Inspection on 12/12/06 for Abbeyfield Ilkley Society Limited

This inspection was carried out on 12th December 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 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 Ilkley Society Limited 19/09/08

Abbeyfield Ilkley Society Limited 20/09/07

Abbeyfield Ilkley Society Limited 09/02/06

Abbeyfield Ilkley Society Limited 12/08/05

Abbeyfield Ilkley Society Limited 25/08/04

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

CARE HOMES FOR OLDER PEOPLE Abbeyfield Ilkley Society Limited 12 Riddings Road Ilkley West Yorkshire LS29 9BF Lead Inspector Steve Marsh Key Unannounced Inspection 12th December 2006 09:30 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 Ilkley Society Limited DS0000059448.V311083.R01.S.doc Version 5.2 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 Ilkley Society Limited DS0000059448.V311083.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbeyfield Ilkley Society Limited Address 12 Riddings Road Ilkley West Yorkshire LS29 9BF 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) 01943 886000 01943 886030 Abbeyfield Ilkley Society Limited Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15), Physical disability (1) of places Abbeyfield Ilkley Society Limited DS0000059448.V311083.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th February 2006 Brief Description of the Service: Abbeyfield Care Home was first registered in May 2004 and is located within the Abbeyfield complex, which also provides a number of facilities for older people including sheltered housing and a day centre. The home is registered to care for fifteen residents on both a long stay and respite care basis. The accommodation consists of spacious en-suite single bedrooms and wellappointed communal lounge and dining room areas. There is also a communal assisted bathroom and toilet facilities conveniently situated throughout the home. All the bedrooms and communal facilities are on one floor of the building (first floor) and there is a passenger lift available. The home is located in the Ilkley area very close to the main shopping area and within easy walking distance of local churches, town centre amenities, and local transport. Current fees for long-stay residents are £525:00 per week minimum to £600:00 per week maximum. The current fee for respite care is £525:00 per week. Abbeyfield Ilkley Society Limited DS0000059448.V311083.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care homes are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home, Health and Personal Care etc. An overall judgement reflects how well the home delivers outcomes to the people using the service. The judgement categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded in the body of the report. More detailed information about these changes is available on website – www.csci.org.uk This unannounced inspection was carried out by one inspector between the hours of 9:30am and 4:00pm. The registered manager left the home earlier in the year and Mrs Vivienne Clark was recently appointed manager. Mrs Clark has many years experience in the caring profession and previously managed another care home in the Ilkley area. The last inspection of this service was in February 2006 and there were three requirements. The purpose of this inspection was to assess what progress the service was making in meeting statutory requirements and to assess the impact of any changes in the quality of life experienced by people living at the home. The methods used during this inspection included the examination of records, observation of care/work practices, discussion with residents and staff and a tour of the premises. A pre-inspection questionnaire was also completed and returned to the Commission by the manager before the date of inspection. Survey questionnaires were provided to enable residents and/or their relatives share their views of the service with the Commission. Unfortunately no questionnaires were returned prior to the completion of the report. The manager was not on duty when the visit was done and therefore an experienced senior carer was managing the home. Detailed feedback was given to the senior care assistant at the end of the visit. Requirements and recommendations made during this visit can be found at the end of the report. Abbeyfield Ilkley Society Limited DS0000059448.V311083.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? 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 Ilkley Society Limited DS0000059448.V311083.R01.S.doc Version 5.2 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 Ilkley Society Limited DS0000059448.V311083.R01.S.doc Version 5.2 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, 2, 3, 4 and 5 – standard 6 does not apply to this service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with sufficient information to enable them and/or their relatives to make an informed decision about the home. The admission procedure is thorough and the home will not admit a resident unless staff are able to meet their needs. EVIDENCE: There have been no changes to the home’s statement of purpose and service user guide, which are available to prospective residents before admission. A copy of the service user guide is also available in every bedroom for residents, family, and friends to read. The guide now needs to be amended to reflect the change in management arrangements. The records showed that pre-admission assessment visits are carried out to see prospective residents. The needs identified during this visit are reflected in their initial care plan. Abbeyfield Ilkley Society Limited DS0000059448.V311083.R01.S.doc Version 5.2 Page 9 As well as pre-assessment visits prospective residents and/or their relatives are always invited to visit the home before admission to view the accommodation, meet other residents and staff and stay for a meal if they wish to do so. Residents are also able to move into the home for a trial period so that they can experience first hand the standard of care and facilities provided. There was documented evidence that residents and their families are supported throughout the admission process and care is taken in helping residents settle at the home. All residents receive contracts/terms and conditions of residency on admission and signed copies are kept on their personal files. Residents confirmed that the financial aspects of their stay had been discussed with them before admission and they were aware that they and/or their relatives would be informed in writing of any increase in fees. During discussions with care staff it was apparent that they had a good understanding of the residents needs and felt well supported by the senior management team. Staff training continues to be actively encouraged at the home, both to meet the needs of the residents and for individual’s personal development. The home does not provide intermediate care. Abbeyfield Ilkley Society Limited DS0000059448.V311083.R01.S.doc Version 5.2 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, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care needs of the residents are met and their privacy and dignity is respected at all times. However, to safeguard the residents the manager must make sure that senior staff are more vigilant when administering/recording medication. EVIDENCE: Care plans are in place for all residents and there is sufficient evidence to show that residents and/or relatives are involved in the care planning process. The care plans of the last four admissions to the home were looked at and were completed to a satisfactory standard. All residents are registered with a general practitioner and have access to the full range of NHS services. Residents who do not live in the area but who are admitted for respite care continue to be registered with a local medical practice for the duration of their stay. Abbeyfield Ilkley Society Limited DS0000059448.V311083.R01.S.doc Version 5.2 Page 11 The input of other healthcare professionals is clearly recorded in the residents’ care plans and specialist equipment is provided if required. Residents confirmed that they were pleased with the standard of healthcare they received and said that prompt medical attention was provided both during the day and night. Through observations made during the visit and discussions with residents it was clear that the privacy and dignity is respected and assistance with personal care is carried out in a discreet and sensitive manner. Staff were seen to always knock on residents’ bedroom doors before entering the room and used their preferred term of address at all times. Some improvements had been made to the medication systems since the last inspection visit. However, in a number of cases staff had given medication but had not signed the Medication Administration Record (MAR) sheet. In addition the medication prescribed for one resident could not be accounted for, although the senior care assistant felt that it might have been discontinued and returned to the pharmacy. On the day of the visit the medication trolley required a thorough clean. Concerns about the administration and recording of medication have now been highlighted in the last two inspection reports and therefore action must be taken to address this matter. Only two residents administer their own medication. All new residents either for long-stay or respite care are encouraged to do so if they are able. Staff confirmed that they continue to monitor residents taking long-term medication and would contact their general practitioner or pharmacist if they had concerns. Abbeyfield Ilkley Society Limited DS0000059448.V311083.R01.S.doc Version 5.2 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, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home responds to individual needs and choices and continues to be an integral part of the local community. EVIDENCE: The daily routines of the home appear flexible and the residents confirmed that they are encouraged to make as many decisions as possible about their daily lifestyle. The home employs an activities co-ordinator who is responsible for arranging daily activities, entertainment, and outings for the residents. Residents staying at the home for respite care are able to attend the day centre in the complex provided that they usually attend the centre when living in the community. Residents living at the home on a long-stay basis do not have access to the day centre but can join in other actives organised within the Abbeyfield complex. A newsletter is published to keep residents informed of forthcoming events including birthdays, outings etc. Abbeyfield Ilkley Society Limited DS0000059448.V311083.R01.S.doc Version 5.2 Page 13 The home continues to have strong links with the local community and residents use the shops and other facilities in Ilkley and support community events. The senior care assistant also confirmed that religious leaders visit the home on a regular basis and church services are held within the complex, which the residents can attend. The home will also make arrangements for residents to attend church if they wished to do so. Residents spoken with appeared happy with the level of activities organised for them, and were looking forward to joining in the planned Christmas festivities. Examples were given of how staff had encouraged them to retain their independence, exercise choice and take control of their daily lives. Relatives confirmed that they were able to visit at any time, were always made to feel welcome by staff, and offered a meal or light refreshments. The meals at the home where described by the residents as generally good both in quality and presentation and they confirmed that both a meat and fish dish is provided every lunchtime. A choice of meals is also available at other meal times and special diets can be catered for on request. Menus are displayed in the dining room and are discussed at the residents meetings, which are held on a regular basis. The meal served at lunchtime on the day of the visit looked appetising, was well presented and appeared to be enjoyed by all the residents. Abbeyfield Ilkley Society Limited DS0000059448.V311083.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be assured that the manager will take all concerns/complaints seriously and take action to resolve matters. EVIDENCE: The home has a complaints’ procedure. Residents said that if they had any concerns they would feel able to raise them with the manager in the knowledge that they would be taken seriously and sorted out. Residents also said that they and/or their relatives had been given a copy of the complaints’ procedure on admission. The pre-inspection questionnaire showed that the home has received one complaint in the last twelve months. This was dealt with by the home and was substantiated. Policies and procedures are in place in relation to the protection of vulnerable adults. The training records show that all staff receive adult protection training. Staff confirmed that they were aware of the homes policy on “whistle blowing” and their responsibility to protect the residents from any form of abuse. Abbeyfield Ilkley Society Limited DS0000059448.V311083.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24 and 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home provides the residents with a high standard of both communal and private accommodation. EVIDENCE: The home was opened and first registered on the 7th May 2004 and is located within the Abbeyfield complex, which is an imposing building close to Ilkley town centre. The home provides well-planned spacious accommodation for fifteen residents in single en-suite bedrooms and has a very pleasant communal lounge and dining room areas. Abbeyfield Ilkley Society Limited DS0000059448.V311083.R01.S.doc Version 5.2 Page 16 All the bedrooms are furnished to a high standard and there was evidence of the resident’s personal belonging in every room, which made them individual and homely. There is wheelchair access to the Abbeyfield complex and a passenger lift to the residential unit, which is located on the first floor of the building. Externally the grounds are extensive and well kept and there is parking to the front of the property. All the residents said that they were very happy with the standard of accommodation and pleased that they had been able to furnish their private accommodation with personal belongings. On the day of the visit the standard of hygiene and cleanliness throughout the home was good and there were no unpleasant odours. Abbeyfield Ilkley Society Limited DS0000059448.V311083.R01.S.doc Version 5.2 Page 17 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): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported and protected by thorough staff recruitment and selection procedures. However to safeguard the residents, management must ensure that two written references are obtained for staff before they are employed. There appears to be a genuine commitment to staff training, both to meet the needs of the residents and for personal development. EVIDENCE: A staff rota was taken, which showed that sufficient care staff are employed on day and night duty to care for the residents and meet their needs. Abbeyfield does not employ its own cleaning staff, but employs contract cleaners to ensure that the home is kept clean and free from offensive odours. Staff recruitment and selection procedures are thorough, although on checking the employment file of one recently employed member of staff it was noted that only one written reference had been received before she had started work. Abbeyfield Ilkley Society Limited DS0000059448.V311083.R01.S.doc Version 5.2 Page 18 The General Manager dealt with this matter immediately after the inspection visit and an assurance was given that in future all references will be available in the employment files. The staff team is now well established and staff said that morale was good and everyone worked as a team to ensure the residents received the best possible quality of care. Agency staff are only used as a last resort to cover for annual leave or sickness. Staff training continues to be encouraged at the home. Information provided by the manager indicates that with one exception all care staff have achieved a National Vocational Qualification (NVQ) at level two (does not include bank staff) or above depending on the post they hold. Staff spoken with said that the level and quality of training provided by the home is very good and confirmed that the home is committed to having a trained and competent workforce. Abbeyfield Ilkley Society Limited DS0000059448.V311083.R01.S.doc Version 5.2 Page 19 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, 32, 33, 35, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home appears well managed and the staff remain committed to providing the residents with a quality service. The health and safety of the residents, staff and visitors is promoted and protected by the policies and procedures in place. EVIDENCE: The Registered Manager left the home earlier in the year and Mrs Vivienne Clark was appointed as the new manager on the 1 December 2006. Ms Clark has achieved a National Vocational Qualification at level four in Management and Care and managed another care home in the Ilkley area before moving to Abbeyfield. Abbeyfield Ilkley Society Limited DS0000059448.V311083.R01.S.doc Version 5.2 Page 20 Both staff and residents spoke highly of the new manager and felt that she offered them support when needed and was always willing to listen and advise if they had a problem. To ensure clear channels of communication regular day and night staff meetings are held and staff also receive formal one-to-one supervision with their line manager at least every two months. There are recognised quality assurances monitoring systems in place. The views and opinions of the residents and/or relatives are actively sought as part of the quality assurance process. The home holds money in safekeeping for a number of residents and transaction sheets are in place showing income, expenditure and a balance. Only senior staff complete the financial transactions sheets and regular audits are carried out by management to ensure they are kept in good order. Receipts are obtained for any items purchased by staff on behalf of residents. Policies and procedures are in place to ensure the health and safety of the residents, staff and visitors and they continue to be audited on a regular basis to ensure that they meet present legislation. From the pre-inspection inspection information provided it is evident that regular and routine safety checks are made of equipment and utilities for example the gas installations, electrical installations, fire safety equipment, and the passenger lift. Abbeyfield Ilkley Society Limited DS0000059448.V311083.R01.S.doc Version 5.2 Page 21 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 3 8 3 9 2 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 3 X X X 4 X 3 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 X 3 Abbeyfield Ilkley Society Limited DS0000059448.V311083.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13(2) Requirement The manager must ensure that medication is administered, recorded and disposed of in line with the policies and procedures in place. Outstanding from the last inspection report. Timescale 31/03/06 not met. Senior Management must ensure that two written references are obtained for all staff before to them starting work. Timescale for action 31/01/07 2 OP29 19 31/01/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Abbeyfield Ilkley Society Limited DS0000059448.V311083.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Ilkley Society Limited DS0000059448.V311083.R01.S.doc Version 5.2 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. 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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