Inspection on 19/09/08 for Abbeyfield Dene Holm

This inspection was carried out on 19th September 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Abbeyfield Dene Holm 18/09/07

Abbeyfield Dene Holm 31/07/06

Abbeyfield Dene Holm 16/08/05

Abbeyfield Dene Holm 19/04/05

Abbeyfield Dene Holm 29/11/04

Abbeyfield Dene Holm 09/06/04

Abbeyfield Dene Holm 08/01/04

Abbeyfield Dene Holm 17/07/02

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The Shelley

Springfield House

Sutton Lodge Nursing Home

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 19/03/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Abbeyfield Dene Holm Dene Holm House Dene Holm Road Northfleet Gravesend Kent DA11 8JY     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Jenny McGookin     Date: 2 4 0 9 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 39 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 39 Information about the care home Name of care home: Address: Abbeyfield Dene Holm Dene Holm Road Dene Holm House Northfleet Gravesend Kent DA11 8JY 01474567532 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): deneholm@abbeyfieldkent.org The Abbeyfield Kent Society Name of registered manager (if applicable) Type of registration: Number of places registered: Conditions of registration: Category(ies) : care home 47 Number of places (if applicable): Under 65 Over 65 0 47 dementia old age, not falling within any other category Additional conditions: 47 0 The maximum number of service users to be accommodated is 47. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia (DE) Old age, not falling within any other category (OP). Date of last inspection Brief description of the care home Dene Holm is a large purpose built residential unit situated in Northfleet, on the outskirts of Gravesend. The home provides support to older people and people with dementia. The downstairs unit in the home is dedicated to supporting people with dementia. The building is accessible to wheelchair users with lift access to the first Care Homes for Older People Page 4 of 39 Brief description of the care home floor. Dene Holm has a team of staff covering a 24-hour rota. Current fees range from 346.29 pounds to 550 pounds per week. Information on the home?s services and the CSCI reports for prospective residents is detailed in the Statement of Purpose and Service User Guide. Care Homes for Older People Page 5 of 39 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This report is based on two site visits, the first of which was unannounced and the second or which (the following week) was by prior arrangement. These site visits were used to inform this years key inspection process; to check progress with matters raised at the last key inspection visit (September 2007); and to review findings on the day-to-day running of this home. The inspection process took fourteen hours, spread over the two days. It involved meetings with a group of three residents over one lunch session, and a visiting relative. It also involved meetings with a number of individuals representing a range of functions of the home - the Manager, the Assistant Manager, the homes administrator and the cook. We also met with a sister from the District Nursing team. Care Homes for Older People Page 6 of 39 We observed interactions between residents and staff at various stages throughout our visits, most notably over a second lunch sitting. And we took a selection of feedback questionnaires with us for distribution to residents, their relatives, staff and visiting professionals (health and social care). Feedback was obtained from three staff and two health care professionals in time for the issue of this report. Any others will be used to inform the Commissions intelligence in due course. Consideration was given to the Annual Quality Assurance Assessment (AQAA) submitted by the manager in June 2008, ahead of its due date. The AQAA is a selfassessment that focuses on how well outcomes are being met for people using the service. It also gives some numerical information about the service. The inspection also involved an examination of records, including three residents case files, to track their care and a selection of personnel files. Eleven bedrooms, selected at random, were checked for compliance with the National Minimum Standards on this occasion, along with some communal areas. What the care home does well: What has improved since the last inspection? The homes AQAA told us about a number of improvements since the last key inspection visit, which it has attributed to listening to people who use the service. Inclusion: *The AQAA told us that more staff, residents and relatives meetings have been undertaken, and that this has led to improved catering standards, an ongoing programme of improvements to the site and building, as well as an improved programme of activities. * Equality and diversity training has been given to all staff, and Dene Holm is represented on Abbeyfields Equality and Diversity Sub Committee. Early outcomes include extending its services and meeting the needs of people with hearing loss. Services and facilities: *The quality of preadmission assessments is reported to have been improved, and this has been confirmed by feedback from new residents. * The new activities programme referred to above has been facilitated by a dedicated activities co-ordinator and has resulted in more events and more input from professionals from outside the home as well as motivational events. * A better relationship is reported to have been developed with health professionals. * The format and content of care plans have been re-evaluated and improved to make them more person-centred. * There have been changes to the catering arrangements. Building and site * All proposed decoration is being discussed with residents prior to being undertaken. * Work has been carried out to a patio area so that residents can make more use of it. * There is new flooring, redecoration, new tables and chairs throughout the home, as well as new carpets in a number of bedrooms. * The manager has been looking at ways to improve the laundry facilities (which is too small) and the possibility of extending it is under consideration. * A garden room is being developed. Staffing arrangements: * Recruitment drives have been successful and less agency cover is warranted. * The manager is reporting better communication at all levels throughout the staff group. * A new cook has been appointed and the standard of food has improved in terms of choice and quality. * The manager has also been carrying out a review of the laundrys staffing levels and Care Homes for Older People Page 8 of 39 deployment. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 39 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 39 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective residents and their representatives benefit by having access to most of the information needed to decide whether this home will meet their needs. Prospective residents can feel confident that their needs will be properly assessed and that they will be supplied with a contract, which clearly tells they what to expect. This home does not provide intermediate care. Evidence: This homes Service User Guide is clearly intended to be read in conjunction with other separate documents in an information pack, to describe the homes range of facilities, services and service principles. Judged on its own, it did not have all the elements we would expect to see and we have reported the details back to the manager separately to ensure that prospective residents or their representatives could be confident they Care Homes for Older People Page 11 of 39 Evidence: have all the information they need to decide whether this home will meet their needs. In common with other homes in the Abbeyfield group, this homes admissions procedure does not evidence whether other languages or formats (such as large print, tape etc) were warranted. A checklist was recommended as it would compensate for people not being able to recall with any accuracy when we asked them. As is often the case, residents and a visiting relative told us that the decision to apply to this home was in practice influenced more by its locality (i.e. close to where they lived) than by any public information produced by the home itself. We found evidence of a range of assessments accompanying each prospective admission, and the AQAA told us that the quality of the homes preadmission assessments had been evaluated and improved over recent months. We were told that feedback from new residents had confirmed their satisfaction with this process. We understand that preadmission visits are welcomed, though none of the residents we spoke to recalled having visited - one came straight from hospital and two others relied on relatives to make the choice for them. A trial stay of one month is available, to help all parties decide whether this home is suitable for them. See section on Health and Personal Care for our findings on the quality and development of care plans. Funding authorities have their own contracted terms and conditions, which are outside the scope of this inspection. But Abbeyfield has its own licence agreement for self funded residents. We were shown a copy, complete with appendix material, and judged the format of this document generally comprehensive, but felt it did not make sufficient reference to care plans (as it does with other key documents) so that residents and their relatives could make the connection. And we noted that it did not commit Abbeyfield to the provision of two comfortable chairs and a table to sit at in each bedroom - these elements are listed by the National Minimum Standard, so people may feel they need to provide these themselves. Finally, we judged our recommendation about a checklist to evidence whether its issue in other languages or formats was warranted, applied here, so that people are as informed about their rights and responsibilities as they are able. We were satisfied that the home can demonstrate its capacity to meet the needs of residents. See sections on Environment, Health and Personal Care and Staffing for key findings. Care Homes for Older People Page 12 of 39 Evidence: This home does not provide intermediate care. Should it provide rehabilitation and/or convalescence, all the elements of National Minimum Standard 6 will apply. Care Homes for Older People Page 13 of 39 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can be reasonably confident that the health and personal care they receive, is based on an assessment of their individual needs, but person-centred care planning will more reliably ensure this. Day-to-day practice needs to be more conspicuously led by the principles of personcentred-planning so that residents can confidently expect respect, dignity and privacy. Evidence: See section on Choice of Home for our findings in respect of preadmission assessments. On their admission, the home sets up care plans for its residents, and carries out further assessments (nutrition, dental health, moving and handling, pressure sore, personal care needs - this list is not exhaustive) - all of which are reviewed regularly in-house every three months, to keep people healthy and safe. Care Homes for Older People Page 14 of 39 Evidence: The format of the care plans used by this home properly identify a range of health, psychological / social and personal care needs in the first instance, and these are intended to be read in combination with the assessments described above and records of contact with healthcare professionals to provide a rounded picture of each residents care needs. Three residents files were selected for case tracking on this occasion, to represent the latest admissions (i.e. over the past 12-18 months). Some care planning included the detailed practical instruction to staff we expect to see, and were written in the 1st person to keep the residents perspective central. However, a larger part of the care plans seen relied on vague, generic instructions likely to apply to everyone and would not distinguish one individual from another. Nor did the in-house reviews of care plans reflect the adjustments we would expect to find in recent admissions settling into their new environments. The manager told us he is very committed to promoting the principles of personcentred care planning in the staff group, which is judged promising, and we did some elements of this in care plans, but it will take time and training investments to ensure this is embedded in records and practice. None of the residents we spoke to showed any recognition of the concept of care plans. Nor did a visiting relative though she did recall filling in very detailed forms. Feedback was generally very appreciative about the care given in this home but one healthcare professional told us there had been an occasional lack of continuity i.e. we get called to see a patient by one member of staff and due to staff changes we are attended to by a different staff member who may not get the full picture. And see section on Daily Life and Social Activities for our detailed observations on the variable quality and level of support given to residents over lunch, which are bound to contribute to the judgement given in this section. In common with other homes in the Abbeyfield group, there are no formal multidisciplinary reviews except those led by funding authorities. The reader is advised that we would expect to see evidence of the involvement of all interested parties in this process, at least periodically. Records confirm that residents have access to a range of medical services. Like other homes in the Abbeyfield group, unless subject to a GP referral, residents would need to pay for additional medical treatment or medication themselves. The manager told us that he intended to make more use of therapeutic input, which was judged Care Homes for Older People Page 15 of 39 Evidence: promising. All the bedrooms in this home are used for single occupancy, which means health and personal care can be given in privacy. See section on Staffing for our findings in respect of training. We were advised that all ten staff who have responsibility for administering medication have completed a 12week course in safe handling of medication, with another four in prospect. We were reassured to hear this as our own records showed that there had been three medication errors reported to the Commission since September 2007. The most recent of these was in June 2008. The presumption is that residents would be supported to administer their own medication, subject always to properly documented risk assessments and consultation, and the manager told us he is looking into having lockable facilities in each room to facilitate this. In practice, however, most residents are reliant on staff for this and the home uses the Monitored Dosage System of medication administration, over a fourweek cycle. There were no gaps or anomalies in the medication administration record (MAR) sheets we spot checked on this occasion, and records show that quarterly checks are made, most recently in July 2008. The manager told us that he is trying to arrange a system of external inspections by a pharmacist, which we would judge another useful safeguard. We were satisfied that the homes medication was being kept properly secured when not in use. Care Homes for Older People Page 16 of 39 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Most residents are supported to make decisions and choices about their daily routines, but staff practice is variable. The increase in social, cultural and recreational activities being offered by the home will meet the expectations of more residents, and even further investments are planned. Residents can be confident the home will support them to keep in contact with family and friends. Residents can be more confident now that they will receive a healthy, varied diet according to their assessed requirements and choice. Evidence: In the files we selected for case tracking, we were particularly interested to see biographical histories set up in each case, as we judged this should provide staff with meaningful talking points and a way into person-centred care planning. But there was scant evidence of interests, aspirations etc being actively pursued in the care planning Care Homes for Older People Page 17 of 39 Evidence: processes we saw thereon. Person-centred care planning should help activate that. As is often the case, residents were not individually able to give many examples of any particular activities promoted by the home. One told us there had been an Elvis impersonator and some entertainment. But she said the elderly frail residents did not want to mix with those who had dementia. And she told us she didnt like colouring in baby pictures. We understand that consultation events have led to the home arranging for a dedicated activities co-ordinator to come into the home in once or twice a week. And we saw feedback forms used to record activities, their times and dates, participants and their comments, so that this element of the service could be promoted meaningfully for the residents. There is a three-week cycle of events and records show a range of activities. Examples include: traditional events such as Bingo, board games (droughts, Scrabble), jigsaw puzzles and card games; pampering sessions (such as hairdressing, nail care, facials); and special interest clubs (reading, art, crafts and pottery), knitting, sewing and cooking sessions. The home also organises sporting events such as darts, carpet bowls, ball games, skittles, basket ball and snooker (though we were told the pool table was being removed to extend the dining area). And there are reminiscence sessions, sing songs and mentally stimulating sessions (Connect 4 for the dementia unit, word search, crossword puzzles) as well as one-to-one chats. As one source told us if you have enough carers you have so much going on. See section on Staffing. The home has four communal TVs, and stock of DVDs etc, so there is some scope for choice of viewing, if residents dont have TVs in their bedrooms. But we did not see any Loop systems for use with hearing aids. Residents would need to pay for newspapers and magazines of their own choice themselves. Like other homes in the Abbeyfield group, this home has detailed templates for assessing peoples spiritual needs, which are judged exemplary in their scope, and records showed that services are arranged on site. Residents can choose when to go to bed or get up, as far as they are able, and they were observed being supported to make some choices and decisions during out inspection visits. Residents are able to have visitors at any reasonable time, and the home is reasonably well placed for links with the community and public transport, though on-site car parking facilities are limited (see section on Environment. There is a pay phone on Care Homes for Older People Page 18 of 39 Evidence: the 1st floor outside the Dickens Unit and a mobile handset is available from the office for incoming calls, to ensure some privacy. Unless other arrangements have been made, residents receive their mail unopened. We were told that quite a few manage their own mail. Catering needs are properly identified as part of the admissions process and are updated or amended thereon. Meat, fish, milk, fruit and vegetables are all sourced fresh locally. We were told that up until recently, the cooks had been using preexisting menus and that meals had become repetitive and predictable. But we were told this was undergoing change as menus were being evaluated. The cook we spoke to has been at this home since February, having transferred from another home in the Abbeyfield group when it closed down. A number of residents had also transferred from there to Dene Holm and have been able to benefit by some continuity of her catering. This cook told us she goes around to speak to the residents individually to ensure they got what theyd like. And we were given several examples of how she catered for individual preferences. When I first came here the service users and staff were under the impression if it wasnt on the menu they couldnt have it but I say if they want it we can try to accommodate it. Sometimes you dont fancy it when it comes to it. This is their home. If they choose to eat biscuits they should be able to do so, even if it spoils their dinner. The home can cater for some special diets. We were told there hadnt been a lot of choice for vegetarian up until now. Hardly anyone had salads when I first came here but I found the more colour I put in, as well as my homemade coleslaws and mayonnaise or beetroot/sweetcorn mix led to a few compliments. When I was told only six would eat it I said they will want it when they see it. Not one bit came back! A couple of residents are diabetic. One residents insulin is controlled by diet and tablets. A few have pureed meals - and we were assured that the cook purees the components separately so that people can enjoy their separate tastes, colours and textures - and she presents them in little ramekin bowls. There are some plate guards, large handled cutlery and beakers in use to help people manager for themselves. We were surprised to hear that the cook had not been given any specialist training in catering for the elderly or dementia. She told us she would love to have an NVQ in catering. When asked what improvements she would like to see, the cook told us from the catering side, I would like to see more (earthenware) pots, pans and vessels - ones that can go from the oven to the table and look nice. Food goes to the units in terrines Care Homes for Older People Page 19 of 39 Evidence: and is served from trolleys. If youve done a really nice pie but have to put it in a makeshift dish it doesnt look nice. I like to see something that looks nice. It might look like it will be enjoyed. We joined the residents for lunch on both days and judged the meals tasty. We needed to make some allowances for one setting, as one lounge was being used as a dining room while building work was extending the dining room. Interactions between carers and residents were warm and friendly in both sittings. But we were concerned to see medication left in a pot for one resident at one sitting, without staff overseeing it being taken. This did not happen at the second sitting, But we were concerned by the variable level of care available to individuals there. More specifically, while some residents were seated around dining tables with one carer, a few others stayed in their upright armchairs and we saw that they clearly needed assistance. Staff would come over to them periodically and help them with a few mouthfuls at a time before leaving them to do something else. One was left to manage with a wobbly coffee table she needed to reach to. We noted that another one of these residents was slouching very badly in her upright chair - it was clearly not supportive. Carers would periodically try to straighten her up but this appeared to cause her considerable discomfort, if not pain. From this slouched position she clearly wasnt able to pick up food from her plate for herself. Unsurprisingly, she dropped many pieces of her meal onto a plastic apron that had been put on her, over her clothes and onto the floor and much of her meal was wasted. This was judged very undignified. Jolly music was playing loudly from music system at one end, but we noted that 2-3 residents called out hoorah when it came to a stop. Instead of realising they preferred not to have it on, one of the carers simply turned it on again. The residents did not complain, but we noted that while it was off some attempts were being made to talk to each other. Their attempts were stifled by the music coming back on. In short we counted three residents who did not benefit from having a proper meal that day, and that others were effectively prevented from having meaningful interactions with each other. This raised questions not only about staffing levels and their deployment during peak periods (see section on Staffing), but also about the facilities (see section on Environment) and individual staffs grasp of person centred care (see section on Health and Personal Care). This was all reported back to the manager for immediate corrective action. Care Homes for Older People Page 20 of 39 Care Homes for Older People Page 21 of 39 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents and their representatives can be confident that their concerns and complaints will be properly addressed, whether or not they use the homes formal complaints procedure. Residents can feel confident that they will be protected from abuse and will have their legal rights protected. Evidence: Abbeyfield has a clear complaints procedure, which is referred to in the homes Service User Guide, and is a separate document included in the residents information pack and is available on request. This home keeps formal complaints in a loose-leaf ring binder, which we judged was not sufficiently confidential, though we understand access is restricted to authorised personnel. And we judged the detailed contents should be subject to index numbering and better secured against disarray. This arrangement is subject to quarterly in-house audits (most recently July 2008) and to assessments in Abbeyfields own unannounced monthly inspections, so that the company is always aware of emerging issues. The range of registered complaints was judged a realistic reflection of communal living (e.g. building and property matters, laundry, daily routines and one staffing issue) and Care Homes for Older People Page 22 of 39 Evidence: there was good evidence of the homes response in each case. One would, however, need to look at other sources such as records of meetings with residents, their relatives or staff to get the complete picture. The home has information on independent advocacy services on display but the records of meetings with families and friends referred to above showed that they tend in practice to be relied on to provide this. We understand Abbeyfield will be pilotting an advice line of its own, which is judged promising. Like other homes in the Abbeyfield Group, Dene Holm has procedures to ensure that residents are safeguarded from abuse in all its forms. We can confirm that no complaints or adult protection concerns have been raised with the Commission since our last key inspection visit (September 2007). But on our arrival on this occasion we were immediately alerted to a suspected lapse in care, which had been duly reported to management. We were satisfied that the managers response had been decisive and robust, to keep people safe. Care Homes for Older People Page 23 of 39 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from living in an environment which is reasonable safe, adequately maintained and homely. But a number of matters have been raised for attention to ensure full compliance with the National Minimum Standards. Evidence: This is a purpose built two-story home in Northfleet. Gravesham town centre is about one and a half miles away. There are two bus stops directly outside the home and another in Coldharbour Road nearby. The nearest train station is in Northfleet but Gravesham station is reported to be more convenient. For car drivers, the home is accessible from the A2, A227 and A220. But on-site car parking facilities are limited (7-8 spaces at the front, and 2-3 to one side). The property is divided into three units. Measures are in place to keep the premises secure against unauthorised access, including key pad access for staff use, and security lighting on the outside. Residents would need to be escorted outside. The layout of this home is judged generally suitable for its stated purpose. There is ramped access into the garden, and a ramp at the front - another ramp is recommended for the rear. We were told that as a direct result of discussions with the residents, work has been carried out on a patio area so that residents could make Care Homes for Older People Page 24 of 39 Evidence: more use of it, and a garden room is being developed. The home has five communal lounges, and building work is extending a dining area so that it can separated from lounge facilities, and to create more usable floor space in each case (matter raised for attention at the last key inspection visit). The furniture in this home tends to be domestic in style (e.g. divan beds). This is judged appropriate and homely, only as long as it is suitable to the assessed needs of the individual residents. As with other homes in the Abbeyfield group, there is some specialist provision in place but it is not overly conspicuous. Examples include: grab rails, bath seats and lifting equipment. The home has a lift and its corridors have hand rails down either side. We judged the doorways wide enough to allow the passage of wheelchairs and mobility aids. The list is not exhaustive. All areas are linked with a call bell system, to keep people safe. However, see section on catering in Daily Life and Social Activities for our findings in respect of the discomfort of one resident slouched in one chair, and the provision of a wobbly table for another resident to reach over. The home has undergone a number of improvements since the last key inspection visit. New flooring, tables and chairs (including lounge chairs) have been introduced, and a number of areas have been redecorated. We were told that residents were consulted over the choice for decor. The home has nine WC/bathrooms (including some bath seats), two wet rooms and six WCs - in one case there are two WCs cubicles alongside each other. Thirteen bedrooms have en-suite facilities. This means they are reasonably close to bedrooms and communal areas, so that people can exercise some choice. This home is registered to provide accommodation for up to forty four elderly residents, who are physically frail or have dementia. All the bedrooms are used for single occupancy, which means health and personal care can be given in privacy. Eleven bedrooms, selected at random, were inspected on this occasion, and judged adequately maintained and personalised. We had been told that there were new carpets in quite a few bedrooms. But two clearly needed redecorating and three needed better odour control - in one case the smell of smoke over the bed appeared to be contravening the homes stated No Smoking policy. Five bedrooms in this home are below 10 square metres, which would make them unsuitable for use, if this were a new registration. The reader is advised that Care Homes for Older People Page 25 of 39 Evidence: exemptions apply in respect of properties predating the emergence of the National Minimum Standards, and each one in this case is to some extent compensated by having en-suite facilities. In terms of their furniture and fittings, moreover, the bedrooms we looked at did not show full compliance with all the provisions of the National Minimum Standards. Even if it were accepted that the discreet commode provided the required second comfortable chair in some rooms, five others needed the second comfortable chair. And eight needed a table to sit at. The homes contract does not commit Abbeyfield to providing either, as standard. It should do so. Our detailed findings were reported back to the manager separately, for attention. We were told that only three residents have keys to their bedroom doors. The reader is advised that non-provision of keys (to bedrooms, lockable facilities and to the front door)must be justified by a properly documented risk assessment or opt out consultation. We understand the manager is intending to introduce lockable cabinets for medication in each room. Records (maintenance and in-house inspections) indicate that this home is adequately maintained. The laundry facilities and their staffing arrangements were, however, judged inadequate in terms of its size and staffing arrangements. But we understand the manager is looking to improve both. Care Homes for Older People Page 26 of 39 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from the staff training investments. But gaps in training have been identified. And the numbers of staff on duty at peak times may not be enough to reliably meet the aims and objectives of the home , or the emerging needs of the residents. Evidence: The homes staffing arrangements are designed to ensure that (excluding the manager) one should expect to find: * From 7am till 2.20pm - 6-7 carers plus a senior carer * From 2pm till 9.20pm - 5-6 carers plus a senior, who stays on call overnight * At night there should always be 3 waking night staff. *There is a cook and a weekend cook, each of whom works from 7am till lunch is completed (e.g. 2pm). They are each supported by two of four kitchen assistants, working in a rota. When they go off duty, the carers take on the catering e.g. making sandwiches or snacks. * A senior domestic works from 7am till 2pm. There are 2-3 domestics each morning and another comes on duty from 3pm till 7pm. * One laundry lady works from 7am till 1pm. Care Homes for Older People Page 27 of 39 Evidence: The Manager and Assistant Manager each work a 37.5 hour week, Mondays to Fridays. The Manager told us he also comes into the home some weekends, and the Assistant Manager comes in at 6.45am each day for the shift handover. This effectively means that there should always be someone in charge, to keep people safe. The AQAA told us that there had been some staff turnover during the past year, and that finding suitable replacements had been a challenge. In common with other homes in the Abbeyfield group, the manager has, however, been able to call on an agency approved by Abbeyfield for cover. We can confirm that no information has been received by the Commission about any concerns the homes capacity to maintain adequate staffing levels since the last key inspection visit. But we noted that staff availability did feature in one complaint to the manager this year, and quickly became aware of one suspected lapse when we arrived, which was addressed decisively by the manager and Assistant Manager. Our own observations indicated that peak times such as lunch times may well require further provision. See section on Daily Life and Social Activities for our detailed findings. Feedback from staff indicated that this home has a systematic recruitment process to comply with key elements of the standard. And our assessment of four personnel files, selected at random, generally confirmed that a range of checks was being instigated to keep people safe - though in two cases, some outcomes (e.g. reports from police checks) were not being logged. Records confirm that staff receive a range of relevant training. Examples include: 1st Aid, Food Hygiene, Health and Safety, Manual Handling, fire safety, control of substances hazardous to health (COSHH), infection control, and adult protection. We also saw training investments in issues such as pressure ulcer care, prevention of falls, and managing challenging behaviour. And in some cases, training material included policy guidance and competency testing - all of which is designed to keep people safe and prevent practice becoming variable. Staff told us they generally feel well invested in. However, we were surprised to see that dementia care and medication administration did not feature in the register of training we were shown. And although we understand some work has been started on person-centred care, our own assessment of residents files and observed practice indicates there is much more work to be done there. Care Homes for Older People Page 28 of 39 Evidence: The homes AQAA told us that 26 out of the 33 staff (i.e. 78 ) have NVQ accreditation to Level 2 or above, with another 2 staff in prospect. Care Homes for Older People Page 29 of 39 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home can demonstrate that it is being run for the benefit of the residents. But staff practice risk becoming variable without the checks and balances provided by regular supervision sessions. Abbeyfield has done the home, and its residents and staff a disservice by not complying with its regulatory duty to carry out unannounced inspections of its own. Evidence: The current manager, Geoff Fielding, has only been in post for a few months, having been seconded from a senior management post in Abbeyfield to cover the vacant home managers post. The intention is take on this role as his substantive post, but the Commissions registration processes will need to take their course. The indications are that he has the relevant qualifications and experience, and has had a decisive impact on many aspects of this homes operation. Feedback from staff has been Care Homes for Older People Page 30 of 39 Evidence: supportive and appreciative. There are clear lines of accountability within the home, and within Abbeyfield on a wider scale. As part of our inspection methodology we try to judge how inclusive services are, and whether they reflect the larger population. The homes AQAA told us about the composition of the client and staff groups. 39 of the 41 residents are white British. 31 residents are female, the rest are male. The staff group shows slightly more ethnic diversity though the majority are white British. 29 are female and 3 are male. No diversity problems were raised. Abbeyfield has formal annual business planning processes, which the manager told us he has contributed to with an Improvement plan. The home uses a range of feedback tools, such as complaints and compliments monitoring systems, meetings with residents and their relatives as well as staff group meetings. We looked at a selection of these. Outcomes already included a significant increase in activities, the introduction of dedicated activities co-ordinators, changes to menus, and decisions about refurbishment, building work and decor, with more improvements in prospect. We judged this very promising, and should enable Abbeyfield to evaluate the homes performance against its stated aims and objectives and allow people to see how feedback can influence the way services are delivered. Records confirm that staff supervision agreements have been put into place, but we noted that they only commit Abbeyfield to five a year - the standard is six, unless Abbeyfield intends to top this up with annual appraisals. We scanned 11 personnel files and found scant evidence of compliance with this - in many cases the last recorded supervision sessions were in 2007. This was judged very worrying as staff practice risks becoming variable without periodic checks and balances, and this will require a concerted effort to obtain compliance. We were also disappointed to see that Abbeyfield was not able to evidence compliance with its duty to carry out formal documented unannounced inspection visits of its own, at least once a month (Regulation 26). There were four gaps in 2008 not accounted for. This shortfall, combined with shortfalls in staff supervision sessions, is a major contributory factor in the judgement given to this section, and to the home as a whole. We were, to some extent, reassured to see that the home carries out a range of health and safety audits to keep people safe. Care Homes for Older People Page 31 of 39 Care Homes for Older People Page 32 of 39 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 9 13(2) The registered person shall make arrangements for the recording, handling, safekeeping, safe administration of medicines in that appropriate facilities must be provided for the storage and preparation of medicines. An improvement plan must be received by CSCI by the given timescale. Not assessed as part of this thematic inspection A 2nd trolley is required. There is only one senior on duty. Manager is trying to introduce a lead carer arrangement and back up. 28/02/2007 2 12 12(1) 16(2)(n) The registered person shall 28/02/2007 having regard to the size of the care home and the number and needs of service users consult service users about the programme of activities arranged by or on behalf of the care home, and provide facilities for recreation including, having regard to the needs of service users, activities in relation to recreation, fitness and training. An improvement plan must be received by CSCI by the given timescale. Page 33 of 39 Care Homes for Older People Not assessed as part of this thematic inspection This has been a difficult matter to pursue because the local area does not have much to offer. The home can access teh minibus attached to the Alzheimers Unit. Care Homes for Older People Page 34 of 39 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 15 23 The home must provide suitable equipment and adaptation to meet individuals assessed catering needs. Action Plan to be submitted. To promote Their health and safety. 28/04/2009 2 19 23 There needs to be a programme of maintenance and renewal in respect of all areas of the home. Action plan to be submitted. So that standards of living do not become variable 31/03/2009 3 22 16 An assessment of facilities 09/04/2009 must be made by suitably qualified persons, with specialist knowledge of the individuals being catered for, and recommended equipment and adaptations must be provided. Action plan to be submitted. Care Homes for Older People Page 35 of 39 So that individuals health and safety is not compromised by communal provision. 4 27 18 There must be sufficient laundry staff to ensure laundry is properly maintained. Action plan to be submitted. To maintain expected standards of care. 5 27 18 Sufficient additional staff must be available at peak times of activity to meet the individual needs of the residents. Action plan to be submitted. So that their needs are not compromised. 6 33 26 The registered person must carry out formal documented unannounced inspection visits at least monthly to comply with the elements of this standard. To keep people safe. 7 36 13 The home must be able to evidence that staff receive documented supervision sessions to comply with the provisions of this standard. To maintain expected standards, prevent practice becoming variable and to keep people safe. 31/03/2009 31/03/2009 31/03/2009 31/03/2009 Care Homes for Older People Page 36 of 39 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 1 The Service User Guide should be checked for compliance with the detailed provisions of this standard, to obtain full compliance. The Licence Agreement should be amended to commit Abbeyfield to the provision of two comfortable chairs and a table to sit at in each bedoom, as standard. There should be a checklist to evidence the issue of the Statement of Purpose, Service User Guide and contract, and whether other languages or formats were warranted. The home should take the lead in periodic formal multidisciplinary care plan reviews, which can evidence the participation of residents (where they are able and willing) and/or their representatives (familial and professional) Training in person-centred care planning should be given to all staff. Activities should be as age appropriate as possible. The home should consider installing Loop systems for use with hearing aids, subject to specialist assessment. The home should consider introducing oven to table ware to enhance the presentation of meals. Staff involved in catering should have specialist training in catering for older people and for people with dementia. Concerns raised through other routes should be cross referred to the homes complaints register, to obtain the full picture. The contents of the homes complaints register should be more robustly secured against disarray and access by 3rd parties. Consideration should be given to installing a ramp at the rear of the home. Consideration should be given to increasing the on-site car parking spaces available. Bedroom furniture and fittings should be checked against the provisions of the National Minimum Standard; and non provision should only be justified by documented risk assessment or Opt Out consultation. This includes the Page 37 of 39 2 2 3 4 4 7 5 6 7 8 9 10 7 12 14 15 15 16 11 16 12 13 14 19 19 24 Care Homes for Older People provision of keys. 15 16 26 29 Consideration should be given to improving the current laundry facilities and staffing arrangements. Recruitment records kept on site should detail outcomes of CRB checks as evidence of due diligence. Care Homes for Older People Page 38 of 39 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 39 of 39 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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