Inspection on 11/07/05 for Abbeyfield Woodgate

This inspection was carried out on 11th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Abbeyfield Woodgate 06/10/08

Abbeyfield Woodgate 16/10/07

Abbeyfield Woodgate 30/10/06

Abbeyfield Woodgate 30/11/05

Abbeyfield Woodgate 16/12/04

Abbeyfield Woodgate 21/07/04

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

CARE HOMES FOR OLDER PEOPLE Abbeyfield Woodgate Woodgate Tudeley Lane Tonbridge Kent TN11 0QJ Lead Inspector Fiona Holdaway Announced 11 July 2005 10:00 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 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 Woodgate H56-H06 S23772 Woodgate Abbeyfield V227109 110705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Abbeyfield Woodgate Address Woodgate Tudeley Lane Tonbridge Kent TN11 0QJ 01732 350952 Telephone number Fax number Email 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 Vivien Littlechild CRH Care Home 54 Category(ies) of Old age (54) registration, with number of places Abbeyfield Woodgate H56-H06 S23772 Woodgate Abbeyfield V227109 110705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Care of one Service User with Physical Disability is restricted to one person whose date of birth is 22/08/1953 Date of last inspection 16 December 2004 Brief Description of the Service: Woodgate is part of the Abbeyfield group. The home is a detached purpose built care home situated in a quiet residential area approximately 1/4 mile from the town of Tonbridge. The home has 42 single rooms and 4 of these have ensuite facilities. There is a large dining room, 4 sitting rooms and gardens. The home is accessible throughout and there is a passenger lift to the first floor. Part of the home is in the process of being converted into a dedicated dementia care wing. Abbeyfield Woodgate H56-H06 S23772 Woodgate Abbeyfield V227109 110705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Announced Inspection was carried out by Regulatory Inspector Fiona Holdaway. A tour of the home took place and the Inspector met with service users and staff, the Manager was present in the home throughout the Inspection, care records, policy documents and staff files were inspected. There have been no complaints received by CSCI about this home. What the service does well: 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. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Abbeyfield Woodgate H56-H06 S23772 Woodgate Abbeyfield V227109 110705 Stage 4.doc Version 1.40 Page 6 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 Standards Statutory Requirements Identified During the Inspection Abbeyfield Woodgate H56-H06 S23772 Woodgate Abbeyfield V227109 110705 Stage 4.doc Version 1.40 Page 7 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 standard(s) 2,3,4 and 5 Each service user has a contract that protects their rights. Service users needs are fully assessed to ensure that the home can meet their needs. Prospective service users have the information they need to make a choice about living in the home and are encouraged to visit beforehand. EVIDENCE: Service users contracts with the home stated the terms and conditions of their residency and were signed by both parties. Service users and their relatives are encouraged to visit the home before the person moves in and the first month of stay is a trial period for both parties. Service users needs are assessed prior to being offered a place at the home to ensure that the home is able to meet the needs of the individual. Two service users that had recently moved into the home told the Inspector that they or their relatives had visited the home and been provided with sufficient information to make a decision about it. Assessments and care plans sampled were in good detail and provide staff with clear guidance to support service users with personal and health care needs. Abbeyfield Woodgate H56-H06 S23772 Woodgate Abbeyfield V227109 110705 Stage 4.doc Version 1.40 Page 8 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 standard(s) 7,8 and 9 Service users personal, social and health care is provided according to service users needs and wishes. Service users are protected by the home’s medication policies and procedures but one area of practice could be improved. EVIDENCE: Service users have access to healthcare services such as the G.P., Dietician, District Nurse, Dentist and Optician, Chiropodist etc as required. Care records included healthcare appointments and the outcomes and assessments of moving and handling, nutrition and risk of pressure sores. Medication was seen kept securely in a dedicated room. A monitored dosage system is in place and the homes MARs (Medication Administration Records) were properly recorded with one exception. A system should be put into place to check the recording of changes in medication to ensure they are correct. Abbeyfield Woodgate H56-H06 S23772 Woodgate Abbeyfield V227109 110705 Stage 4.doc Version 1.40 Page 9 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 standard(s) 12, 13 and 14 Service users have access to a range of activities in the home although some service users would like more activities throughout the day. Service users’ religious needs are met. Service users are encouraged to make choices about all aspects of their daily routine. Service users are supported to maintain contact with family, friends and the wider community. EVIDENCE: Abbeyfield Woodgate H56-H06 S23772 Woodgate Abbeyfield V227109 110705 Stage 4.doc Version 1.40 Page 10 The home is supported by the VSU (Voluntary Service Unit) and a group of young volunteers provide an excellent range of activities once a week, including crafts and playing musical instruments. The home’s timetable of activities was viewed, this is prominently displayed for all service users. Activities included quizzes, word games, bingo, reminiscence activities, sing-a-longs and exercises and aromatherapy, these are provided by staff. Staff said that they also tried to find time just to sit and talk with residents or read the paper to them. Some service users said in their comment cards that they would like more activities. Service users’ spiritual needs are assessed as part of the pre-admission assessment. The home is well supported by local clergy, a service is held in the home weekly and a Communion service is held monthly, there are also regular prayer meetings held. Minutes of residents and relatives meetings were seen which evidenced that service users are consulted about all aspects of the home and their comments and suggestions (there is also a suggestions box) are acted on. From the comments made by service users it was evident that they make decisions based on information and choice. The home operates an open visiting policy and service users stated that friends and family could visit at any time. Abbeyfield Woodgate H56-H06 S23772 Woodgate Abbeyfield V227109 110705 Stage 4.doc Version 1.40 Page 11 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 standard(s) 16 and 18 The home has a clear complaints procedure and service users and relatives are aware of how to complain. Staff have good knowledge and understanding of adult protection issues which protects Service Users from abuse. EVIDENCE: The home’s complaints record was viewed and evidenced that service users benefit from having any concerns or complaints that they have listened to and responded to promptly. Service users spoken with were well aware of their right to complain and generally presented as very satisfied and happy with the service provided. The manager of the home is a trained Adult Protection trainer; she attends regular practice meetings with other trainers. The content of the adult protection training provided was excellent and staff were knowledgeable on the subject. Abbeyfield Woodgate H56-H06 S23772 Woodgate Abbeyfield V227109 110705 Stage 4.doc Version 1.40 Page 12 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 standard(s) 19, 20, 21, Service users live in a safe and clean environment. Service users have benefited from improvements to the home including new bathrooms. Service users would benefit from a more pleasing environment if further improvements were made to the standard of décor. EVIDENCE: Much improvement has been made to the home, the reception area has been redecorated, improvements have been made to the décor and equipment in the kitchen and the home was awarded a Clean Food Award in March 05 by the Environmental Health Office. Several bedrooms have been repainted and there are no longer any shared rooms. Part of the home is in the process of being converted into a dedicated dementia care wing. The home is accessible, safe and clean throughout. Hallways are equipped with grab rails to assist mobility and the home has a call system operating throughout all public areas and private accommodation. Radiator covers have been fitted to all radiators and this has improved the safety of the home for service users. Abbeyfield Woodgate H56-H06 S23772 Woodgate Abbeyfield V227109 110705 Stage 4.doc Version 1.40 Page 13 The home has ample communal space there are four separate lounges that are all individually decorated and comfortably furnished. The home has 4 bathrooms all of which have assisted baths, two of these bathrooms have a new bath and there are 2 new showers. All the bathrooms have been refurbished, retiled and redecorated. However, the hallways are in need of redecorating, the skirting boards and architrave are damaged and tatty. This is an outstanding requirement, the manager stated that redecoration on these areas was due to start in the next month. Service users would benefit from this being improved. Abbeyfield Woodgate H56-H06 S23772 Woodgate Abbeyfield V227109 110705 Stage 4.doc Version 1.40 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28 and 29 The numbers of staff employed are sufficient to provide the level of care required. The home has a good recruitment procedure that supports and protects service users. EVIDENCE: The manager evidenced that there are sufficient numbers of staff at present to meet the needs of service users and there was consistent planning to cover any absences. Staff files were seen including a new member of staffs’. Files included application forms, written references, proof of identity, and CRB (Criminal Record Bureau) checks. Staff interaction with service users was excellent and members of staff demonstrated that they have the necessary skills and knowledge to meet individual needs of service users. A number of staff were enrolled on a 12 week ‘positive dementia’ course in preparation for the new dementia care wing. The manager stated that all care staff would undertake this training. Abbeyfield Woodgate H56-H06 S23772 Woodgate Abbeyfield V227109 110705 Stage 4.doc Version 1.40 Page 15 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 36 The atmosphere of the home is friendly and welcoming. The manager is open and approachable to service users and staff, she offers clear guidance and support to staff and runs the home in the best interests of service users. EVIDENCE: The manager has 20 years experience of working with older people in various care settings and she is currently working towards the Registered Managers Award. The Manager demonstrated through discussion, a clear understanding of the needs of the service users and any current issues. Evidence was seen that staff receive formal supervision and an annual appraisal of their work. Abbeyfield Woodgate H56-H06 S23772 Woodgate Abbeyfield V227109 110705 Stage 4.doc Version 1.40 Page 16 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION 2 3 3 x x x x x STAFFING Standard No Score 27 3 28 3 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 4 3 x 3 x x 3 x x Abbeyfield Woodgate H56-H06 S23772 Woodgate Abbeyfield V227109 110705 Stage 4.doc Version 1.40 Page 17 yes 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 OP19 Regulation 23.2 Requirement Fitness of premises23. - (2) The registered person shall having regard to the number and needs of theservice users ensure that (b) the premises to be used as the care home are of sound construction and kept in a good state of repair externally and internally;(d) all parts of the care home are kept clean and reasonably decorated;The interior of the home is to be repaired / repainted where wheelchairs have damaged doorframes and walls. (2) The registered person shall make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. A system should be put in place to ensure that any changes in medication are correctly recorded. Timescale for action Action Plan 2. OP9 13.2 31.8.05 Abbeyfield Woodgate H56-H06 S23772 Woodgate Abbeyfield V227109 110705 Stage 4.doc Version 1.40 Page 18 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 Good Practice Recommendations Abbeyfield Woodgate H56-H06 S23772 Woodgate Abbeyfield V227109 110705 Stage 4.doc Version 1.40 Page 19 Commission for Social Care Inspection The Oast, Hermitage Court Hermitage Lane Maidstone Kent 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. 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