Inspection on 16/02/06 for Abbeygate Care Centre

This inspection was carried out on 16th February 2006.

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 11/07/08

Abbeygate Care Centre 14/01/08

Abbeygate Care Centre 12/06/07

Abbeygate Care Centre 16/01/07

Abbeygate Care Centre 25/10/05

Abbeygate Care Centre 17/03/05

Abbeygate Care Centre 15/02/05

Abbeygate Care Centre 12/02/04

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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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Abbeygate Care Centre 2 Leys Road Brockmoor West Midlands DY5 3UR Lead Inspector Mr Jon Potts Announced Inspection 16th February 2006 09:40 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.V276533.R01.S.doc Version 5.1 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.V276533.R01.S.doc Version 5.1 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 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.V276533.R01.S.doc Version 5.1 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 25/10/05 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 some ancillary staff. Abbeygate Care Centre DS0000025048.V276533.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection commenced at 09.40am, lasted 5.0 hours, and was undertaken by one Inspector. Evidence was gathered from discussions with the Registered Manager/Joint Proprietor, other Staff members, 4 residents (one via CSCI comment card) and 11 relatives via CSCI comment cards. Three residents care was tracked this involving review of care related documentation, including staff recruitment/deployment records, and some documents/records reflecting the general operation of the Home. Information was also supplied in written form by the registered manager/provider. What the service does well: What has improved since the last inspection? What they could do better: There were a few areas where practices were inconsistent, these relating to the issuing of contracts, pre admission assessment, confirmation of the homes ability to meet needs and recording of inventories of resident’s property. There was also insufficient evidence of all the resident’s G.Ps giving permission for homely remedies in accordance with the homes protocol for the same, this needing to be updated. Written directions for when residents need to use aids for transfer into the bath also need to be completed in any advice from environmental services. Abbeygate Care Centre DS0000025048.V276533.R01.S.doc Version 5.1 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Abbeygate Care Centre DS0000025048.V276533.R01.S.doc Version 5.1 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.V276533.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3 Not every resident has a written contract with the home. Some residents have moved into the home without evidence of their needs having been assessed and assurance that these will be met. EVIDENCE: Out of the three residents whose care was tracked, two were privately funded and there was some concern as to the pre- admission assessment information that was available for the one resident. The manager stated that the home does have a standardised pre –admission assessment form (this seen on previous inspections) this not available at the time of the inspection. There must be a pre admission assessment that contains all the information detailed within the national minimum standards for all residents. There was also gaps where there was no evidence that the home has confirmed its ability to meet the needs of the resident at the point of admission, although there is a standardised letter available this seen on one resident’s case file. Abbeygate Care Centre DS0000025048.V276533.R01.S.doc Version 5.1 Page 9 Two of the three case files seen contained a contract between the home and the resident, these signed by the residents’ representatives. The third case file contained no evidence of such a contract. Abbeygate Care Centre DS0000025048.V276533.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 10 Resident’s health, personal and social care needs are set out in an individual plan of care and accompanying documentation. EVIDENCE: There were care plans in place for all those residents whose care was tracked, these, following discussion with the residents concerned, consistent with their needs as they verbally expressed them. They also confirmed that the care staff were meeting the actions detailed within the plans. The plans seen were concise and all signed by residents or their representatives with evidence seen of monthly review. There was seen to be some risk assessments in place. It was not possible to correlate that all the plans followed on from pre admission assessments as these were not available in all cases, but where available it could be seen that the basis of the information was drawn from this assessment. Whilst standards on medication were not fully assessed it was noted that some of the homely remedies given are confirmed as appropriate for some residents through the signature of the G.P on the homes protocol. This was not present for all residents though and needs to be updated. The manager stated that Abbeygate Care Centre DS0000025048.V276533.R01.S.doc Version 5.1 Page 11 there was a verbal agreement in place for the one resident who care was tracked, this not however confirmed in writing. In discussion with residents there were a number of examples cited in which the staff promoted their privacy and dignity including knocking on bedroom doors, allowing privacy in toilets and assisting female residents with make up. In discussion with some of the residents some issues did however come to light that indicated that two of the residents were having some difficulties adjusting to acceptance of receipt of intimate care. In both instances the residents understood that they needed assistance and felt the staff were good in the way they provided personal care. It would however be useful if the manager reviewed issues around residents’ views in respect of the provision of intimate care on an on-going basis. Abbeygate Care Centre DS0000025048.V276533.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of the above outcomes were fully assessed at the time of this inspection. EVIDENCE: See above comment. Abbeygate Care Centre DS0000025048.V276533.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Relatives are fully aware of the homes complaints procedures and residents are able to raise concerns with staff. The home has clear procedures in respect of resident protection that staff are aware of, with residents feeling safe at the home. EVIDENCE: The home was seen to have a clear complaints procedure that was displayed in large print in the entrance area. The responses from eleven relatives through the CSCI comment cards all indicated that they were aware of the home’s complaints procedure with only one stating that they had ever made a complaint, this not within the last 12 months according to the homes records. There were some minor issues raised by one resident during discussion and they were able to raise these comfortably with the manager, this an action agreed prior to this discussion between the inspector and the resident. The home was seen to have policies and procedures in place in respect of dealing with any issues relating to adult protection and related areas, this including the local authorities. Discussion with staff indicated that they had a clear awareness of what abuse was and the action they should take if witnessing any such incident. Protection of resident’s financial affairs is discussed later in this report (standard 35), with the only issue identified the lack of inventories of residents property in some instances. Abbeygate Care Centre DS0000025048.V276533.R01.S.doc Version 5.1 Page 14 There was also discussion with the manager as to the behaviours of one resident that need to be monitored as there have been some limited instances of verbal aggression and inappropriate behaviour. Residents did however indicate that they felt safe at the home. Abbeygate Care Centre DS0000025048.V276533.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 Residents live in a well-maintained environment EVIDENCE: Abbeygate is a well presented home that was seen to provide a safe and wellmaintained environment for residents. The communal areas seen were clean, comfortable and well presented. There is a maintenance programme in place with evidence of on-going redecoration and replacement of a number of doors including the front entrance door. Abbeygate Care Centre DS0000025048.V276533.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 Staff numbers on duty were consistent with that shown on the rota, and were sufficient to meet the assessed care needs of current residents. Recruitment and employment practices are consistent with the safeguarding of residents. EVIDENCE: The home was seen to have sufficient care staff on duty at the time of the inspection, and based on the hours allocated per week and the current dependency levels of the residents, sufficient care hours available to meet with the expectations of the Department of Health recommended staffing tool. There are currently six staff with an NVQ level 2 in care, this providing the home with a ratio of 50 of staff so qualified thereby meeting the expectations of the national minimum standards. The staff files for two recently appointed staff were examined and the actions taken by the home through the recruitment process were found to be consistent with those needed for the employment of staff that were safe to work with vulnerable adults. Abbeygate Care Centre DS0000025048.V276533.R01.S.doc Version 5.1 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35 Overall resident’s financial interests are safeguarded with the exception of the home consistently documenting items of value within an inventory. EVIDENCE: The home was seen to have policies and procedures in respect of the safeguarding of residents finances and valuables and staff when asked were clearly aware of the policy on the receipt of gifts. The home does not act as an appointee for any resident with financial affairs dealt with by the relatives or appropriate others. There are small amounts of monies safe kept by the manager, these documented on appropriate records that were found to balance with the monies kept. The home was seen to have records of resident’s property although these were missing for some residents. The manager must ensure that all items of possible value are documented. Whilst there was not a full assessment of safe working practices the manager was advised that there should be moving and handling risk assessments in Abbeygate Care Centre DS0000025048.V276533.R01.S.doc Version 5.1 Page 18 place for any task that involved use of aids. If staff are expected to use a bath hoist to transfer residents into the bath then these instructions should be documented. Further advice can be obtained from Environmental Services. Abbeygate Care Centre DS0000025048.V276533.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 2 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 X 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X 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 X X X X 2 X X X Abbeygate Care Centre DS0000025048.V276533.R01.S.doc Version 5.1 Page 20 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. 1. Standard OP3 Regulation 14(1) d Requirement The manager must consistently confirm in writing that the home is able to meet the needs of a resident prior to their admission to the home. A pre admission assessment must be carried out for all residents prior to their admission to the home. To update the permissions for the homes homely remedies policy with residents G.Ps as appropriate. Inventories of resident’s property are to be consistently maintained. Inventories of resident’s property are to be consistently maintained. There should be clear written directions in place (in the form of a moving and handling risk assessment) for any resident that requires the use of aids (i.e. bath hoists). Further advice to be sought from Environmental services. Timescale for action 15/03/06 2. OP3 14 (1) a 15/03/06 3. OP9 13 (2) 30/04/06 4. 4. 5. OP18 OP35 OP38 13 (6) 13 (6) 13 (5) 15/03/06 15/03/06 31/03/06 Abbeygate Care Centre DS0000025048.V276533.R01.S.doc Version 5.1 Page 21 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 OP2 OP10 OP18 Good Practice Recommendations All residents should be in receipt of a contract/terms and conditions between themselves and the home. The manager should monitor resident’s views in respect of intimate personal care. The behaviour of the one resident (as discussed at the time of the report) should be monitored. Abbeygate Care Centre DS0000025048.V276533.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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 Abbeygate Care Centre DS0000025048.V276533.R01.S.doc Version 5.1 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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