Inspection on 09/02/06 for Abbeyfield Ilkley Society Limited

This inspection was carried out on 9th February 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 12/12/06

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 Unannounced Inspection 9th February 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.V277495.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V277495.R01.S.doc Version 5.1 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 Ms Fiona Jayne Collins 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.V277495.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th August 2005 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 other facilities for the elderly 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. In addition 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 areas very close to the main shopping area and within easy walking distance of local churches, town centre amenities and local transport. Abbeyfield Ilkley Society Limited DS0000059448.V277495.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second unannounced inspection visit for the year ending 31st March 2006 and was carried out by one Inspector over approximately seven hours. No additional visits have been made. The methods used during this inspection included the examination of records, observation of care practices, discussions’ (group and individual) with residents, staff and management and a tour of the premises. Comment cards were left for the residents and /or relatives to enable them to share their views of the service with the Commission. Ten comment cards were returned by relatives and five by residents. Feedback was given to Mrs Fiona Collins (registered manager) at the end of the inspection. Requirement and recommendations made during this visit can be found at the end of the report. What the service does well: What has improved since the last inspection? Abbeyfield Ilkley Society Limited DS0000059448.V277495.R01.S.doc Version 5.1 Page 6 The staff recruitment and selection procedure is now more thorough and the manager ensures that at least two written references are obtained for all new employees prior to them starting work. The night staffing arrangements at the home have been reviewed and there is now a designated senior member of staff on duty at all times. The cleaning hours have also been reviewed and are now in line with the operational needs of the home. The quality assurance monitoring systems in place now not only seek the views and opinions of residents and relatives but also healthcare professional accessing the service i.e. district nurses, general practitioners etc. 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.V277495.R01.S.doc Version 5.1 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.V277495.R01.S.doc Version 5.1 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): These standards were not reviewed on this inspection visit. EVIDENCE: These standards were not reviewed on this inspection visit. Abbeyfield Ilkley Society Limited DS0000059448.V277495.R01.S.doc Version 5.1 Page 9 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): 7,8,9,11 Care plans are completed to a good standard and give clear guidelines to the staff on how to meet the individual resident’s needs. Records and reports indicate that the resident’s healthcare needs are met in line with their care plans and any problems are identified and dealt with at an early stage. However, to safeguard the residents the manager must ensure that the senior staff team administer medication as prescribed. EVIDENCE: Care plans have been completed for all residents and cover all aspects of their health and general welfare. The care plans are reviewed at least monthly or sooner if the resident’s needs change significantly. The care plans reviewed were completed to a good standard and there was evidence to show that the residents and/or relatives are involved in the care planning process. 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 are admitted for respite care are registered with a local medical practice for the Abbeyfield Ilkley Society Limited DS0000059448.V277495.R01.S.doc Version 5.1 Page 10 duration of their stay. The input of other healthcare professionals is clearly recorded in the residents care plan and specialist equipment is provided if required. Residents said that they were very pleased with the medical attention they received and confirmed that medical examinations were always carried out in their own rooms. At present only two residents administer their own medication although all new admissions to the home are encouraged to do so if they have the capability. On reviewing the medication system in place a number of concerns were raised. In two instances prescribed medication was coded “out of stock” for an unacceptable period of time. In another instance the Medication Administration Record (MAR) sheet had been altered reducing medication from three times daily to twice daily. However, staff were still signing for the medication three times a day and appeared unaware of the correct dosage or why the MAR sheet had been altered. The stock control figure for painkillers administered to one resident on a prn (as and when required) basis was also incorrect. The manager confirmed that the staff team continue to monitor the general health of residents taking long-term medication and would contact the pharmacist or general practitioner if they had concerns. The home has policies and procedures in place in relation to the dying and death of a resident and the manager confirmed that comfort and support is offered to all parties during this very difficult period. Abbeyfield Ilkley Society Limited DS0000059448.V277495.R01.S.doc Version 5.1 Page 11 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): 14 Residents are encouraged and supported by the staff team to make informed decisions and choices about their daily lives for as long as it is practical for them to do so. EVIDENCE: The daily routines of the home appear flexible and the manager confirmed that the residents are encouraged to make as many decisions as possible in relation to their lifestyle. Two residents in particular said that one of the main reasons they had chosen the home was because the manager had been made clear to them that their freedom of movement and choice would not be restricted in any way. Residents are encouraged to handle their own finances if they have the capability and are made aware of external agencies that will act in their best interest if necessary. The manager confirmed that the residents are made aware that they can have access to their personal records held by the home in line with the Data Protection Act 1998. Abbeyfield Ilkley Society Limited DS0000059448.V277495.R01.S.doc Version 5.1 Page 12 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): 16,18 Robust complaint and adult protection procedures ensure that the residents are listened to and protected from abuse. EVIDENCE: The home has a complaints procedure and the residents confirmed that if they had any concerns they would feel able to raise them with the manager or senior staff team. They were also confident that their concerns would be taken seriously and resolved without them having to make a formal complaint. However, two of the ten comment cards returned by relatives indicated that they were not aware of the complaints procedure even though it appears to be well publicised. The manager confirmed that no complaints had been received by the home since the last inspection visit. Policies and procedures are in place in relation to adult protection and all members of staff receive appropriate adult protection training. Staff appeared aware of the home’s policy on “whistle blowing” and were able to detail what they would do if they felt any practices were not in the residents best interest. Abbeyfield Ilkley Society Limited DS0000059448.V277495.R01.S.doc Version 5.1 Page 13 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): 19,20,21,22,24,26 The home continues to provide a very pleasant and comfortable environment for the residents. However, to assist residents with mobility problems the manager must ensure that secure grab rails are installed in all toilet areas. 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 offering a range of services/accommodation to elderly people. The home provides well-planned spacious accommodation on one level for fifteen residents in single en-suite bedrooms and there is a communal lounge and dining room. Abbeyfield Ilkley Society Limited DS0000059448.V277495.R01.S.doc Version 5.1 Page 14 Residents confirmed that the bedrooms were comfortable and that staff respected their right to privacy by never entering their room without first asking permission. Telephones and televisions are provided in every bedroom as standard and a loop system is provided in the lounge area to assist residents with hearing impairment. In addition to the en-suite facilities available in every bedroom there are also communal toilet facilities conveniently situated throughout the home and one communal bathroom. It was noted that secure grab rails still need installing in two communal toilets to assist residents with mobility problems. The manager confirmed that although the equipment was on site there is an ongoing dispute about who should pay the cost of installation. The manager was reminded that the safety of the resident must be the main concern and therefore this matter must now be addressed with some urgency. On the day of the visit the standard of cleanliness and hygiene throughout the home was good and no odour problems were noted. Abbeyfield Ilkley Society Limited DS0000059448.V277495.R01.S.doc Version 5.1 Page 15 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): 27,28,29,30 Residents are protected by a robust staff recruitment and selection procedure, which includes Criminal Record Bureau (CRB) checks. There is a genuine commitment to staff training and the skill mix within the staff team ensures that residents’ needs are met. EVIDENCE: A rota for the week of inspection showed that sufficient care staff are employed on day and night duty to meet the needs of the residents. As required in the last inspection report one of the two staff on wakeful night duty is now a senior care assistant designated to take responsibility for the shift. The manager confirmed that at the present time the home has no permanent vacancies for care staff, however recruitment continues to take place for bank staff to cover sickness, annual leave etc. In exceptional circumstances agency staff are also used to cover some shifts. All staff providing personal care are over eighteen years of age and all senior staff are over twenty-one years of age in line with the National Minimum Standards. Abbeyfield Ilkley Society Limited DS0000059448.V277495.R01.S.doc Version 5.1 Page 16 The employment file for one recently appointed member of care staff was reviewed and it contained all the relevant information including Criminal Record Bureau checks to evidence that a safe recruitment and selection procedure is in place. The home continues to employ contract cleaners however, as required in the last inspection report the hours they work have been reviewed and are now more in line with the operational needs of the service. The manager confirmed that staff training is encouraged at the home and all staff receive at least three paid training days per years. There is also an expectation that all members of care staff will achieve a National Vocational Qualification (NVQ) at level two or above depending on the post they hold. Abbeyfield Ilkley Society Limited DS0000059448.V277495.R01.S.doc Version 5.1 Page 17 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): 31,32,33,36,38 The home is well managed and the views and opinions of the residents and/or relatives is sought and valued. All policies and procedures in use at the home are reviewed on a regular basis to ensure the health and safety of the residents, visitors and staff. EVIDENCE: Mrs Fiona Collins has been the registered manager of the home since June 2005 and she is presently studying for the Registered Manager’s Award. Mrs Collins continues to communicate a clear sense of leadership and direction to the staff team and has an open and approachable management style. Abbeyfield Ilkley Society Limited DS0000059448.V277495.R01.S.doc Version 5.1 Page 18 The home has recognised quality assurance monitoring systems in place and the views and opinions of the residents, relatives and professionals accessing the service are actively sought. Residents and relatives confirmed that they were kept informed of any changes in policies and procedures, which affect the running of the home and felt that their views and opinions were listened to and valued. Staff meetings are held on a regular basis to ensure that information is also shared with the staff team and formal one-to-one supervision continues to be held at least every two months in line with the National Minimum Standards. Policies and procedures are in place to ensure the health and safety of the residents, visitors and staff and they are reviewed on a regular basis to ensure that they meet with present legislation. Abbeyfield Ilkley Society Limited DS0000059448.V277495.R01.S.doc Version 5.1 Page 19 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 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 3 3 2 X 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X X 3 X 3 Abbeyfield Ilkley Society Limited DS0000059448.V277495.R01.S.doc Version 5.1 Page 20 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 registered manager must ensure that medication is administered as prescribed. Accurate stock control figures must be available for medication administered on a PRN (as and when required) basis. Grab rails must be fitted in the toilet areas identified on the day of the visit. The registered manager must achieve a National Vocational Qualification at level four in management and care or equivalent. Timescale for action 31/03/06 2. 3. OP22 OP31 23(2)(n) 9(2)(b) 31/03/06 31/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Abbeyfield Ilkley Society Limited DS0000059448.V277495.R01.S.doc Version 5.1 Page 21 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.V277495.R01.S.doc Version 5.1 Page 22 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!