Inspection on 12/12/05 for Abbeyfield St Martins

This inspection was carried out on 12th December 2005.

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.

Other inspections for this house

Abbeyfield St Martins 02/11/09

Abbeyfield St Martins 30/07/07

Abbeyfield St Martins 02/08/06

Abbeyfield St Martins 27/06/05

Abbeyfield St Martins 24/11/04

Abbeyfield St Martins 13/07/04

Abbeyfield St Martins 06/01/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Abbeyfield St Martins St Martins Martin Square Larkfield Aylesford Kent ME20 6QJ Lead Inspector Sally Hall Announced Inspection 12th December 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 St Martins DS0000024021.V259683.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 St Martins DS0000024021.V259683.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Abbeyfield St Martins Address St Martins Martin Square Larkfield Aylesford Kent ME20 6QJ 01732 842628 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) The Abbeyfield Medway Valley Society Mrs Janet Moulton Care Home 41 Category(ies) of Old age, not falling within any other category registration, with number (41) of places Abbeyfield St Martins DS0000024021.V259683.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th June 2005 Brief Description of the Service: St Martins is a purpose built dwelling owned by the Abbeyfield Medway Valley Society and registered for the care of forty-one older people who do not require nursing care. The home is situated in the centre of Larkfield with shops and other facilities in the immediate vicinity. Accommodation consists of twentyone single bedrooms and five shared rooms. Only three of the single rooms have en-suite facilities but the home has adequate toilets and bathrooms. There are four separate day rooms and a large dining room. There is also a day care centre within the home. There is adequate parking either in the grounds of the home or in the public car park opposite the home. Abbeyfield St Martins DS0000024021.V259683.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Announced Inspection at St Martins took place on 12th December 2005 between 10am and 5pm. The Inspector agreed and explained the inspection process with the Registered Manager and her assistant. Documentation and records were read, including care plans. Time was spent reading a sample of written policies and procedures, reviewing care plans and records kept within the home. A tour of premises was also undertaken although not fully inspected. The focus of the inspection was to assess St Martins in accordance with the National Minimum Standards for Older People. In some instances the judgement of compliance was based solely on verbal responses given by those spoken with or canvassed. What the service does well: What has improved since the last inspection? What they could do better: The Service Users Guide and Statement of Purpose need to be reviewed to include relevant information for prospective service users to make an informed choice. Medication received needs to be recorded to ensure that an audit is possible on a regular basis. All care and assistance that staff provide to service users should be reflected in the daily notes so that they cross reference well with the care plans. The home has allowed the periodic electrical certificate and PAT testing certificate to expire, all maintenance certificates must be monitored and kept current. Abbeyfield St Martins DS0000024021.V259683.R01.S.doc Version 5.0 Page 6 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 St Martins DS0000024021.V259683.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Abbeyfield St Martins DS0000024021.V259683.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1-5 Service users do not have all the information they need to ascertain whether the home can meet their needs. Service users rights are protected by a written contract / statement of terms and conditions. Service users care needs are assessed to ensure the home can meet their individual needs before a place is offered. Prospective service users have the benefit of a trial period at the home to assess whether the home can meet their needs. EVIDENCE: There is a Statement of Purpose and Service Users Guide as one document. It was not evident when this was last reviewed. The manager was asked to check the contents as not all the information required was available for service users and their families to make an informed decision about the home. The service users are provided with contracts that are clearly written and contain the required information including the fee payable and who is responsible for that payment. Abbeyfield St Martins DS0000024021.V259683.R01.S.doc Version 5.0 Page 9 A pre-assessment is completed for all new service users coming in to the home. The manager or her assistant visit the service users at home or in hospital to start to complete the assessment. The assessment is completed when the service user comes into the home for their trial period. The manager also ensures that the home receives the care manager’s assessment / care plan before assessing if they can meet the service user’s needs. The home develops a plan of care from the assessments in order to ensure that the service users need’s will be met. The staff receive training to ensure that they can meet these needs. All prospective service users are offered a chance to spend at least a day at the home prior to moving in. The families are also encouraged to visit and ask questions before the service user is admitted. All admissions are on a 28 day trial period. Abbeyfield St Martins DS0000024021.V259683.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): 7-11 The care needs of service users are protected by the home’s robust care planning procedures. The health and wellbeing of service users is preserved by staff monitoring and taking action when required. The residents could potentially be put at risk by the inadequate recording of the administration and dispensing of medication. The service users dignity and privacy are preserved, and their last wishes are respected. EVIDENCE: Service users files contained a care plan, which was based on the assessment done carried out prior to admission. Staff are reviewing these plans each month but are not recording any outcomes. There was no evidence that service users are re-assessed regularly. Good practice indicates service user assessments need to be reviewed every 6 months or before if there are significant changes, with a new plan of care being agreed with the service user. There was evidence seen that service users are involved in the formation Abbeyfield St Martins DS0000024021.V259683.R01.S.doc Version 5.0 Page 11 of these plans. The content of the daily reports was discussed. These did not detail all the care and input service users had received through the course of the day. It was evident that staff provide a lot of care for the service users, but this was not reflected in the daily notes and entries did not contain the times events and care provision had taken place. All service users have access to their GP. There is a surgery next to the home and many service users can have an appointment and visit the doctor there. Service users are encouraged to keep the doctor they had at home if they are still in the area. Health problems were recorded in daily reports, along with any follow up action. The home facilitates visits from the optician, dentist and the chiropodist as required if service users are not able to visit them. The Manager monitors falls and accidents and risk assessments were seen in place for service users that are at risk. The home always tries to provide an escort for planned hospital visits if the family are not available. The storage, administration and recording of medication was inspected. The manager stated that she and the assistant monitor the recording of medication. However, there the Medication Record Sheets did not show the total amount of medication received into the home at the beginning of the period, or what had come in during the period. This made an audit of medication difficult. Medication did not tally with the sheets. The large amounts of PRN medication that are used on a regular basis was discussed with the manager and it was suggested that perhaps this could be put in to the system used in the home. The manager was also asked to ensure that any allergies service users have should be recorded on the Medication Record Sheet. Storage met the standard, as did the recording of controlled medication. The room used for medication was found to be clean and tidy, the trolley is locked to the wall when not in use. The assistant manager explained that medical examinations and consultations take place in the service users’ own rooms. The home has visitors’ rooms and areas where the service users can sit quietly if they wish. Staff treated the service users with respect and took care when enquiring about personal issues. They were seen knocking on bedroom doors before entering. Service users spoken to confirmed that the staff at the home respect their privacy and dignity. The home has documented the funeral wishes of the service users. The manager explained that a home for life is offered, and they are often able to offer care and support with the help of the GP and district nurse. The deputy manager explained that the families of terminally ill clients are supported as well as the service users themselves. Abbeyfield St Martins DS0000024021.V259683.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): 12-15 Service users are provided with a choice of activities and entertainment. Family and friends are encouraged to visit by the welcoming atmosphere created in the home. Service users benefit from a varied and nutritious menu. EVIDENCE: The home has an activity programme that was seen displayed in the day centre lounge. Activities are organised by a co-ordinator and partly facilitated by staff and volunteers. Activities on offer included bingo, quizzes, flower arranging, arts and crafts, reminiscence, puzzles and games. At the time of the inspection the co-ordinator was on annual leave and staff were fitting activities in around their other work. Service users are able to choose which activities they wish to participate in and the home has organised outings, seasonal activities and visiting entertainers. The record of activities showed that there are a number of service users that join in on a regular basis. Some service users prefer the one to one chats etc. One service user spoken with said that they had certain events they liked to take part in, but the rest of the time they liked to stay in their room. Another said the staff always tell them what is going on and they can choose whether they attend. The home operates an open visiting policy and service users can meet with their relatives in private or in one of the lounges. A number of friends and Abbeyfield St Martins DS0000024021.V259683.R01.S.doc Version 5.0 Page 13 family were visiting relatives at various times during the day. One family spoken with said that they are always made to feel welcome and enjoy visiting the home. It was evident from discussion with several service users that the routines of the home are sufficiently flexible to allow for individual preferences in respect of personal care. Throughout the day staff encouraged service users to make choices about various aspects of their lives. Several service users confirmed that they spend the day the way they want to and the staff help them to do this. Service users have a choice of meals through the day and lighter options are also available. A daily record is kept of what choices the service users make. Service users spoken with said they enjoy the meals most days. They said there was not always a choice at lunchtime as they felt salad was not a choice. The meal on the day of inspection was not a favourite with all the service users but they felt there was no real alternative. This was brought to the attention of the manager. The menu showed a choice of salad for that day and a number of other days. Service users said they would prefer the choice of another hot meal through the winter. The manager is to review this and talk to the service users at their next meeting. Abbeyfield St Martins DS0000024021.V259683.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Service users can be assured that any complaint will be taken seriously and used to improve the service when possible. Service users are protected by the home having an adult protection policy. However it has not been reviewed and does not reflect recent changes to legislation and local protocols. EVIDENCE: There is a complaints procedure and file. Two complaints have been received since the last inspection. Both have been brought to a satisfactory conclusion within the timescale framework. The manager stated that they look at complaints in a positive way that helps them to improve the service they offer. The home has a copy of the local authority adult protection protocols issued earlier this year. There is a whistle blowing policy for staff. However, this needs to be reviewed to reflect the recent changes in the local protocol and legislation regarding POVA etc. Not all staff had undertaken adult protection training. Abbeyfield St Martins DS0000024021.V259683.R01.S.doc Version 5.0 Page 15 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): These standards were not assessed during this inspection. EVIDENCE: Abbeyfield St Martins DS0000024021.V259683.R01.S.doc Version 5.0 Page 16 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): 28,27 Service users benefit from being care for by staff who have undergone the relevant checks at the point of employment and have been trained. EVIDENCE: The home has been proactive regarding NVQ’s. Over half the home’s staff have achieved NVQ level 2 or above in care, and further staff are either on the course or have a starting date. Staff files sampled contained the required documentation and included application forms, interview notes, references, ID and CRB checks etc. Abbeyfield St Martins DS0000024021.V259683.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): 32,35, 36,38 Service users benefit from the management ethos and approachable staff. Their personal monies are safeguarded by the home if they choose not to handle their own finances. Service users would benefit from staff receiving regular supervision. The service users health and safety is not fully protected due to the required testing of electrical installation and appliances not taking place. EVIDENCE: The home has a very positive and friendly atmosphere, with service users who appeared comfortable with their surroundings. Service users who were able to express an opinion said that the staff were “very patient and kind”, “they Abbeyfield St Martins DS0000024021.V259683.R01.S.doc Version 5.0 Page 18 always listen and do what they can to help”. Service users said that they felt that all staff were approachable especially the managers. The home holds a small amount of personal monies for those service users who don’t wish to handle their own finances. Records for a number of service users were sampled and the money was found to be correct. Records showed that all staff are starting to receive formal supervision. Documentation covers the topics needed to meet the criteria set out in this standard. The manager is aware of the frequency needed for staff supervision and is now monitoring to ensure that the sessions happen on a regular basis. Various measures have been taken to promote safe working practices in the home. This includes training staff in moving and handling, first aid, health/safety, infection control plus regular checks and monitoring of systems in the home. The home has a COSHH file available for staff to use in an emergency. The fire log is being completed, and staff have now had fire training. The home has building risk assessments both general and for each service user’s bedroom. The maintenance certificates such as gas and LOLER were in place and current. However, the periodic electrical certificate was 2 years out of date and the manager said that she had arranged for this to be completed the following day. PAT testing was also out of date and the manager was asked to ensure that this is completed by the 13 January 2006. When these tests have been completed a copy of the certificates are to be sent to the Commission for Social Care Inspection. The home has recently been awarded a gold with distinction for the cleanliness of their kitchen. Abbeyfield St Martins DS0000024021.V259683.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 2 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 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 2 X X X X X X X X STAFFING Standard No Score 27 X 28 3 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 X X 3 2 X 2 Abbeyfield St Martins DS0000024021.V259683.R01.S.doc Version 5.0 Page 20 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 OP38 Regulation 23 Requirement The registered manager must ensure so far as is reasonably practicable the health, safety and welfare of service users and staff. Copies of the PAT testing and periodic electrical certificate must be sent to Commission for Social Care Inspection when received. The registered person must ensure that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. Timescale for action 13/01/06 2 OP9 17(1)(a) 31/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations DS0000024021.V259683.R01.S.doc Version 5.0 Page 21 Abbeyfield St Martins 1 2 3 Standard OP7 OP1 OP18 Entries in daily records should include the time of care provision and events and the input to service users through the day. The Statement of Purpose should be reviewed to ensure it contains all the relevant information. The adult protection policy/procedure should be reviewed. Abbeyfield St Martins DS0000024021.V259683.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 St Martins DS0000024021.V259683.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. 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