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Inspection on 14/06/06 for Abbeyfield Residential Care Home

Also see our care home review for Abbeyfield Residential Care Home for more information

This inspection was carried out on 14th June 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The process followed in the home ensures that potential residents are provided with details of the services the home provides which helps them to make an informed decision about coming to stay in the home. Residents were very well cared for and carer staff well informed about their needs. Those residents spoken to said that they were well cared for by the staff and treated well, although one said some staff are better than others. Two residents who replied to our questionnaire, also said they received the care and support they needed, although one said, `occasionally a reminder is needed ...... (but) staff all exceedingly helpful and friendly` and the other said staff `often forget my requests, i.e. tea at a certain time or similar`. Residents enjoy social activities inside and outside the home, which provides variety and interest for them. A resident said she had been disappointed that a social activity had been cancelled on one occasion as staff were busy but had enjoyed a recent Garden Party to celebrate Abbeyfield`s 50th year and was looking forward to an outing to a local park the following week. Visitors are made welcome which helps residents keep in contact with family and friends. A carer also said that relatives could stay for meals and that the conservatory had been used to provide a dining area where a family could eat in private.Residents are encouraged to look after their own financial affairs and are also helped to look after their own medication if they are able to do this safely. There are good choices of well-cooked food available. There were a lot of fresh fruit and vegetables in the stores and fresh whole milk and cream available. A stock of MagnumTM ice creams was also in the fridge which residents were said to enjoy on hot days. Fresh cakes were being baked in the oven and the chef was preparing a home-made Bakewell Tart. Staffing levels are good and staff morale is high resulting in an enthusiastic workforce that works positively with residents to improve their whole quality of life. They were kind and respectful when supporting residents. Residents spoken to said that staff were kind and caring. The Manager provides clear leadership throughout the home, which ensures all of the staff team are aware of their roles and responsibilities. The Abbeyfield Society regularly reviews the home`s performance and seeks the views of residents, relatives and other interested parties about the service provided.

What has improved since the last inspection?

Overall, there has been a big improvement in the standard of care planning. Care plans were detailed with relevant information and were easy to read and understand. There was written evidence that 3 of the 4 residents, whose care plans were looked at, had been regularly consulted about their own plan of care. Since the last inspection, the Deputy Manager`s hours have been increased and both management and staff felt that this had led directly to improvements in the home. The records of three recently employed staff were examined. This showed that appropriate vetting checks had been carried out, which helps to protect residents.

What the care home could do better:

It was noted that one resident, who has poor mobility, did not have her call bell close to hand. She was also not wearing her glasses, although her plan of care indicated that she should be reminded to do this. A carer spoken to was unsure whether she needed to wear glasses. The care staff should be reminded of the importance of these matters. The systems for the administration of medication were generally good but need some improvement to ensure that medications are recorded correctly for the safety of residents.The Manager needs to ensure that any cupboards used to store linen, are marked with appropriate fire safety signage and kept locked. The hot water temperature supplied to a bath was higher than it should be for safety. This needs to be attended to.

CARE HOMES FOR OLDER PEOPLE Abbeyfield Residential Care Home 40 The Grove Gosforth Newcastle Upon Tyne Tyne & Wear NE3 1NH Lead Inspector Janine Smith Key Unannounced Inspection 14th June 2006 09:00 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 Residential Care Home DS0000000429.V290713.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 Residential Care Home DS0000000429.V290713.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbeyfield Residential Care Home Address 40 The Grove Gosforth Newcastle Upon Tyne Tyne & Wear NE3 1NH 0191 285 2211 0191 285 2211 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) Abbeyfield Newcastle upon Tyne Society Mrs Kath Brown Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32) of places Abbeyfield Residential Care Home DS0000000429.V290713.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: There are no additional Conditions of Registration. Date of last inspection 22nd November 2005 Brief Description of the Service: The Abbeyfield residential care home at 40 The Grove, Gosforth, provides care for up to thirty-two frail elderly people. Nursing care is not provided. The fees are £1,748 per calendar month. The fee does not include hairdressing, private chiropody, toiletries or newspapers. Part of the building is an older style but has been adapted well. The other part was purpose built and all on ground level. There are a variety of aids and adaptations around the building to help residents to move about more independently. Single bedrooms are provided throughout. Each has an en-suite toilet and sixteen have an en-suite shower. The bedrooms are located on the ground and first floor of the building, which has a passenger lift. The home has several lounges and dining areas. There are four assisted baths and one shower, along with eight separate toilets. The home is set with large, attractive grounds filled with mature plants, which are well maintained. The home is run by the Abbeyfield Society. Information about the service, including inspection reports, is readily available. Abbeyfield Residential Care Home DS0000000429.V290713.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took 9 ¾ hours and the home had not been given advance warning. A tour of the premises was made and some of the bedrooms were seen. The systems for the storage, handling and administration of medication were looked at, as well as the system for handling residents’ personal monies. A sample of records about residents and staff were also looked at. 7 of the people living in the home were spoken to. The Manager and 4 of the staff were also spoken to. Before the inspection took place, a number of questionnaires for the use of residents and relatives, were sent to the home. The questionnaires provide an opportunity for residents and relatives to pass on their opinions about the home directly to the Commission. On arrival at the home, it was noted that these questionnaires were placed in the foyer area for people to help themselves. At the time of writing this report, 2 replies had been received from residents and 1 from a relative. What the service does well: The process followed in the home ensures that potential residents are provided with details of the services the home provides which helps them to make an informed decision about coming to stay in the home. Residents were very well cared for and carer staff well informed about their needs. Those residents spoken to said that they were well cared for by the staff and treated well, although one said some staff are better than others. Two residents who replied to our questionnaire, also said they received the care and support they needed, although one said, ‘occasionally a reminder is needed …… (but) staff all exceedingly helpful and friendly’ and the other said staff ‘often forget my requests, i.e. tea at a certain time or similar’. Residents enjoy social activities inside and outside the home, which provides variety and interest for them. A resident said she had been disappointed that a social activity had been cancelled on one occasion as staff were busy but had enjoyed a recent Garden Party to celebrate Abbeyfield’s 50th year and was looking forward to an outing to a local park the following week. Visitors are made welcome which helps residents keep in contact with family and friends. A carer also said that relatives could stay for meals and that the conservatory had been used to provide a dining area where a family could eat in private. Abbeyfield Residential Care Home DS0000000429.V290713.R01.S.doc Version 5.2 Page 6 Residents are encouraged to look after their own financial affairs and are also helped to look after their own medication if they are able to do this safely. There are good choices of well-cooked food available. There were a lot of fresh fruit and vegetables in the stores and fresh whole milk and cream available. A stock of Magnum™ ice creams was also in the fridge which residents were said to enjoy on hot days. Fresh cakes were being baked in the oven and the chef was preparing a home-made Bakewell Tart. Staffing levels are good and staff morale is high resulting in an enthusiastic workforce that works positively with residents to improve their whole quality of life. They were kind and respectful when supporting residents. Residents spoken to said that staff were kind and caring. The Manager provides clear leadership throughout the home, which ensures all of the staff team are aware of their roles and responsibilities. The Abbeyfield Society regularly reviews the home’s performance and seeks the views of residents, relatives and other interested parties about the service provided. What has improved since the last inspection? What they could do better: It was noted that one resident, who has poor mobility, did not have her call bell close to hand. She was also not wearing her glasses, although her plan of care indicated that she should be reminded to do this. A carer spoken to was unsure whether she needed to wear glasses. The care staff should be reminded of the importance of these matters. The systems for the administration of medication were generally good but need some improvement to ensure that medications are recorded correctly for the safety of residents. Abbeyfield Residential Care Home DS0000000429.V290713.R01.S.doc Version 5.2 Page 7 The Manager needs to ensure that any cupboards used to store linen, are marked with appropriate fire safety signage and kept locked. The hot water temperature supplied to a bath was higher than it should be for safety. This needs to be attended to. 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 Residential Care Home DS0000000429.V290713.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 Residential Care Home DS0000000429.V290713.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 5. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Potential residents are provided with details of the services the home provides which helps them to make an informed decision about coming to stay in the home. A contract is agreed with new residents, which means they can be clear about the services the home will provide and the fees charged for this. Detailed assessments are made before people are offered places in the home, which ensures that their needs can be met. Abbeyfield Residential Care Home DS0000000429.V290713.R01.S.doc Version 5.2 Page 10 EVIDENCE: Two residents completing questionnaires stated they have received a contract and received enough information about the home. One also stated that they had a trial period and soon found it a good move. The other stated staff paid a visit to their home to explain. Inspection of the records for a recent admission showed that a full assessment had been carried out before their admission, including making contact with their GP to obtain information about health care needs. A thorough care plan had then been put in place and discussion with a carer showed that they were well informed about this resident’s needs. The resident confirmed that they had visited the home and received written information about it which helped them make a decision about whether it was the right place for them. They had been given a list of useful things to bring with them and a copy of a recent inspection report. They had received a Contract once they decided to stay in the home. This resident said that the staff team provided good care and she was happy to stay in the home. The Manager said that the information produced by the home for residents is also available in a Large Print format. Abbeyfield Residential Care Home DS0000000429.V290713.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Good care planning arrangements are in place, which means that residents are consulted about how they want to be supported and that staff are well informed about their needs. However, staff may need reminders about those residents who need extra monitoring. Residents are treated with respect by the staff team. There are good arrangements in place to ensure that residents’ health care needs are met. The systems for the administration of medication were generally good but need some improvement for the safety and well-being of residents. Abbeyfield Residential Care Home DS0000000429.V290713.R01.S.doc Version 5.2 Page 12 EVIDENCE: Four care plans were inspected and found to be thorough and based on a clear, up-to-date assessment of the individual residents’ needs, apart from one lacking a written plan of care for the prevention of falls, where it was known there was a risk of this resident having falls. However, overall there has been a big improvement in the standard of care planning. Residents are encouraged to be as independent as possible. Care plans were detailed with relevant information and were easy to read and understand. 3 of the 4 residents had been regularly consulted about their own plan of care. In addition, a meeting is held with each resident at six monthly intervals to review their care formally. Residents confirmed that they saw doctors when they needed to and saw dentists, opticians and chiropodists as they wished. The outcome of these consultations was clearly recorded in the care records seen. A resident, who has poor mobility, did not have her call bell close to hand. She was also not wearing her glasses, although her plan of care indicated that she should be reminded to do this. A carer spoken to was unsure whether she needed to wear glasses. However, otherwise residents were very well cared for and carers were well informed about their needs. Their health was monitored closely. They were being weighed regularly and residents at risk of pressure sores were being assessed and provided with pressure relieving equipment. Residents said that they were well cared for by the staff and treated well, although one said some staff were better than others. Two residents who replied to our questionnaire, also said they received the care and support they needed, although one said, ‘occasionally a reminder is needed …… (but) staff all exceedingly helpful and friendly’ and the other said staff ‘often forget my requests, i.e. tea at a certain time or similar’. One relative said via a questionnaire that they were not always kept informed of important matters affecting their relative. Residents are encouraged and supported to look after their own medication, if they are able to do this safely. Otherwise, senior care staff take responsibility for this and have received training from their supplying pharmacist. A random sample of medication records and the system for storage and handling medication was looked at and found to be appropriate, other than: a controlled medication, which was being stored for a resident, had not been logged into the Controlled Drug Register; Abbeyfield Residential Care Home DS0000000429.V290713.R01.S.doc Version 5.2 Page 13 - there was an inconsistency in the written records about the times at which several medications prescribed to relieve the symptoms of Parkinson’s Disease, should be administered. As the time of administration is important, all of the records must be kept up to date. In this case, the resident administered her own medication and was said to know when to do this. The staff respect residents’ privacy and dignity and a resident confirmed this. The manager of the home ask residents for their opinions about this area of their care when reviews are carried out and via a quality assurance questionnaire. Residents are also asked whether they prefer a female or male carer to help them with personal care tasks. Staff were patient and kind to residents and supported them to make their own choices. Abbeyfield Residential Care Home DS0000000429.V290713.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Residents enjoy social activities inside and outside the home, which provides variety and interest for them. Visitors are made welcome which helps residents keep in contact with family and friends. Residents are helped to have choice and control over their lives, which means their wishes and rights are respected. There are good choices of well-cooked food available, which provides nutrition and interest for the residents living in the home. Abbeyfield Residential Care Home DS0000000429.V290713.R01.S.doc Version 5.2 Page 15 EVIDENCE: Information provided by the Home before the inspection showed that social activities carried out in the home include board games, exercises, crafts and television, videos and music. A carer confirmed that staff had time available to support residents with social activities including walks around the garden, soft ball, knitting, manicures and film shows with ice cream. Social activities are provided daily. A student on placement also said that she had helped with social activities. A carer was playing a board game with a resident during the inspection. A resident said that the planned social activities were shown on the noticeboard and in a newsletter. She had been disappointed that a social activity had been cancelled on one occasion as staff were busy but had enjoyed a recent Garden Party to celebrate Abbeyfield’s 50th year and was looking forward to an outing to a local park the following week. Another resident also said she had enjoyed the garden party. She also enjoyed visits by entertainers that she said took place now and again. Some other residents could not recall any social activities. Residents are asked about their spiritual requirements when they come to stay at the home and arrangements are made for them to attend places of worship if they wish to. This is detailed in their care records. Two residents confirmed that their family could visit at any time. A relative completing a questionnaire also said that they were welcome to visit at any time and could see their relative in private. A carer also said that relatives could stay for meals and that the conservatory had been used to provide a dining area where a family could eat in private. A resident said that she liked to have a lie in and have breakfast in bed, which was respected. Residents are encouraged to look after their own financial affairs. They are also helped to look after their own medication if they are able to do this safely. The Manager was aware of local Advocacy services and said that she has offered support to residents in the past to obtain these. Information about the Advocacy Services was posted on the notice-board. A resident said that she could bring items of furniture from her home to furnish her bedroom. A menu was provided which showed that choices are available at every meal. A resident also confirmed this. One resident completing a questionnaire said that they ‘always liked the meals’ and another said they ‘usually’ liked them. Abbeyfield Residential Care Home DS0000000429.V290713.R01.S.doc Version 5.2 Page 16 One commented in addition, ‘What lovely soups always’, whilst the other said, ‘Not enough at times’. One resident said that the chef was very good but had sometimes forgotten to re-order the ‘Nescafe’ before it ran out. One resident said that they did not like the food but did not know how it could be improved. The staff were trying to address this. The staff offered choices to residents before and during the lunch-time meal. They also observed whether residents were eating well and if not, offered an alternative meal. Residents who needed help were given sensitive support. The lunch-time meal provided on the day of inspection was juice and soup followed by a choice between roast lamb, vegetables and Yorkshire pudding or sweet and sour chicken with rice. This was followed by bread and butter pudding with custard or ice cream. The chicken and pudding were sampled and found to be hot, tasty and very appetising. The dining tables were set out attractively, including freshly cut flower posies from the garden. The chef was well informed about the residents and about good nutrition for older people. There were a lot of fresh fruit and vegetables in the stores and fresh whole milk and cream available. A stock of Magnum™ ice creams was also in the fridge which residents were said to enjoy on hot days. Fresh cakes were being baked in the oven and the chef was preparing a home made Bakewell Tart. Abbeyfield Residential Care Home DS0000000429.V290713.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. There is an effective complaints procedure which means that residents and their representatives are listened to and concerns acted upon. Staff have good knowledge of adult protection issues which helps protects residents from abuse. EVIDENCE: Two residents completing a questionnaire said they knew who to speak to if they were unhappy. A resident confirmed that she would readily tell the staff if she had any concerns and that she had been given a copy of the Home’s complaints procedure. The Manager had investigated three complaints and a record had been kept of the outcome of these. A carer confirmed that they would inform the Manager or Deputy Manager is they became aware any resident was unhappy about anything. The carer was also aware of the Home’s whistle blowing procedure and what action to take if they suspected abuse, having had training. Examination of staff records showed that training in the protection of vulnerable adults has taken place and further training is planned. Abbeyfield Residential Care Home DS0000000429.V290713.R01.S.doc Version 5.2 Page 18 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 and 26 Quality in this outcome area is excellent. This judgement has been made from evidence gathered both during and before the visit to this service. The building provides suitable, well-maintained accommodation for older people who require care due to frailty, which means they have a clean, comfortable and suitably equipped home. EVIDENCE: Each resident has a single en-suite bedroom. A tour of the premises was made and seven residents’ bedrooms were seen. The home is comfortable and maintained to a good standard. It was noted, however, that the doors to the kitchen and food storage need repainting. There was no waste paper bin for used paper hand towels in a bathroom. Consideration should be given to whether additional privacy screening is needed in the bathrooms with large frosted glass windows. Abbeyfield Residential Care Home DS0000000429.V290713.R01.S.doc Version 5.2 Page 19 The home is clean and staff were aware of good hygiene practice and have protective clothing available to them. There is a large garden, which is well maintained and offers lovely sitting areas. It was noted that one lounge has a French door to the garden but there was a deep step down which might cause difficulties to residents using mobility aids or with visual impairments. Abbeyfield Residential Care Home DS0000000429.V290713.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The number and type of staff on duty throughout the day and night is sufficient to meet the needs of residents. Staff morale is good resulting in an enthusiastic workforce that works positively with residents to improve their whole quality of life. Thorough vetting procedures are followed before staff are recruited, which helps to protect the residents. The arrangements for the induction and training of staff are good, which helps ensure that the staff have a clear understanding of their roles. EVIDENCE: Examination of the staff rotas and discussion with the Manager and other members of the staff team showed that the numbers of staff are as follows:8 am to 10 pm 5 10 pm to 8 am 3 (sometimes 4) waking Abbeyfield Residential Care Home DS0000000429.V290713.R01.S.doc Version 5.2 Page 21 The above includes a senior member of staff and is enough to meet the needs of residents. The Manager’s hours are not included in the above nor staff employed for other tasks such as food preparation, cleaning and laundry. Since the last inspection, the Deputy Manager’s hours have been increased and both management and staff felt that this had led directly to improvements in the home. There has been about 33 staff turnover since the last inspection due to various reasons. The Manager is currently seeking suitable staff to fill these vacancies and in the meantime, agency staff are being used. The Manager tries to ensure that the same people are provided by the agency, which helps consistency of care. The records of three recently employed staff were examined. Appropriate vetting checks had been carried out. It was confirmed with the Manager, a member of staff and examination of records that induction training to Topss standards is carried out. The Manager confirmed that 60 of the care staff team have now achieved an National Vocational Qualification (NVQ) at Level 2 or above. NVQ certificates were seen on staff files examined. The staff were kind and respectful when supporting residents. They enjoyed their work and were keen to develop their skills further. Residents said that staff were kind and caring. Abbeyfield Residential Care Home DS0000000429.V290713.R01.S.doc Version 5.2 Page 22 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, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The Manager provides clear leadership, which ensures all of the staff team are aware of their roles and responsibilities. The Manager and the Abbeyfield Society regularly review the home’s performance through a good quality assurance system, which includes seeking the views of residents, relatives and other interested parties. The system for handling residents’ money is thorough, which helps protect residents and staff. There is generally a thorough approach to health and safety, which helps to protect residents and staff, though a couple of matters need to be dealt with. Abbeyfield Residential Care Home DS0000000429.V290713.R01.S.doc Version 5.2 Page 23 EVIDENCE: The Registered Manager, Mrs Kath Brown, has managed the home successfully for a number of years. She has achieved the Registered Manager’s qualification. A member of staff said that the Manager was always approachable and they could raise any issues with her. The home uses various methods to seek the views of residents, relatives and other interested parties, to provide feedback on the quality of care provided. Formal review meetings are held with residents individually at 6 monthly intervals. There are also informal meetings to which all residents are invited. Residents and their relatives are also sent questionnaires and the results of these are analysed. Members of the Abbeyfield Committee also make unannounced visits to the home and write a report. The Manager has implemented various audit procedures and in addition, the Abbeyfield Society carries out a quality assurance assessment of all its homes. The system for handling and storing money held on behalf of residents was looked at. This was found to be appropriate. A generally thorough approach is adopted towards health and safety. There is a system in place to ensure that the staff team are given training in moving and handling skills, fire safety, food hygiene, first aid and infection control. A fire risk assessment has been carried out and regular fire safety checks take place. Since the last inspection, a small fire broke out in a grill in the kitchen but appropriate emergency action was taken at the time and other steps taken to prevent a recurrence. A cupboard was being used to store linen and was not marked with appropriate fire signage and kept locked. The temperature of water to 2 baths was tested; one was too hot at 46o centigrade. Abbeyfield Residential Care Home DS0000000429.V290713.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 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 3 17 X 18 3 3 X X X X X X 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 3 X 3 X 3 X X 3 Abbeyfield Residential Care Home DS0000000429.V290713.R01.S.doc Version 5.2 Page 25 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 OP8 Regulation 12(1) Requirement Timescale for action 31/07/06 2. OP9 13 Ensure that care staff are fully aware of those residents who may need prompting to wear glasses and that the pull cords are placed close to residents who have mobility difficulties. The times at which each 16/06/06 medication must be administered must be recorded accurately on the medication administration record and the medi-pack used by a resident. The details of any controlled drugs being stored by the home must be entered into the Controlled Drug Register. 3. 4. 9. OP26 OP38 OP38 13(3) 23(4)(c) (i) 13(4) Ensure that suitable waste bins are provided in bathrooms for used paper hand towels. Ensure cupboard used to store linen is marked with appropriate fire signage and is kept locked. Ensure that the thermostatic control device on the bath is functioning correctly to deliver hot water at no more than 43o centigrade. Monitor the DS0000000429.V290713.R01.S.doc 31/07/06 16/06/06 16/06/06 Abbeyfield Residential Care Home Version 5.2 Page 26 temperature of hot water at regular intervals and always before bathing residents. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP19 Good Practice Recommendations Consideration should be given to whether additional privacy screening is needed in the bathrooms with large frosted glass windows. Review accessibility/safety of high step down to the garden from ground floor lounge in Ellerby wing and give consideration to need for ramp or suitable alternative. 2. OP19 Abbeyfield Residential Care Home DS0000000429.V290713.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 Residential Care Home DS0000000429.V290713.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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