Inspection on 09/08/05 for Abbeyfield Grange

This inspection was carried out on 9th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Abbeyfield Grange 03/01/07

Abbeyfield Grange 14/02/06

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 9DH Lead Inspector Robert Curr Unannounced 09 August 2005 09.00 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 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 Stationary 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 20050809 Abbeyfield Grange X00023 UN Stage 4 S2931 V232998 J55.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Abbeyfield Grange Address 148 Burngreave Road, Sheffield, South Yorkshire, S3 9DH Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0114 275 9482 0114 275 9996 Abbeyfieldgrange@aol.com Mr Kenneth Trevor Brack Ms Zofia Britain Care Home 26 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (26) of places ABBEYFIELD Grange 20050809 Abbeyfield Grange X00023 UN Stage 4 S2931 V232998 J55.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 26.1.05 Brief Description of the Service: Abbeyfield Grange provides a service for 26 service users with mental health problems. It is registered to provide a service for men and women between the ages of 18-65 – the current service user group is all male. ABBEYFIELD Grange 20050809 Abbeyfield Grange X00023 UN Stage 4 S2931 V232998 J55.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place between the hours of 9.00 am and 2:00 pm. The manager was present during the inspection process and has been managing the service for a number of years. The deputy manager Rachel Coates escorted the inspector on a partial tour of the home. A small number of policies, procedures, and records were checked. The service users were very helpful during the inspection process, offering ample opportunity to talk about what life was like at the home. In all – 6 residents and 4 staff members were spoken to. What the service does well: What has improved since the last inspection? The deputy manager has been co-ordinating the redecoration of bedrooms, toilets, and bathrooms. This work is on target and will be completed within the identified timescales provided by the management. ABBEYFIELD Grange 20050809 Abbeyfield Grange X00023 UN Stage 4 S2931 V232998 J55.doc Version 1.30 Page 6 The service users confirmed that they were fully involved in the admissions process including assessment and review. One person said that his parents had been fully involved in the planning of his care needs. The dependency levels of the service users were monitored closely and appropriate staffing levels deployed when necessary. Service users are able to receive personal care from staff of the same gender. The service users said that the menus had been reviewed and that they had a choice of food. A training plan had been developed and this was being implemented. 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 20050809 Abbeyfield Grange X00023 UN Stage 4 S2931 V232998 J55.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection ABBEYFIELD Grange 20050809 Abbeyfield Grange X00023 UN Stage 4 S2931 V232998 J55.doc Version 1.30 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 standard(s) 1,2,3 and 4. Service users needs were assessed prior to admission and they were fully involved in the assessment process, so this ensured that the home was able to meet their needs. The manager did not offer places to any individual whose needs they could not meet. The staff-training plan was on target. EVIDENCE: Copies of full needs assessments were in the service user files. All the relevant information from the assessments had been built into the care plan. Two services said that they had been invited to view the home and attend a variety of meetings prior to them moving into the home. Staff training records indicated that they had undertaken relevant training required to assist them in caring for the people that reside at Abbeyfield Grange. ABBEYFIELD Grange 20050809 Abbeyfield Grange X00023 UN Stage 4 S2931 V232998 J55.doc Version 1.30 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 standard(s) 6,7,8,9 and 10. The information within the care plans was clear. The care planning process has empowered service users to make decisions about their lives with support from staff and others. Service users were involved in making decisions about their own lives, including holidays although service user meetings had not taken place regularly. Advocates were available. Service users could choose their GP and could see them in private so that their privacy and dignity was respected. Risk assessments to minimise any risks associated with the service users lifestyles had been devised and had been regularly reviewed. Systems were in place to ensure that service users confidentiality was maintained in the home. ABBEYFIELD Grange 20050809 Abbeyfield Grange X00023 UN Stage 4 S2931 V232998 J55.doc Version 1.30 Page 10 EVIDENCE: Two risk assessments were checked. These contained all of the relevant information in order to minimise risks to service users and they had been reviewed on a regular basis. Peoples likes and dislikes in relation to food was recorded in care plans to ensure the staff knew the service users personal preferences. Service user meetings had taken place, but not regularly. The service users said, “I like to go to meetings with staff”, “we talk about holidays and outings”, the staff said this gave residents the opportunity to be consulted on how the home was organised and run. The service users files were found to be stored securely and staff showed an awareness of confidentiality issues. The staff said that service users could see their files with staff support. ABBEYFIELD Grange 20050809 Abbeyfield Grange X00023 UN Stage 4 S2931 V232998 J55.doc Version 1.30 Page 11 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 standard(s) 11,12,13,14,15 and 16. Some of the people have regular opportunities to access age, peer and culturally appropriate activities, others with higher support needs had limited opportunities. One service user regularly accessed community day services and leisure activities. They were also supported to access other community facilities, such as shops and pubs etc. The service users were supported to have appropriate relationships with their peers and relatives. The staff showed respect for the people; in the way they spoke to and addressed them. The service users were observed to be offered choices and were supported to make everyday decisions. There is a cooks post vacant. The manager stated that they had difficulty recruiting to this post. ABBEYFIELD Grange 20050809 Abbeyfield Grange X00023 UN Stage 4 S2931 V232998 J55.doc Version 1.30 Page 12 EVIDENCE: Service users told the inspector that they took part in a range of leisure activities although there was no programme of activities taking place within the home. One person said they had attended college courses. This confirmed that people were enabled to take part in their local community and to maintain relationships. One service user said that it was sometimes difficult to access transport at short notice. One person told the inspector, “I like it here, because I like (another resident), he’s my friend and we spend time together”. They went on to say, “the staff are nice, and my key-worker is my favourite person”. Staff were observed to treat people with respect as they knocked on the service users doors before entering, addressed service users by their preferred names and spoke of them with regard. Someone that was on a ‘placement’ was cooking the meals. He was not able to fully demonstrate his knowledge of the service users needs or of catering in general. The manager stated that he was only covering whilst the other cook was off duty. ABBEYFIELD Grange 20050809 Abbeyfield Grange X00023 UN Stage 4 S2931 V232998 J55.doc Version 1.30 Page 13 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 standard(s) 18,19 and 21. Staff were supportive and helped service users to choose their daily routines. Health needs were met and monitored and service users were helped to identify their own needs through their involvement in care planning. This ensured the well being of the service users. The organisation had a clear medication policy. Resident’s wishes regarding dying and death were addressed. A range of health care professionals visited the home to assist in meeting the needs of the service users. EVIDENCE: Staff provided flexible personal support. Service users said they were encouraged to choose what time to get up and go to bed. The files checked had a section to record visits, treatment and identified future needs relating to healthcare professionals. Access to Psychologists had been provided where there was an identified need. ABBEYFIELD Grange 20050809 Abbeyfield Grange X00023 UN Stage 4 S2931 V232998 J55.doc Version 1.30 Page 14 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 standard(s) 22 and 23. Service users were aware of how to make a complaint and were confident that they would be listened to. An adult protection procedure was in place to ensure service users safety was promoted. EVIDENCE: The complaints procedure was on display in the main lounge, which contained relevant information and provided the reader with details of who to contact outside the home, to ensure complaints were taken seriously. The home kept a record of complaints. Staff training in adult abuse had been identified within the training plan and a number of staff had already undertaking this training. The service users and staff all stated that they had confidence in the homes manager. They said that she would listen and respond to any concerns they raised. All the service users spoken to said they felt safe at the home. ABBEYFIELD Grange 20050809 Abbeyfield Grange X00023 UN Stage 4 S2931 V232998 J55.doc Version 1.30 Page 15 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 standard(s) 24,25,26,27,28 and 30 The home was generally well maintained and homely. The majority of service users bedrooms were comfortable, individually personalised and furnished to meet their needs. There were rooms that were in need of redecoration. The deputy manager stated that there were plans to make alterations to room sizes and facilities in the near future. One bedroom on the ground floor of the main house needs to be monitored closely for cleanliness and safety. The outside areas and the gardens were generally well maintained. There was an unpleasant smell of stale urine on the ramped area to the front of the main house. The laundry areas were appropriately equipped to meet the service users needs. EVIDENCE: An inspection of the environment showed that generally the home was clean, well maintained and provided homely and comfortable accommodation to meet ABBEYFIELD Grange 20050809 Abbeyfield Grange X00023 UN Stage 4 S2931 V232998 J55.doc Version 1.30 Page 16 the service users needs. Some service users smoke in their rooms, thus leading to nicotine stains. One bedroom was untidy, dirty and had used cigarette ends on the floor. A number of bedrooms were checked. These rooms varied in their need for redecoration. The deputy manager stated that some of the service users were urinating inappropriately outside the front door of the main house thus creating an unpleasant odour. The staff endeavoured to eliminate this odour by pressure cleaning the area. ABBEYFIELD Grange 20050809 Abbeyfield Grange X00023 UN Stage 4 S2931 V232998 J55.doc Version 1.30 Page 17 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,33,34,35 and 36. Sufficient staff were provided to meet the needs of service users. The majority of staff undertook NVQ training. The home did not have appropriate recruitment systems in place, improvements to this system need to take place in order to promote the safety of service users and meet standards. A stafftraining programme for the year had been organised and planned, in order that staff had the skills to meet the needs of service users. EVIDENCE: The deputy manager was fully aware of the training needs of the staff group and had developed a staff-training plan. The home had achieved having 50 of the care staff group gaining NVQ level 2 in care. On examination of the staff recruitment procedures the following issues were noted: • • Staff did not have Criminal Records Bureau (CRB) disclosure or a POVA first check prior to employment. Staff members had been employed without references from their previous or current employers. 20050809 Abbeyfield Grange X00023 UN Stage 4 S2931 V232998 J55.doc Version 1.30 Page 18 ABBEYFIELD Grange • • • • Gaps in employment histories were not explained Not all references had confirmation of dates of previous employment. No evidence that ID had been checked. There was no information available for a person that was on ‘placement’ working in the kitchen. ABBEYFIELD Grange 20050809 Abbeyfield Grange X00023 UN Stage 4 S2931 V232998 J55.doc Version 1.30 Page 19 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,38,40,41 and 42. The registered manager does not yet hold a recognised management qualification. A health and safety policy was in place. Staff had received appropriate training, and appropriate recording of accidents and risk assessments were in place. EVIDENCE: The manager stated that she was nearing the completion of her management diploma. The service users said that there was a fire drill actioned every week. ABBEYFIELD Grange 20050809 Abbeyfield Grange X00023 UN Stage 4 S2931 V232998 J55.doc Version 1.30 Page 20 A member of staff was using electric equipment outside the build and using the supply from inside the biulding without the use of a circuit breaker. ABBEYFIELD Grange 20050809 Abbeyfield Grange X00023 UN Stage 4 S2931 V232998 J55.doc Version 1.30 Page 21 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 2 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 x 3 Standard No 11 12 13 14 15 16 17 3 2 3 2 3 3 2 Standard No 31 32 33 34 35 36 Score x 2 3 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 ABBEYFIELD Grange Score 3 3 x 3 Standard No 37 38 39 40 41 42 43 Score 2 3 x 3 3 2 x 20050809 Abbeyfield Grange X00023 UN Stage 4 S2931 V232998 J55.doc Version 1.30 Page 22 Yes 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. 2. 3. 4. Standard 8 14 17 17 Regulation 24 24 24 24 Requirement The service user meetings must continue, be promoted and increase in frequency. The servcier users must be offered more leasure opportunities within the home. A further cook must be recruited. The person working in the kitchen on placement must have a full knowledge of the service users nutritional needs. The odour of stale urine must be eliminated from outside the entrance to the building. Care practices must reflect the ways in which service users should be discouraged from urinating outside the front door. The registered persons must operate a thorough recruitment procedure. All of the required checks must be completed before staff commence working at the home. The identified member of staff that had no CRB or Pova First check must not work unsupervised until all the required checks have been completed. Timescale for action 11.10.05 11.10.05 11.10.05 11.10.05 5. 6. 24 24 23 23 11.10.05 11.10.05 7. 34 Sch. 2 9.8.05 8. 34 Sch. 2 9.8.05 ABBEYFIELD Grange 20050809 Abbeyfield Grange X00023 UN Stage 4 S2931 V232998 J55.doc Version 1.30 Page 23 9. 34 Sch. 2 10. 42 24 The manager must seek out the information held on the person who is working on placement and forward this to the local office of the CSCI. All staff must use circuit breakers when using electrical equipment outside. 9.8.05 9.8.05 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 37 Good Practice Recommendations The manager must have an NVQ Level 4 (or equivalent) in management and care by 2005. ABBEYFIELD Grange 20050809 Abbeyfield Grange X00023 UN Stage 4 S2931 V232998 J55.doc Version 1.30 Page 24 Commission for Social Care Inspection Ground Floor, Unit 3 Waterside Court Bold Street, Sheffield S9 2LR 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 20050809 Abbeyfield Grange X00023 UN Stage 4 S2931 V232998 J55.doc Version 1.30 Page 25 - 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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