaires to residents and their relatives twice a year. The results of the surveys are collated and included in the Service user Guide. The home is also accredited with the Investors In People quality assurance award and has successfully achieved accreditation for another three years. Monthly residents/relatives meetings are held. The manager said that a resident had asked for one to be held so that they compliment the staff on how well they had handled a recent emergency situation. Abbeydale DS0000001237.V273519.R01.S.doc Version 5.0 Page 15 The provider acts as appointee for one resident. Appropriate records of all financial transactions are kept. The provider said that it is now the home’s policy to request that either residents or their relatives deal with finances. The provider said that all required maintenance and annual servicing of equipment in the home was carried out and that records are kept. Abbeydale DS0000001237.V273519.R01.S.doc Version 5.0 Page 16 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 X 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 3 3 X X 3 Abbeydale DS0000001237.V273519.R01.S.doc Version 5.0 Page 17 Are there any outstanding requirements from the last inspection? NA 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. 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. Refer to Standard OP28 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. (This standard was not assessed and the recommendation has been carried forward.) The registered person should make sure that interview records are kept. These should evidence that gaps in employment have been explored. 2. OP29 Abbeydale DS0000001237.V273519.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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