Inspection on 11/07/08 for Abbeygate Care Centre

This inspection was carried out on 11th July 2008.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 Care Centre 14/01/08

Abbeygate Care Centre 12/06/07

Abbeygate Care Centre 16/01/07

Abbeygate Care Centre 16/02/06

Abbeygate Care Centre 25/10/05

Abbeygate Care Centre 17/03/05

Abbeygate Care Centre 15/02/05

Abbeygate Care Centre 12/02/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Abbeygate Care Centre 2 Leys Road Brockmoor West Midlands DY5 3UR Lead Inspector Jon Potts Key Unannounced Inspection 10:10 11 , 14 & 25th July 2008 th th 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 Abbeygate Care Centre DS0000025048.V368277.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. Abbeygate Care Centre DS0000025048.V368277.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbeygate Care Centre Address 2 Leys Road Brockmoor West Midlands DY5 3UR 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) 01384 571295 01384 571295 abbeygate@abbeycare.org Mr Dasrath Sahadew Mrs Hilary May Sahadew Mr Dasrath Sahadew Care Home 17 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (1), Old age, of places not falling within any other category (16), Physical disability over 65 years of age (1) Abbeygate Care Centre DS0000025048.V368277.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service Users to include 16 OP and up to 1 MD (E) and 1 PD (E) Date of last inspection 14th January 2008 Brief Description of the Service: Abbeygate Care Centre is a detached building, with original parts of the house dating from 1845, situated in Brockmoor, which is to the west of Brierley Hill and close to the Merry Hill Shopping Centre. Sited in its own grounds, with mature gardens and car parking available, it has been adapted and extended for use as a Care Home for older people. Accommodation comprises 17 single bedrooms (8 with en-suite), plus two communal lounges, one of which includes a conservatory/dining area. A shaft lift provides access to the first floor. The Home is registered for the provision of personal care only, with any required nursing care being provided through local health services. The home is managed by one of the joint providers with a staff team consisting of a deputy, senior carers and care staff in addition to a cook and cleaner. Fees detailed in the service user guide vary between £400 and £405. Items that are not covered by the fee include hairdressing, chiropody, toiletries and newspapers. Abbeygate Care Centre DS0000025048.V368277.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people that use this service experience adequate quality outcomes. This inspection was carried out over three days, the first day involving two inspectors, the 2nd a CSCI pharmacy inspector and the third primarily consisting of consolidation and feedback. The inspection was focussed on assessing the homes performance against key national minimum standards and previously identified concerns (from the last key inspection). Evidence was drawn from a number of sources and involved tracking the care of a number of residents that included looking at care records, discussion with residents and observation of the care provided. There was also a tour of the premises and examination of a number of management records and we received feedback from residents, relatives and staff. We also receive a number of comments from residents and relatives via comments cards prior to the visit to the home. What the service does well: What has improved since the last inspection? There have been numerous improvements since the time of the last inspection this including the following: • The process for assessing resident’s needs prior to admission is better meaning the needs of individuals are better identified. Abbeygate Care Centre DS0000025048.V368277.R01.S.doc Version 5.2 Page 6 • • • • • • • The fee information in the statement of purpose has been updated meaning people have access to up to date fee information. There has been improvement in care plans, which whilst not necessarily person centred are more detailed and followed by staff. The homes medication storage is now safer. Staffing levels have improved allowing staff more time to interact with residents and provide more stimulation. The décor and furnishings in the home have been improved in a number of areas. Infection control practices have improved potentially reducing the risk of cross infection. The home was seen to have responded to the last environmental health food safety inspection, this so as to improve food safety. What they could do better: The following were areas where it was judged the home could perform better: • Despite staff training in adult abuse there was a limited understanding of when matters need to be referred to the local social services department. There have been instances of potential abuse, not necessarily due to the home, which have not been referred to the appropriate agency. Staff must fully understand when a referral is to be made. Training to facilitate this has however been arranged by the manager/provider. Identification of potential hazards to residents and staff needs to be better (i.e. lifting residents after falls, protecting staff from second hand smoke) and when actions to remove risk are identified the provider must follow the actions identified as necessary. The manager/provider is yet to implement a proposed quality assurance system that could help identify shortcomings in the service and thereby improve outcomes for service users. Despite improvement in care planning the home needs to develop a person centred approach to care planning that fully recognises diversity in terms of meeting individual needs, and any limitation that maybe present in ensuring individuals safety. Some people told us residents access to the wider community could be better and not purely reliant on relatives assisting service users to go out. • • • • 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. The summary of this inspection report can be made available in other formats on request. Abbeygate Care Centre DS0000025048.V368277.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 Abbeygate Care Centre DS0000025048.V368277.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 & 5 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who may use the service and their representatives have the information needed to choose a home that will meet their needs. The homes assessment process whilst not always fully compliant with the National Standards is sufficient to allow an informed decision to be made about meeting individuals needs. EVIDENCE: We saw that the home had a statement of purpose and service users guide that was readily accessible in the foyer to the home. Information within these was in written form and included information relating to the homes current charges for residency. Some consideration in respect of the use of alternative formats (such as photographs and images) may be appropriate. We noted that some minor update would be advisable as there was reference in one of these documents to the NCSC (our predecessor). It was good to see that there was Abbeygate Care Centre DS0000025048.V368277.R01.S.doc Version 5.2 Page 9 information as to how individuals could contact a range of other organisations however this including the local social services and advocacy. Contracts were seen to be available in individual residents files and these were signed by either the resident or their representative, with information within broadly reflecting the expectations of the national minimum standards. We looked at the case files for residents that had been admitted to the home since the last inspection, whether new admissions or re-admissions from hospital. Based on the information that we saw was available, this including the homes own assessment and assessments from social services or hospitals, we judged this to be sufficient for the owner/manager to make a decision as to whether the home was able to realistically meet their needs. This was confirmed by the owner/manager within letters to the prospective residents pre admission. It was noted that care management assessment was not available in every instance although comparable information had been obtained from other sources when this was not the case. We saw review minutes from social services departments that echoed this judgement with comments for one resident that stated “carers were satisfied with the quality of care provided and felt that a very good care home had been selected” We had 12 comment cards from relatives, 9 of these saying that they always had sufficient information about the home to allow decisions, the other three saying this was usually the case. The same proportion also felt the home always met the needs of residents at the home. 6 residents comments cards told us that they all felt they had received sufficient information about the home pre admission. We saw from documentation that staff at the home offer the opportunity for the prospective resident or relatives to view the home prior to admission, with records showing that brochures were offered at this point. Abbeygate Care Centre DS0000025048.V368277.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Responses to service users health and personal care needs are good and planning for delivery of care that covers all individual needs shows improvement, although there is further scope for recognising individual’s diversity. Staff provide care in a way, which recognises privacy and dignity although acknowledgment of limitations due to risk could be better. Overall medication was being carefully handled to ensure that people who use the service were safeguarded. EVIDENCE: Based on the comments we received from residents and relatives staff at the home understand the right of individuals to have a say in how they live their lives and have a degree of involvement in making decisions and choices. 10 relatives told us that support was provided as expected, 2 others saying this was usually the case. This was echoed by six residents saying they always or Abbeygate Care Centre DS0000025048.V368277.R01.S.doc Version 5.2 Page 11 usually received the care and support they needed. We saw recording in case files showing that residents views in respect of some issues were documented such as resident’s views in respect of the use of terms of endearment (i.e. acceptance of these although we heard none used by staff). We did however hear staff use residents preferred titles as recorded in case files. Many of the residents we spoke to were able to clearly express their opinions although there are some who have difficultly communicating. Discussion with, and observation of staff indicated that they had an awareness of how to pick up on non-verbal communication although this detail was not always fully reflected in communication plans. We saw that each individual that we case tracked had a care plan and the majority of the information in those we looked at was verified by other records, discussion with residents and observation on the days of inspection. This in part confirmed that the information in these plans was clearly based on information that was accurate as recorded in the homes assessments. In the most part there was evidence of regular reviews of these plans which contained the basic information necessary to deliver the person’s care, although they would benefit from further development so that they are more detailed and person centred. Whilst it was clear that there has been improvement in the plans since the time of the last inspection there was not always reference to an individual’s particular needs regarding gender (including gender identity), age, sexual orientation, race, religion or belief or follow up to identify how these needs were to be met. We saw that there are risk assessments in place of individuals in respect of numerous areas including such as tissue viability, nutrition, falls, and moving residents. We saw that there were some inconsistencies/omissions, examples such as in respect of bed rails, with some conflicting information that in cases questioned the reasoning for their use (with the resident said not to move in bed) and no risk assessment of how residents would be lifted from the floor if having fallen (a number of such occurrences seen in the accident book) in light of the fact that the home does not have mechanical lifting equipment. The provider/manager was able to verbally recount the steps that should be taken however, these not documented for staff guidance. We did however see that the risk assessments did generally inform the practices of the home such as frequency of checks on residents, what equipment was to be used for prevention of pressure areas and so on. There is scope for expansion of risk assessments to take on board where there maybe limitations place on residents, possibly due to their mental capacity and risk. This would be useful in allowing the home to demonstrate that the home use’s risk assessment as a means of ensuring that any limitations do not compromise choice and are agreed with the individual consistently. An example of such would be the individual’s access to bedroom door keys, which in some instances has been assessed and agreed with them, but not consistently. Abbeygate Care Centre DS0000025048.V368277.R01.S.doc Version 5.2 Page 12 We saw and heard evidence that resident’s health care needs are met in a timely fashion, contact with all medical services clearly documented in case files. Comments made to us included the following ‘They have always called the GP when they felt it was necessary to do so’. In addition 5 out of six residents who replied in comment cards told us they always receive medical care as needed. We did see evidence of the staff delivering care in a way that showed respect for residents however, this by knocking on doors prior to entry, allowing them access to their bedrooms when ever wished and such like. The residents spoken to confirmed that staff provided care in a way that respected their dignity and privacy. The majority of medication seen was stored safely in locked cupboards. For example, we saw medication stored in a locked container in the kitchen refrigerator. Creams and ointments were seen stored in a locked cupboard. This means that residents medication was stored safely and therefore protected them from harm. We saw written records to ensure that medication was documented when it arrived into the home and also when medication was no longer needed and returned to the pharmacy. This helped to ensure that safe levels of medication were stored within the home. The majority of the medicine records seen were well documented with staff signatures to record that medication had been administered to people living in the service or a code was recorded to explain why medication had not been administered. Random checks were done to see that medication had been given as the doctor had prescribed. For example, one check showed that the number of staff signatures on the medicine record chart was the same as the number of tablets that had been removed from the medication container, which shows that medication was being recorded accurately to ensure the well being of people who live in the service. We saw two care plans for medication. They were up to date and recorded why medication was being administered. For example, one person was prescribed a medicine to calm and control their behaviour when required. The care plan did contain sufficient written information to inform staff under what circumstances this medicine should be administered. The medicine records showed that staff had administered the medication on certain dates. It was therefore pleasing to see that the daily notes seen for the resident did reflect the reason why the medicine had been administered on those specific dates. This means that the medication records were clear and up to date and explained why the medication had been administered according to the doctor’s instructions. Abbeygate Care Centre DS0000025048.V368277.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Resident’s choices as to their lifestyle and access to activities has improved with the recent increase in staffing levels although community involvement could still be better. The home is good at maintaining and encouraging contact with relatives. Food provided meets the expectations of the residents and staff assist sensitively with feeding. EVIDENCE: There was evidence that the home is trying to be flexible and provide a service that is as individual as possible, using its staff and resources effectively. Some residents indicated that they are happy with routines at the home although some stated that they did not always get up when they wished, this known in some cases not to have been discussed with the staff. We saw that there was some assessment of resident’s preferences through a daily life assessment, this making reference to some preferences in respect of their daily routines. Comment from relatives as to whether residents lived the life they chose indicated that 8 out of 12 that contacted us said that they Abbeygate Care Centre DS0000025048.V368277.R01.S.doc Version 5.2 Page 14 always or usually did, although some did highlight that moving to a care home was a difficult choice and one made necessary due to their personal circumstances. Comments indicated that the home did their best to alleviate these concerns with comments ‘Having to make the decision for a loved one to go into a home is difficult. To have found a home where not only does your relative feel comfortable but the family are treated with respect is really as good as it gets. The staff are very caring and kind’ ‘My mother hasn’t chosen to live the life she is living, circumstances forced the issue. Mom on a good day is happy and chatty etc. on a bad day she gets distressed and wants to go home etc. but the good days far exceed the bad days’ It was evidence that staffing improvements have assisted with the provision of activities for residents, and we saw that staff were playing board games with a number of staff at the time of our arrival, staff seen to engage in lots of conversation with the residents, about the game and asking other things, such as what they prefer from the fish shop when they get fish and chips. Staff were also seen to take time to help a lady who was wandering about looking for her watch to be put on. She helped her to put it on and reassured her. Later in the day we saw staff chatting to 2 residents, sharing experiences about when they had their children. A member of staff was seen to have involvement with one resident in the afternoon, on a one to one basis, this found to be in accordance with instruction in the homes care plan. The home was seen to have an activities programme on display in the hallway and five of the residents that responded to comments cards said there was usually activities available. There was indication that community involvement could be better however, residents usually going out when relatives take them and not as part of a planned activity or on the spur of the moment to have a trip to the shops for instance. There was comment from some relatives that the home could ‘Improve on the outdoor activities and access to it’ this supported by staff comment to the effect that ‘More day trips for the residents would break up the everyday routine and give them something to look forward too’. Relatives indicated to us that the home is generally good at encouraging contact between them and individuals at the home and out of 12 respondents to comment cards 11 said the home always kept them up to date on important issues. Comments made reflected this: ‘I am only able to visit once a week but I find the staff very pleasant, prepared to answer any problems we might have’ and ‘The home liaises well and quickly when ever I need to know or be informed of any changes that effect my mother or her treatment’. The only other concern raised was that some felt there should be more privacy for visitors (although the staff stated that residents were able to use their Abbeygate Care Centre DS0000025048.V368277.R01.S.doc Version 5.2 Page 15 bedrooms) and one relative stated that drinks were not always made available to them when they visited. We saw staff offer residents choice of meals, this by verbally asking them what they wished to eat off the days menus (which gave a choice of meals and was on display in the hallway, this with a notice to say alternatives to these were also available – this confirmed by the cook). We saw the meal of the day and this was well presented (being served by the cook) and in fair portions. The cook was seen to serve the meal in accordance with the list of resident’s choices she had drawn from discussion with residents. Residents were overheard saying that the food was good and also confirmed the same in comment cards and later discussion with us. It was also highlighted that the staff encouraged residents to drink, these always been made available, as we saw to be the case. We observed a member of staff feed a dependent resident and they were seen to do so at the pace of the resident, this by taking cues from her non verbal communication, with these cues explained to us by the staff member .The food was not liquidised but a soft diet, and the staff member explained how she would ensure that the individual was encouraged to eat the food. The staff member encouraged drinks in between solids and was constantly talking to the resident, reassuring and explaining what she was doing. Abbeygate Care Centre DS0000025048.V368277.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People who use the service are able to express their concerns and have access to a robust, effective complaints procedure, although some of the homes practices in respect of ensuring residents are safeguarded need improvement. EVIDENCE: We saw that the home has a complaints procedure that meets the National Minimum Standards and regulation and is readily available within the home in large print. Residents told us that staff listen and act upon what they say, and that the know how to make a complaint. Out of 12 relatives that responded via comment cards 9 stated that they were aware of the homes complaints procedure and 8 that the home responded appropriately to any matters raised. We were told that the home has received no complaints in the last 12 months and none have been received by us over the same period. We saw that the home has policies and procedures in respect of safeguarding including the local authorities procedures. When we spoke to staff, who have received recent training in abuse, they were able to identify what abuse was but where unclear as how to make a safeguarding referral and who to. We told the provider that there is a need for staff to have a better awareness of what their responsibilities are in terms of reporting and how the local social service Abbeygate Care Centre DS0000025048.V368277.R01.S.doc Version 5.2 Page 17 department’s referral process works. To his credit he was in the process of arranging said training on the last day of the inspection. There was concern that an incident was identified where a resident had returned from hospital with bruising, this identified clearly in the homes records by staff. There was no action taken however to refer any concerns to the social services department in respect of what was essentially unexplained bruising. In addition there was also a past incident where the provider had disciplined a member of staff for raising their voice to a resident. Whilst positive that the provider took action the statement in records that. ‘I consider this to be a case of verbal abuse and it will not be tolerated by this establishment’ underlines that there would have been a need to refer this matter to the local social services as a safeguarding alert. We discussed the above matters with the provider who gave a commitment to ensure that any matters that involved abuse, not necessarily at Abbeygate, would be referred to Social services and other agencies as appropriate. An example of the later is the need to ensure any instances of staff misconduct are reported to us as a regulation 37 notification. There was little evidence of staff employing any methods of restraint in their day to day practice although staff do need to be aware that use of such equipment as bed rails is a form of restraint and therefore a limitation, meaning justification for their use needs to be very clear, and based on risks presented to the resident (see earlier comments in health and personal care). It was also noted there had been 8 accidents where residents had fallen on to the floor since 4/4/08. This would have meant that residents have been lifted from the floor, this potentially presenting risks to the staff lifting and the residents. As the home has no mobile person hoist, mechanically lifting residents is not possible. We discussed this with the provider/manager and advised that lifting residents who fall on the floor must be risk assessed. We were told of steps that would be taken to reduce the risks such as phased lifting techniques and dialling 999. The later was not documented for the purposes of staff guidance however. Abbeygate Care Centre DS0000025048.V368277.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables people who use the service to live in a safe, well-maintained and homely environment, which encourages independence. Infection control procedures have improved and reduced the potential for cross infection. EVIDENCE: The home provides a physical environment that is appropriate in meeting the needs of the residents currently accommodated at the home. The environment was seen to be pleasant and homely with, large print books and magazines about for people to read. Plenty of houseplants and vases of fresh and silk flowers helped add to the environment. The home has no shared bedrooms and those seen were generally spacious and a number equipped with an ensuite facility. There has been and still is on going works to improve the building, this seen to be the case with painters on site at the time of our first Abbeygate Care Centre DS0000025048.V368277.R01.S.doc Version 5.2 Page 19 visit. Of note was the improvements carried out to the laundry which have made this a safer and easier to clean environment, this important in terms of infection control with such as the hand wash basin now easier for staff to access for washing their hands. The home does not provide for residents with substantive physical disability and as such the aids and adaptations available are limited to those needed to meet lesser physical dependency. As previously stated there is no provision of mobile hoist equipment, this meaning that if this should be required the home would either need to provide such or advise an individual that they are unable to meet their needs. There are two communal areas available to residents, a small and large lounge/dining area although the dining area in the conservatory does provide some privacy from the large lounge. Residents sat in the smaller lounge stated they liked this, as it was quieter than the other room. The larger lounge has been part refurnished with new dining table and chairs and new large screen TV. The kitchen was also seen to have been refurbished with new unit fronts, floor and dishwasher. Some of the residents showed us their bedrooms and said that they were happy with them. Where necessary rooms were seen to be laid out in accordance with specific individual requirements i.e. access was unrestricted by furniture as detailed in risk assessments in one instance. The majority of the bedrooms (with a few exceptions) are fitted with turnbolt locks and the management told us that residents do not wish to hold keys. This was confirmed by some of the residents we spoke to. The home was seen to have made improvements in respect of infection control, examples including the use of individual wash bags for residents these seen by us during the visit. As a result the homes main bathroom was less cluttered and cleaner, this assisted by the fitting of a new bath panel. There was no evidence of any unpleasant odours at any time during the course of the inspection. We saw, and staff confirmed that equipment such as gloves and overalls were readily available to them. The manager/provider was advised to strengthen the homes risk assessment in respect of infection control with reference to the department of health document ‘essential steps’. In addition he was advised that they do need to ensure we are made aware of any outbreaks, although there was evidence that these had been brought to the attention of the health protection agency. We saw the homes fire risk assessment and whilst this was generally acceptable it we saw that it referred to use of automated door closers when residents wished to have doors kept open. Practice in respect of one bedroom door that was wedged open did not reflect this. The manager/provider stated that he would ensure that an automated closer was fitted. Abbeygate Care Centre DS0000025048.V368277.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staff in the home are generally trained to an acceptable level. Improved staff numbers and deployment has improved the support available to people whom use the service. The home’s recruitment procedures are safe and protect people who live at the home. EVIDENCE: Based on comments made to us residents and their relatives have confidence in the staff team and they are satisfied that the care they receive to meets their needs. Comments made included the following: ‘ Most of the staff are excellent in their care of mom and the attitude to both her and ourselves’ ‘Always found the staff to be very friendly and honest. Always manage our circumstances the best they can’ Staffing levels have increased since the last inspection this leading to residents telling us that there is always or usually sufficient staff available. Staff also confirmed this. It was pleasing to see during our time at the home that staff had time to spend talking to residents and giving them individual attention where time allowed. The deputy told us that there are still some gaps where Abbeygate Care Centre DS0000025048.V368277.R01.S.doc Version 5.2 Page 21 staffing could be better and these are to be targeted by on – going recruitment. The service recognises the importance of training, and tries to delivers a programme that meets any statutory requirements and the NMS. Whilst there are some gaps the manager/provider is generally aware of these. We saw a number of staff files and copies of certificates confirmed detail seen within the staff-training plan. Staff tell us that the training they receive helps them carry out their roles effectively and the comments from residents and their relatives confirms that the staff provide a service that meets their individual needs in a way that they are generally satisfied with. We examined staff files in respect of the homes recruitment processes and saw that the way that they were employed ensured that they were safe to work with vulnerable adults. There was also evidence of the home having an induction process that is task based and covered areas that gave staff a basic grounding in of the service’s expectations of them. Staff told us that the home carried out recruitment checks and that the induction covered most of the information they needed to know. Abbeygate Care Centre DS0000025048.V368277.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 & 38 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The management and administration of the home has improved of late although the lack of a fully operational quality assurance system has compromised the services ability to identify shortfalls consistently. Not withstanding the former the people that use the service say they have confidence in the service. EVIDENCE: The manager of the home is also the company director/owner and has extensive experience of home management. We have been concerned as to the running of the home at previous inspections and were pleased to see that there has been a positive response to many of the concerns raised. One of the concerns was that the manager was also working as a carer where need Abbeygate Care Centre DS0000025048.V368277.R01.S.doc Version 5.2 Page 23 demanded, and there was concern that he had not updated basic training such as food hygiene, moving and handling, abuse awareness or infection control that would allow him to better supervise care staff. He was able to evidence that he is now updating his training but at the same time, due to staffing levels increasing the need for his involvement in day-to-day care has decreased. The Manager is a Registered nurse and has also an NVQ level four qualification in care although has not extended this to include his Registered Manager’s award (RMA). In discussion he did tell us that he is exploring the possibility of doing so. It is of note that the manager has undertaken some management training in the past and has also a D32/33 qualification, this one of the modules that comprises the RMA. He told us that he is to undertake ‘dignity champion’ training latter in the year. The Manager in discussion was well aware of the basic processes within the National Minimum standards. The manager was not available at the first two days of our visits due to leave but the inspection was competently facilitated by the deputy who presented to us as knowledgeable as to the service and issues from past inspections. In discussion both the manager and deputy are aware of the need to promote safeguarding and have developed a health and safety policy that generally meets health and safety requirements and legislation. There was however some weaknesses in practice that needed to be addressed as follows: - Staff need better awareness of the action to take in respect of taking action in response to potential abuse (see earlier comments). - Risk assessments are of a basic nature and could be improved, for example providing evidence of how the service is following these by using such as regular audits to check the safety of the service and practices within. Such audits would also be useful in supporting a Quality assurance system. There was earlier comments as to practice that was contradictory to the homes fire risk assessment. This suggests that further input into risk assessment training is needed. - There were earlier comments as to lifting residents post falls from the floor and the need to risk assess this process to ensure it is carried out safely. - The manager also needs to risk assess the impact from second hand cigarette smoke as one resident does smoke in their private accommodation. The risks in respect of fire safety in regard to this issue have been explored but not the risk to staff entering the room. Advice must be sought from Environmental Services. The home does not currently have an operational quality assurance tool although we did have sight of a system that the provider is looking to introduce in the near future. This is easier to understand than the previous system and closely follows the National Minimum Standards. It is hoped that the introduction of the same will assist the management identify issues arising, and then address these before they become problematic. It was pleasing to see that the home does however make use of regular questionnaires to Abbeygate Care Centre DS0000025048.V368277.R01.S.doc Version 5.2 Page 24 residents and their relatives and these show that there is overall positive outcomes. The findings from these are summarised and displayed in the foyer of the home and generally reflect the generally positive comments we received from the same source. We spoke to residents as to how their finances were handled and most stated that they preferred their representatives to handled these maters, this confirmed by the manager. The home handles small amounts of monies in safekeeping and records in respect of these we saw are satisfactory. The home at their last Environmental Health Food safety inspection received a two star rating but it was pleasing to see from observation, discussion with the cook and sight of appropriate records that the service has addressed outstanding requirements. Checks show that servicing and maintenance records are up to date. Abbeygate Care Centre DS0000025048.V368277.R01.S.doc Version 5.2 Page 25 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 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 3 X X 2 Abbeygate Care Centre DS0000025048.V368277.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No 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. 6. Standard OP18 Regulation 13(6) Requirement The registered provider must ensure that where potential abuse is identified that the local authorities procedures for safeguarding are always followed and the matter referred to the appropriate agency. This is essential to ensure individuals are protected from abuse. The registered provider should ensure that all risk to individuals using the service are comprehensively assessed in respect of safe working practices and that where risks are identified the risk assessment is followed consistently so as to reduce or eliminate any dangers. Timescale for action 31/08/08 4. OP38 13(4)(c) 30/09/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Abbeygate Care Centre DS0000025048.V368277.R01.S.doc Version 5.2 Page 27 No. 1. 2. 3. 4. 5. 6. 7. 8. 9. Refer to Standard OP1 OP7 OP7 OP8 OP12 OP18 OP26 OP31 OP33 Good Practice Recommendations The registered provider should ensure that all references to the NCSC are removed from the statement of purpose to ensure that people have access to accurate information. The registered provider should ensure that care plans are consistently agreed and signed by the resident or their representative to evidence their involvement in the same. The registered provider should ensure that all care plans and associated risk assessments are reviewed consistently every month to ensure that they are up to date. Staff should receive accredited dementia training to ensure that needs concerning dementia are met. The registered provider should ensure that residents have access to the community in accordance with their wishes. The registered provider should notify CSCI of any staff misconduct. The registered provider should ensure that all matters in respect of outbreaks of infection are reported to the CSCI as soon as possible. The registered manager should have a level 4 in NVQ management (Registered Manager’s Award). The registered manager should introduce the quality assurance system proposed and ensure it is used appropriately to inform practice and improve outcomes for service users. The registered provider should discuss how best to risk assess the effects of second hand smoke with environmental services. The registered provider should ensure that the homes fire risk assessment is followed so as to protect residents and where issues arise this should be discussed with the fire prevention officer. 10. 11. OP38 OP38 Abbeygate Care Centre DS0000025048.V368277.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Abbeygate Care Centre DS0000025048.V368277.R01.S.doc Version 5.2 Page 29 - 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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