CARE HOMES FOR OLDER PEOPLE
Abbeyfield Lear House Darmonds Green West Kirby Wirral CH48 5DT Lead Inspector
Inger Moynihan Key Unannounced Inspection 23rd April 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 Lear House DS0000018850.V328683.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 Lear House DS0000018850.V328683.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Abbeyfield Lear House Address Darmonds Green West Kirby Wirral CH48 5DT 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) 0151 625 1883 Abbeyfield Hoylake and West Kirby Limited Mrs Lesley Joyce Saunders Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Abbeyfield Lear House DS0000018850.V328683.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 13th January 2006 Brief Description of the Service: Lear House was first registered in 1984. The home is owned and managed by The Abbeyfield Society and provides accommodation for 24 service users in a large detached house in its own grounds. The home is close to local facilities including shops, leisure centre, library, churches, and public transport including bus and train services. The home provides single accommodation with en-suite facilities consisting of a toilet and washbasin. There is one lounge/dining room and two further lounges one on the ground floor and another on the first floor. A seating area is also provided in the former entrance hall. The home is furnished and decorated to a high standard throughout. There is a passenger lift, which accesses the bedrooms on the first floor. There are four bedrooms, which are accessed by four stairs. All corridors have handrails. There is a level access to the front and rear gardens. All the grounds are well maintained with mature trees, shrubs and flowerbeds. The garden room opens directly on to the garden where there is an ornamental fishpond, benches and other garden furniture. There is parking space for twenty cars within the grounds of the home. Abbeyfield Lear House DS0000018850.V328683.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. Information about Abbeyfield Lear House was obtained through a preinspection questionnaire and examination of the homes policies and procedures and supporting documentation. Discussion took place with residents, the Registered Manager and members of the staff team. A tour of the building also took place. Prior to the inspection CSCI questionnaires were sent to a number of residents and health care professionals who visit the home. Information from these questionnaires is included in the report and contributes to the basis of any judgements made. Fees - £340.00 What the service does well:
Residents are only provided with a service after their needs are assessed and they have been assured these needs will be met. Systems are in place to ensure residents health care needs are fully met. The service users spoken to during the visit said they felt well cared for. One resident said the staff are marvellous, they are very useful and helpful. Another resident said the staff are very good, they are always very kind and caring. One GP questionnaire was returned to the CSCI. It recorded this is an excellent care home with good leadership from the manager. The residents spoken to during the visit confirmed the staff treat them with respect and their privacy and dignity is always upheld. The residents questionnaires returned to the CSCI indicated the staff are available when necessary and they receive the care and support they need. One questionnaire recorded the staff are very helpful and attentive to all my needs. All of the staff are very dedicated people. A range of social activities is provided to ensure residents do not become bored and have an opportunity to mix with other people living in the home. The Registered Manager has set up links with the local church where residents attend a coffee morning and a devotional service is held at the home every month. The residents spoken to during the visit said they are happy with the social activities provided. They all confirmed the social activities are optional and staff respect their decision not to join in. One resident recorded in their questionnaire there are lots of activities however I pick and choose which I attend. A varied menu is in place. The residents spoken to during the visit confirmed they receive a copy of the weeks menu in advance and a choice is always available. The chef provides homemade meals which most of the residents
Abbeyfield Lear House DS0000018850.V328683.R01.S.doc Version 5.2 Page 6 reported are very enjoyable. One of the residents said the food is very good and there is always plenty of choice. Some comments were made about the food being a little repetitive, particularly at weekends. The residents spoken to during the visit said they were completely satisfied the care they receive and knew who to contact if it were unhappy about any aspect of the service. All staff are trained on how to protect residents from abuse and harm. The residents spoken to during the visit said the staff are extremely caring, polite and helpful. One resident said the staff are marvellous, they are always polite and I have never experienced anyone being rude to me. One of the questionnaires returned to the CSCI noted I have never needed to complain about anything or anybody, the staff are helpful and attentive to all my needs. The standard of the furnishings throughout the home remains very high and the grounds are well kept. A programme of refurbishment is in place to ensure this standard is maintained. The staff at the home are suitably qualified and competent to ensure the residents are well cared for. The staff spoken to during the visit said the Society was an excellent organisation to work for and they felt well supported in their role. The Registered Manager is competent and qualified to run the home for the residents best interests. She has introduced effective quality assurance systems to ensure the ongoing monitoring and improvement of the service. The residents health, safety and welfare are well promoted. What has improved since the last inspection? What they could do better:
Some improvements need to be made to the record keeping in relation to the way residents are looked after to ensure their holistic care needs are met. Abbeyfield Lear House DS0000018850.V328683.R01.S.doc Version 5.2 Page 7 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 Lear House DS0000018850.V328683.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Abbeyfield Lear House DS0000018850.V328683.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are only provided with a service after their needs are assessed and they have been assured these needs will be met. EVIDENCE: An assessment of residents care needs is carried out to ensure staff have all the information they need about their individual care needs. However, more detailed records need to be kept on residents specific care needs in relation to their safety and welfare. This will ensure staff have the necessary information on how to keep them safe from harm. The Registered Manager acknowledged that issues relating to equality and diversity, such as residents age, disability, gender, race, religion or belief and sexuality need to be explicitly addressed during the assessment process to ensure their holistic care needs are met. Abbeyfield Lear House DS0000018850.V328683.R01.S.doc Version 5.2 Page 10 Intermediate care is not provided at Lear House. Abbeyfield Lear House DS0000018850.V328683.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 and 10 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Systems are in place to ensure residents health care needs are fully met. EVIDENCE: A documented plan of the support provided to each service user is in place, which gives staff guidance and information on residents individual care needs. The Registered Manager acknowledged that issues relating to equality and diversity, such as residents age, disability, gender, race, religion or belief and sexuality need to be explicitly addressed during the care planning process to ensure residents holistic care needs are met. Residents have access to a range of health care professionals such as their GP, chiropodist and dentist. Their health care needs are monitored with a record of their daily welfare being kept. Staff have completed training on a range of issues relating to the conditions of old age which means the residents will be cared for in accordance with current good practice. The residents spoken to during the visit said they felt well cared for. One resident said the staff are marvellous, they are very useful and helpful. Another resident said the staff are very good, they are always very kind and caring.
Abbeyfield Lear House DS0000018850.V328683.R01.S.doc Version 5.2 Page 12 One GP questionnaire returned to the CSCI noted this is an excellent care home with good leadership from the manager. The residents questionnaires returned to the CSCI indicated the staff are available when necessary and they receive the care and support they need. One questionnaire noted the staff are very helpful and attentive to all my needs. All of the staff are very dedicated people. Another questionnaire recorded excellent medical help is always available for genuine problems. However additional attention to allay minor concerns could be beneficial. This issue was raised with the Registered Manager at the time of the visit. The residents spoken to during the visit confirmed the staff treat them with respect and their privacy and dignity is always upheld. Systems are in place to ensure residents receive their medication as prescribed by their GP and all staff that handle residents medication are trained. Appropriate storage facilities are in place and all records are up-to-date. Staff can access supporting documentation when necessary and a risk assessment has been carried out for any service user who administers their own medication. This is in line with good practice and ensures residents safety and welfare. Abbeyfield Lear House DS0000018850.V328683.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes routines are flexible and varied, which suit residents preferences and choices. EVIDENCE: A range of social activities are provided to ensure residents do not become bored and have an opportunity to mix with other people living in the home. The homes visiting times are flexible which means residents can maintain contact with their family and friends. The Registered Manager has set up links with the local church where residents attend a coffee morning and a devotional service is held at the home every month. The residents spoken to during the visit said they are happy with the social activities provided. They all confirmed the social activities are optional and staff respect their decision not to join in. One resident recorded in their questionnaire there are lots of activities however I pick and choose which I attend. Other questionnaires indicated that activities are usually and sometimes provided. This issue was discussed with the Registered Manager who agreed to look into the matter straight away in order to establish whether a broader range of activities need to be provided. Abbeyfield Lear House DS0000018850.V328683.R01.S.doc Version 5.2 Page 14 The routines in the home are flexible which means service users can come and go as they wish with minimal restrictions in place. The pre-inspection questionnaire indicated that a varied menu is in place. The residents spoken to during the visit confirmed they receive a copy of the weeks menu in advance and a choice is always available. The chef provides homemade meals which most of the residents reported are very enjoyable. One of the residents said the food is very good and there is always plenty of choice. Some comments were made about the food being a little repetitive particularly at weekends. A number of questionnaires returned to the CSCI recorded the residents usually enjoyed the meals. One questionnaire recorded, greater variety would help together with attention to personal preferences. Another questionnaire recorded the menu is superb, five star cooking, meals served perfectly........ These issues were discussed with the Registered Manager who agreed to speak with the residents in order to improve this area of service provision. Abbeyfield Lear House DS0000018850.V328683.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems are in place to ensure residents of protected from abuse and they know who to contact if they want to make a complaint. EVIDENCE: The residents spoken to during the visit said they were completely satisfied the care they receive and knew who to contact if it were unhappy about any aspect of the service. This was further reinforced in the questionnaires returned to the CSCI. A copy at the homes complaint procedure is displayed and the staff spoken to were aware of the action they should take in the event of them receiving a complaint. All staff are trained on how to protect residents from abuse and harm and during discussion they demonstrated an understanding of the different types of abuse that can occur. The residents spoken to during the visit said the staff are extremely caring, polite and helpful. One resident said the staff are marvellous, they are always polite and I have never experienced anyone being rude to me. One of the questionnaires returned to the CSCI stated I have never needed to complain about anything or anybody, the staff are helpful and attentive to all my needs. Another questionnaire stated the staff are all very pleasant and approachable. Abbeyfield Lear House DS0000018850.V328683.R01.S.doc Version 5.2 Page 16 Abbeyfield Lear House DS0000018850.V328683.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The standard of the decor at Lear House remains very high and provides residents with a comfortable and pleasant environment to live. EVIDENCE: The standard of the furnishings throughout the home remains very high and the grounds are well kept. A programme of refurbishment is in place to ensure this standard is maintained. The size of the bedrooms vary but all have en suite facilities and are well maintained. Specialist bathing facilities are provided. There is a main lounge / dining room where service users can meet together, there are also a number of smaller lounges if residents wish to sit quietly. The home is set in large grounds which are well maintained. There is a pleasant seating area at the front of the home and a large patio area at the back with raised flower beds, a pond and summer house. Hand rails and good footings are provided to ensure residents safety.
Abbeyfield Lear House DS0000018850.V328683.R01.S.doc Version 5.2 Page 18 To ensure residents safety and welfare, the Registered Manager must fit a lock to the laundry door and ensure the kitchen is always kept locked when staff are not at work in this area. A record of the water temperatures must also be kept. Abbeyfield Lear House DS0000018850.V328683.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff at the home are suitably qualified and competent to ensure the residents are well cared for. EVIDENCE: There are sufficient staff on duty to look after the service users in accordance with their particular needs. The pre inspection questionnaire indicated that staff have completed a range of appropriate training last year and that nearly 75 of the staff are qualified to National Vocational Qualification level 2. A programme of training is in place for this year. The Registered Manager acknowledged that issues relating to equality and diversity need to be included in this programme to ensure residents holistic care needs are met. Staff are provided with induction training when first employed. This training needs to be developed to be in line with Skills for Care, which is the recognised training programme for staff working in a care home. This will ensure newly appointed staff, which may be inexperienced, have the most up to date information on current care practice. The staff spoken to during the visit said the Society was an excellent organisation to work for and they felt well supported in their role. They said
Abbeyfield Lear House DS0000018850.V328683.R01.S.doc Version 5.2 Page 20 they meet regularly with the Registered Manager to discuss their development within their role and confirmed that regular training is provided. The staff recruitment procedures ensure suitably qualified and competent staff are employed and all the necessary records are in place. The Registered Manager agreed to ensure issues of equality and diversity are explicitly addressed during the staff recruitment procedures to enable her to assess an applicants understanding of issues relating to residents age, disability, gender, race, religion or belief and sexuality. Abbeyfield Lear House DS0000018850.V328683.R01.S.doc Version 5.2 Page 21 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 33 35 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is run and managed by a person who is fit to be in charge and ensures the ongoing monitoring and improvement of the service. EVIDENCE: The Registered Manager is competent and qualified to run the home for the residents best interests. She has introduced effective quality assurance systems to ensure the ongoing monitoring and improvement of the service. Staff are supported and monitored in their role and administrative procedures are reviewed. Questionnaires are sent to service users in order to gain their views on the care they receive. The Registered Manager stated she is looking to develop the questionnaires so they are in line with the National Minimum Standards for Older People. This will enable her to monitor different aspects
Abbeyfield Lear House DS0000018850.V328683.R01.S.doc Version 5.2 Page 22 of the service in more detail. The Society and House Chairpersons also speak to the residents to ensure they are happy about the care they receive. The Registered Manager does not handle residents money, this is done by the Society head office. The pre inspection questionnaire indicated that regular health and safety checks are carried out on equipment around the building. Supporting documentation is in place to confirm this information. Staff are provided with a range of health and safety training and all fire safety checks are up to date. All of this is in line with good practice and ensures staff and residents safety and welfare. Abbeyfield Lear House DS0000018850.V328683.R01.S.doc Version 5.2 Page 23 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 2 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 4 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 4 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 4 X 3 X 3 X X 4 Abbeyfield Lear House DS0000018850.V328683.R01.S.doc Version 5.2 Page 24 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 OP3 Regulation 13 &14 Requirement Timescale for action 25/06/07 2 OP3 12 & 14 3 OP7 15 3 OP19 13 The registered person is required to ensure detailed risk assessments are routinely carried out during the assessment process. (Previous timescale of 30/3/06 not met) The six strands of equality and 25/06/07 diversity must be incorporated into the assessment process to ensure residents holistic care needs are fully addressed. The six strands of equality and 25/06/07 diversity must be incorporated into the care planning process to ensure residents holistic care needs are fully met. To ensure residents safety the 30/04/07 following issues must be addressed: • A lock must be fitted to the laundry door • The kitchen door must be kept locked when staff are not working in that area • A record of the water temperatures must be kept. Abbeyfield Lear House DS0000018850.V328683.R01.S.doc Version 5.2 Page 25 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 Lear House DS0000018850.V328683.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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
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