Inspection on 06/10/05 for Abbeygate

This inspection was carried out on 6th October 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

Abbeygate 08/08/06

Abbeygate 11/08/04

Abbeygate 19/04/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Abbey Gate 71 Beach Road Weston Super Mare North Somerset BS23 2BG Lead Inspector Carrolle Wise-Scanlan Announced 6 October 2005 th 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. Abbey Gate DD53-D02 S8027 Abbey Gate V247169 310805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Abbey Gate Address 71 Beach Road Weston Super Mare North Somerset BS23 4BG 01934 621166 01934 419244 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) WSM Free Church Hosuing Association Mrs Joan Patricia Duffy Care Home 21 Category(ies) of OP - Old Age (21) registration, with number of places Abbey Gate DD53-D02 S8027 Abbey Gate V247169 310805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th May 2005 Brief Description of the Service: Abbey Gate is owned by Weston-super-Mare Free Church Housing Association. The home overlooks the sea front at Weston-super-Mare and is able to accommodate 21 elderly residents, who require personal care only. The property is a large Victorian house with a long conservatory leading to an annex at the rear. There is a large lounge, leading to a well-stocked library. This is used for daily prayers and Sunday church services. A television lounge and dining room are also located on the ground floor. There is a wellmaintained garden to the front and a sheltered courtyard outside the conservatory. A local park is situated behind the home. Buses pass the home; otherwise a car would be necessary to access the town centre. Abbey Gate DD53-D02 S8027 Abbey Gate V247169 310805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection that took place over eight hours. The inspector met with eight residents during the course of the inspection. The chaplain was also met briefly whilst she was visiting and conducting a memorial service on the morning of the inspection. There were twelve resident feedback comment cards received by the commission, all contained positive comments about the home. One resident wrote “ I am very happy, all the staff are my friends, I am so thankful for this my home”. Five relative/visitors comment cards were received all gave positive reports. Two stating that they ‘would recommend Abbeygate to anyone’. A GP practice and a District Nurse who visit the home also gave positive feedback. Several records, which are required to be kept by the home, were sampled and reviewed. The pre inspection documentation was also used during the inspection process. The inspector used ‘Case tracking’ methodology. What the service does well: What has improved since the last inspection? Staff have received updates and further training in medication administration for the benefit of the residents. The residents have welcomed the addition of further ensuite facilities. The COSHH storage cupboard is now lockable and secure reducing risk for the residents. Abbey Gate DD53-D02 S8027 Abbey Gate V247169 310805 Stage 4.doc Version 1.40 Page 6 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. Abbey Gate DD53-D02 S8027 Abbey Gate V247169 310805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Abbey Gate DD53-D02 S8027 Abbey Gate V247169 310805 Stage 4.doc Version 1.40 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 standard(s) 1, 2, 3, 4 & 5. Residents make informed choices about living here. Residents are appropriately assessed to ensure that the home can safely meet their needs. EVIDENCE: The homes statement of purpose is currently in the process of its annual review and will include the changes in the homes facilities such as the extra ensuite rooms and room sizes. The registered manager Mrs Joan Duff will forward a copy to the commission should there be any changes made. Residents who live at Abbeygate were well informed as to the facilities and services provided by the home. Several had visited the home prior to moving in and a few residents were former visitors to the home, either in a pastoral role or to visit friends. All felt that they received sufficient information to enable them to make an informed choice to live here. Residents recalled being offered a ‘trail period’ of four weeks. One resident summed this up by saying this had given her the opportunity to ensure that she was ready to move into the home permanently. Abbey Gate DD53-D02 S8027 Abbey Gate V247169 310805 Stage 4.doc Version 1.40 Page 9 Records sampled demonstrated excellent practice, with residents files containing signed terms and conditions of the home. Residents have an assessment to ensure that their care needs can be safely met prior to moving into the home. The home has a ‘house visitor’ who offers further information regarding the Weston-Super-Mare Free Church Housing Association and completes an application for residency report. Abbey Gate DD53-D02 S8027 Abbey Gate V247169 310805 Stage 4.doc Version 1.40 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 standard(s) 7, 8, 9, 10. Care plans are completed with the residents input. Improvement has been made in the written care plans but the level of detail could be improved further. Medication administration has developed and improved with staff receiving further training. Further improvement is needed in the recording of residents medication stock onto the Medication Administration Record sheet. EVIDENCE: Residents felt involved in the drawing up of their care needs and in how their needs can be met by the staff. These are signed by the residents and reviewed by the staff on a monthly basis. Several residents continue to be self-reliant with regard to their day-to-day personal routines with assistance needed only with mobility issues, such as getting in and out of a bath. Each resident completes a ‘getting to know you’ questionnaire providing information on preferences, such as favourite suppertime drinks and their preferred routines. Residents care plans according to the registered manager now contained more detail regarding how to meet the care needs identified. The care plans sampled and the residents met during the inspection demonstrated this further. Abbey Gate DD53-D02 S8027 Abbey Gate V247169 310805 Stage 4.doc Version 1.40 Page 11 Residents who receive care from other health and social care professionals have records of that care kept separately in their rooms. When these records contain direction or information for the staff to continue with, such as ‘elevation of legs’ for someone with ankle swelling, this should be translated into the homes care plan also. Every resident met had positive things to say about the staff, the home and how it is managed. One resident said, “next to your own home, you couldn’t hope for a better place to live”. Risk assessments are completed on an individual basis. Once the risk factors are identified they are classed as low, medium or high risk and evaluated and monitored regularly. A risk assessment for a resident who chose to selfmedicate had not been completed. Medication procedures had been updated and improved. Staff had also received further training. The medication file contained a list of signatures of all the staff trained to administer medications. Staff on receipt of medication note the stock received and the total remaining stock. However, on one record of a residents ‘as required’ Paracetamol, the actual stock did not meet that which was recorded on the Medication Administration Record (MAR) sheet. Abbey Gate DD53-D02 S8027 Abbey Gate V247169 310805 Stage 4.doc Version 1.40 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 standard(s) 12, 13 & 14 The home s routines and services are organised around residents preferred lifestyles. Residents have choice and control of their day-to-day lives. EVIDENCE: Residents continue with their day-to-day lives and their own routines once moving into the home. Several residents have activities outside of the home, which they either attend or maintain contact and links with. Residents decide on whether they wish to attend the organised activities. Several residents choose to retire to their own private accommodation following the lunchtime meal. Many read, relax and catch up with correspondence or watch favourite television programs. The events diary kept by the home record the date and the activity but not who attended. The registered manager was able to list however those events which the majority of residents attended such as an afternoon when ‘slides from abroad’ where shown, and a recent flower arranging craft afternoon. The home has a hairdresser and beautician who visit regularly as well as regular group events such as a quiz and bingo. Coffee is served in the lounge area each morning and residents get the opportunity to catch up with each Abbey Gate DD53-D02 S8027 Abbey Gate V247169 310805 Stage 4.doc Version 1.40 Page 13 other socially around meal times also. It was suggested by a resident during their meeting that a ‘newsletter’ would be welcomed. Last month was the first newsletter. This contained information on the local activities and events and for those who consent to it, one staff member and one resident profile. This has been well received by all involved. The home has a visiting Chaplain with service held regularly at the home. Abbey Gate DD53-D02 S8027 Abbey Gate V247169 310805 Stage 4.doc Version 1.40 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 standard(s) 16 Residents felt that if they had concerns or complaints these would be taken seriously and acted upon by the home. EVIDENCE: Residents felt that they ‘had no reason to complain’. However, when the inspector discussed whether there are appropriate avenues for them to discus or disclose a concern or complaint they said they would go to the Registered Manager or house visitor. They felt this information would be kept with the utmost confidence and would be acted upon appropriately. The residents have the opportunity to discus things with the ‘House visitor’ at the home who can act as an intermediary. Abbey Gate DD53-D02 S8027 Abbey Gate V247169 310805 Stage 4.doc Version 1.40 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 standard(s) 19, 20, 21 & 26 Resident’s benefit from a well maintained, clean and comfortable home. Improvements made to the facilities are for the benefit of the residents. EVIDENCE: Abbeygate is arranged over two floors with access via a chair lift or stairs. The home has two separate stairwells accessing the different sides of the home. It is a well presented home with good quality furniture and furnishings. It continues to be well maintained and at each inspection has been immaculately clean and tidy. The facilities include a separate dining room, two lounge areas and gardens. One of the larger lounge areas lies at the front of the property. This lounge has a wall divide providing a small quiet library/reading area. The other lounge area overlooks the inner courtyard, this room is on occasions used by the hairdresser or visiting professionals. The home provides seating in a conservatory area, which again overlooks two inner courtyard gardens. Abbey Gate DD53-D02 S8027 Abbey Gate V247169 310805 Stage 4.doc Version 1.40 Page 16 Since the last inspection there has been the addition of an ensuite to a double room, which is currently used as a single, and two other ensuite room additions. The installation of ensuite facilities should be in addition to the ‘minimum usable floor space standards’ in each resident’s room. The inspector did not measure these rooms during this inspection. The bathrooms had paper towels for hand washing, soap and alcohol gel provided. One bathroom needed a new light cord and one toilet had a tile missing which needed to be replaced. The home provides laundry services but also has a separate laundry area to enable the residents who choose to do their own personal laundry items. This room also has an iron and ironing board. Several residents choose to wash and dry their personal items in their own rooms. Every opportunity is provided for residents to maintain their independence. Abbey Gate DD53-D02 S8027 Abbey Gate V247169 310805 Stage 4.doc Version 1.40 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 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) 30 Staff are well-trained and work in sufficient numbers to provide appropriate care for the current residents. EVIDENCE: One of the deputy relief managers provides the expertise in the training program for the staff at the home. Eleven of the care staff are qualified to NVQ level two or above which represents sixty-one percent of the staff. Fifteen care staff have a current first aid certificate ensuring that there can be a ‘first aider’ available at the home at all times. The staff training over the last twelve months has included mandatory training such as fire and health and safety, as well as dementia care; abuse awareness and infection control. The senior staff training also received training in medication and effective delegation. Residents find the staff approachable, kind and patient. One resident stated, “when I was unwell, they really looked after me, they called the doctor, let my family know and made sure that I had all I needed”. Abbeygate is one home amongst a group of three homes within the organisation. The staff at all three homes may be asked to work at one of the other homes should the need arise, so the use of agency and bank staff is generally at a minimum. The residents therefore enjoy consistency of care from the staff they have come to know. The night care provision is that of two staff members on a ‘sleep’ shift. The staff members work the shift should the dependency of the residents increase or a resident becomes unwell. This is risk assessment based. The total care hours provided per week, according to the pre inspection documentation, suggest that the staffing numbers are sufficient Abbey Gate DD53-D02 S8027 Abbey Gate V247169 310805 Stage 4.doc Version 1.40 Page 18 to meet the current services users needs. This was verified further by the comments made by the residents that although the staff work hard and are busy ‘the staff always have time for you and are incredibly kind’. Abbey Gate DD53-D02 S8027 Abbey Gate V247169 310805 Stage 4.doc Version 1.40 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 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) 32, 33, 34, 35, 38 Resident’s benefit from a well managed home. EVIDENCE: Mrs Joan Duffy is the homes Registered Manager. She is an experienced carer who has completed the Registered Manager Award and more recently an update in management skills. She is a well-respected manager. The residents are well versed in the staffing structure of the home and that of the various staff roles. Residents meetings are regularly held and there was plenty of evidence to suggest that resident’s views are taken account of in every day practice. Examples of how the home responded to ideas and suggestions were plentiful. Resident’s thoughts on activities were recorded. A recent suggestion of a newsletter was taken up and acted upon. Suggestions regarding menus and food are listened to, and where practicable to do so acted upon. Resident’s Abbey Gate DD53-D02 S8027 Abbey Gate V247169 310805 Stage 4.doc Version 1.40 Page 20 views are sought on a regular basis by the registered manager who ensures that she meets with each resident during the course of a shift. The house visitor also produces a monthly report, which fits in as a source of suggestions and ideas for improvement from the resident’s viewpoint. Residents or their representatives look after their own financial affairs. Records are kept of whether residents have a power of attorney, which is good practice. The home keeps records of residents ‘pocket money’. These records were reviewed during the inspection and demonstrated good practice. One record seen had a significant amount of money held. The registered manager stated that this was due to family circumstances as they had not been able to visit to collect the monies and place in the resident’s own personal account for a number of weeks. This money could be accruing interest for the resident if held in an account. In light of the requirement made at the last inspection the COSHH cupboard was checked and found to be locked. Abbey Gate DD53-D02 S8027 Abbey Gate V247169 310805 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION 3 3 3 x x x x 3 STAFFING Standard No Score 27 x 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x 3 3 3 3 x x 2 Abbey Gate DD53-D02 S8027 Abbey Gate V247169 310805 Stage 4.doc Version 1.40 Page 22 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 OP9 Regulation 13(2) Timescale for action Medication Administration Record 06/11/05 Sheet must reflect the residents stock of medication. Risk assessments for those residents who self medicate must be undertaken. Requirement 2. 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. 2. 3. Refer to Standard OP38 OP38 OP35 Good Practice Recommendations Light Pull cords to be repaired or replaced. Tiles in the bathroom o be repaired or replaced. Forward an updated copy of the homes environment layout/plan to the appropriate fire department. The amount of residents monies held by the home for the residents pocket money should be kept to a minimum. Abbey Gate DD53-D02 S8027 Abbey Gate V247169 310805 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection Riverside Chambers Castle Street Tangier Taunton TA1 4AL 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 Abbey Gate DD53-D02 S8027 Abbey Gate V247169 310805 Stage 4.doc Version 1.40 Page 24 - 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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