Inspection on 20/10/05 for Abbeyfield Edward Moore House

This inspection was carried out on 20th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 Edward Moore House 06/11/07

Abbeyfield Edward Moore House 07/11/06

Abbeyfield Edward Moore House 27/02/06

Abbeyfield Edward Moore House 10/01/05

Abbeyfield Edward Moore House 16/06/04

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

CARE HOMES FOR OLDER PEOPLE Abbeyfield Edward Moore House Trinity Road Gravesend Kent DA12 1LX Lead Inspector Sally Hall Unannounced Inspection 20th October 2005 11:00 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 Edward Moore House DS0000023928.V254064.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Abbeyfield Edward Moore House DS0000023928.V254064.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Abbeyfield Edward Moore House Address Trinity Road Gravesend Kent DA12 1LX 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) 01474 321360 01474 533712 felicity.somerville@abbeyfield.medway.or The Abbeyfield Medway Valley Society Mrs Felicity Anne Somerville 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 Edward Moore House DS0000023928.V254064.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Dementia category to reside in Rumcroft Unit only Care of 5 older persons with a diagnosis of dementia is restricted to 5 service users whose date of births are: 31/08/07 07/03/36 27/04/09 01/06/21 03/02/21 10th January 2005 Date of last inspection Brief Description of the Service: Edward Moore Residential Home is a large, detached premises designed specifically for the care of older people. Shops and other amenities are about ten minutes walk away from the home and the nearest bus stop is five minutes walk. The home has good parking facilities and is set in well laid out and accessible gardens that are well maintained. All bedrooms are equipped with call bells, telephone points, wash hand basins and television aerial points. A shaft lift connects the ground and first floor. The home has a dedicated dementia care assessment unit. Abbeyfield Edward Moore House DS0000023928.V254064.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced Inspection at Edward Moore took place on 20th October 2005 at 11.00am. The Inspector agreed and explained the inspection process with the Assistant Manager, Senior Carer and Registered Manager (on her return). Time was spent reading a sample of written policies and procedures, reviewing care plans and records kept within the home. A tour of premises was also undertaken, but a full inspection of the building was not carried out. The focus of the inspection was to assess Edward Moore in accordance with the National Minimum Standards for Older People. In some instances the judgement of compliance was based solely on verbal responses given by those spoken with. What the service does well: What has improved since the last inspection? What they could do better: Staff training needs to be monitored to ensure all staff undergo the required training and that courses are available to ensure the training remains current. Staff provide a great deal of care and support to the service users that they are not currently detailing within the daily records. This has resulted in the daily record not cross referencing with the plan of care. The daily records did not evidence that the needs of the service users were being met. Abbeyfield Edward Moore House DS0000023928.V254064.R01.S.doc Version 5.0 Page 6 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 Edward Moore House DS0000023928.V254064.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Abbeyfield Edward Moore House DS0000023928.V254064.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1-5 Service users are provided with the information they require to make a decision before moving into the home. However, this needs to be made available in other formats to suit all service users’ needs and must contain all the relevant information. Service users are provided with a contract/terms and conditions, however not all these show the fee payable. EVIDENCE: The home provides a combined Service Users Guide and Statement of Purpose. The home needs to ensure that all the required information is included in the document and that it is available in formats to suit the needs of the service users. The newer service users’ contracts contain most of the required information, however they need to include details of who is responsible for the payment. The service users who are sponsored by the local authority do not have the fee detailed and this needs to be revised. Abbeyfield Edward Moore House DS0000023928.V254064.R01.S.doc Version 5.0 Page 9 All prospective service users are visited prior to admission and an assessment of their needs is undertaken. The manager, or her senior team, usually undertakes this assessment. The assessment record is based on the staff recording the relevant code numbers. This does mean however, that you need to have sight of the code book to understand the assessment. The home cares for older people who are frail and has a separate unit for older people who have a diagnosis of dementia. The home is very pro-active in ensuring all staff have received relevant certificated training in dementia care, as well as encouraging and supporting staff through NVQ’s in care. All prospective service users and their families are invited to visit the home prior to admission. At this time they are shown the room that is available and the facilities the home has to offer. If the service user chooses to move into the home this will be on a 28 day trial basis. At the end of this time a review is held to ascertain if the home is meeting the service user’s needs and that the service user is happy. If the trial period has been successful the stay then becomes permanent. Abbeyfield Edward Moore House DS0000023928.V254064.R01.S.doc Version 5.0 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): 7-9 The home has a comprehensive assessment and care planning system to ensure service users’ needs are identified and met. However, the daily records need to reflect fully the care provided. The service users can be confident that their health and well being needs will be met. The medication administration and recording in the home needs to be more robust to ensure service users are not at risk. EVIDENCE: The home has a very comprehensive assessment process and the care plans seen were also considered to be very detailed. The daily records did not cross reference well with the care plans and it became evident that staff are not fully recording the care and social interaction they have with service users. The detail in the reports also varied between staff. For example it was evident that staff are not recording the personal care they provide to all service users in the evening. The daily records did not record the times that events and care provision took place. Abbeyfield Edward Moore House DS0000023928.V254064.R01.S.doc Version 5.0 Page 11 Service users are able to keep their own doctor when possible. Where this is not possible a list is made available of those doctors who are able to take on new patients, so the service users and family can choose. District nurses visit as required. Evidence was seen that the chiropodist, optician and dentist all visit those service users who cannot visit them. The assessment process of the home identifies the need of the service users regarding these services. The administration of medication was observed and a member of staff who is trained to do so administered this in the correct manner. One of the medication storage rooms was inspected, although untidy it appeared clean. Medication was kept in locked cupboards within this room but the controlled drugs are not being stored correctly and this was discussed with the manager. The check of the medication records indicated that there was some discrepancy between the tablets signed for and those taken. The manager is to investigate but a full audit was not possible, as a record is not made of the medication carried forward from each month. Abbeyfield Edward Moore House DS0000023928.V254064.R01.S.doc Version 5.0 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): 12-15 The service users are provided with a choice of activities and entertainment. Family and friends are encouraged to visit by the welcoming atmosphere created in the home. Service users benefit from a varied and nutritious menu. EVIDENCE: The home has an activity programme that was seen displayed in the lounges; the home also gives each service users a copy of the monthly programme. Activities are organised by a senior carer and facilitated by staff and volunteers; activities on offer included bingo, quizzes, flower arranging, arts and crafts, tea dances, reminiscence, puzzles and games. At the time of the inspection a sing-a-long was in progress. Service users are able to choose which activities they wish to participate in and the home has organised outings, seasonal activities and outside entertainment. The home operates an open visiting policy and service users can meet with their relatives in private or in one of the lounges. A number of friends and family were observed visiting relatives at various times during the day. One family spoken with said that they are always made to feel welcome and enjoy visiting the home. Abbeyfield Edward Moore House DS0000023928.V254064.R01.S.doc Version 5.0 Page 13 It was evident from discussion with several service users that the routines of the home are sufficiently flexible to allow for individual preferences in respect of personal care. The service users throughout the day were seen being encouraged by staff to make choices about various aspects of their lives. Several service users confirmed that they spend the day the way they want to and that the staff help them to do this. Service users have a choice of meals through the day and lighter options are also available. It was noted that staff do comment in the daily record the amount the service users eat during the day, the staff also keep a record of what choices the service users make. The meal on the day of inspection looked appetising, and several service users spoken with said they enjoy the meals. They said there was always plenty of variety and choice. Abbeyfield Edward Moore House DS0000023928.V254064.R01.S.doc Version 5.0 Page 14 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, 18 The home has a complaint procedure, however this needs to include time scales for action. The home has an adult protection policy for the protection of its service users. It is recommended that this be reviewed in light of recent changes to legislation and local protocols. EVIDENCE: The complaints procedure was seen as part of the Statement of Purpose and Service Users Guide. The procedure within this did not contain the required timescales and the manager said this would be reviewed. Staff said that all complaints were taken seriously and used to improve the service they offered. The home has a copy of the local authority adult protection protocols. The home’s policy was found to include a whistle blowing policy for staff. This policy needs to be reviewed to reflect the recent changes in the local protocol and legislation regarding POVA. Abbeyfield Edward Moore House DS0000023928.V254064.R01.S.doc Version 5.0 Page 15 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): These standards were not inspected during this inspection. EVIDENCE: Abbeyfield Edward Moore House DS0000023928.V254064.R01.S.doc Version 5.0 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): 30 Staff receive specialist training in dementia etc. to ensure they can meet the needs of the service users in the home. EVIDENCE: The home has managed to provide a number of staff with certificated training in dementia. Staff who had completed this training were spoken with and said they found it very useful and that it gave them a better understanding of the service users’ care needs. The home has now organised another course that staff are just about to commence. The home is also providing many staff with the opportunity to achieve an NVQ level 2 or above, in care. Abbeyfield Edward Moore House DS0000023928.V254064.R01.S.doc Version 5.0 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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): 35,38 The home has a system in place to protect service users’ personal monies held by them. The home strives to ensure that the health, safety and welfare of the service users is promoted and protected, however improvement is needed in some areas. EVIDENCE: Service users have a lockable drawer in their bedrooms if they wish to look after their own personal monies. The home also has a system in place to hold a small amount of personal money for those who can’t manage. This money is kept in a safe and when audited was found to be correct against the home’s records. The home ensures that all the monies are held separately for each service user along with the receipts for monies spent. The manager stated that she monitored the system on a regular basis. Abbeyfield Edward Moore House DS0000023928.V254064.R01.S.doc Version 5.0 Page 18 The fire test record book was viewed and evidenced that tests were being carried out in the home. The manager was asked to include the names of the staff that were present when a fire drill was carried out in the home. The compliance certificates for gas, LOLER for the lift and electrical installation were seen. The electrical appliance testing although started had not been completed and this meant the previous ‘passed’ certificate was now out of date. There was no safety certificate for a hoist, although staff stated that they remembered this check being done, the manager promised to following this up. The home has a COSSH file, which staff said contained a sheet for all the chemicals used in the home. The training matrix seen showed the staff that have undertaken the required courses, such as manual handing, infection control, fire training health and safety etc. it showed that not all staff have yet completed all the courses required or had completed the required refresher. The manager explained that she has already organised and booked many of the courses that are needed. Abbeyfield Edward Moore House DS0000023928.V254064.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 2 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 X 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 2 17 X 18 2 X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X 2 Abbeyfield Edward Moore House DS0000023928.V254064.R01.S.doc Version 5.0 Page 20 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 OP7 Regulation 15, sched 3(1)(b) Requirement Timescale for action 30/11/05 2 OP9 13,17, sched 3(3)(i) 3 OP38 23,13,16, d,e A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. That the daily report then reflects and cross references with that plan of care. Plus the time of care delivery is etc. is also recorded. The registered person ensures 30/11/05 that there is a policy and staff adheres to the procedures for the receipt, recording, storage, handling administration and disposal of medicines. The registered manager ensures 31/03/06 so far as is reasonably practicable the health, safety and welfare of service users and staff. By ensuring all tests are completed and certificates are up to date. Ensuring that all staff undergo the required training and that this is kept current. Pat testing by 10/11/05, training by 31/03/06 Abbeyfield Edward Moore House DS0000023928.V254064.R01.S.doc Version 5.0 Page 21 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard OP1 OP2 OP16 OP18 Good Practice Recommendations Review the Statement of Purpose and Service Users Guide to ensure it contains all the information, and provide in a format that suits all service users. Ensure that the fee and who is responsible for paying appears on all contracts/terms and conditions. The registered person ensures that there is a simple, clear and accessible complaints procedure, which includes the stages and time-scales for the process. Review the home’s current policy and procedure on adult protection to reflect recent changes. Abbeyfield Edward Moore House DS0000023928.V254064.R01.S.doc Version 5.0 Page 22 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 Edward Moore House DS0000023928.V254064.R01.S.doc Version 5.0 Page 23 - 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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