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Inspection on 20/09/06 for Abbeygate Rest Home

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

This inspection was carried out on 20th September 2006.

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

This home has a prominent position and is well established as the local community`s home. It does this by maintaining good care practices and good relationships with the service users and their families and by involving the community in events happening in the home. The residents were all positive about the care they received from the staff and made comments such as `It`s excellent` and `I`m very happy here`. Training is to a good standard, with regular ongoing training. The staff group is stable, most of the care staff having been at the home for many years; this provides a consistency of care practice.

What has improved since the last inspection?

Since the last inspection the home has continued with the rolling maintenance programme of redecorating bedrooms as they are vacated. The bathroom on the first floor and the ground floor toilet are now more welcoming and homely. A new sluice has been installed. Improvements have been made to the statement of purpose and the service users` guide and some policies and procedures have been revised and updated.

What the care home could do better:

The home still does not devote enough hours to designated activities coordination. Consequently care plans do not demonstrate that residents` hobbies, interests, routines and lifestyles have been explored in depth. The first floor corridors are undecorated and would benefit from having pictures, wall hangings or stencils to give a more homely atmosphere. Accidents to residents which involve a visit to the Accident and Emergency department should be notified to the commission in accordance with Regulation 37.

CARE HOMES FOR OLDER PEOPLE Abbeygate Rest Home 9 North Street Crowland Lincs PE6 0EG Lead Inspector Julie Western Key Unannounced Inspection 20th September 2006 09:00 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 Rest Home DS0000002314.V312017.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 Rest Home DS0000002314.V312017.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbeygate Rest Home Address 9 North Street Crowland Lincs PE6 0EG 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) 01733 211429 01733 211553 broadgatehomes.com Abbeygate Rest Homes Limited Mrs Gay Addy Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (31) of places Abbeygate Rest Home DS0000002314.V312017.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd November 2005 Brief Description of the Service: Abbeygate Care Home is a two storey older building with a purpose built single storey extension. The home is set in its own grounds within walking distance of the centre of the market town of Crowland where there are shops and local facilities. Peterborough and Spalding are seven and ten miles away respectively. There is a small car park to the front of the home and garden areas to the side and rear of the building. The home is on a bus route from Spalding to Peterborough. The bedrooms are single with the exception of three which are shared. The home is registered for up to 31 service users aged over 65 years and on the day of the inspection there were 17 service users. The home is one of two homes owned by Broadgate Builders, one of the Directors being the General Manager, who oversees both homes. Abbeygate Rest Home DS0000002314.V312017.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over 3 hours. A partial tour of the building took place and care records were inspected. The main method of inspection used was called ‘case-tracking’; this involved selecting three residents and tracking the care they received through the checking of their records, discussions with residents and care staff and observation of practices. Some policies and procedures were examined and records concerning the safety of the home were also seen. Three of the 17 residents, two care and ancillary staff and four visitors were spoken with. The registered Manager was present throughout the inspection. What the service does well: What has improved since the last inspection? Since the last inspection the home has continued with the rolling maintenance programme of redecorating bedrooms as they are vacated. The bathroom on the first floor and the ground floor toilet are now more welcoming and homely. A new sluice has been installed. Improvements have been made to the statement of purpose and the service users’ guide and some policies and procedures have been revised and updated. Abbeygate Rest Home DS0000002314.V312017.R01.S.doc Version 5.2 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 Rest Home DS0000002314.V312017.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 Rest Home DS0000002314.V312017.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6 Quality in this outcome area is excellent. This judgement has been made using available evidence, including a visit to the service. The home’s records give a full picture of the needs of each resident to ensure that health and personal needs are met. The home does not provide intermediate care. EVIDENCE: Both the statement of purpose and the service user guide have been updated and are comprehensive and in clear print and easily understood language. Records showed that each resident received a detailed statement of their terms and conditions. The Care Manager said that she usually conducted initial assessments, in the prospective residents’ own homes or in a care setting. Residents spoken with confirmed that they had visited the home for a coffee or a day before permanent placement. A resident described how she had been to the home for a day and taken part in the daily activities, including lunch, before permanent admission. The home has three day care places. Abbeygate Rest Home DS0000002314.V312017.R01.S.doc Version 5.2 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): 7-10 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the service. The home’s records give a clear and full picture of the needs of each resident to ensure that health and personal needs are met. EVIDENCE: The home uses a card system for recording care plans; these were clear as to the needs of residents and contained full assessments including risk assessments. They did not however, contain much information about the residents’ hobbies, interests, routines and lifestyles. There was a fully developed procedure for medication, which had recently been updated. There had not been a visit from a pharmacist since 27/11/04 and the Manager said that this would be addressed. A resident said ‘The care is excellent’. A number of residents were spoken with and all said they could get up and go to bed when they chose. Staff members were observed to knock on doors before entering and to give time and consideration to residents, particularly with regard to assistance with toileting and assisting with moving around the home. Abbeygate Rest Home DS0000002314.V312017.R01.S.doc Version 5.2 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): 12-15 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the service. Social activities are extensive and are well managed, creating daily variation and interest for people living in the home. The residents can exercise choice regarding daily activities and meals. EVIDENCE: One staff member was responsible for approximately 6 hours of activities weekly but this time was not designated. Current activities provided by the home included board games, cards, dominoes, exercises, coffee mornings, music and outside entertainment every two weeks; on the day of the inspection a singing duo was entertaining the residents. In the community there is access to the Library, church activities, luncheon club and various other clubs and a weekly market. Residents spoken with said how much they enjoyed the meals served at the home. Kitchen staff members were spoken with and menus were examined; there were two alternative choices. The midday meal was sampled and was balanced, nutritious and easy for older people to eat. Service users were observed eating the mid-day meal and they commented that the food was very good, both in quantity and quality and that they had an extensive choice. Abbeygate Rest Home DS0000002314.V312017.R01.S.doc Version 5.2 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, 18 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the service. Complaints are handled objectively and residents are confident that their concerns will be listened t and acted upon. There is a robust vulnerable adults procedure. EVIDENCE: Residents and visitors to the home all said they did not wish to complain but knew how to make a complaint; a resident said ‘all the staff are willing to listen and help as much as possible – I’ve not needed to complain’. The home had received no complaints in the last twelve months. The home has a clear adult protection policy, which was linked to the Local Authority Adult Protection Procedures. The Care Manager said that all staff members had now received training on adult protection issues and staff members spoken with confirmed this. Abbeygate Rest Home DS0000002314.V312017.R01.S.doc Version 5.2 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, 26 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the service. The home is maintained to a high standard internally, with well-furnished rooms which residents are able to personalise. Work is continually in progress to ensure that the environment is kept up to standard EVIDENCE: Overall, the standard of decoration internally and in the gardens was good and afforded residents a great degree of comfort. The Care Manager said that the General Manager was responsible for the rolling maintenance programme and rooms were redecorated as a general policy when they were vacated. The bathroom on the first floor and the ground floor toilet are now more welcoming and homely and a new sluice has been installed. The corridors on the first floor still lack interest and it was suggested that residents decided what they wished to have on the walls at a residents’ meeting. The home has overhead and Abbeygate Rest Home DS0000002314.V312017.R01.S.doc Version 5.2 Page 13 under floor heating and thermostatic valves are present on all baths and showers. Abbeygate Rest Home DS0000002314.V312017.R01.S.doc Version 5.2 Page 14 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): 27-30 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the service. Sound procedures for the recruitment of staff are in place and the residents are cared for by a knowledgeable and well-trained group of staff. EVIDENCE: The residents were very positive about the care they received from the staff. One said ‘They look after me very well and they’re very kind and a feedback questionnaire from a resident said ‘the staff are always ready to help and are very caring’. The most recent staff member to be appointed confirmed that she had given two references, which were followed up, a CRB check and undertaken an induction programme before commencing work. Ten staff members had National Vocational Qualification at Level 2 and three staff members had achieved the NVQ at Level 3. The cooks were also undertaking the NVQ at Level 2 for catering. Minutes of the recent staff meeting were available for all staff. The staff rota showed that there were enough staff numbers according to the staffing matrix and shifts were staggered to accommodate the needs of residents. Residents spoken with thought there were enough staff and staff confirmed this. Abbeygate Rest Home DS0000002314.V312017.R01.S.doc Version 5.2 Page 15 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, 33, 38 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the service. The open management style of both the proprietor and the Manager enable the home to run smoothly and ensure that the best interests of residents are safeguarded. EVIDENCE: The General Manager currently divides his time between the two Abbeygate homes. He has the responsibility for conducting an ongoing risk assessment on the building. The registered Manager has now been in post for over a year. She has worked in the home for five years, has had seven years’ experience in care practice and has achieved NVQ Level 3 and the Assessor’s Awards. She is currently working towards the Registered Manager’s Award. The home has the Investors in People award and letters from residents’ relatives showed that Abbeygate Rest Home DS0000002314.V312017.R01.S.doc Version 5.2 Page 16 they felt very much a part of the home and questionnaires showed that their views were sought. One resident described how she had not been able to attend the recent residents’ meeting but had written down some issues needing addressing and they had all been resolved within two weeks. The open-door policy allowed residents and staff to talk to the Manager throughout the day. Visitors and staff were very positive in their comments about the staff and said they were very hardworking. A resident said ‘they’re very caring’. Abbeygate Rest Home DS0000002314.V312017.R01.S.doc Version 5.2 Page 17 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 4 X X N/A 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 X 18 3 3 X X X X X X 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 X X X 3 X X 3 Abbeygate Rest Home DS0000002314.V312017.R01.S.doc Version 5.2 Page 18 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 OP38 Regulation 17, 37 Requirement All accidents to residents involving a journey to hospital should be notified to the commission. Timescale for action 22/09/06 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 OP12 OP7 OP19 Good Practice Recommendations It is a recommendation that designated hours are given to organising the programme of events and activities. It is a recommendation that care plan assessments include information on the hobbies, interests, routines and lifestyles of residents. It is a recommendation that the first floor corridors are made more homely and interesting by the use of pictures, stencils etc. and that residents are involved in the choice of wall decorations. Abbeygate Rest Home DS0000002314.V312017.R01.S.doc Version 5.2 Page 19 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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 Rest Home DS0000002314.V312017.R01.S.doc Version 5.2 Page 20 - 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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