Inspection on 04/10/06 for Abbeyfield Stangrove Lodge

This inspection was carried out on 4th October 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.

Other inspections for this house

Abbeyfield Stangrove Lodge 09/09/08

Abbeyfield Stangrove Lodge 10/09/07

Abbeyfield Stangrove Lodge 10/10/05

Abbeyfield Stangrove Lodge 22/06/05

Abbeyfield Stangrove Lodge 05/10/04

Abbeyfield Stangrove Lodge 13/05/04

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 Stangrove Lodge Manor House Gardens Edenbridge Kent TN8 5EG Lead Inspector Alison Spreadbridge Key Unannounced Inspection 4th October 2006 11:00 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 Stangrove Lodge DS0000024017.V312186.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 Stangrove Lodge DS0000024017.V312186.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbeyfield Stangrove Lodge Address Manor House Gardens Edenbridge Kent TN8 5EG 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) 01732 864975 The Abbeyfield Kent Society Mrs Rita Beryl Blatcher Care Home 49 Category(ies) of Dementia (7), Dementia - over 65 years of age registration, with number (22), Old age, not falling within any other of places category (20) Abbeyfield Stangrove Lodge DS0000024017.V312186.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Only 6 Younger Adults are to be admitted to the home until additional communal space has been provided to meet the National minimum Standards Younger Adults with Dementia admitted to the home must be between the ages of 40 and 65 years old Care of two service users in the non dementia wing is restricted to two persons whose date of birth is 01/07/30 and 29/04/19 10th October 2005 Date of last inspection Brief Description of the Service: Stangrove Lodge is located in a quiet residential area within easy walking distance of local shops. All accommodation is on the ground floor. There are plenty of communal areas for residents to access and the majority of bedrooms are single. The gardens include an enclosed sensory garden, which is attractively laid out and well maintained with a paved area and seating, the garden is easily accessible from the home. 24 hour care and support is provided to older people, some of whom have Dementia. The current fees range from £475.00 to £525.00 per week. Abbeyfield Stangrove Lodge DS0000024017.V312186.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced visit was made to the home on the 4th October 2006 at 11.00 am by Alison Spreadbridge. The manager staff and some of the service users were spoken with. Some documentation was seen and a tour of the home made. It was noted during the inspection that the staff on duty were insufficient to meet the assessed needs of service users. This was discussed with the manager who said that one member of staff had rung in sick that morning. The service users spoken with said the staff are always cheerful and made their families welcome when they came to visit. The service users in the dementia unit were interacting well with staff and had ample walking space around the unit. The house and grounds were tidy but is in need of a refurbishment programme. The home will provide past inspection reports on request. What the service does well: What has improved since the last inspection? What they could do better: The service users in the younger adult unit would benefit from additional day space being built as the current day space is clearly too crowded. Parts of the house are in need of redecoration and refurbishment. The home must ensure that staff undertake fire drills as well as awareness training. The home must ensure that there is sufficient staff on duty at all times. The home must ensure that information in service users’ care plans accurately inform the care provided and recorded by staff. Abbeyfield Stangrove Lodge DS0000024017.V312186.R01.S.doc Version 5.2 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 Stangrove Lodge DS0000024017.V312186.R01.S.doc Version 5.2 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 Stangrove Lodge DS0000024017.V312186.R01.S.doc Version 5.2 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, 2,3,4,5,6, Quality of this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users are provided with all of the information they need before moving into the home. EVIDENCE: Prospective service users are encouraged to visit the home prior to taking up residence. Staff spoken with said the prospective service user usually comes for the day so they can see their bedroom and spend time with the other service users. The relative spoken with said the home made them very welcome. As part of the introductory package they are given a copy of the service user’s guide and the home’s statement of purpose. These documents have been updated since the last inspection to take account of the promotion of the deputy manager into the manager’s role. Each service user has a contract with The Abbeyfield Kent Society which outlines their rights and responsibilities. This document is then signed by the Abbeyfield Stangrove Lodge DS0000024017.V312186.R01.S.doc Version 5.2 Page 9 service user or their representative and kept in the service users’ personal files. The manager said that prospective service users are assessed prior to moving into the home. This assessment is usually carried out by herself or one of the senior carers. Assessments are usually undertaken during the day trial visit or staff go out and make the assessment in the person’s home. The home does not provide intermediate care. Abbeyfield Stangrove Lodge DS0000024017.V312186.R01.S.doc Version 5.2 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): 7,8,9,10,11 Quality of this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users have a care plan that meets their assessed needs. The care plans seen had been reviewed within the last two months. EVIDENCE: The service users have an assessment on arrival and from that their care plans are made. These would include suitable risk assessments. The service users spoken with said they felt their needs were being met. Some of the service users were unable to discuss their care plans or understand the care they were receiving. Visitors and relatives spoken with said their family members were well looked after and staff were always cheerful and helpful. The service users were seen to be appropriately dressed for the season and staff were heard speak to them respectfully and in a friendly manner. The storing of the service users’ medication was not seen on this occasion, the home’s policies and procedures were seen. Abbeyfield Stangrove Lodge DS0000024017.V312186.R01.S.doc Version 5.2 Page 11 Service users have access to all local amenities including dental practices. The manager said that the home has a good working relationship with the local doctors surgery and that the district nurses call into the home when requested. It was seen that service users care plans included service users’ individual wishes for their end of life. Abbeyfield Stangrove Lodge DS0000024017.V312186.R01.S.doc Version 5.2 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): 12,13,14,15 Quality of this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home’s lack of staff and an activities co-ordinator is having an effect on the daily lives of service users. The service users would benefit from a more varied activities programme EVIDENCE: There was insufficient staff on duty in the home to meet the assessed needs of service users. On the day of the inspection there was a shortage of staff. The day staff were trying to support service users’ individual personal needs while clearing away breakfast things. One member of staff was cutting a service user’s finger nails in the dining room as she was alone on the unit and it was the only way she could ensure the service users were safe. Some service users spoken with said they had very little to do during the day. It was noted that during the inspection the television was on in one of the unit with a children’s programme which the service users said they did not like. When asked why they did not ask for it to be changed they said the staff were not really around to ask. The member of staff on the unit at the time was attending to another service user’s personal needs. There were three staff working with the service users in the dementia unit. Staff were seen to interact in a very positive way with service users. They Abbeyfield Stangrove Lodge DS0000024017.V312186.R01.S.doc Version 5.2 Page 13 were reassuring one person who was quite anxious and sitting chatting with others as they waited for their lunch. The service users have a varied diet with some choice. The manager said that they are putting new menus into place for the winter, which will offer service users a more balanced and nutritious diet, offering choice and variety. It was noted in one service users care plan that she prefers the support of a female carer. This was not clearly identified on the service user’s daily notes. She had also had a fall, this too was not identified in the daily notes. Abbeyfield Stangrove Lodge DS0000024017.V312186.R01.S.doc Version 5.2 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): 16,17,18 Quality of this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users’ complaints are taken seriously and are fully investigated and a written response made. EVIDENCE: There have been five complaints made to the manager since the last inspection. The concerns raised have been taken seriously. They were investigated and responses made to the service users or their relatives. The concerns were fully documented and written responses made. The complaints procedure is park of the welcome pack provided when people move into the home. This includes the address of the Commission for Social Care and Inspection. The home’s policies and procedures ensure service users rights are protected. Service users and their relatives who were spoken with during the inspection said they felt confident that any concerns brought to the managers attention would be dealt with swiftly. Abbeyfield Stangrove Lodge DS0000024017.V312186.R01.S.doc Version 5.2 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): 19.20.21.22, 23.24.25.26. Quality of this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The house is in need of refurbishment and more attention to safe storage around the house. EVIDENCE: Some parts of the house are showing signs of wear and need to be decorated. In Windsor unit the door had fallen off the cupboard in the kitchen area. Toilets were dirty and smelt of urine. Boxes of pads were being stored in the fire exit, this needs to be removed and stored in a more suitable place. The laundry area was very messy with dirty clothes in the clean area; it is small and difficult to work in. Notices were put on the wall regarding service users’ missing laundry. The lounge in the younger adults unit is very small and does not allow the service users very much personal space. Abbeyfield Stangrove Lodge DS0000024017.V312186.R01.S.doc Version 5.2 Page 16 One of the toilet seats in Malic is loose and needs to be made safe for service users to use. Abbeyfield Stangrove Lodge DS0000024017.V312186.R01.S.doc Version 5.2 Page 17 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): 27,28.29.30 Quality of this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users must be supported by sufficient staff to ensure their assessed needs are met. EVIDENCE: There was insufficient staff on duty at the time of the visit. There were seven staff spread around the various units. Service users were seen wandering around, there were no activities taking place in the majority of the units. One member of staff was seen trying to engage staff with colouring at the table while she was attending to a resident’s personal care. It was clear that staff were stretched and at 11.45 staff were still trying to attend to service users personal needs and clear away from breakfast as well. Staff spoken with said they have a six week induction period and one new member of staff said she had already been put onto an NVQ course. Basic care training including moving and handling is taking place. However some training is being overlooked. One member of staff has been working in the home for a year and has still not undertaken food hygiene training when all staff are responsible for the handling and preparation of snacks on the units. The manager said that supervision is now taking place and this was confirmed by the staff. Formalised supervision taking place and staff said they can have a printed copy of the notes if they want them. Abbeyfield Stangrove Lodge DS0000024017.V312186.R01.S.doc Version 5.2 Page 18 The home must ensure sufficient staff are on duty to meet the assessed needs of service users and enable a wider range of activities to take place. Abbeyfield Stangrove Lodge DS0000024017.V312186.R01.S.doc Version 5.2 Page 19 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): 31,32,33,34,35,36,37,38 Quality of this outcome area is good. This judgement has been made using available evidence including a visit to this service. The new manager is beginning to undertake quality assurance monitoring around the home. EVIDENCE: A new manager has been appointed since the last inspection. The home’s manager has been in post for approximately four months prior to that she was the home’s deputy manager so she knows the home and service users well. She is well qualified to take on the position of home manager. It was noted during the inspection of the fire records that a number of staff are being missed out from the fire drills, some have never taken part at all. The last fire drill was in July. The location of the fire alarms has not been updated since the units had their names changed. This should have been done for the benefit of the person checking the system and the fire service in the event of Abbeyfield Stangrove Lodge DS0000024017.V312186.R01.S.doc Version 5.2 Page 20 an emergency. The records showed that the emergency lighting was last checked on the 31 January 2006. A redecoration programme needs to be put in place to ensure the home is maintained. It is beginning to show signs of real wear and tear. The gardens were however well maintained. The parking area and pathways to the front of the house need to be cleared of moss; it had been raining on the day of the inspection and the surface was quite slippery. The service users’ finances handled by the home were not inspected on this occasion. The home’s policies and procedures are in place to ensure the health and safety of service users is maintained. Abbeyfield Stangrove Lodge DS0000024017.V312186.R01.S.doc Version 5.2 Page 21 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 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 1 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 3 3 3 3 2 3 2 STAFFING Standard No Score 27 1 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 X 3 3 3 Abbeyfield Stangrove Lodge DS0000024017.V312186.R01.S.doc Version 5.2 Page 22 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 OP7 Regulation 15 Requirement The registered provider must ensure that information in the service users care plans is reflected in the care provided and recorded on the daily logs. The home must ensure service users have sufficient activities available throughout the day The home must ensure a varied and well balanced diet is available to service users. The home must ensure the premises is maintained and a programme of maintenance and renewal is in place The registered person shall ensure that all parts of the home to which service users have access are, so far as reasonably practicable, free from hazards to their safety. In that, the fire escapes are storage free. Timescale for action 30/12/06 2 OP12 12 30/12/06 3 OP15 15 30/12/06 4 OP19 13 30/12/06 5. OP24 13(4)(a) 30/12/06 Abbeyfield Stangrove Lodge DS0000024017.V312186.R01.S.doc Version 5.2 Page 23 6 OP26 12 The home must ensure the premises is kept free from offensive odours The registered person shall, having regard to the size of the care home, the statement of purpose and the number and needs of the service users ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users. In that, sufficient staff must be working at the home at weekends. 30/12/06 7. OP27 18(1)(a) 31/12/06 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 Standard Good Practice Recommendations Abbeyfield Stangrove Lodge DS0000024017.V312186.R01.S.doc Version 5.2 Page 24 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 Stangrove Lodge DS0000024017.V312186.R01.S.doc Version 5.2 Page 25 - 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. 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