Inspection on 03/11/05 for Abbeygate Rest Home

This inspection was carried out on 3rd November 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 Rest Home 22/10/08

Abbeygate Rest Home 20/09/06

Abbeygate Rest Home 04/07/05

Abbeygate Rest Home 13/10/04

Abbeygate Rest Home 12/05/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Abbeygate Rest Home 9 North Street Crowland Lincs PE6 0EG Lead Inspector Julie Western Unannounced Inspection 3rd November 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 Rest Home DS0000002314.V264361.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 Rest Home DS0000002314.V264361.R01.S.doc Version 5.0 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 211557 Abbeygate Rest Homes Limited Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (31) of places Abbeygate Rest Home DS0000002314.V264361.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th July 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 19 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.V264361.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over 4 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 21 residents, three of the 19 care and ancillary staff and two visitors were spoken with. The Care Manager, who is awaiting the result of a Fit Person Interview with CSCI to become the registered person, was present throughout the inspection and the General Manager was present for part of the inspection. What the service does well: What has improved since the last inspection? What they could do better: The statement of purpose needs updating and the service user guide could be made more user-friendly for the residents. The home still does not have an activities co-ordinator, although currently a staff member organises activities and events over 6 hours a week. Staff folders require up to photographs of Abbeygate Rest Home DS0000002314.V264361.R01.S.doc Version 5.0 Page 6 staff members. All staff members handling food, including those serving refreshments need to complete a basic food hygiene certificate. 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.V264361.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 Rest Home DS0000002314.V264361.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): 2,4,5 The home clearly sets out what it intends to do for its residents and this information is freely available, although some updating is required. Prospective residents are encouraged to take time, before making the decision to move into the home on a permanent basis. EVIDENCE: Both the statement of purpose and the service user guide are comprehensive and in clear print and easily understood language. The statement of purpose needs updating and the service user guide contains some duplication of information found in the statement of purpose. 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 Abbeygate Rest Home DS0000002314.V264361.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): 7-10 The home’s records give a clear picture of the needs of residents and enable staff to meet their needs with sensitivity and regard for their privacy and dignity. EVIDENCE: The three care plans looked at in depth contained clear assessments, were reviewed regularly and were signed where possible by the service user or relatives/advocates. The Care Manager said that all care plans were gradually being updated. There was a clear medication policy and the pharmacist visited regularly; his last report, on 24/11/04 said ‘excellent use made of system and procedures’. All night staff had attended training on medication. Residents said they felt safe and well looked after; one said ‘they’re very nice’ and a visitor said ‘they’re attentive’. The staff team were observed carrying out their duties with kindness and sensitivity towards the residents, especially when attending to their personal needs. Abbeygate Rest Home DS0000002314.V264361.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): 13-15 Social activities create a variety of events and activities, which residents are informed about, but would benefit from having a designated member of staff to co-ordinate activities; the General Manager is currently advertising for this post, possibly to be shared between the two Abbeygate homes. The residents exercise choice about which activities, if any, they wish to participate in and what meals they want to eat. EVIDENCE: One staff member was responsible for 6 hours of activities weekly. Current activities provided by the home included board games, cards, dominoes, Thai Chi exercises, coffee mornings, music and outside entertainment every two weeks. 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 mid-day 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.V264361.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): 16,18 The home’s complaints procedure is clear and gives residents and their relatives the confidence that comments and concerns will be listened to; there is a robust adult protection procedure. EVIDENCE: Residents and visitors to the home all said they did not wish to complain but knew how to make a complaint. The home had received one complaint in the last twelve months; this had been responded to appropriately and was still ongoing. The home has a clear adult protection policy, which was linked to the Local Authority Adult Protection Procedures. The Care Manager said that most staff members had received training on adult protection issues and staff members spoken with confirmed this. Abbeygate Rest Home DS0000002314.V264361.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): 19-21, 24-26 The residents live in a comfortable, pleasant and safe environment with both private and communal space being on the whole suitable for their needs. 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. One of the ground floor toilets was very basic in appearance, having no decoration such as pictures or curtains and an upstairs bathroom used for respite was also in need of some decoration. The home has overhead and under floor heating and thermostatic valves are present on all baths and showers. Abbeygate Rest Home DS0000002314.V264361.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): 27,29 Staff numbers are in sufficient quantity for them to be able to care for the residents. Staff members are on the whole suitably trained, qualified and competent; they undergo an induction programme before commencing their duties. 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’. 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. Nine staff members had National Vocational Qualification at Level 2 with two currently undertaking it and three staff members had achieved the NVQ at Level 3. 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. All staff members handling food should have the Basic Food Hygiene Certificate. Abbeygate Rest Home DS0000002314.V264361.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): 32, 33, 35 The home is managed competently and the staff are supported and supervised in carrying out their respective roles. The views of residents are listened to and they are involved in decisions affecting them. 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 Assistant Manager has been in post eight months. She has worked in the home for four years, has had six years’ experience in care practice and achieved NVQ Level 3 and the Assessor’s Awards. She is currently working towards the Registered Manager’s Award and is awaiting the result of the Fit Person Interview with the CSCI to become the Registered Manager. The home has the Investors in People award and letters from residents’ relatives Abbeygate Rest Home DS0000002314.V264361.R01.S.doc Version 5.0 Page 15 showed that they felt very much a part of the home and questionnaires showed that their views were sought. Abbeygate Rest Home DS0000002314.V264361.R01.S.doc Version 5.0 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 2 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 X 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 2 X X 3 3 3 STAFFING Standard No Score 27 3 28 X 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 3 X 3 X X X Abbeygate Rest Home DS0000002314.V264361.R01.S.doc Version 5.0 Page 17 Are there any outstanding requirements from the last inspection? NONE 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 OP1 Regulation 4[1] Requirement The registered person must update the statement of purpose to reflect the managerial changes in the home The registered person must confirm in writing that the care home is suitable for the purpose of meeting the needs of the serviced user in respect of his health and welfare The registered person must repair/redecorate the crack in the ceiling on the first floor corridor. The registered person must make the first floor bathroom and the ground floor w.c. more welcoming and cheerful with the use of pictures, curtains or plants. The registered person must ensure that all staff members handling food have achieved the basic food hygiene certificate. Timescale for action 02/01/06 2 OP3 14[1][d] 02/01/06 3 OP19 23[2][b] 02/01/06 4 OP21 23[2][b] 02/01/06 5 OP30 18[1] 02/01/06 Abbeygate Rest Home DS0000002314.V264361.R01.S.doc Version 5.0 Page 18 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 Refer to Standard OP12 Good Practice Recommendations It is a recommendation that a designated person is appointed to organise a programme of events and activities. Abbeygate Rest Home DS0000002314.V264361.R01.S.doc Version 5.0 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. 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