Inspection on 14/02/06 for Abbeyfield Grange

This inspection was carried out on 14th February 2006.

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 no outstanding requirements from the previous inspection report, but made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Abbeyfield Grange 03/01/07

Abbeyfield Grange 09/08/05

Abbeyfield Grange 26/01/05

Abbeyfield Grange 21/09/04

Similar services:

Whiteley House

Tyndale Avenue

2-10 Norfolk Road

Bennfield House Nursing Home

Eastfield Residential Home

Sign Health

Springwood

Fairburn Mews

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

CARE HOME ADULTS 18-65 Abbeyfield Grange 148 Burngreave Road Sheffield South Yorkshire S3 9DL Lead Inspector Marina Warwicker Unannounced Inspection 15th February 2006 10:00 Abbeyfield Grange DS0000002931.V281535.R01.S.doc Version 5.1 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 Grange DS0000002931.V281535.R01.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 Adults 18-65. 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 Grange DS0000002931.V281535.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Abbeyfield Grange Address 148 Burngreave Road Sheffield South Yorkshire S3 9DL 0114 275 9482 0114 275 9996 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) Mr Kenneth Trevor Brack Mr Paul Britain Ms Zofia Sabina Janina Britain Care Home 26 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (26) of places Abbeyfield Grange DS0000002931.V281535.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th August 2005 Brief Description of the Service: Abbeyfield Grange Care Home comprises two houses. Numbers 143 and 148 Burngreave road. Number 148 is the main care home with extensions and has room for twenty beds and the second building number 143 which is across the road, has room for six beds. The home caters for people with mental health problems. It is registered to provide personal care and support to men and women between the ages of 18 – 65 years. However, the clients are all male. The home is in a residential area of Burngreave and near a GP surgery, a hospital, day centres and other amenities. There is regular public transport to the city centre and other areas from Burngreave. Abbeyfield Grange DS0000002931.V281535.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced inspection of Abbeyfield Grange care home was carried out on Wednesday 15th February 2006 between 10am and 5pm. The deputy manager and the owner were present and the inspector toured the premises, spoke with the residents, interviewed staff and checked some of the records. It is suggested that this report is read in conjunction with the previous report to gain a balanced view of the service. What the service does well: What has improved since the last inspection? The recruitment records have improved. Staff have regular supervision. Two new cooks have been recruited. The cleanliness of the building has improved and the stale odour within the home has been eliminated. The staff commence work at the home following satisfactory Criminal Record Bureau check. Abbeyfield Grange DS0000002931.V281535.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Abbeyfield Grange DS0000002931.V281535.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Abbeyfield Grange DS0000002931.V281535.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 5 The service users have copies of the statement of terms and conditions in their care plans. EVIDENCE: Three service users files were checked and all of them had copies of a general statement of terms and conditions. However, the information on the fees charged, what they covered, when they must be paid, by whom and also the cost of facilities or services not covered by fees were not recorded. The deputy manager explained that social services and health funded the service users and that the service users did not pay for their care directly hence the lack of information. Out of three contracts checked one was not signed by either the service user or the manager. The deputy manager was aware of this. Abbeyfield Grange DS0000002931.V281535.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 8 The manager gives the residents opportunities to contribute to the day to day running of the home. EVIDENCE: During conversations with the residents and the staff it was evident that the residents were encouraged to participate in the activities of the home. The residents were aware of the staff roles and had a good rapport with the staff on duty. Abbeyfield Grange DS0000002931.V281535.R01.S.doc Version 5.1 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16&17 The residents are given opportunities to maintain and develop social, emotional, communication and independent living skills. Staff, with the help of outside professionals, support residents to become part of the community. Residents have access to a range of leisure activities. EVIDENCE: One service user said that he was not interested in going to the workshop where he used to take part in woodwork. He showed the inspector some of the items he had made when he had attended the workshop. But he insisted that he did not want to attend the workshop anymore. Some residents refused to participate in any activities and were happy to sit around and chat to the other residents. Community mental health workers have an active role within the home and the inspector witnessed this. Both staff and residents said that when the weather becomes warmer the residents are more amenable to outdoor leisure activities. The present resident group are more interested in outdoor pursuits. This will be monitored at the next inspection. The residents were able to maintain their own daily routine. Abbeyfield Grange DS0000002931.V281535.R01.S.doc Version 5.1 Page 11 On the day of inspection two care staff and the cook were off sick. The deputy manager made arrangements for off duty staff to come in and fill the gaps. When the staff arrived they were very accommodating and helpful. The inspector was informed that two new cooks have been employed and that all staff have been trained in basic food hygiene by the deputy manager. The staff said that they encourage the residents to eat healthily and some residents did not comply. The deputy manager showed the inspector weekly menus and explained that they were planned with the help of residents. There were choices at each mealtime. Abbeyfield Grange DS0000002931.V281535.R01.S.doc Version 5.1 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 The home has policies and procedures for the safe handling of medication. The staff who administer medication have had appropriate training. EVIDENCE: The inspector checked three residents’ Medication Administration Sheets. They were appropriately recorded. However, there were gaps in the controlled drug records where only one person had signed. This finding was witnessed by one of the senior carers. The inspector would like to commend the staff for the medication records maintained on each resident’s care plan. There were lists of the medication each resident was prescribed and the most common side effects from the drugs. Staff also said that if in doubt they use the Internet to look up information. The recent pharmacy audit was satisfactory. The home disposes the unused or wasted medication according to the Medicine Act 1968. Abbeyfield Grange DS0000002931.V281535.R01.S.doc Version 5.1 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22&23 The home has a clear and effective complaints procedure, which the staff and the residents are aware of. The staff have attended training on protecting residents from abuse, harm and degrading treatment from others. EVIDENCE: There was a complaint book, which did not have any record of complaints. Three staff were interviewed and staff files were checked. These confirmed that the staff had received training on how to protect vulnerable adults from abuse and neglect. Abbeyfield Grange DS0000002931.V281535.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29&30 These are converted old houses therefore regular maintenance is required. The houses and their surroundings are accessible, safe and meet the needs of the residents. However the layout and the present arrangement on the ground floor of the main house (Number 148) needs to be reconsidered by the management. EVIDENCE: The deputy manager said that there was a planned maintenance and renewal programme for the fabric and decoration. There was evidence of the ongoing programme. The CCTV cameras were restricted to the entrance areas and towards the main office for security purposes and these did not impinge on the daily life of the residents. Furnishings and fittings are domestic in appearance. There were some residents who were experiencing problems with continence. The inspector noted that on the ground floor where the communal areas were in the main house there were no toilets. The residents had to go upstairs to the toilet and this was proving difficult for them. The residents are able and independent therefore the home does not have any adaptations or equipments such as lifts and hoists. However, one resident has Abbeyfield Grange DS0000002931.V281535.R01.S.doc Version 5.1 Page 15 a wheelchair for when he wants to travel distance. The home has ramps and railings for residents to use as part of complying with disabled access. During the tour of the premises the inspector noted that not all residents bedrooms were clearly identified and the deputy manager was informed of this. The laundry facilities and hand washing arrangements comply with the relevant legislation. Abbeyfield Grange DS0000002931.V281535.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The management structure clearly defines the responsibility of staff. The staff have job descriptions. The staff are given the opportunity to work towards NVQ in care. The recruitment procedure is based on equal opportunities and protection of residents living at the home. The management is committed to staff training and development. Staff receive support and supervision. However, this process needs to be formalised by addressing the following: • • • • Helping staff understand and appreciate the home’s philosophy and aims and how this could be translated into working with the residents. Monitoring of key worker contribution to the lifestyle of the residents. Identifying the needs for support and professional guidance to deal with the specialist needs of the residents. Recognising the training needs of the individuals. EVIDENCE: There is a registered manager in post. On the day of this inspection the manager was on leave. The deputy manager is to apply for registration and if successful will be job sharing with the present manager. The staff said that the managers were supportive and help them in their professional or personal lives. Abbeyfield Grange DS0000002931.V281535.R01.S.doc Version 5.1 Page 17 The recruitment records have improved and the following was noted: Out of two, one file had a signed contract by both the staff and the manager, where as the other did not have a contract. Only one file, of the two checked, had photo identification of the care staff. The deputy manager was aware of this at the inspection. On examination of the staff rota, the inspector noted that the shift patterns did not allow time for staff handover. The owner and the manager were made aware of the need to ensure that the staff have allocated time for handover. The staff said that they were working towards NVQ2 award in care. There has been a high staff turnover, which has resulted in new staff having to be trained. During interview the staff said that they had received induction but there was inadequate documentation to support the dates and the people involved. These aspects were discussed with the deputy manager at the inspection. Staff also said that they had received supervision and their interpretation of supervision varies with each person. There was discussion between the deputy manager and the inspector to resolve this matter. Abbeyfield Grange DS0000002931.V281535.R01.S.doc Version 5.1 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38.39,40,41,42&43 The registered manager’s training and development will be checked at the next inspection since she was on leave. The management approach creates an open, positive and relaxed atmosphere. The home had a quality monitoring system. The deputy manager said that the policies and procedures were checked and updated regularly. Records are kept in a secure area, maintained and used according to the Data Protection Act 1998. The manager and staff as far as is possible maintain the health & safety and welfare of residents. EVIDENCE: The deputy manager said that both managers and the senior staff attended training to support the resident group and the care staff. The inspector observed a calm and friendly atmosphere among the residents and staff. The management has carried out a quality assurance survey. The results were positive and encouraging. The last residents’ meeting was held in September 2005. The deputy manager agreed that the frequencies of the meetings needed to be increased. Abbeyfield Grange DS0000002931.V281535.R01.S.doc Version 5.1 Page 19 Residents knew that they could read the daily statements and said that staff consulted them from time to time about their needs. Abbeyfield Grange DS0000002931.V281535.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 X 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 2 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X 3 X X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 X X 3 2 3 3 3 3 Abbeyfield Grange DS0000002931.V281535.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? 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 YA5 Regulation 5 Requirement Each service user must have copies of the terms and conditions in respect of accommodation provided including the amount and method of payment. The administration of controlled drugs must be witnessed by another designated member of staff and there must be documentary evidence to support this. Immediate. The management must ensure that the staff have formal handover time between shifts to promote continuity of care. All staff must receive a statement of terms and conditions, which are agreed and signed by both staff and the manager. Proof of staff identity must include a recent photograph. All staff must receive structured induction training within six weeks of appointment and foundation training within six months of appointment. There must be formal documentation available to support this. DS0000002931.V281535.R01.S.doc Timescale for action 15/04/06 2 YA20 13 15/02/06 3 YA33 18 15/03/06 4 YA34 18 15/04/06 5 6 YA34 YA35 Schedule 2 12,18 15/04/06 15/03/06 Abbeyfield Grange Version 5.1 Page 22 7 YA36 18,19 8 YA39 24 The staff must have regular, recorded supervision meetings. They must also have access to specialist supervision as indicated by the residents assessed needs. The manager must actively seek feedback from the residents through regular residents meetings. 15/04/06 15/04/06 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 YA27 YA25 Good Practice Recommendations The residents would benefit from a ground floor toilet. Residents who experience problems with continence would benefit greatly. The residents’ rooms should have a form of identification. Abbeyfield Grange DS0000002931.V281535.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Doncaster Area Office 1st Floor, Barclay Court Heavens Walk Doncaster Carr Doncaster DN4 5HZ 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 Grange DS0000002931.V281535.R01.S.doc Version 5.1 Page 24 - 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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