Inspection on 16/08/05 for Abbeymoor Care Home

This inspection was carried out on 16th August 2005.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Abbeymoor Care Home 17/09/09

Abbeymoor Care Home 28/11/08

Abbeymoor Care Home 30/06/08

Abbeymoor Care Home 27/07/07

Abbeymoor Care Home 19/10/06

Abbeymoor Care Home 31/01/06

Abbeymoor Care Home 19/10/04

Abbeymoor Care Home 21/04/04

Similar services:

Trevayler Residential Care Home

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Abbeymoor Care Home Sherwood Road Worksop Nottinghamshire S80 1QW Lead Inspector Judith Avill and Lee West Unannounced 16 August 2005 @ 09:30 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 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 and Care Homes for Adults 18 – 65*. 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. Abbeymoor Care Home C53 C03 S59941 Abbey Moor V243529 160805 Stage 2.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Abbeymoor Care Home Address Sherwood Road, Worksop, Nottinghamshire, S80 1QW Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Care Companions Healthcare Ltd 01909 475660 01909 480998 Ms Rosa Arthur Care home only (PC) 25 Category(ies) of Old age, not falling within any other category registration, with number (OP) 19 of places Physical disability over 65 years of age (PD(E)) Terminally ill (TI) 19 Mental disorder, excluding learning disability or dementia (MD) 6 Dementia - over 65 years of age (DE(E)) 19 Abbeymoor Care Home C53 C03 S59941 Abbey Moor V243529 160805 Stage 2.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 4 of the beds may be used for service users over the age of 60 years 2 There will be a Lead, Head of care,for the eating Disorders unit on site between the hours of 08:00 and 18:30 3 MD Category can only be used for Younger adults (Eating Disorder) age 18 to 65 Date of last inspection 19th October 2005 Brief Description of the Service: Abbeymoor is a care home that provides residential, nursing and specialist care to adults from the age of eighteen. There are 25 places and services are offered to both female and male residents. The care home is registered to provide specialist care and support for up to six adults between the ages of eighteen and sixty-five,and 19 places for older people, people with dementia and people with a physical disability over 65 years. Six beds provide a specialist ‘Younger Adult unit’ for women and men who have a diagnosed ‘Eating Disorder’. The home can offer short term and long term residential/nursing care. Abbeymoor is located close to shops and local amenities (about 500 metres) and there is access to public transport including a train station (about 500 metres).The home is detached and set in its own grounds with a car park to the front of the building. The building is adapted to cater for the needs of people with mobility problems and all areas within the home are accessible. The Younger Adult unit has its own newly installed kitchen, dining and lounge area, separate from the communal facilities offered to service users residing within the main building of the care complex. Abbeymoor Care Home C53 C03 S59941 Abbey Moor V243529 160805 Stage 2.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Inspection was the first of two unannounced Inspections to be carried out between April 2005 and March 2006. The inspection lasted for 5.30 hours and the main focus of Inspection checking previous requirements, a tour of the environment, records and ‘case tracking’ which involved selecting residents and tracking the care they receive checking through their records and discussing this with them or staff as appropriate. Discussion was held with the registered manager, qualified nurses, and observing care practices. What the service does well: What has improved since the last inspection? Previous requirements issued are being addressed and policies and procedures are in place for staff to follow. Abbeymoor Care Home C53 C03 S59941 Abbey Moor V243529 160805 Stage 2.doc Version 1.40 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. Abbeymoor Care Home C53 C03 S59941 Abbey Moor V243529 160805 Stage 2.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Standards Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Abbeymoor Care Home C53 C03 S59941 Abbey Moor V243529 160805 Stage 2.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) older people 1,3 Adults 1, 2 The Statement of Purpose is not up to date. Assessment documentation is completed by qualified staff. EVIDENCE: The Statement of Purpose viewed referred to the National Care Standards Commission not the Commission for Social Care Standards. Pre- admission assessments viewed included some aspects of daily living and Risk Assessments. Abbeymoor Care Home C53 C03 S59941 Abbey Moor V243529 160805 Stage 2.doc Version 1.40 Page 9 Abbeymoor Care Home C53 C03 S59941 Abbey Moor V243529 160805 Stage 2.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards to be inspected at least once during a 12 month period JUDGEMENT – we looked at outcomes for standard(s) Older people 7,8 9&10 Adult 6, 7, 9, 18,19 &20. Record keeping is not consistent and up to date. Healthcare needs and risk assessment’s are in place but has limited information in identifying individual preferences, personal health care needs and the procedures for staff to follow. The medication room is not secure and not all medication administered is recorded. EVIDENCE: Abbeymoor Care Home C53 C03 S59941 Abbey Moor V243529 160805 Stage 2.doc Version 1.40 Page 11 Initial assessment’s are completed by qualified staff. Records seen include daily living and Risk Assessments. Some of the monitoring records were not signed or dated. Care plans and risk assessments viewed did not reflect specific action to be taken by staff to meet individual service users needs. Follow- ups and monitoring following resident’s falls and accidents were not consistently maintained. No record of how often monitoring or tests to be completed by staff was evidenced on care plans viewed. Staff’s spoken with were aware of the needs of service users. Service user / relative involvement in care plans and reviews is being developed. Personal interests were recorded on initial assessments but no record of planned activities was evidenced on older residents records seen. Medication records were well maintained, medication for both units are stored in one area. On the day of the visit the medication room was not secure, the manager and staff confirmed that this is normal practice. Details of medication received and self -administered was not recorded. The manager was aware of the new system for the disposal of medication. Abbeymoor Care Home C53 C03 S59941 Abbey Moor V243529 160805 Stage 2.doc Version 1.40 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with asssistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Older people 12, Adults 16 17 The home has no activities co-ordinator. Records of preferences, participation in activities were not recorded. Food being served to residents seen looked nutritious. EVIDENCE: The acting manager reported that the senior care who had been responsible for activities has recently left the home. No plan of activity was seen. Records seen for older residents did not include details of recent interests and Abbeymoor Care Home C53 C03 S59941 Abbey Moor V243529 160805 Stage 2.doc Version 1.40 Page 13 activities. Staff reported residents in the specialist unit preferences and activities are planned on a short- term basis. Residents spoken with commented that food was good and plentiful. Details of assistance with eating and drinking required and individual style was not recorded. Specialist residents are served separately and make their personal choices and requests. Abbeymoor Care Home C53 C03 S59941 Abbey Moor V243529 160805 Stage 2.doc Version 1.40 Page 14 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) older people 18 adults 23 Staff report concerns to the qualified staff or the manager. EVIDENCE: Induction training programme viewed covers adult protection reporting procedures. Abbeymoor Care Home C53 C03 S59941 Abbey Moor V243529 160805 Stage 2.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Older people 19, 20, 21,24&26 Adults 24, 28, 27 &30 No programme of redecoration was available. The shower room is a poor condition. The home was clean and well aired. Seating in some of the residents bedrooms is not suitable for the age and physical needs of residents or relatives. EVIDENCE: The manager reported that the proprietors have undertaken redecoration and refurbishment since the last Inspection and further work was planned. No written programme of maintenance and renewal of fabric and redecoration was Abbeymoor Care Home C53 C03 S59941 Abbey Moor V243529 160805 Stage 2.doc Version 1.40 Page 16 available. The radiators covers have been covered in the older persons unit as required from the last inspection. In the older peoples unit paint is chipped, wallpaper needs replacing and some furnishings are worn. Some of the seating in resident’s bedrooms is not suitable for existing residents and their visitors. The home has 1 assisted bath, and 1 walk in bath with shower for the older peoples unit. Staff reported that residents do not use this bath due to limited space and poor condition of the bath and room. The specialist unit rooms have 3 en suite facilities and a bathroom. The two single rooms have an adjoining en –suite. The gardens are spacious and have garden furniture for residents use. An enclosed garden is adjacent to the area of the specialist unit. The boilers are situated within the laundry area ventilation to this room is poor, on the day of the visit the fire escape near the rooms were open. A separate room is used for ironing and storage. Neither room has a door lock. Fire doors were wedged open to the kitchen and corridors. No restrainer was in place to a window on the first floor stairway. Abbeymoor Care Home C53 C03 S59941 Abbey Moor V243529 160805 Stage 2.doc Version 1.40 Page 17 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 29 and 30 (Older People) and Standards 34 and 35 (Adults 18-65) the key standards to be inspected at leat once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Older people 27,29 adults 34 Staffing levels meet the assessed needs of the residents accommodated at the home. The recruitment process ensures the protection of residents. EVIDENCE: The rota provided did not include details of the hours worked by the manager and staff. Staff files viewed evidenced that recruitment policies and procedures are followed and all checks and references are obtained prior to employment. The manager reported she is re-organising staff files. Abbeymoor Care Home C53 C03 S59941 Abbey Moor V243529 160805 Stage 2.doc Version 1.40 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s polies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 33, 35 and 38 (Older People) and Standards 23, 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) older people 31,35&38 Adults 37, 33 42 The manager is not registered with the Commission for Social Care Inspection. Financial records are not accurately maintained. Fire records are not maintained up to date. Abbeymoor Care Home C53 C03 S59941 Abbey Moor V243529 160805 Stage 2.doc Version 1.40 Page 19 EVIDENCE: The manager reported she has not completed her application for registered manager at the time of the visit. Financial records viewed were not accurate, monies were not stored individually and receipts for all transactions were not provided. Records of fire tests, drills were not maintained up to date. Other Health and Safety checks were well maintained. Abbeymoor Care Home C53 C03 S59941 Abbey Moor V243529 160805 Stage 2.doc Version 1.40 Page 20 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 2 x 3 2 4 x 5 x 6 x HEALTH AND PERSONAL CARE ENVIRONMENT Standard No 19 20 21 22 23 24 25 26 STAFFING Score 2 x 2 x x 2 x 2 Score Standard No 7 8 9 10 11 Score 2 2 2 x x Standard No 27 28 29 30 2 x 3 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 3 COMPLAINTS AND PROTECTION Standard No 16 17 18 Score x x 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 2 32 x 33 x 34 x 35 2 36 x 37 2 38 2 Abbeymoor Care Home C53 C03 S59941 Abbey Moor V243529 160805 Stage 2.doc Version 1.40 Page 21 yes 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. 2. 3. Standard 1 7 7 Regulation 4 17 15 Requirement The Statement of Purpose needs to be maintained up to date The registered person must ensure that all records are maintained up to date The registered person must ensure that care plans are developed and identify all the needs of the service users in sufficient detail to enable staff to ensure all aspects of health, personal and social care needs are met. The registered person must ensure that risk assessments include action to be taken by staff The registered person must ensure that details of medication received and administered to service users is recorded. The registered person must consult with residents about their programme of activities and provide facilities for recreation having regard to the needs of the residents The registered person must ensure that the home is kept in a C53 C03 S59941 Abbey Moor V243529 160805 Stage 2.doc Timescale for action 30th September 2005 17th September 2005 17th September 2005 4. 8 13 17th September 2005 5. 9 13 6. 12 16 17th September 2005 7. 19 23 17th September Page 22 Abbeymoor Care Home Version 1.40 8. 9. 21 24 23 16 10. 11. 26 9 23 31 12. 35 17 13. 38 23 good state of repair externally and internally and reasonably decorated. The en-suite facility for the single room must be used bu one resident only The registered person must provide chairs in residents rooms to meet the needs of the residents Complete a risk assessment on the laundry and record the oucome and action. The regigistered person must ensure that the permanent manager of the home registers with the CSCI The registered person must ensure that written records are maintained for all transactions, residents monies are stored individually and records are accurately recorded. The registered person must ensure that fire test and records are maintained up to date. 2005 22nd August 2005 17th September 2005 17th September 2005 17th September 2005 30th August 2005 21st August 2005 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. 4. Refer to Standard 9 19 21 27 Good Practice Recommendations Complete a risk assessment on the medication room and record the outcome and action. The registered person develops a written programme of routine maintenance, renewal of fabric and decoration Consideration is given to the replacement of the existing shower facility. Record hours staff work on the rota Abbeymoor Care Home C53 C03 S59941 Abbey Moor V243529 160805 Stage 2.doc Version 1.40 Page 23 Commission for Social Care Inspection Edegely House Riverside Business Park Tottle Road Nottingham NG2 1RT 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. Abbeymoor Care Home C53 C03 S59941 Abbey Moor V243529 160805 Stage 2.doc Version 1.40 Page 24 - 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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