CARE HOMES FOR OLDER PEOPLE
Abbeyfield Residential Care Home Castle Farm Road Newcastle Upon Tyne Tyne & Wear NE3 1RF Lead Inspector
Janine Smith Unannounced Inspection 28th September 2005 10:00 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 DS0000000430.V252241.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 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 DS0000000430.V252241.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Abbeyfield Residential Care Home Address Castle Farm Road Newcastle Upon Tyne Tyne & Wear NE3 1RF 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) 0191 2841344 0191 2841331 Abbeyfield Newcastle upon Tyne Society Mrs Christine Major Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Abbeyfield Residential Care Home DS0000000430.V252241.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 20th April 2005 Brief Description of the Service: Abbeyfield Castle Farm provides a home for twenty-four older people who require residential care. Nursing care cannot be provided. The building is single storey providing ground floor accommodation throughout and is set in a residential area close to Jesmond Dene and the Freeman Hospital. There are public transport links close by. There are a variety of aids and adaptations around the building to allow residents to move about more independently. All of the bedrooms are single and have an en-suite toilet. There are three communal bathrooms, which also have toilet facilities and a shower. The home is set within very attractive large grounds filled with mature plants, which are well maintained. The home is run by the Abbeyfield Society, which is a voluntary organisation. Abbeyfield Residential Care Home DS0000000430.V252241.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place over 5 hours and was an unannounced visit. A partial tour of the premises took place and a sample of care records were inspected as well as other records. The Manager and four of the staff on duty and six of the twenty-four residents were spoken to. This was a very positive inspection and there was good evidence that the home is well run and that residents were satisfied and happy living here. What the service does well:
Since the last inspection the previous Manager has retired. A new Manager, Mrs Christine Major has been appointed and has been registered by the Commission. There was plenty of evidence to demonstrate that Mrs Major provides good leadership to the staff team and sets and maintains high standards within the home. The home has a group of staff have worked at the home a long time. They are caring and enthusiastic and appear to enjoy their work and have a genuine regard for the people living in the home. Residents spoken to felt that the staff team were kind and helpful to them. A resident said that this was a good place to live. Good arrangements are in place to ensure that residents’ health and wellbeing is monitored and they see health care professionals at appropriate intervals. Medication is stored well and the systems for ordering, checking and giving medication were safe. There is a good range of daily activities and entertainments providing stimulation for mind and body. A resident said they had recently had outings to Corbridge and Seaton Sluice and enjoyed a tribute concert at the City Hall about the ‘War Years’. He also confirmed that they were consulted for their opinions at regular meetings and that action is taken when they make suggestions. Residents are very involved in setting the agenda for their meetings and running the Committee. Abbeyfield Residential Care Home DS0000000430.V252241.R01.S.doc Version 5.0 Page 6 The home provides good quality accommodation within very pleasing grounds and both are well maintained. The home was very clean and no unpleasant smells were noted. Seventy-one per cent of the care staff team have now achieved an NVQ Level 2 or above, which helps to ensure that the staff team are well trained and understand their job. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection.
Abbeyfield Residential Care Home DS0000000430.V252241.R01.S.doc Version 5.0 Page 7 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Abbeyfield Residential Care Home DS0000000430.V252241.R01.S.doc Version 5.0 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 DS0000000430.V252241.R01.S.doc Version 5.0 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): Standards 1,3, 4 and 5 were inspected at the last inspection. EVIDENCE: Abbeyfield Residential Care Home DS0000000430.V252241.R01.S.doc Version 5.0 Page 10 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 9. There are good arrangements in place to ensure that residents’ health care needs are met, which ensures that their wellbeing is monitored by the staff team at all times. The systems for the administration of medication are good with clear and comprehensive arrangements being in place to ensure service users medication needs are met. EVIDENCE: Two care plans were inspected and found to be thorough and based on a clear assessment of the individual residents’ needs. The records showed they had regular appointments with dentists, opticians and chiropodists. Where particular health concerns arose, there was evidence that doctors and/or community nurses were contacted for advice and treatment. The new Manager has introduced a more detailed nutritional assessment, which helps identify residents who may need additional support. She has also introduced a ‘Falls Risk Assessment’, which helps identify those factors, which
Abbeyfield Residential Care Home DS0000000430.V252241.R01.S.doc Version 5.0 Page 11 may put a resident at risk of a fall so that preventative action can be taken where possible. All of those residents spoken to, said that they were treated well by the staff. One said that this was a very good place to live. It was apparent that attention was paid to residents’ dignity. The system for the storage, ordering and administration of medication was examined and found to be appropriate. A small sample of medication records were inspected and found to be appropriate. The Manager confirmed that all of the staff handling medication had received accredited training and evidence of this was seen on a small sample of records examined. Abbeyfield Residential Care Home DS0000000430.V252241.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 Social activities are well managed, creative and provide daily variation and interest for people living in the home. EVIDENCE: A resident described the outings and entertainments available to residents, which recently have included trips to Corbridge, Seaton Sluice and a concert at the City Hall about the ‘War Years’. He also regularly participates in the Residents Committee meetings held regularly to obtain residents views and suggestions. He had also organised a ‘sherry’ do for residents with the help of the staff team. Some of the residents run the committee meetings, preparing the agendas and minutes. During the inspection, some residents were participating in a crafts group, which they used for a variety or activities, including writing and reading poetry, craftwork, quizzes and exercises. During the afternoon, the home was visited by a ‘Pets as Therapy’ dog and owner. Abbeyfield Residential Care Home DS0000000430.V252241.R01.S.doc Version 5.0 Page 13 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): Standards 16 and 18 were reported on at the last inspection. EVIDENCE: Abbeyfield Residential Care Home DS0000000430.V252241.R01.S.doc Version 5.0 Page 14 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): 26 As on previous inspection visits, the home was found to be very well maintained with good quality furnishings and décor which creates a pleasant, homely and safe environment for those living there and visiting. EVIDENCE: A tour of the premises was undertaken and a small number of bedrooms viewed. The home is well maintained and décor and furniture is of good quality. The home was very clean and no unpleasant smells were noted. Abbeyfield Residential Care Home DS0000000430.V252241.R01.S.doc Version 5.0 Page 15 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. The number of staff and type of staff on duty throughout the day and night is sufficient to meet the needs of residents. Staff morale is high resulting in an enthusiastic workforce that works positively with residents to improve their whole quality of life. There is little staff turnover and some staff had worked in the home for many years, which provides consistency of care to the residents living in the home. The procedures for the recruitment of staff are robust, which helps to safeguard and protect the people living in the home. There are good training arrangements in place, which means staff are given a thorough grounding in the areas they need to know to provide good care. EVIDENCE: Examination of staff rotas and discussion with members of the staff team provided evidence that there are adequate care staff, including senior carers, on duty as follows:8am-2.30pm 4 2.30pm-9.00pm 3 9.00pm-8am 2 waking Abbeyfield Residential Care Home DS0000000430.V252241.R01.S.doc Version 5.0 Page 16 The Manager’s hours are not included in the above or staff employed for duties such as food preparation, laundry and cleaning. Staff stated that they enjoyed working in the home and had done so for many years. Residents spoken to said that the staff were kind and caring. As there has been little staff turnover, no new staff have been recruited in the last twelve months and therefore recruitment records were not inspected. However, the Manager confirmed that suitable written references and a Criminal Records Disclosure would be obtained before any new staff are recruited. It was confirmed from staff records and from discussion with staff that they receive induction training. The Manager confirmed that ten of the fourteen care staff (71 ) have now achieved an NVQ2 or above. Evidence of NVQ training was seen on a sample of staff records. There was also evidence that staff had received training in other areas, such as diabetes, depression in the elderly, and awareness training re dementia. Abbeyfield Residential Care Home DS0000000430.V252241.R01.S.doc Version 5.0 Page 17 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. The Manager provides clear leadership, which ensures that the home is well run and the staff team are fully aware of their roles and responsibilities. The organisation regularly reviews aspects of its performance through a programme of self-review and consultations, which include seeking the views of residents, relatives and staff. There is an appropriate system in place to safeguard small amounts of money kept by the Management team at the request of some residents. There is a thorough approach to health and safety, which ensures the home provides a safe environment for residents, however, some documentation was out of date. EVIDENCE: Abbeyfield Residential Care Home DS0000000430.V252241.R01.S.doc Version 5.0 Page 18 Since the last inspection, the previous Manager has retired. A new Manager, Mrs Christine Major, has been appointed and has been registered by the Commission. The positive comments of residents, relatives and the staff team give confidence that the Manager provides good leadership throughout the home and has an ‘open door’ policy which encourages good communication. The home has a quality assurance programme in place, which includes seeking the views of residents, relatives and other interested parties, to provide feedback on the quality of care provided. Members of the Abbeyfield Committee make regular unannounced visits to monitor the quality of care provided in the home. In addition, Mrs Major is introducing new internal audit tools to provide information on the way the Home is performing. The payment of fees is handled by the Home’s head office and therefore no records could be examined during this visit. Some residents have asked the Management of the home to look after small amounts of money for them. The system for the storage and handling of this was examined and found to be appropriate. An audit check on two records shows the balances held were correct and receipts and up-to-date records were kept. Mrs Major is currently reviewing the health and safety training for staff and is arranging update training for staff where necessary in the following areas, moving and handling skills, fire safety, first aid, infection control and good hygiene. The Fire Log Book indicated that fire safety checks are carried out routinely, however there was no documentary evidence that fire drills were carried out at the frequency recommended by the Fire Brigade. Evidence of maintenance and servicing contracts were seen in respect of some of the equipment and systems in the home, which ensures that they are maintained safely. But up-to-date documentation could not be found for the testing of portable electrical appliances and electrical wiring in the home. No health and safety hazards were noted during this inspection. Abbeyfield Residential Care Home DS0000000430.V252241.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 Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X X X 3 STAFFING Standard No Score 27 3 28 4 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 DS0000000430.V252241.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 38 Regulation 23(4)(e) Requirement Ensure that the date and outcome of fire drills are recorded in the Fire Log Book. Timescale for action 31/10/05 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 Residential Care Home DS0000000430.V252241.R01.S.doc Version 5.0 Page 21 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
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