Inspection on 16/06/08 for Abbeydale

This inspection was carried out on 16th June 2008.

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

The inspector 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 30/05/07

Abbeydale 21/06/06

Abbeydale 11/11/05

Abbeydale 06/07/04

Abbeydale 08/07/02

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Abbeydale 182 Duffield Road Derby DE22 1BJ Lead Inspector Steve Smith Unannounced Inspection 16th June 2008 10:35 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 DS0000002104.V366608.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. Abbeydale DS0000002104.V366608.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbeydale Address 182 Duffield Road Derby DE22 1BJ 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) 01332 331182 01332 344481 office@willover.co.uk Willover Limited Pamela Margaret Slonimski Care Home 41 Category(ies) of Old age, not falling within any other category registration, with number (41) of places Abbeydale DS0000002104.V366608.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th May 2007 Brief Description of the Service: Abbeydale Nursing Home provides 41 places for people over the age of 65 years and is situated in a residential area of Derby city. The property was originally a private dwelling that has been tastefully and extensively converted into the current nursing home. The bedrooms of the people staying in the Home are located across 4 floors. All floors are accessed via a passenger shaft lift and staircase. Four shared bedrooms have ensuite facilities. The home is close to a local park, churches and public houses. It is also on a regular bus route from Derby city centre, which is not far away, which means that all the amenities of the city centre are within easy reach. The charges made for a room at Abbeydale Nursing Home range from £404.00 a week to £425.00 a week, dependent on the bedroom provided and the needs of any particular person. An additional charge of £100.00 a week is made for those people requiring specialist nursing care, which is paid for by the Health Authority. Details of previous inspection reports can be found on the Commission for Social Care Inspection’s website: www.csci.org.uk Abbeydale DS0000002104.V366608.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 Star. This means that people who use the service experience Good quality outcomes. The focus of inspections, undertaken by the Commission for Social Care Inspection (CSCI), is upon outcomes for people and their views of the service provided. This process considers the Home’s capacity to meet regulatory requirements, minimum standards of practice, and focuses on aspects of service provision that needs further development. This inspection visit was unannounced and took place over a period of approximately 7 hours. In order to prepare for this visit we looked at of all the information that we have received, or asked for, since the last key inspection of the Home, which took place on 30 May 2007. This included: The ‘Annual Quality Assurance Assessment’. This is a document completed by the Registered Providers of the Home that focuses on how well outcomes are being met for people using the service. What the service has told us about things that have happened in the service. These are called ‘notifications’ and are legal requirements. The previous ‘Key Inspection Report’, and the results of any Other Visits that we have made to the service in the last 12 months. Relevant information from Other Organisations, and what Other People have told us about the service. Surveys returned to us by people using the service, from the relatives of those staying in the Home, and from the staff working in the Home. For this inspection of the service the Commission’s Residents questionnaire (a ‘survey’ mentioned above) was sent to ten people staying in the Home, and ten were returned. Ten questionnaires were also sent to relatives of those staying in the Home, and nine were returned. Ten questionnaires were also sent to staff, and six were returned. During this visit to the Home ‘case tracking’ was used as a system to look at the quality of the care provided. This involved the sampling of a total of four peoples records, being a cross-section of people staying in the Home. Abbeydale DS0000002104.V366608.R01.S.doc Version 5.2 Page 6 Discussions were held with those people, if they were able, together with a number of others, about the care and services the Home provided. Their care plans and care records were also examined, and their private bedrooms and communal facilities were seen. Discussions were also held with any relatives that were visiting during this visit to the Home. In addition, discussions were held with the Manager of the Home about its general operation. Discussions were also held with staff about the arrangements for peoples care, and also about the staffs recruitment, induction, deployment, training and supervision. What the service does well: What has improved since the last inspection? The last inspection of this Home took place in May 2007. All but one Requirements made at that time have been met, and the remaining Requirement, said a Registered Provider, will be addressed within the next few months. The issues that the Registered Providers and Manager have met are: The management of the administration of medication is now much improved. Concern was expressed about the nature of care provided at night, which has also been addressed. Bathing facilities have been improved, or are in the process of being improved. When recruiting new staff, the Manager now ensures that two references are always obtained, and that photographs of the new members of staff are contained within their files. The quality assurance provided by the Registered Provider and Manager is now greatly improved. Abbeydale DS0000002104.V366608.R01.S.doc Version 5.2 Page 7 All care staff undergo supervision, by senior nurses or the Manager, every two months. Mandatory training had been provided for all staff. 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. The summary of this inspection report can be made available in other formats on request. Abbeydale DS0000002104.V366608.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Abbeydale DS0000002104.V366608.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2, 3 & 6. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. All new people moving to the Home were appropriately assessed prior to their admission, so that they were reassured that their needs would be met. EVIDENCE: The Registered Providers had provided a detailed statement of purpose for the Home together with a Resident’s Guide, which were seen in the bedrooms visited during this visit to the Home. The Guide was well completed, and included information from people that had stayed in the Home on what life was like in the Home. The Residents Guide also contained information on how contact could be made with the Commission, the local Social Services Dept and the local Health Authority. People staying in the Home were very happy with the admission procedures, for example they said – ‘I was quite happy with all the information (received prior to admission) so that I could make up my own mind’ – and – ‘I am very Abbeydale DS0000002104.V366608.R01.S.doc Version 5.2 Page 10 happy now I am here.’ Relatives, of people staying in the Home, were also happy with the admission procedures, saying – I was ‘…always well informed about everything’ – and – the staff were ‘…very supportive…’ during the admission procedure. Staff said that – ‘Before every shift, in ‘report’, we are given updates in detail about every person we care for’ - and – ‘We are always given reports before starting our shifts. So we are always aware of our clients needs.’ The records of four people were examined during this visit and a copy of the statement of terms and conditions of residency or a contract, if purchasing their care privately, was found in each file. When new people were admitted to the Home, the Manager was provided with a summary of the needs of each person, completed by the Social Services Dept Care Manager supporting each person, copies of which were seen. The Manager also assessed all people sponsored by Social Services Depts. If the person was self-funding from the outset, the Manager completed her own summary of needs, which were also seen during this visit. This was confirmed by the Annual Quality Assurance Assessment completed by the Registered Providers, prior to this visit to the Home. They said – ‘Prior to admission, each new Resident is assessed by a senior trained member of staff to assess their individual needs, and obtain a clear knowledge of their medical history. This enable us to meet the Resident’s needs and to have in place on admission the relevant equipment they may require.’ Standard 6 does not apply to this Home. Abbeydale DS0000002104.V366608.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): Standards 7, 8, 9 & 10. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. Peoples health and personal care needs were being well met, as demonstrated within care plans and by comments made by those staying in the Home. Medication was also administered appropriately to meet peoples needs. EVIDENCE: To help assess Standard 7, the Resident’s Plan of Care, the records of four people staying in the Home were examined, for the purpose of case tracking. The medical records and records maintained by nursing staff were found to be very well completed, providing all the necessary information to staff. However, the following issues were found to need addressing. The Manager had commented that formal reviews of care were being undertaken by her on a 6 monthly basis for all people staying in the Home. However, in the four files examined during this visit no records of these reviews were found. Abbeydale DS0000002104.V366608.R01.S.doc Version 5.2 Page 12 In the nursing records, for people staying in the Home, the nursing staff occasionally used the phrase ‘Please observe’ concerning a particular need of a person. However, in subsequent entries nursing staff had not commented on their observation of the particular need. As already stated, the majority of the record keeping was completed by nursing staff. However, during this last year the Manager had required the care staff to also record the social activities and social needs of those staying in the Home in appropriate detail. Four of these records were seen and the recording was found to be poorly maintained. One of the records showed that recording had not been completed for a 7 month period, then just two lines were recorded to bring events up to date. In general, however, the nursing records were found to be very well organised, Staff were observed talking and assisting those staying with meals in the dinning room and in the lounges. This was seen to be done very positively, with a relaxed atmosphere, which was enjoyed by the people staying in the Home. The records of peoples health needs were observed and a good record was found to be maintained. The Annual Quality Assurance Assessment stated that a full assessment of new people was made, detailing the medical assessments undertaken, and that this is kept up to date. All medication and the method of distributing it to people was examined, and a good system was found to be in use. The Annual Quality Assurance Assessment stated the Home’s policies and procedures that the staff of the Home have to follow, in order to meet the standards expected by the Commission. In the questionnaire sent to those staying in the Home one person commented on the medical support by saying – ‘It’s a higher quality than I expected, because they act on what I say, or ask for, so I am more than pleased.’ Discussion was held with people about life in the Home. They said that staff were very good at listening to their views on how they liked to be cared for and staff would carry out their wishes. They also said that their care needs were always met with dignity and respect. As a result, they felt very safe in the Home, and appeared to have a strong sense and appearance of well being. One person said, when asked if staff did things the way the person wanted – ‘Oh yes, very much so, they always do things my way’. Another person said that ‘What staff do for me is always good.’ In the questionnaire sent to people staying in the Home one said that – care is ‘…above average and far above the quality of care I expected.’ The Registered Provider’s Annual Quality Assurance Assessment stated that a questionnaire was sent to people staying in the Home and to relatives, and Abbeydale DS0000002104.V366608.R01.S.doc Version 5.2 Page 13 that, amongst other things, said that people were always treated with respected by staff. All staff were observed to be very caring in their dealing with people, and spoke to them in a caring manner. Abbeydale DS0000002104.V366608.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 & 15. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. Peoples preferred lifestyles were respected by the Home, and they were given a wholesome and appealing diet in pleasant surroundings, that enhanced their well being. EVIDENCE: Residents were asked about the activities provided in the Home. Those spoken with said that bingo was played, and this activity took place during this visit. Cooking was also described as a regular activity, with the results often been eaten at tea time. A number of trips out were also described, and it was noted on one of the Home’s notice boards a number of trips were listed from July to September this year. The Home had an Activities Coordinator, who in the main worked in the afternoons, and arranged the above activities as well as games and quizzes. In the questionnaire sent to people staying in the Home one of the comments was – ‘I play bingo, musical entertainment and Easter bonnet parade and lots more.’ Staff said that activities included those already mentioned, and that ‘exercises’ took place and that visiting entertainers called at least monthly. Abbeydale DS0000002104.V366608.R01.S.doc Version 5.2 Page 15 The Annual Quality Assurance Assessment, provided by the Home’s Registered Providers, said that activities were provided to suit peoples capabilities, and that relatives of those staying were encouraged to take part. This was seen during this visit to the Home, one visitor/relative assisted with the bingo game being played. People said that they decided when they got up and went to bed, saying things like – ‘Staff ask (me when I want to go to bed), and I decide.’ People also said that they could have a bath or a shower and that they chose to have one a week. People staying in the Home said that relatives and friends were able to visit at anytime, and could always be seen in private. ‘I always see my daughter in my bedroom’ – and – ‘Yes, I always see them in private in my room here.’ The staff spoken with also said that relatives could visit at anytime. It was said that those staying could chose where they wanted to see their relatives, in one of the lounges, or in the person’s bedroom. One person said that a friend takes her to a church service about once a week ‘if I am well enough.’ The privacy of peoples bedrooms was respected by staff. One person said – ‘I have a quiet voice and so staff knock and open the door and ask if they can come in.’ People staying in the Home were able to say that the Home provided good meals and that a choice was available at breakfast, dinnertime and teatime meals – ‘A choice is provided at every meal, food here is excellent’ – and – Oh, a choice is now always provided.’ Staff also confirmed this. People staying and staff said that drinks and snacks were always provided between meals, and that people could also ask for additional drinks at anytime. Mealtimes were never rushed, which was witnessed during this visit to the Home. Staff were also seen to assist people with meals, which was done in a caring and helpful way. It was observed that some people in the Home had their relatives visit at the lunchtime meal to assisted them to eat their meal. The Annual Quality Assurance Assessment commented that some relatives regularly had meals at the Home and that they praised the Home on the quality of them. Abbeydale DS0000002104.V366608.R01.S.doc Version 5.2 Page 16 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): Standards 16 & 18. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. Complaints made to the Manager were addressed to meet peoples needs. The protection policies and procedures provided meant that people staying in the Home were well protected. EVIDENCE: One person staying in the Home commented that if she had a complaint to make she would tell senior staff or the Manager. She said that she had had to do this recently, and had a positive result. Another person said that if they had a complaint they would – ‘Tell the Matron, I suppose, but I have never had to do this.’ From one of the questionnaires sent to those staying, one person said – ‘Yes, I have used this system and (was) pleased with the result on all areas of my complaint.’ Two relatives who completed the questionnaire sent out by the Commission said – ‘If I had an issue, I would always speak to matron or her deputy first. This has never been necessary’ – and – ‘Fortunately, up to now, I have not had cause and my husband has resided here for two and a half years.’ The Annual Quality Assurance Assessment said that the Home had a simple, clear and accessible complaints procedure, that was available in all bedrooms and on the Home’s notice board. The Commission had not received any notice of complaint since the last visit to the Home, in May 2007. Abbeydale DS0000002104.V366608.R01.S.doc Version 5.2 Page 17 Since that visit, the Manager, and Registered Provider, had recorded one verbal complaint. This complaint was examined and a good system was found to operate. Good procedures were seen for both written and verbal complaints. The Registered Providers complaints procedure detailed that all complaints would be responded to by a Registered Provider or Manager within at least 28 days. The Registered Providers had a Safeguarding Adults procedure that included a ‘Whistle Blowing’ policy, which staff said they were aware of, and had received training about. This meant that a procedure was in place to allow staff to inform the Manager of any inappropriate actions by other staff. The Manager had copies of the Public Interest Disclosure Act of 1998, and of the Dept of Health’s policy called ‘No Secrets’. The Manager confirmed that all allegations and incidents of abuse would be promptly followed up and that all actions taken would be recorded. However, she said that she had never had to do this. Staff said that they understood that people staying in the Home might, on occasion, show anger and aggression, and that they had received training on the best way to resolve these situations. The Manager said that a policy was available to staff stating that they could not benefit from Residents wills, which was also understood by the staff, with whom discussions were also held. Abbeydale DS0000002104.V366608.R01.S.doc Version 5.2 Page 18 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): Standard 19, 20, 21, 22, 23, 24, 25 & 26. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. The Home was well maintained throughout, providing all people staying in the Home with a safe, comfortable environment in which to live. EVIDENCE: The Annual Quality Assurance Assessment produced by the Registered Providers said that the Home is accessible, safe and well maintained, with a passenger lift that provides access to all four floors of the Home. The Annual Quality Assurance Assessment also say that the Home is warm, comfortable and homely, that peoples bedrooms were individually decorated, and that all bedrooms were supplied with a television together with a remote control, where necessary. The Home’s corridors are wide with many pictures displayed. A tour was made of the public areas of the Home, and included the four bedrooms of the people whose care was reviewed at the time of this visit. Abbeydale DS0000002104.V366608.R01.S.doc Version 5.2 Page 19 The Home was attractively decorated throughout, and the lounges and dining room were pleasant to sit in, and were provided with appropriate items for those staying. All 10 of the questionnaires completed by those staying in the Home said that the Home was very pleasant, fresh and clean. During this visit it was noted that the Home did not have any unpleasant odours at all. The bedrooms seen provided sufficient space and provision for each person. In each bedroom a notice had been provided telling the person staying in the Home the name of their key personal member of staff, together with a photograph to ease identification. The Registered Providers had provided appropriate furnishings in all locations seen during this visit. In two of the bedrooms visited, people had decided to furnish the bedroom from their original own homes. Toilets were easily available to all people staying in the Home and were clearly marked. During this visit it was noted that the Registered Providers were improving two of the bathrooms/shower rooms; the work being due to be completed in the near future. However, in the Home’s Annual Quality Assurance Assessment it was mentioned that toilets would benefit from the fitting of handrails to assist people where necessary. This was confirmed during this visit made to the Home. A ‘staff call’ system was also available throughout the Home. Radiators were not all guarded, although the Registered Provider and Manager pointed out that this was work that was planned to take place within the next few months. The Home had appropriate sluicing facilities, and laundry was washed at appropriate temperatures. Abbeydale DS0000002104.V366608.R01.S.doc Version 5.2 Page 20 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): Standards 27, 28, 29 & 30. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. A good level of care staffing was provided to meet the needs of people staying in the Home. Recruitment practices kept people safe. EVIDENCE: Levels of care staffing were examined for the 3 weeks beginning 19 May 2008. This showed that a good level of staffing was being provided. The Home’s Annual Quality Assurance Assessment stated that there were always an appropriate mix of qualified and unqualified staff on duty. At the time of this visit to the Home it was found that over 50 of care staff had a qualification of at least NVQ level 2 in Care; 17 out of a total of 23 staff, 74 . A further 4 staff were currently undertaking the training at this time. This was confirmed by the Registered Providers Annual Quality Assurance Assessment, which also said that all staff who work at night now held at least an NVQ level 2 in Care. The records of two new staff employed during the past 12 months were examined to see whether the Manager had obtained all relevant information about them. It was found that almost all information had been obtained. However, the history of employment of both staff had only been taken over the previous 10 years, and not back to when they had left school. This was needed to allow the Manager to check whether the potential members of staff Abbeydale DS0000002104.V366608.R01.S.doc Version 5.2 Page 21 had worked in care in the past, to allow contact to be made with the care agency, to ensure the person had not been dismissed due to offences against those looked after. All other information was found to be satisfactory. Staff spoken with were able to confirm that they had been given copies of the General Social Care Council’s code of conduct and practice. The Manager said that all new staff would be provided with induction and foundation training, which was confirmed by staff. She also said that all care staff were provided with at least three paid days training a year, which again was confirmed by staff spoken with; one said that she had had 5 days training during this past 12 months. The record of all of this training was seen. All staff also had an individual training and development assessment and profile. In the questionnaire completed by those staying in the Home, one person said - ‘I can always rely upon at least 2-3 (staff) with training to get anything I wish done immediately or as soon as possible.’ One member of staff said in the questionnaire they completed – ‘We are always given the chance to attend has many training days as possible, I and most of my colleagues have achieved an NVQ 2, with some of us completing NVQ 3.’ Abbeydale DS0000002104.V366608.R01.S.doc Version 5.2 Page 22 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): Standards 31, 33, 35, 36 & 38. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. Management arrangements, at the Home, were in place to ensure that peoples care was maintained at a positive standard. EVIDENCE: The Manager was appropriately qualified to manage the Home, having an NVQ level 4 qualification in Management and a nursing qualification. In the Annual Quality Assurance Assessment, the Registered Providers commented that the Manager had 30 years of experience as a nurse, which enabled her to meet the Home’s stated purpose, aims and objectives. The records of the monthly ‘inspections’ of the Home, carried out by a Registered Provider, were examined and were found to be satisfactory. Abbeydale DS0000002104.V366608.R01.S.doc Version 5.2 Page 23 The Manager was able to show the annual development plan for the Home, completed in conjunction with a Registered Provider, reflected the aims and outcomes for people staying in the Home. Very detailed surveys had been undertaken of peoples opinions of the operation of the Home, and these had been published. She also stated that she and the staff would be able to demonstrate the Home’s commitment to lifelong learning and development of each person in the Home, which was also confirmed by the conversations with staff during this visit. The opinions of Residents families and friends, and of GPs and District Nurses were obtained on how well they all thought the Home was achieving goals for those staying. These were again published, of a very good standard, and were posted on a notice board of the Home. The Registered Providers Annual Quality Assurance Assessment stated that they continually monitor and aim to improve the quality of care and standards in the Home. The Manager, and again the Annual Quality Assurance Assessment, stated that the Home did not hold any savings money on behalf of those staying. Peoples purchases and hairdressing etc were paid by the Home and relatives were then billed for these amounts. Two members of staff were asked about the supervision they received from the Manager or other senior staff in the Home. They said that this was done on approximately a 2 or 3 monthly basis, when their own needs and the needs of the people staying in the Home were discussed. The Manager confirmed that supervision was provided by herself or senior staff, for all care staff working in the Home. A copy of the planned programme of staff supervisions was seen in the Manager’s office. The training required by the Regulations was examined. This showed that only one member of staff was out of date for training in Moving and Handling and Fire Safety. Training in First Aid, Food Hygiene and Infection Control were found to be all up to date. Two staff were spoken with about the mandatory training provided. They both were able to say that they had had all of the training listed above, although one staff member said that she was the one person requiring training in Moving and Handling. The Manager was spoken with about this and she was aware of the training needs of this member of staff. The Manager was able to say that in addition to the mandatory training, the Home provided training in the follow subjects: Arjo training in the use of hoists, Safeguarding Adults, Palliative Care, the Liverpool Care Pathway, Catheter Care, Speech and Language training for those people who had suffered a stroke, P.E.G. training, Physiotherapy training, Safe Handling of Residents, Continence Care and Pharmacy/Medication training. However, the Manager was not sure that this was a complete list. The two staff spoken with were also asked what additional training they had received, and they were both able to list some of the training events detailed here. Abbeydale DS0000002104.V366608.R01.S.doc Version 5.2 Page 24 The Manager, and the Annual Quality Assurance Assessment, were able to show that all accidents, injuries and incidents of illness or communicable disease were recorded and reported to the relevant government bodies. With the assistance of the Fire Service, fire safety notices were also posted in relevant places around the Home. Abbeydale DS0000002104.V366608.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 3 3 3 3 3 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Abbeydale DS0000002104.V366608.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No 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. 2. Standard OP29 Regulation Reg 19 & Sch 2 Requirement The Manager must ensure, when appointing new staff, that all the requirements listed in Regulation 19 and Schedule 2 of the Care Homes Regulations 2001, as amended during 2004, are obtained. Timescale for action 11/08/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Refer to Standard OP7 No. 1. Good Practice Recommendations Formal reviews of care should be undertaken at 6 monthly intervals. Those taking part should at least include staff from the Home, the Resident and their relatives, particularly the ‘personal representative’. The review of care should be shown to the Resident (or representative) for signature. One of these reviews, each year, could be conducted by the Social Services Dept, although the Manager should provide formal written input to the review of the welfare and care provide to the person staying in the Home. DS0000002104.V366608.R01.S.doc Version 5.2 Page 27 Abbeydale In peoples records of care, when nursing staff request other nursing staff to ‘Please observe’, concerning an aspect of care, subsequent entries should address the request to observe, until the nurse making the request states in the record it is no longer needed. The daily records of care, for each person staying in the Home, to be maintained by care staff, should be kept up to date to provide relevant information on the needs of all people staying in the Home. 2. OP22 Handrails should be provided in all toilets and bathrooms to improve the safety and comfort for those staying. Abbeydale DS0000002104.V366608.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Abbeydale DS0000002104.V366608.R01.S.doc Version 5.2 Page 29 - 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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