Inspection on 27/02/06 for Abbeyfield Edward Moore House

This inspection was carried out on 27th February 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Abbeyfield Edward Moore House 06/11/07

Abbeyfield Edward Moore House 07/11/06

Abbeyfield Edward Moore House 20/10/05

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 Announced Inspection 27th February 2006 10:00 10:00 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.V274048.R02.S.doc Version 5.1 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.V274048.R02.S.doc Version 5.1 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 Kent 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.V274048.R02.S.doc Version 5.1 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 20th October 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.V274048.R02.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection at Edward Moore House took place on 27th February 2006 at 9:55 concluding at 14.30. The inspector agreed and explained the inspection process with the registered manager. Documentation and records were read, including care plans. Time was spent reading a sample of written policies and procedures and reviewing care plans and records kept within the home. A tour of the premises was also undertaken. The focus of the inspection was to assess Edward Moore House in accordance to 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: The medication procedures need to be more robust to ensure the system can be audited and monitored effectively. The home is large and has areas where redecoration and refurbishment is required. The home has chairs in lounges and furniture in bedrooms, which are in need of replacement. This makes some areas look unkempt and unclean. An action plan has been requested for this work to be completed over the next nine months. Abbeyfield Edward Moore House DS0000023928.V274048.R02.S.doc Version 5.1 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.V274048.R02.S.doc Version 5.1 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.V274048.R02.S.doc Version 5.1 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): 1-6 Service users are provided with the information they require to make an informed decision before moving into the home. The pre-assessment and trial stay at the home ensures the home is able to meet the service users needs before a permanent place is offered. Service users are provided with a contract/terms and conditions. EVIDENCE: The home provides a combined Service Users Guide and Statement of Purpose. This document contains all the required information. Newer service users’ contracts contain the required information, including details of who is responsible for the payment of fees. All prospective service users are visited prior to admission and an assessment of their needs is undertaken. The manager or her senior team, usually undertake this pre-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 receive relevant certificated training in dementia care, as well as encouraging and supporting staff through NVQ’s in care. The assessment record is based on the staff recording the Abbeyfield Edward Moore House DS0000023928.V274048.R02.S.doc Version 5.1 Page 9 relevant code numbers. This does mean however, that you need to have sight of the code book to understand the assessment. All prospective service users and their families are invited to visit the home prior to admission. During this visit 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. The home does not offer intermediate care. Abbeyfield Edward Moore House DS0000023928.V274048.R02.S.doc Version 5.1 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): 7-10 The home has a comprehensive assessment and care planning system to ensure service users’ needs are identified and met. However, the daily records do not reflect fully the care provided. 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 very detailed. The daily records have improved and cross-reference better with the care plans. Staff are now recording much of the care and social interaction they have with service users. The detail in the reports is, however, inconsistent and varies depending on the staff member. The daily records still do not record the times that events and care provision take place. The record of care and events has improved since the last inspection. Unfortunately the quality of the record is not consistent across all staff. This was discussed with the manager who is setting up training workshops. Abbeyfield Edward Moore House DS0000023928.V274048.R02.S.doc Version 5.1 Page 11 Where a service user comes from the locality of the home every effort is made to ensure their GP remains the same. Where this is not possible a list is made available to service users and their family of those doctors who are able to take on new patients. District nurses visit as required and it was evident that the home has a good rapport with the nurses that visit the home on a regular basis. Evidence was seen that the chiropodist, optician and dentist all visit those service users who are unable visit them. The assessment process identifies service users’ needs regarding these services and a pro-active role is taken in ensuring that they get the input they require. One of the medication storage rooms was inspected. The area was tidy and clean. Medication was kept in locked cupboards within this room. The senior member of staff on duty confirmed that none of the service users currently at the home has been prescribed controlled medication. Should this change the correct storage will need to be provided. Medication records indicated that there was some discrepancy between the tablets signed for and those in stock. The home has put in place a new monitoring system. Unfortunately this is complicated and requires staff to record medication in a different place from the medication record sheet. Due to the confusion this causes it was not possible to do a full audit. The administration of medication was observed and a member of staff who is trained to do so administered this in the correct manner. Service users spoken with all said that they felt the staff treated them with respect and dignity. Staff talked to service users about personal issues in a sensitive manner. One service user said that they liked the way staff were there to help when she could not manage, but when she could they stood back and let her do things for her self. Abbeyfield Edward Moore House DS0000023928.V274048.R02.S.doc Version 5.1 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 The service users are provided with a choice of activities and entertainment. Family and friends are encouraged to visit. EVIDENCE: The home has an activity programme that was displayed in the lounges. Each service user is given a copy of the monthly programme and some of these were seen in the service users bedrooms. 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 game of bingo was observed. Service users confirmed they are able to choose which activities they wish to participate in. A number of friends and family visited service users at various times during the day. One family spoken with said that they are always made to feel welcome and enjoy visiting the home. Another family member described how they are able to not only maintain contact with their relative but take an active part in helping them on a regular basis. The home operates an open visiting policy and service users can meet with their relatives in private or in one of the lounges. Abbeyfield Edward Moore House DS0000023928.V274048.R02.S.doc Version 5.1 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): 16,18 Service users can be confident that their complaints will be taken seriously. The home has an adult protection policy for the protection of its service users. EVIDENCE: The complaints procedure was seen as part of the Statement of Purpose and Service Users Guide. This has been reviewed since the last inspection and contains realistic timescales. The home has a copy of the local authority adult protection protocols. The home’s policy includes a whistle blowing policy for staff. This policy has been reviewed to reflect the recent changes in the local protocol and legislation regarding POVA. Abbeyfield Edward Moore House DS0000023928.V274048.R02.S.doc Version 5.1 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): 19-26 Service users live in a relatively safe, well-maintained and clean environment. However areas of risk and further refurbishment have been identified. The standard of décor, furnishings and fittings in some areas is low, although generally a homely and pleasant living environment is offered. EVIDENCE: The premises were designed specifically for the care of older people. It is a large property spread over two floors. 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 large shaft lift connects the ground and first floor. The home has a dedicated dementia care unit on the first floor. Abbeyfield Edward Moore House DS0000023928.V274048.R02.S.doc Version 5.1 Page 15 A programme of refurbishment and redecoration is in progress throughout the home. However there are still areas and service users bedrooms that are in need of work. The worst areas were identified and brought to the attention of the manager with particular regard to possible health and safety risks. These included infection control risks where some commodes needed re-varnishing to ensure the surface could be cleaned effectively and trip hazards where carpets need replacing. The home has 8 toilets and 4 bathrooms. None of the bedrooms have en-suite facilities. One bathroom has been unavailable for some time as it is being refurbished. It is hoped this work will be completed soon. Service users’ personal toiletry items and prescribed creams were in the bathroom on the ground floor. These should be kept in the service users’ bedrooms not in a communal bathroom where other service users could use them. There is a lift to access the first floor and grab rails and other aids such as manual handling equipment are available around the home. The district nurse provides pressure-relieving equipment where a need has been identified. There is a call system in all rooms and bathrooms. Bedrooms seen were generally found to be clean and furnished according to the wishes of the occupant. However some of the furniture is of poor quality and needs replacing urgently. Service users’ bedrooms were personalised with pictures, photographs and ornaments. All rooms inspected were well ventilated and had domestic lighting. All bedrooms have central heating radiators that can be controlled from the room. The home was generally clean throughout, but some areas were in need of refurbishment and looked grubby and tatty. Some of the lounge chairs are in need of replacement. The kitchen area in the lounge to the right of the front door on the ground floor needs replacing. There were some odours detected in the home and there was a strong smell of urine in a few bedrooms. A number of service users had experienced a stomach bug and this was discussed with the manager. The sluice area is in need of redecoration. Abbeyfield Edward Moore House DS0000023928.V274048.R02.S.doc Version 5.1 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): 28,29 The home has a robust recruitment procedure in place to protect its service users. The home is working towards half it’s staff gaining the NVQ level 2 or above award which will benefit the service users by improving the care delivery. EVIDENCE: The home employs a large number of care staff which total 57. So far 17 staff have gained the NVQ award. Another 15 staff have the opportunity of achieving an NVQ level 2 or above, in care. Once completed fifty per cent of the staff will have achieved the award. Staff files sampled contained evidence that new staff are asked to complete an application form, their interview is recorded, references are taken up and CRB checks are sent for. They are issued with a contract and have a probationary period. The files also contained relevant ID and staff photograph. Abbeyfield Edward Moore House DS0000023928.V274048.R02.S.doc Version 5.1 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): 31, 36, 38 Service users benefit from having a well trained and experienced manager. They are also benefiting from staff who are now being supervised on a regular basis. 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: The manager has completed her NVQ level 4 registered managers award, is a registered nurse and is doing a degree in dementia studies. She also has many years experience in the caring profession. The staff at the home are now having regular supervision. Regular staff meetings are also held and these are recorded. The fire test record book showed that tests were being carried out in the home. The pre-inspection questionnaire gave details of the dates of Abbeyfield Edward Moore House DS0000023928.V274048.R02.S.doc Version 5.1 Page 18 certificates and showed that there are current compliance certificates for gas, LOLER for the lift, electrical installation and electrical appliance testing. A training matrix showed the staff that have undertaken the required courses, such as manual handing, infection control, fire training, health and safety etc. It also showed that most staff have completed all the courses required and that these courses are being booked for those staff yet to complete. Abbeyfield Edward Moore House DS0000023928.V274048.R02.S.doc Version 5.1 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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 2 3 2 STAFFING Standard No Score 27 X 28 3 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X 3 X 2 Abbeyfield Edward Moore House DS0000023928.V274048.R02.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP26 Regulation 12,13,23 Requirement The premises must be kept clean, hygienic and free from offensive odours throughout and systems must be put in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. The home must provide private accommodation for each service user which is furnished and equipped to assure comfort and privacy, and meets the assessed needs of the service user. Action plan to be provided for the outstanding works with timescales to complete within the next 9 months The registered person must ensure that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling, administration and disposal of medicines. Timescale for action 31/05/06 2. OP24 12,13,16, 23 30/04/06 3. OP9 13,17, sched 3(3)(i) 15/04/06 Abbeyfield Edward Moore House DS0000023928.V274048.R02.S.doc Version 5.1 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 Refer to Standard OP7 OP38 Good Practice Recommendations All staff should understand and detail all the care provided through the day for individual service users including the time of provision and not the time the report was written. Training should continue so that all staff complete the required training courses. Abbeyfield Edward Moore House DS0000023928.V274048.R02.S.doc Version 5.1 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.V274048.R02.S.doc Version 5.1 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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