Inspection on 25/10/05 for Abbeygate Care Centre

This inspection was carried out on 25th 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 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 16/02/06

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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Abbeygate Care Centre 2 Leys Road Brockmoor West Midlands DY5 3UR Lead Inspector Mr Keith Salmon Unannounced Inspection 25th October 2005 09:30 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.V260863.R01.S.doc Version 5.0 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.V260863.R01.S.doc Version 5.0 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.V260863.R01.S.doc Version 5.0 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 17th March 2005 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. Abbeygate Care Centre DS0000025048.V260863.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Announced Inspection commenced at 09.30, lasted 5.0 hours, and was undertaken by one Inspector. This Report is a product of observations made during a tour of the Home, discussions held with Mr. Dasrath Sahadew (the Registered Manager/Joint Proprietor), other Staff members, 9 Residents and 2 Visitors, together with a review of care related documentation, including staff recruitment/deployment records, a range of documents/records reflecting the general operation of the Home. High standards of direct care provision, and overall management are provided in a friendly and open atmosphere. This is strongly reflected through verbal comments, made to the Inspector, by Residents and Visitors and included:…“The care my Mother receives at Abbeygate is exceptional…”, “...Residents are treated with respect and dignity…”, “…The Staff are always available and appear to make great efforts for those in their care…”, “…The Home is always clean and tidy…”, ”…I enjoy my food and the cook gives us just what we like.” What the service does well: What has improved since the last inspection? There have been a number of recent improvements, which relate directly to the quality of service provided to Residents. These include:- new carpeting in the lounge and hall-way areas, Residents being aware they may have a choice for their main mid-day meal, all bedrooms now having the facility to enable Residents to lock away valuables. A number of health and safety related measures have also been effected, including arrangements put in place to ensure maintenance of fire safety equipment, and provision of a thermostatic control to the hot water supply to the wash hand basin in the laundry. Abbeygate Care Centre DS0000025048.V260863.R01.S.doc Version 5.0 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. Abbeygate Care Centre DS0000025048.V260863.R01.S.doc Version 5.0 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.V260863.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 & 5. Prior to admission to the Home prospective Residents are enabled to reach an informed choice, and to fully understand the service they can expect. Processes to ensure appropriate, thorough, and effective care needs assessment are diligently undertaken and applied. EVIDENCE: The Home has a Statement of Purpose and User Guide, both of which are concise and easy to read, with content, which clearly meets the requirements of the Standard. Service Users are provided with a Statement of Terms and Conditions detailing the accommodation to be provided. Evidence from 10 randomly selected Care Plans, and discussions with Residents, demonstrated the Registered Manager, or Deputy Manager, assess all prospective Residents/Service Users prior to admission, and new Residents have the opportunity to visit the Home, or enter the Home on a trial basis, prior to admission. Abbeygate Care Centre DS0000025048.V260863.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10. The model of Care Plan utilised by the Home is of an effective design, and is diligently applied to aid the provision of care pertinent to individual Residents’ assessed care needs. Staff relate to Residents in a friendly and respectful manner. The storage, administration, and disposal of medicines are generally in accordance with accepted good practice. EVIDENCE: The Home’s Care Documentation includes full pre-admission assessment, carried out by suitably qualified Staff; Care Plans which are well-organised, clearly written and current; and recently revised Policies and Procedures. Individual discussions held by the Inspector with Residents and Relatives confirmed Residents’ needs are being met. Inspection of medicine storage provision, and administration records, demonstrated the Home’s practices generally meet the guidelines of the Royal Pharmaceutical Society. Abbeygate Care Centre DS0000025048.V260863.R01.S.doc Version 5.0 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15. The Home works continuously, and effectively, to involve all Residents in a range of leisure opportunities, consistent with each Resident’s capabilities. Residents are actively assisted in maintaining contact with relatives and friends. Continuation of religious practices is encouraged and supported wherever possible. The Home works hard to provide the type of meals preferred by the Residents. EVIDENCE: The case files were seen to contain ‘life biographies’, which include and cater for individual Residents ‘leisure’ preferences. There was a daily record of activities made available to Residents. Visitors confirmed there was no restriction of visiting hours (as per the Home’s Policy), and they were able to enjoy sufficient privacy when visiting. Abbeygate Care Centre DS0000025048.V260863.R01.S.doc Version 5.0 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17 & 18. The interests of Residents are protected through ready access to the Home’s Complaints Procedure, together with information being made available relating to advocacy services. All Staff are aware of their role in protecting Residents from abuse. EVIDENCE: Complaints Procedure details are included in the Service User Guide and are displayed prominently for the benefit of Visitors. Policies and procedures intended to provide protection for vulnerable people were seen to be in place. These fully meet the requirements of this Standard, and the topic is covered both at induction and through on-going staff training. Abbeygate Care Centre DS0000025048.V260863.R01.S.doc Version 5.0 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25 & 26 The Home provides a generally safe environment, and is decorated to a satisfactory standard with furniture and furnishings, which help to create a comfortable and ‘homely’ atmosphere. There are well-maintained gardens, which are easily accessible to Residents. Infection control policies/procedures appear satisfactory. Specialist equipment is available to facilitate provision of care consistent with the needs of the Service Users, and with the demands of tasks carried out by Care Staff. There is a potential scalding hazard to Residents arising from the hot water tap, in the toilet situated in the Hallway. EVIDENCE: The Home has a full range of maintenance contracts in place, which are current. There is an on-going refurbishment/redecoration programme covering the bedrooms as they become vacant. Re-carpeting of ‘public areas’ has recently been completed. The standard of cleanliness in the Home is good. The hot water tap on the wash-hand basin in the hallway toilet does not have a thermostatic control valve. Abbeygate Care Centre DS0000025048.V260863.R01.S.doc Version 5.0 Page 13 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30. Staff numbers and skill-mix 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. The Home has an established training programme, which ensures induction and foundation training for all newly appointed Staff, and provides opportunities to undertake appropriate NVQ Training. EVIDENCE: The current Staff Rota, and several from preceding weeks, were examined and showed that staffing levels were sufficient to meet the assessed care needs of the current Residents. Perusal of Staff Personnel Files demonstrated evidence of full compliance with the Standard and Schedule 2 of the Regulations. Training records showed the proportion of Care Staff who have completed NVQ Level 2 training easily meets the requirement of the Standard. Abbeygate Care Centre DS0000025048.V260863.R01.S.doc Version 5.0 Page 14 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,36,37 & 38. Operationally, the Home is very well organised, with the central purpose being ‘the best interests of Residents’. Staff appeared involved and happy in their work, and are subject to effective support, with regular ‘supervision by the Registered Manager. EVIDENCE: Evidence was based on discussion with Residents, Staff of relevant documentation. Mr. Sahadew, the Registered Manager/Joint Owner, is an RGN, who has daily ‘hands-on’ input to the care management process. A presence and input much appreciated by the Staff. It was noted that several members of Staff have been in post for many years contributing to a stable and reliable workforce. It was evident there are clear lines of accountability established within the Home. The Home’s practices, in the context of health, safety and welfare of Residents, Visitors and Staff, were seen to be generally in accordance with the Regulations. However, (as identified in Standard 25 above) there is an issue relating to the protection of Residents and Staff from the risk of scalding. Abbeygate Care Centre DS0000025048.V260863.R01.S.doc Version 5.0 Page 15 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 3 3 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X 3 3 2 Abbeygate Care Centre DS0000025048.V260863.R01.S.doc Version 5.0 Page 16 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP19 Regulation 13.-(4)(a) Requirement To fit a thermostatic control valve to the hot water tap on the wash-hand basin situated in the toilet off the main hallway. Timescale for action 31/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Abbeygate Care Centre DS0000025048.V260863.R01.S.doc Version 5.0 Page 17 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.V260863.R01.S.doc Version 5.0 Page 18 - 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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