Inspection on 24/10/06 for Abbeyfield Connors House

This inspection was carried out on 24th October 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Abbeyfield Connors House 17/02/06

Abbeyfield Connors House 01/08/05

Abbeyfield Connors House 19/03/05

Abbeyfield Connors House 23/06/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Abbeyfield Connors House Craddock Road Canterbury Kent CT1 1YP Lead Inspector Alison Spreadbridge Key Unannounced Inspection 24th October 2006 12:00 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 Abbeyfield Connors House DS0000023364.V300616.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. Abbeyfield Connors House DS0000023364.V300616.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbeyfield Connors House Address Craddock Road Canterbury Kent CT1 1YP 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) 01227 769774 01227 784290 The Abbeyfield Kent Society Vacant Care Home 40 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (20) of places Abbeyfield Connors House DS0000023364.V300616.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. MD is restricted to one (1) person whose date of birth is 07.05.1927 Date of last inspection 17th February 2006 Brief Description of the Service: Connors House is registered to provide accommodation and personal care for 40 older people, twenty of whom may have dementia and one of whom may have a discrete physical disability. The Registered Provider is Abbeyfields Medway Valley Society, which is a charitable organisation, and is responsible for overseeing the operation of the Home. Mrs Wood is the Registered Manager, and is an employee of the Registered Provider. This is a predominantly single storey building, which was purpose built by Kent County Council in the 1980s. It transferred to Abbeyfield Medway Valley Society in 2000. The residents accommodation is arranged in two wings, each comprising two units, on the ground floor - Holly and Evergreen, Ash and Cedar. The Holly and Evergreen units are used principally to accommodate service users with dementia / cognitive impairment; and the Ash and Cedar units are for physically frail elderly people. Each pair of units shares a lounge/dining room, which has its own kitchenette facility, toilets, bathrooms and a suite of bedrooms. There is also a communal conservatory area and courtyard garden facilities. There are in total 32 single occupancy bedrooms, and four bedrooms which can be shared. All areas of the home are linked to a call bell system, which is designed to assist service users to summon help should it be needed. Abbeyfield Connors House DS0000023364.V300616.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was made on the 24 October 2006 by Alison Spreadbridge, during the inspection some staff, service users and relatives were spoken to. A tour of the building was undertaken, some documentation was seen, and a number of questionnaires were received prior to the inspection from service users, family relatives and professionals and in the main they are very satisfied with the service provided. Service users spoken to said they were happy living in the home and that the care staff were kind and friendly. They said there were plenty of opportunities to join in with the activities and that sometimes entertainers came into the home. The service users said they have meetings where they can voice their concerns or ask for different activities. The service users were very complimentary about the meals provided. The chef is currently reviewing the menus ready for the winter months. The current fees range from £390.00 to £430.00 pounds per week. What the service does well: What has improved since the last inspection? What they could do better: Some service users were of the opinion that the doctors did not come to the home as quickly as they would like. They were unclear as to the reasons for the delay. The home is in need of refurbishment and some of the windows need to be replaced to ensure service users safety. Abbeyfield Connors House DS0000023364.V300616.R01.S.doc Version 5.2 Page 6 Weekend staffing numbers remains an issue, and service users said they sometimes had to wait when needing staff assistance. It was noted during the inspection that one of the service users from the dementia unit was left in the smoking room and was later seen wandering around the main corridor. 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. Abbeyfield Connors House DS0000023364.V300616.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Abbeyfield Connors House DS0000023364.V300616.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5,6 Quality of this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are provided with the information they need to make an informed choice about moving into the home. EVIDENCE: The home has still not updated the statement of purpose and the service users guide to reflect the change of management in the organisation and the homes management. The service users files seen evidenced that each service user has a written contract and a statement of the homes terms and conditions when moving into the home. The contract between Kent Abbeyfield Society and the prospective service user was seen to be signed by the service user or their representative. There was evidence that pre assessments are undertaken by the manager or one of the senior carers before a service user moves into the home. Abbeyfield Connors House DS0000023364.V300616.R01.S.doc Version 5.2 Page 9 The service users are encouraged to visit the home and perhaps stay for lunch or tea before making a decision to move into the home. Once a decision is made to move into the home service users are offered a trial period of four weeks before taking up permanent residency. The home does not offer intermediate care. Abbeyfield Connors House DS0000023364.V300616.R01.S.doc Version 5.2 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): 7,8,9,10,11 Quality of this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users spoken to said they felt their needs were being met by the home. EVIDENCE: Each of the service users has an assessment prior to moving into the home. It is used to prepare a more in depth care plan which was seen include some risk assessments. None of the current service users are self medicating. All medication is held centrally and administered by the senior member of the care staff on duty. The home needs to develop a suitable protocol which outlines the action staff should take if service users make the choice to refuse their medication on a regular basis. The home is supported by six doctors surgeries. The staff said that the home has good relationships with them all and the community nurses are very supportive. Two of the questionnaires received stated they felt their relative had waited too long for the doctor to call. It was not possible to clearly ascertain if there had been a delay in requesting the doctor to call to see the Abbeyfield Connors House DS0000023364.V300616.R01.S.doc Version 5.2 Page 11 service user or the doctors availability as the daily records do not clearly evidence all of the service users changing needs or daily activities. Resident confirmed that staff treat them well and their privacy and dignity is maintained. Staff were seen to interact with the service users in a kind and caring way. The homes policies around the care of the dying is designed to support the service users and their relatives. The home is able to meet the identified spiritual needs of the service users which is written in their care plan. Abbeyfield Connors House DS0000023364.V300616.R01.S.doc Version 5.2 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): 12,13,14,15 Quality of this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users said they were very pleased with the care they receive in the home and the meals are excellent. EVIDENCE: The service users live in a very comfortable home. They have access to a variety of activities and are also able to join some of the activities in the day centre depending on the number of people using the service. The service users are provided with access to a good selection of library books. The service users are encouraged to attend the residents meetings. The last meeting was the 5th September 2006 when the new manager was introduced to the service users. Service users spoken to said the meals are excellent. They said they have home made soup and the fish they have is caught locally. They said they have a choice of main courses each day. The chef provides a five week menu and that they will soon be changing the menus for the winter months. The kitchen staff are undertaking their NVQ2 in catering. Abbeyfield Connors House DS0000023364.V300616.R01.S.doc Version 5.2 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): 16,17,18 Quality of this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes complaints procedure ensure service users concerns are taken seriously. EVIDENCE: Service users spoken to said they would be happy to raise any concerns they had with the manager or the care staff. They said they were listened to and staff were always helpful. The complaints book was seen and concerns raised with the home had been address within the homes complaints policy and within timescales. The complaints procedure is discretely displayed in service users bedrooms. It also includes the address of the Commission for Social Care and Inspection should they wish to take the concern further. The home has suitable policies and procedures in place to ensure service users are protected from abuse. Abbeyfield Connors House DS0000023364.V300616.R01.S.doc Version 5.2 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): 19,20,21,22,23,24,25,26 Quality of this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home must ensure the health and welfare of service users is maintained. EVIDENCE: A number of the windows in the home are in need of replacement. On the day of the inspection the window in the lounge fell out of its frame and had to be made safe by the maintenance worker. At the last inspection a requirement was made to ensure service users safety by the installation of covers on the radiators. This has not be implemented and remains a health and safety issue. There were a number of issues raised during the inspection around health and safety. The COSHH cupboard was left unlocked with chemicals left in a bucket. A number of light bulbs needed to be replaced in corridors. One of the toilet seats was not fitted securely. The bath seat in the assisted bathroom was Abbeyfield Connors House DS0000023364.V300616.R01.S.doc Version 5.2 Page 15 chipped and needed to be replaced. and tidy. The sluice areas were found to be clean There was a strong smell of urine in a number of rooms and this was discussed with the senior carer on duty, who said that carpets were cleaned regularly. A number of carpets had been cleaned that morning but he smell had not improved. Pads had been left in service users rooms or under sinks in full view. The staff need to be more aware of service users dignity and privacy. The house has a security system on the front door to ensure staff know that visitors are in the home. However, the laundry had door had been left open leaving the house and service users vulnerable. Abbeyfield Connors House DS0000023364.V300616.R01.S.doc Version 5.2 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): 27,28,29,30 Quality of this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There must be sufficient staff on duty at all times to meet the assessed needs of service users. EVIDENCE: There were six members of staff on duty at the time of the inspection. Service users said that the staff are kind and always willing to help. Staff were seen to knock on service users doors when returning clean clothes from the laundry. The staff were heard to speak to service users in a very caring way using their preferred names. There is an issue around the number of staff available for duty at the weekends. The staffing levels need to be maintained throughout the week. During the inspection on entering one of the Dementia units there were no staff supporting the service users in the main day areas. On investigation both staff on duty were assisting a service users with her bath. The home has had a number of staff on long term sick which is putting pressure on the staff team. One service users with dementia who smokes, was taken to the smoking room near to the day centre and left there unattended, he was later seen wandering around the corridor. Abbeyfield Connors House DS0000023364.V300616.R01.S.doc Version 5.2 Page 17 Staff confirmed that they are receiving regular training and supervision is beginning to take place more regularly. On inspecting the fire training records it became clear that some of the care staff have not received any up to date training nor have they taken part in any fire drills held recently in the home and some have not taken part in any. Some staff are undertaking NVQ training, this includes the laundry staff. The home is following sound recruitment policies and procedures. Staff are expected to supply two references one from their last employer. They are CRB checked before starting their employment. Supervision and annual appraisals are being implemented. Abbeyfield Connors House DS0000023364.V300616.R01.S.doc Version 5.2 Page 18 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): 31,32,33,34,35,36,3,7,38 Quality of this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is being managed in the best interests of the service users. EVIDENCE: A new manager has just come into post. She is currently trying to ensure all of the homes policies and procedures are updated to ensure service users rights are protected. The manager must ensure that regular health and safety checks and general quality assurance takes place to ensure the safety of service users. The window frames must be replaced to ensure service users safety is maintained. The staff said that the manager is beginning to walk around the house on a regular basis. Any concerns can be written in the maintenance man’s book. It was noted during the inspection that the windows were in a very poor Abbeyfield Connors House DS0000023364.V300616.R01.S.doc Version 5.2 Page 19 condition and a number of light in corridors had not been replaced. The accident book was seen and incidents were seen to be recorded in both the accident book and service users daily records. Some service users relatives leave a small sum of money with the home to meet their relatives day to day needs. The money is kept securely by the home. A sample of the money held for service users was audited and found to be correct. Record sheets and receipts are retained. The secretary said that should service users require their money at the weekends senior staff are able to ensure they received it. Each service user is provided with a lockable facility in their rooms. The staff are beginning to be supervised on a regular basis and annual appraisals are being introduced. A number of concerns around the upkeep of the home were identified during the inspection. The manager must ensure that regular health and safety checks are undertaken to ensure service users safety is maintained. Abbeyfield Connors House DS0000023364.V300616.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 3 3 3 3 3 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 2 3 3 Abbeyfield Connors House DS0000023364.V300616.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 5 Requirement The Service User Guide must be amended to comply with all the elements of National Minimum Standard 1, and associated Regulations. Original timescale 31/12/05 The following matters are raised for attention as precautions against the risk of accident: All radiators need to have guards. The provider must ensure the premises are kept clean and free from odours. Staffing levels must be maintained as appropriate to the assessed needs of residents The provider must ensure that all staff receive regular one-toone formal documented supervision in full compliance with National Minimum Standard 36, to ensure residents are in safe hands at all times. Timescale for action 28/02/07 2. OP19 13 31/03/07 4. 5. OP26 OP27 12 18 31/03/07 28/02/07 6. OP36 18(2) 31/03/07 Abbeyfield Connors House DS0000023364.V300616.R01.S.doc Version 5.2 Page 22 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 Abbeyfield Connors House DS0000023364.V300616.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Abbeyfield Connors House DS0000023364.V300616.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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