Inspection on 13/12/05 for Abbeyfield Lodge

This inspection was carried out on 13th December 2005.

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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Abbeyfield Lodge 12/10/06

Similar services:

21 High Street

Vale House

Chestnut Walk

The Old Vicarage

Cherwood House Care Centre

Ashley House

Ascot Nursing Home

Fountain View

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

CARE HOME ADULTS 18-65 Abbeyfield Lodge 184-186 Reading Road South Church Crookham Fleet Hampshire GU52 6AE Lead Inspector Ian Craig Unannounced Inspection 13th December 2005 10:30a Abbeyfield Lodge DS0000065818.V272839.R01.S.doc Version 5.0 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 Lodge DS0000065818.V272839.R01.S.doc Version 5.0 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 Adults 18-65. 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 Lodge DS0000065818.V272839.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Abbeyfield Lodge Address 184-186 Reading Road South Church Crookham Fleet Hampshire GU52 6AE 01189 581950 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) Truecare Holdings Limited Mr S Lingiah Care Home 12 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (12) of places Abbeyfield Lodge DS0000065818.V272839.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 12 service users in the category MD can be accommodated who require personal care only. 12 service users in the category MD can be accommodated who require nursing care only. 20/04/05 Date of last inspection Brief Description of the Service: Abbeyfield Lodge provides personal and/or nursing care to adults with a mental disorder. There is no provision for the detention of people under the Mental Health Act 1983, although residents may be under community supervision arrangements of the Act. A Registered Mental Nurse (RMN) is on duty at all times. The home works jointly with local hospital and community psychiatric services. Placements at the home may be part of a rehabilitation programme following discharge from an acute psychiatric ward. The home is involved in multi agency planning meetings for individual residents. The facilities of the home are of a high standard. There is a computer with access to the internet and e-mail for the residents to use. Abbeyfield Lodge DS0000065818.V272839.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Four residents were interviewed in private. The home’s manager assisted the inspector. Some of the communal facilities were seen. Since the last inspection, ownership of the home has changed. The new owners are Truecare Holdings Ltd. :- a national organisation providing services for adults with a mental disorder. A new manager has also been appointed, and the current manager is due to leave the home in early 2006. This report should be read in conjunction with the previous report. What the service does well: What has improved since the last inspection? The home continues to improve the physical environment on an ongoing basis and maintains high standards in the care of the residents. Abbeyfield Lodge DS0000065818.V272839.R01.S.doc Version 5.0 Page 6 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 Lodge DS0000065818.V272839.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Abbeyfield Lodge DS0000065818.V272839.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of the standards in this section were assessed at this inspection. EVIDENCE: Abbeyfield Lodge DS0000065818.V272839.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 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 and 8 The home promotes the rights of individual residents. There is choice in food and activities and the residents have opportunities to involve themselves in the decision-making processes. EVIDENCE: Residents described how they are able to spend time as they wish, but that there is also support to ensure that they are helped, where needed, with daily tasks. Of the four residents interviewed, three described the regular meetings to discuss menu plans, future events and activities, as well as any other relevant matters. One resident stated: “Tony (the manager) holds meetings about every 3 weeks with us.” Independence is very much promoted within safeguards to reflect the differing needs of individuals. For instance, all, but one, of the residents manages their own finances; the home deals with the finances of one person because of the person’s needs. Residents also described how they are involved in planning meetings attended by the home, their consultant psychiatrist, social worker and others. Abbeyfield Lodge DS0000065818.V272839.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13, 16 and 17 The home promotes residents attending activities and accessing local community facilities. Residents’ rights are respected and acknowledged in their daily lives. Good quality food is provided and there is a choice. EVIDENCE: Residents are able to come and go from the home unless assessed as needing support with this. Two residents described how they go out for walks and that they also attend social groups. The home employs an activities coordinator for two afternoons per week and this may involve trips out from the home. A resident described how she was offered the opportunity of a holiday. A resident described the numerous leaflets and information available in the home regarding community facilities and activities. Residents are able to spend time as they wish, but the home tries to ensure that each of the residents has an active life. This was confirmed from interviews with the residents. One resident stated that she would like more to do, and, whilst another resident felt there could be more activities he also acknowledged the provision of community facilities. The manager is committed to the promotion of residents’ rights and access to amenities and facilities. For instance, the home has a computer with internet access and e-mail facility for Abbeyfield Lodge DS0000065818.V272839.R01.S.doc Version 5.0 Page 11 the residents to use. A resident described how he frequently uses the internet and how important this is to him, especially for newspaper websites. The residents described the food as good quality and two residents proudly told me, “We have a French chef.” The residents are involved in devising the menu plan. One resident stated that he sometimes helps prepare the food under the supervision of the chef. All the residents stated that the chef will cook something different for anyone who does not like the menu plan. Residents confirmed that they are able to help themselves to snacks and drinks at any time. Abbeyfield Lodge DS0000065818.V272839.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 and 20 Support in personal care is given to residents according to their needs. Residents are able to administer their own medication and whilst procedures for the handling and administration of medication are satisfactory care plans need to record the indicators of when medication “ as required” should be dispensed. EVIDENCE: Residents confirmed that they are able to go to bed and get up when they wish, but that they also receive support with personal care routines. Most residents are independent in personal care but this does vary and some of the residents require specific support and supervision. A resident confirmed that he is reminded of personal hygiene routines. Residents are able to administer their own medication if assessed as being safe and capable of doing so. If not ‘self medicating,’ medication is administered by one of the registered nurses and this includes intravenous depot injections. A monitored dosage system is used to administer medication. Records of medication dispensed were satisfactory. For those residents who have medication “as required” for agitation and distress, there were no records detailing the circumstances and indictors of when this medication should be administered. Daily running records, did, however, record details of the situation occurring when staff had decided to administer this medication. Abbeyfield Lodge DS0000065818.V272839.R01.S.doc Version 5.0 Page 13 Abbeyfield Lodge DS0000065818.V272839.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 The home has clear policies and procedures for dealing with any suspected abuse and for dealing with any possible aggression on the part of residents. Procedures ensure the safekeeping of any resident’s monies or valuables held by the home. EVIDENCE: Training is provided to staff in adult protection and the home has copies of the local authority adult protection procedure. The home has clear policies and procedures for dealing with aggressive behaviour on the part of residents. This is a policy of avoiding conflict and restraint by the use of diversion and diffusion techniques. Residents described the staff as being particularly ‘non intimidating.’ The majority of residents handle their own finances, but the home acts as appointee for one resident; appropriate records were maintained of the handling of this person’s finances. Abbeyfield Lodge DS0000065818.V272839.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 30 The home is clean and hygienic, although there is scope to provide training for staff in infection control. EVIDENCE: Whilst the home was found to be clean and hygienic staff are not provided with training in infection control. There are policies and procedures for infection control. The laundry area was seen and this was clean and well equipped. There are staff with specific responsibilities for laundry. Abbeyfield Lodge DS0000065818.V272839.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33 and 34 Staffing is provided at levels to meet the needs of the residents. Staff recruitment procedures are thorough. EVIDENCE: The staff rota was examined for the week commencing 28th. November 2005. This showed the provision of at least two staff at any one time and periods when there are 3 staff on duty. A Registered Mental Nurse (RMN) is on duty at all times. Nighttime staffing consists of two ‘waking’ staff. The total care staff hours for the week were, 368. In addition to this, the home deploys approximately 119 staff hours for cleaning and cooking. Residents described the staff as “lovely”, “approachable” and very good at recognising when a resident may need extra one to one support. Recruitment procedures were examined. All checks as required by the Care Homes Regulations 2001 had been carried out, including written references, Criminal Record Bureau checks etc. A record is made of the job interviews of staff, including a score system to assess performance. Following the interview, the manager completes an assessment form on the person’s abilities. Abbeyfield Lodge DS0000065818.V272839.R01.S.doc Version 5.0 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 42 Health and safety in the home was found to be generally satisfactory, although improvements could be made in providing training in health and safety areas. EVIDENCE: All staff receive training in first aid and four staff have completed a one day appointed first aid course. None of the staff have completed a four day qualified first aid course. There are policies and procedures displayed in the home regarding manual handling, however, there is no training for staff in this area from a suitably qualified person. The manager explained that staff are not involved in manual handling and lifting of any residents. Current legislation emphasises the responsibility of any employer to the employee regarding safe lifting of any heavy object. The home has policies for dealing with infection control, but staff have not received training in this area. All food handlers have received food hygiene training. Certificates showed that the homes appliances have been serviced. Abbeyfield Lodge DS0000065818.V272839.R01.S.doc Version 5.0 Page 18 The fire log book showed that the home’s fire safety equipment has been tested. Covers have been installed on radiators to prevent possible burning to residents. Baths and showers do not have hot water controls. Each resident has been assessed regarding the risk of accidentally scalding themselves when having a bath or shower. Additional safety measures are taken by staff when supporting a resident with his bath; this includes staff testing the temperature of the water. The inspector highlighted that, whilst safety measures have been taken, the needs of the residents are such that it would be safer to have temperature controls on bath and shower outlets where there is total immersion in water. Abbeyfield Lodge DS0000065818.V272839.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score X 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X 3 3 X X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 3 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X X 3 4 X X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Abbeyfield Lodge Score 3 X 2 X Standard No 37 38 39 40 41 42 43 Score X X X X X 2 X DS0000065818.V272839.R01.S.doc Version 5.0 Page 20 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA20 Regulation 13(4) Requirement Care plans must detail the indicators, signs and symptoms that medication ‘as required’ should be administered especially regarding agitation and distress. Staff must be trained in first aid as follows: • There must be at least one member of staff on duty at any given time that has received first aid training from a suitably qualified person. • The home must have at least one staff member from the staff team who has completed a 4 day qualified first aid course Timescale for action 30/01/05 2 YA42 13(4) 13/03/05 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 Lodge DS0000065818.V272839.R01.S.doc Version 5.0 Page 21 1 2 YA42 YA42 Staff should receive training in manual handling and lifting from a suitably qualified person. Key staff should receive training in infection control. Temperature control devices should be installed on bath and shower hot water outlets. Abbeyfield Lodge DS0000065818.V272839.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Lodge DS0000065818.V272839.R01.S.doc Version 5.0 Page 23 - 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!