CARE HOMES FOR OLDER PEOPLE
Abbeyfield House Abbeyfield House, Union Street Low Moor, Clitheroe Lancashire BB7 2NH Lead Inspector
Christine Marshall Unannounced 7 June 2005 10:00am
th 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 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 House F57 F09 S9529 Abbeyfield House V219287 070605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Abbeyfield House Address Abbeyfield House, Union Street, Low Moor, Clitheroe, Lancashire, BB7 2NH 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) 01200 442550 The Abbeyfield Lancashire Extra Care Society Limited Mrs Georgina Sandra Marsden CRH Care Home 29 Category(ies) of OP Old Age 29 registration, with number of places Abbeyfield House F57 F09 S9529 Abbeyfield House V219287 070605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 2nd March 2005 Brief Description of the Service: Abbeyfield House is part of ‘The Abbeyfield Lancashire Extra Care Society Limited’, which is a voluntary organisation. The home can accommodate 29 older people, aged 65 years and over. It is a purpose built, detached property set in its own grounds and offers 27 single and 1 shared bedroom, all of which have en-suite facilities. There are 2 lounges and a dining room on the ground floor and a quiet lounge on the first floor. There is a paved patio area and garden to the rear of the home with a small car park to the side. The home is non-smoking. Abbeyfield House is located close to a bus route, with access to Clitheroe town centre. The responsible individual for the home is Mr Norman Green. The registered manager is Mrs Georgina Marsden. Abbeyfield House F57 F09 S9529 Abbeyfield House V219287 070605 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This is the first of two unannounced inspection visits, scheduled from 1st April 2005 to 31st March 2006. The inspection took place over a four-hour period, from mid-morning to mid afternoon, and was carried out by the home’s designated lead inspector. The inspector undertook a full tour of the home, including bedrooms, lounge and dining areas and bathrooms. Comment cards were handed out to the residents however very few were returned. The inspector spoke privately with six of the residents, and had group discussions with seven other people living at the home. Comments from residents included: “It’s a smashing home.” “You couldn’t find a better place.” “I am well cared for.” There was one visiting relative available to speak with the inspector during the inspection visit. This person commented: “This is a good home, I am more than happy with the care.” The responsible individual Mr Green, manager Mrs Marsden, five carers and the kitchen and domestic staff spoke with the inspector. Everyone was very friendly, welcoming and co-operative with the inspector throughout the visit. Abbeyfield House F57 F09 S9529 Abbeyfield House V219287 070605 Stage 4.doc Version 1.30 Page 6 What the service does well: What has improved since the last inspection?
The Water Supply (Water Fittings) Regulations 1999 are now fully complied with. Every person who decides to move into this home is given written confirmation that the staff at the home, and the home itself is suitable to cater for the persons needs. The home will give this information to the person’s relative or representative if the resident want this to happen New weighing scales have been purchased for the residents. The staff recruitment files are now improved in that they are fully complete with photograph identification for each member of staff. Abbeyfield House F57 F09 S9529 Abbeyfield House V219287 070605 Stage 4.doc Version 1.30 Page 7 Any handwritten Medication Administration Record (MAR) charts are now checked and signed by another member of staff. This means that any errors when attending to residents medication are minimised by a second person checking the how the medication is given and recorded 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 House F57 F09 S9529 Abbeyfield House V219287 070605 Stage 4.doc Version 1.30 Page 8 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 Standards Statutory Requirements Identified During the Inspection Abbeyfield House F57 F09 S9529 Abbeyfield House V219287 070605 Stage 4.doc Version 1.30 Page 9 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 standard(s) 1,2,4 &5 Standard 6 does not apply to this home. If a person is considering moving into Abbeyfield, they are supplied with enough information to help them make that decision. The home also gathers enough information about the person to ensure that their needs can be met. This means that people can make good choices and receive the care they require EVIDENCE: There is a Statement of Purpose and Service Users Guide in place; this is a set of written information that tells you about the care service that is offered, who the manager and staff are and what the resident can expect if he or she decides to live at the home. Abbeyfield House F57 F09 S9529 Abbeyfield House V219287 070605 Stage 4.doc Version 1.30 Page 10 Prospective residents are always invited to the home to meet the staff and other residents. Every resident gets a contract of care from the home and this ensures that there are no misunderstandings about things such as any extra costs that might be incurred, or periods of notice to leave the home. Trial periods of stay are offered so that if the resident or the manager is not happy, then a review can be done to decide whether or not the resident is in the right home for the care that he or she needs. Abbeyfield House F57 F09 S9529 Abbeyfield House V219287 070605 Stage 4.doc Version 1.30 Page 11 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 standard(s) 8,9,10 & 11 The residents’ their health and social care needs are met and people are treated with dignity and respect at this home. Residents are fully supported in their daily lives. EVIDENCE: Residents spoken to told the inspector that they had the GP of their choice and that they had regular visits by the chiropodist, dentist, optician and also hearing aid services. The residents remarked that they were more than happy at the home and that the staff were very kind. The medication systems are satisfactory, however the inspector recommended that the drug fridge and treatment room temperatures be recorded daily. Abbeyfield House F57 F09 S9529 Abbeyfield House V219287 070605 Stage 4.doc Version 1.30 Page 12 The home’s policies for death and dying are very informative and include support systems for the resident, relatives and staff; this includes bereavement counselling if needed and arrangements for staff to attend funerals if they wish. Discussions with staff confirmed that every consideration is given to everyone during this final aspect of care. Abbeyfield House F57 F09 S9529 Abbeyfield House V219287 070605 Stage 4.doc Version 1.30 Page 13 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 standard(s) 13,14 & 15 Residents are supported in their expectations and preferences of daily living and benefit from meals that are well planned and appetising. EVIDENCE: The inspector spoke to a number of residents an each one said that they enjoyed having their relatives visit and that they were always welcomed by the staff at the home. One visiting relative said that he had visited the home regularly and that he had enjoyed sharing a meal during his visits. One resident was going out with a friend for lunch and told the inspector that she regularly did this and enjoyed it! A comment from one resident was “I do whatever I want and if I need help then the girls are always there.” Abbeyfield House F57 F09 S9529 Abbeyfield House V219287 070605 Stage 4.doc Version 1.30 Page 14 The inspector stayed at the home during the lunch-time meal and this looked very appetising. Residents spoken to said that they could have anything that they wanted; however there is not a choice of cooked breakfast available and although the residents told the inspector that they did not particularly want this, it would be preferable if this were to be offered. Care staff were very attentive during the mealtime and helped any resident who need it in a relaxed and dignified way. Abbeyfield House F57 F09 S9529 Abbeyfield House V219287 070605 Stage 4.doc Version 1.30 Page 15 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 standard(s) 16,17 & 18 Residents are able to voice their complaints and know who to speak to if they have any concerns. Adult protection and quality checks are in place, which means that residents live in a safe environment where their satisfaction is assured. People’s legal rights are promoted at this home. EVIDENCE: There is a clear written complaints procedure for the residents and their relatives; this is included in the information pack this is in every resident’s bedroom. There have been no complaints at the home or to the Commission for Social Care Inspection. All of the residents spoken to told the inspector that they had the opportunity to vote in the recent elections. They also said that they could get in touch with their relatives, solicitors or anyone else that they might need for help, if they wished: There are advocacy information leaflets pinned to the notice boards around the home, which is advice if anyone is without relatives and needs someone to speak on their behalf. Abbeyfield House F57 F09 S9529 Abbeyfield House V219287 070605 Stage 4.doc Version 1.30 Page 16 Care staff spoken to told the inspector that they knew about protecting the residents from abuse and that they had been given training about this. Abbeyfield House F57 F09 S9529 Abbeyfield House V219287 070605 Stage 4.doc Version 1.30 Page 17 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 standard(s) 19, 20, 21, 22, 23, 24, 25 & 26 Residents are provided with very clean, homely and pleasantly furnished surroundings and bedrooms are personalised and comfortable; this means that people feel at home with their photographs and belongings around them. EVIDENCE: Each bedroom is personalised with pictures, photographs and small items of furniture. One resident has brought his own bed. Each bedroom door is fitted with a lock and the resident is given the choice of whether or not they wish to retain the key. Abbeyfield House F57 F09 S9529 Abbeyfield House V219287 070605 Stage 4.doc Version 1.30 Page 18 All the bedrooms have en-suite facilities and there are adequate toilets and bathrooms throughout the home. The inspector noted that there are aids and adaptations such as grab rails in toilets and special lifting and bathing hoists for the residents who need help with their mobility. There are also assisted baths for residents that cannot get in and out of the bath without help. Laundry systems make sure that there are no problems with cross-infection and the laundry area is kept very clean and tidy. The inspector generally commends the cleanliness of the home. Abbeyfield House F57 F09 S9529 Abbeyfield House V219287 070605 Stage 4.doc Version 1.30 Page 19 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 The residents care needs are met through good levels of staff, who have the appropriate qualifications and experience necessary for the delivery of a good care service. EVIDENCE: The list of staff on duty showed that there are good levels of carers and domestic staff on duty at the home. Discussions with the carers and the kitchen and domestic staff were very positive and showed that there is a good skill mix of people in place. A good number of staff have worked at the home for many years and this gives stability to the people living there. Newer members of staff told the inspector that they are supported and welcomed into the home by the other established carers. Abbeyfield House F57 F09 S9529 Abbeyfield House V219287 070605 Stage 4.doc Version 1.30 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 37 & 38 The home makes sure that the best interests of the residents are protected in that there are regular quality checks that focus on the quality of care that is provided. EVIDENCE: The home is accredited with the Investors in People (IIP) quality system: This is a method of checking the quality of the care systems in the home. There are regular residents’ meetings and a monthly monitoring visit from the responsible individual Mr N Green. The home commissioned Blackburn College students to set up an independent survey of care last year and this was very successful in that the outcome was very positive.
Abbeyfield House F57 F09 S9529 Abbeyfield House V219287 070605 Stage 4.doc Version 1.30 Page 21 All records are stored in locked filing cabinets and access to them is on a need to know basis only. The inspector examined the Health & Safety check records and equipment servicing certificates and all were current. There are four qualified first aiders at the home. The manager advised the inspector that she was aware of all of the Health & Safety regulatory requirements in respect of the home. Abbeyfield House F57 F09 S9529 Abbeyfield House V219287 070605 Stage 4.doc Version 1.30 Page 22 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 x 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 3
COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 x x 3 x x x 3 3 Abbeyfield House F57 F09 S9529 Abbeyfield House V219287 070605 Stage 4.doc Version 1.30 Page 23 No 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 Regulation Requirement Timescale for action 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 OP9 OP15 Good Practice Recommendations The medication room and drug refridgerator should have daily temperatures recorded. A choice of cooked breakfast should be offered each day. Abbeyfield House F57 F09 S9529 Abbeyfield House V219287 070605 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection 2nd Floor, Unit 1 Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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