Inspection on 20/09/07 for Abbeyfield Ilkley Society Limited

This inspection was carried out on 20th September 2007.

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 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 12/12/06

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 20th September 2007 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.V346713.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.V346713.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 Mrs Vivienne Clarke 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.V346713.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th December 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 people 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 care range from £555:00 per week (minimum) to £630:00 per week (maximum). The current fee for respite care is £80 per night. Abbeyfield Ilkley Society Limited DS0000059448.V346713.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out between the hours of 9:30am and 4:00pm. The purpose of this visit was to assess how the home is meeting the needs of people who live there. The methods I used included looking at records, watching staff at work, talking to people living at the home, the manager and staff. Survey questionnaires were also sent to people living at the home, relatives and healthcare professionals, so that they can share their views and opinions of the service with the Commission. The manager had also completed an Annual Quality Assurance Assessment (AQAA) form and the information provided has been used as evidence in the body of the report. What the service does well: What has improved since the last inspection? Abbeyfield Ilkley Society Limited DS0000059448.V346713.R01.S.doc Version 5.2 Page 6 The manager has recently been registered with us and continues to work towards the Registered Managers Award. A new assessment and care planning system has been developed and is currently being introduced into the home, which should make sure that people’s needs are fully met. A key worker system has been introduced whereby each person has two named staff to support them. The induction training for new staff has been improved. 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. The summary of this inspection report can be made available in other formats on request. Abbeyfield Ilkley Society Limited DS0000059448.V346713.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.V346713.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,4 and 5 – standard 6 does not applicable to this service. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People are provided with sufficient information to enable them to make an informed decision about the home. The admission procedure is thorough and people will not be admitted unless staff are able to meet their needs. EVIDENCE: All people thinking of moving into the home are provided with an information pack, which includes the home’s statement of purpose, brochure and a copy of the last inspection report. The records show that pre-admission assessment visits are carried out before people are admitted and the needs identified during this visit form the basis for the initial care plan. Abbeyfield Ilkley Society Limited DS0000059448.V346713.R01.S.doc Version 5.2 Page 9 People are encouraged to visit the home before admission to view the accommodation and meet the staff and other people living there. The manager confirmed that people offered a place at the home are always supported throughout the admission process and care is taken to make sure they settle into their new environment. Feedback from people clearly showed that they had been given sufficient information about the home before admission and were pleased they had chosen to live at Abbeyfield. Comments included “You could not wish to live in a better place“ and “I am very happy and content at Abbeyfield.” The manager confirmed that there was a good skill mix within the care staff team and people spoken with said they had confidence that staff had the ability to meet their needs. Abbeyfield Ilkley Society Limited DS0000059448.V346713.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People’s needs are met although the care plans need updating. Medication systems are generally satisfactory although incidents must be thoroughly investigated to make sure people are safe. EVIDENCE: A new assessment and care-planning system is currently being introduced, which covers all aspects of people’s social and healthcare needs. The manager confirmed that care plans are usually reviewed at least monthly or sooner if there are significant changes. However, some of the care plans I looked at had not been reviewed for a considerable period of time. The manager acknowledged that due to recent staffing problems some care plans had not been reviewed as often as they should have been. However, she was confident that the staffing difficulties had been resolved and staff would now have time to implement the new system and make sure that care plans were kept up to date. Abbeyfield Ilkley Society Limited DS0000059448.V346713.R01.S.doc Version 5.2 Page 11 The care plan is a working document and should provide clear guidance to the staff on how the individual’s needs are to be met. Everyone is registered with a general practitioner and are supported in having access to the full range of NHS services. The input of other healthcare professionals is clearly recorded, which shows that staff are seeking advice if they have concerns about an individual’s health. People living at the home said that they were very pleased with the care and attention they received and comments included “all the staff are so kind and caring” and “I receive great help and understanding.” On reviewing the medication system I noted that a serious error had recently occurred whereby a person had been given the wrong strength of medication for over two weeks. Although the manager said it was unclear if the pharmacist or the home had made the mistake there was no evidence to show that a thorough investigation had taken place and we had not been informed of the occurrence. Procedures have now been put in place to stop mistakes like this occurring again. Abbeyfield Ilkley Society Limited DS0000059448.V346713.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People are encouraged and supported to participate in a range of activities and make decisions about their lives, which helps to improve their quality of life. EVIDENCE: People confirmed that they are encouraged to make as many decisions and choices as possible about their daily lives and how they want to spend their time. Feedback from surveys and people I spoke with showed that the level of social and leisure activities arranged is good and they were very complementary about the work done by the activities co-ordinator. Comments included “there are so many activities arranged -- I am happy to join in the ones I especially enjoy” and “there are plenty of organised activities you can join in or you can choose to plan your own day.” Abbeyfield Ilkley Society Limited DS0000059448.V346713.R01.S.doc Version 5.2 Page 13 Information provided in the Annual Quality Assurance Assessment (AQAA) shows that volunteers enable one person to continue her enjoyment of walking and exercise. All volunteers working within the Abbeyfield complex are recruited; trained and supervised by the Volunteer Organiser employed by the organisation so people can be confident that they are suitable to work with vulnerable people. People living at the home on a long-stay basis do not have access to the day centre based within the Abbeyfield complex, but do have access to the Wharfe Valley Community Day Centre, which is run by volunteers. People can also join in other organised activities such as flower arranging, cooking and arts and crafts if they wish, or enrol for courses run by local community groups. To keep them informed of forthcoming events a quarterly newsletter is published and distributed. The home continues to have strong links with the local community especially church groups and regular services are held within the complex, or people are supported in attending their chosen place of worship. Throughout the visit staff were observed to interact well with the people in their care and people were relaxed and clearly felt comfortable in their presence. People said that they were able to see visitors in their own room if they wished to do so and family and friends were always made to feel welcome and offered light refreshment. People living at the home said that the food is good and their preferences are taken into account when menus are planned. At lunchtime there is always a choice of a meat, fish or vegetarian dish and special diets can be catered for on request. Abbeyfield Ilkley Society Limited DS0000059448.V346713.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The complaints procedure is not clear and complaints are not being dealt with in a professional manner. People are not fully protected, as some staff need further training on the recognition and reporting of abuse. EVIDENCE: I looked at two different copies of the home’s complaints procedure, which gave conflicting information about how a complaint would be dealt with and the timescales within which the complainant would be informed of the outcome of an investigation. On discussing this matter with the manager she confirmed that she was aware of the problem and said that she was also unsure if staff were clear about what action to take if they received a complaint, or how complaints should be recorded. The manager is currently addressing this matter by reviewing the policies and procedures in place and arranging staff training. I noted that two complaints had been received from the relative of a person living at the home regarding the standard of care provided. Although the manager confirmed that the complaints had been resolved to everyone’s Abbeyfield Ilkley Society Limited DS0000059448.V346713.R01.S.doc Version 5.2 Page 15 satisfaction there was no evidence to show that an investigation had been carried out or the complaints procedure had been followed. Adult protection policies and procedures are in place and the training records available showed that staff had received appropriate training on the recognition and reporting of abuse. However, on discussing the complaints recently received with the manager concerns were raised that some staff still do not fully understand what constitutes abuse and therefore to safeguard people, further training must be provided. Abbeyfield Ilkley Society Limited DS0000059448.V346713.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The home continues to provide people with a pleasant and comfortable environment in which to live. EVIDENCE: The home was opened and first registered in May 2004 and is located in the Abbeyfield complex, which is close to Ilkley Town centre. The home provides well-planed spacious accommodation for fifteen people in single en-suite bedrooms. There is also a communal lounge and dining room, which people can use if they wish. Abbeyfield Ilkley Society Limited DS0000059448.V346713.R01.S.doc Version 5.2 Page 17 A full tour of the building was not undertaken on this visit, however internally the home is decorated and furnished to a high standard and there is an ongoing programme of refurbishment and renewal. People living at the home said that they were pleased with both their private accommodation and communal areas. Comments included “I could not wish for a better place to live ” and “both the bedrooms and communal areas are spacious and nicely decorated.” On the day of the visit the standard of hygiene and cleanliness throughout the home was good and no unpleasant odours were noted. Abbeyfield Ilkley Society Limited DS0000059448.V346713.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The recruitment procedures are not always followed, which means that people could be put at risk. There is a commitment to staff training and to ensuring that people receive the standard of care they require. EVIDENCE: Information provided in the Annual Quality Assurance Assessment (AQAA) form shows that the home has recently experienced a severe staff shortage due to long-term sickness and extended maternity leave. Although this matter has now been resolved it has meant that the manager has spent much of her time providing “hands on” care and has not been able to move the service forward. The staff rota showed that sufficient staff are employed on day and night duty to meet people’s needs. Abbeyfield employs contract cleaners to make sure the home is clean and free from offensive odours. The home has a staff recruitment and selection procedure in place, which includes obtaining at least two satisfactory written references and a Criminal Record Bureau (CRB) check before new staff start work. Abbeyfield Ilkley Society Limited DS0000059448.V346713.R01.S.doc Version 5.2 Page 19 However, it was apparent that two recently appointed care staff had started work before the home had obtained a satisfactory CRB for them and in one instance only one reference had been requested. This is poor employment practice, which might lead to the home employing staff that are unsuitable to work with vulnerable people. There continues to be a commitment to staff training and the manager confirmed that all staff receive comprehensive induction training using the Skills for Care Common Induction Standards. There is then an expectation that they will achieve a National Vocational Qualification (NVQ) at level two or above depending on the post they hold. Information provided in the Annual Quality Assurance Assessment (AQAA) shows that currently eleven staff out of a staff team of fourteen have achieved a NVQ. Some training records were available and indicated that staff have attended a number of training courses relevant to post they hold. The manager is currently carrying out a full staff training audit to make sure that people are being cared for by an experienced and skilled staff team. Feedback from staff indicates that they are generally pleased with the level and standard of training provided and confirmed that the manager encourages them to take up training opportunities. Abbeyfield Ilkley Society Limited DS0000059448.V346713.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36 and 38 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The home is well managed and people are supported in making decisions and exercising choice. EVIDENCE: Mrs Vivienne Clarke the registered manager of the home has over fifteen years experience in the caring profession has a National Vocational Qualification (NVQ) in care and is currently working towards the Registered Managers Award (RMA). Feedback from staff shows that the manager has an open and approachable management style and ensures clear channels of communication by holding regular staff meetings. Abbeyfield Ilkley Society Limited DS0000059448.V346713.R01.S.doc Version 5.2 Page 21 Staff have formal one-to-one supervision with the manager to discuss care practices and their training and personal development needs, although at present this does not take place as often as required. The manager does however work alongside the staff on a daily basis and is therefore able to provide the support they need to carry out their roles effectively. Quality assurance monitoring systems are in place and the manager is proactive in seeking the views and opinions of people living at the home and their relatives about the service provided. As part of this process the manager is in the near future going to send out survey questionnaires to other social and healthcare professionals to see if they feel the home is meeting stated aims and objectives. The home holds money in safekeeping for a number of people and transaction sheets are in place showing income, expenditure and a balance. Only senior staff complete the transaction sheets and regular audits are carried out to make the records are accurate and in good order. Receipts are obtained for any items purchased by staff on behalf of people. Policies and procedures are in place to ensure the health and safety of the people living at the home, visitors and staff and they are audited on a regular basis to make sure that they meet present legislation. Information provided in the Annual Quality Assurance Assessment (AQAA) form shows that all equipment in use at the home is serviced in line with the manufacturers guideline, so that people can be sure that they are in good working order. Abbeyfield Ilkley Society Limited DS0000059448.V346713.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 4 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 1 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.V346713.R01.S.doc Version 5.2 Page 23 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 OP7 Regulation 15 Timescale for action Care plans must contain accurate 31/10/07 and up to date information about people so that staff can provide the level of care they need. Medication errors must be 31/10/07 thoroughly investigated so that people can be confident that medication is being given as prescribed. To safeguard people living at the 31/10/07 home we must be informed of any event which adversely affects their well-being. All concerns/complaints must be 31/10/07 recorded and dealt with in a professional manner so that people have confidence in the complaints procedure. To make sure that people are 31/12/07 protected from any form of abuse all staff must receive further training on the recognition and reporting of abuse. To safeguard people living at the 31/10/07 home two written references must be obtained for all staff before they start work. Outstanding from last DS0000059448.V346713.R01.S.doc Version 5.2 Page 24 Requirement 2. OP9 13(2) 3. OP9 37 4. OP16 22 5. OP18 13(6) 6. OP29 19 Abbeyfield Ilkley Society Limited 7. OP29 19 inspection – timescale 31/01/07 not met. A satisfactory Criminal Record Bureau check must be obtained before new staff work unsupervised, so that people can be confident that they are suitable to work with vulnerable adults. 31/10/07 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.V346713.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V346713.R01.S.doc Version 5.2 Page 26 - 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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