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Inspection on 13/10/05 for Abbeygate Residential Home

Also see our care home review for Abbeygate Residential Home for more information

This inspection was carried out on 13th 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home is welcoming and homely, the staff know the residents well and provide the care and support that the residents require. The needs of the residents are documented in their individual care plans and every effort is made to ensure that personal, health and social needs are met. Residents that were spoken to praised the staff, saying they received all the care and support that they required. The meals were seen to be appetising; residents confirmed that choices were available.

What has improved since the last inspection?

The new manager has become more assured and confident in her position and is doing well. Requirements made following the last inspection have been completed; all personal care files contain a recent photograph of the resident, the fittings for the bath hoist have been replaced and the recruitment procedure has been followed for new staff.

What the care home could do better:

CARE HOMES FOR OLDER PEOPLE Abbeygate Residential Home 42 Quarry Road Winchester Hampshire SO23 0JS Lead Inspector Pat Griffiths Unannounced Inspection 13th October 2005 10:00 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 Residential Home DS0000012223.V257341.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 Residential Home DS0000012223.V257341.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Abbeygate Residential Home Address 42 Quarry Road Winchester Hampshire SO23 0JS 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) 01962 855056 01962 856910 Avonpark Care Centre Limited Care Home 30 Category(ies) of Dementia - over 65 years of age (4), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (4), Old age, not falling within any other category (30) Abbeygate Residential Home DS0000012223.V257341.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Not more than 5 service users in the category MD (E) referred to above are to be accommodated at any one time for as long as service user D.O.B 01/11/1910 stays in the home; then revert to 4 service users Not more than four service users in the category DE (E) referred to above are to be accommodated at any one time. 5th April 2005 2. Date of last inspection Brief Description of the Service: Abbeygate is a large care home on the outskirts of Winchester and is part of the Avonpark Care Centre Ltd. group of homes. The home is registered to provide non-nursing care for 30 male and female older people over sixty years of age. Four of the male and female beds are registered for dementia and or mental health care provision. The home is located in a quiet, residential, area of Winchester, not far from the city centre and amenities. The home is surrounded by a large mature garden, which is not overlooked. Sufficient parking is available on the premises; there is a steep incline from the car park to the front door of the home but there are also steps from the car park to the side of the house. Abbeygate Residential Home DS0000012223.V257341.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second of two unannounced inspections in the inspection year 2005/06. This inspection took place over one day. Opportunity was taken to look around the home, view records and policies and talk to staff, residents and visitors. The acting manager, who has managed the home since the last inspection and has now successfully completed her probationary period, will shortly apply to the commission for registration. All service users, who prefer to be called residents, spoken to expressed satisfaction with the services and care received at the home. Communal areas were well fairly well maintained but the home would benefit from redecoration in some areas. The home continues to meet most of the minimum standards and regulations, the staff and management are committed to providing a good standard of service to the residents. What the service does well: What has improved since the last inspection? The new manager has become more assured and confident in her position and is doing well. Requirements made following the last inspection have been completed; all personal care files contain a recent photograph of the resident, Abbeygate Residential Home DS0000012223.V257341.R01.S.doc Version 5.0 Page 6 the fittings for the bath hoist have been replaced and the recruitment procedure has been followed for new staff. 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 Residential Home DS0000012223.V257341.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 Residential Home DS0000012223.V257341.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): Standard 3 The assessment of residents prior to their move into the home ensures that their needs can be met. Standard 6 does not apply to this service. EVIDENCE: The manager undertakes a pre-admission assessment on all potential residents, to ensure that the home can meet their needs. The home has recently implemented a new format for recording this information, which the manager advised was working well. Several files were examined and the preadmission documentation was found to contain the relevant information such as medical history, mental state, mobility and dietary preferences. The home does not provide intermediate care. Abbeygate Residential Home DS0000012223.V257341.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): Standards 7, 9 and 10 Arrangements ensure resident’s needs are identified and set out in a care plan. The residents are protected by the homes medication policies and procedures. Arrangements ensure that residents are treated with respect and their dignity maintained. EVIDENCE: The inspector saw several personal care plans, which showed that all sections of the plans were completed and reviewed and updated as appropriate. A new profile for the care plans has been introduced and the information in all files has been transferred. The plans included information about the healthcare needs and daily activities of the residents; their likes and dislikes, such as what time they liked to go to bed and how they wished to be addressed by the staff. Visits by the GP and District Nurse were also recorded in the care plan. The resident’s personal care plans are reviewed and updated regularly; the manager advised that it is planned for the residents or their nominated representatives to be more involved during this process if they wish. Abbeygate Residential Home DS0000012223.V257341.R01.S.doc Version 5.0 Page 10 Recent photographs of all residents have been included in their files, which was a requirement of the last inspection. Residents and their visitors were happy to chat with the inspector. They were very positive about the care provided. The inspector examined the MAR sheets (Medication Administration Record) and found they had been completed correctly. The inspector and the manager discussed the use of the MAR sheet as an audit tool; it should be used to record all medication received into the home, the medication that is administered and any medication that is returned to the pharmacy. The staff in the home have received training in medication administration from Boots chemist, which was last done in April 2005. The home has an open visiting policy and all visitors sign the visitors’ book in the hall when they enter the home. The inspector observed staff knocking on residents’ bedroom doors and waiting to be invited to enter. Abbeygate Residential Home DS0000012223.V257341.R01.S.doc Version 5.0 Page 11 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): These standards were not examined during this inspection EVIDENCE: Abbeygate Residential Home DS0000012223.V257341.R01.S.doc Version 5.0 Page 12 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): Standard 18 Arrangements for the training of staff in adult protection do protect the service users. EVIDENCE: Staff that spoke with the inspector were aware of the need to protect residents from abuse and what to do should they suspect that it is happening in the home. The most recent staff training on adult protection was in July 2005 and the records indicated that all staff attended. The home does have policies and procedures available for dealing with abuse but none for dealing with aggression or violence and the manager was advised by the inspector that one must be written. Abbeygate Residential Home DS0000012223.V257341.R01.S.doc Version 5.0 Page 13 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): The home is clean, safe and well maintained. EVIDENCE: On the day of the visit the inspector was able to tour the home; seeing several bedrooms, the sitting rooms, the kitchen and the dining room. All areas were clean and free from odour. Some carpets have been replaced and some of the bedrooms and the reception area have been decorated. The décor in parts of the communal areas looked grubby and tired, with marks from chairs on the wall and knocks and scrapes from wheelchairs on some of the doorframes. The home has had a new washing machine installed, which is working well. The laundry room floor needs to be repaired or replaced, as there are holes in the floor covering, which means that the floor is no longer sealed and is a potential source of infection. Staff received training on infection control in September 2005. Abbeygate Residential Home DS0000012223.V257341.R01.S.doc Version 5.0 Page 14 Abbeygate Residential Home DS0000012223.V257341.R01.S.doc Version 5.0 Page 15 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): Standards 27, 28, 29, and 30 Arrangements ensure that residents are in safe hands at all times and are protected by the homes recruitment practices and staffing numbers. EVIDENCE: The home employs fifteen care staff that are supported by five cleaners, a cook and a handyman. All staff have undertaken statutory training, which includes manual handling, fire safety and adult protection; over 50 have completed or are studying for an NVQ in healthcare at level 2 or above (National Vocational Qualification). The manager advised that the induction training for all new staff is to be expanded to include the ‘Skills for Care’ training. The manager will be starting her NVQ 4 in management in October 2005. The inspector examined several staff files and found that the file of the newest member of staff had been completed correctly, containing all necessary documentation, such as a correctly filled in application form, proof of identity, two written references had been obtained and a CRB (Criminal Records Bureau) disclosure had been applied for before employment started. Abbeygate Residential Home DS0000012223.V257341.R01.S.doc Version 5.0 Page 16 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): Standards 31, 33, 35 and 38 Arrangements ensure that the home is well run and in the best interests of the residents. Arrangements are in place to ensure that the health, safety and welfare of the residents and staff is protected. EVIDENCE: The manager has recently completed a successful probationary period and it is confirmed that she will apply to the commission for registration. She has many years experience in this field of care and has become a confident manager of the home. Several residents and their visitors have commented that they are very pleased with the choice of the new manager and have every confidence in her skills and abilities to run the home. Abbeygate Residential Home DS0000012223.V257341.R01.S.doc Version 5.0 Page 17 The use of a service user survey is currently being reviewed, once complete the results will made available to all interested parties, including the commission. The homes administrator looks after small amounts of pocket money for some of the residents, which is kept securely in a safe; records include the receipts for all purchases. Some information about the residents is kept on the computer in the home and the inspector, the manager and administrator discussed the Data Protection Act and the need for compliance; the manager advised that a copy of the certificate would be obtained from head office. The home has a maintenance man on site for day-to-day repairs and local contractors undertake the larger repairs. The inspector was able to see the service contracts for systems such as the boilers, the fire safety equipment and the lift, all of which were up-to-date. The record of the weekly fire alarm tests was seen to be up-to-date. The home does not currently have a policy in place to support the routine for securing the building at night; a requirement has been made for this to be written and all staff to be made aware. Abbeygate Residential Home DS0000012223.V257341.R01.S.doc Version 5.0 Page 18 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 3 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 X 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X 2 Abbeygate Residential Home DS0000012223.V257341.R01.S.doc Version 5.0 Page 19 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 OP18 Regulation 13(7)&(8) Requirement The home must have a policy available for dealing with aggression or violence within the home The registered person must ensure that the laundry room floor is repaired or replaced The home must have a policy in place to support the routine for securing the building at night Timescale for action 30/11/05 2 3 OP26 OP38 13(3) 13(4)(c) 30/01/06 30/11/05 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 Residential Home DS0000012223.V257341.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Residential Home DS0000012223.V257341.R01.S.doc Version 5.0 Page 21 - 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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