Inspection on 21/02/06 for Abbeymoor Nursing Home

This inspection was carried out on 21st February 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 found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Abbeymoor Nursing Home 20/11/08

Abbeymoor Nursing Home 18/06/08

Abbeymoor Nursing Home 23/11/06

Abbeymoor Nursing Home 06/09/05

Abbeymoor Nursing Home 01/02/05

Abbeymoor Nursing Home 02/09/04

Abbeymoor Nursing Home 18/12/03

Abbeymoor Nursing Home 10/06/03

Abbeymoor Nursing Home 18/07/02

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

CARE HOME ADULTS 18-65 Abbeymoor Nursing Home 5 Market Lane Swalwell Gateshead Tyne & Wear NE16 3DZ Lead Inspector Mr Tom Moody Unannounced Inspection 21st February 2006 10:00 Abbeymoor Nursing Home DS0000018165.V273779.R01.S.doc Version 5.1 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 Abbeymoor Nursing Home DS0000018165.V273779.R01.S.doc Version 5.1 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 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 Nursing Home DS0000018165.V273779.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Abbeymoor Nursing Home Address 5 Market Lane Swalwell Gateshead Tyne & Wear NE16 3DZ 0191 488 0899 0191 488 8202 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) None Four Seasons Healthcare (England) Limited (Wholly owned subsidiary of Four Seasons Health Care Ltd) Mrs Anne Marie Reader Care Home 40 Category(ies) of Dementia (5), Learning disability (3), Physical registration, with number disability (40) of places Abbeymoor Nursing Home DS0000018165.V273779.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th September 2005 Brief Description of the Service: Abbeymoor is a purpose built two-storey care home that can provide nursing care for up to 40 adults with a physical disability, aged 18 - 65 years. The home is of traditional brick and tile construction and it is located in a residential area, close to the Gateshead Metro Centre. It benefits, therefore, from being close to the associated amenities such as shops, recreational facilities and local transport networks. The home has several lounge and dining areas. Situated throughout the building. The home has well kept grounds that are used by the service users. Access is through the car park, via a steep slope, but there is level access to the building. The home offers single room accommodation, with many rooms having en suite facilities. Abbeymoor Nursing Home DS0000018165.V273779.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over one day on21 February 2006 and it was carried out by a single inspector. Records were examined and a tour of the premises took place. The manager was present during the inspection. The inspector spoke to service users, staff, and the senior nurse in charge. The feedback from service users and relatives was positive and the home has examples of “thank you” messages on display. The home is reasonably well equipped and some modifications have been made to the environment. This is suited to the client group’s age and lifestyle preferences. The home has plenty of space in all areas. It is popular with service users and their families. What the service does well: What has improved since the last inspection? Some decoration has been done but the home is about to undergo a major refurbishment, Abbeymoor Nursing Home DS0000018165.V273779.R01.S.doc Version 5.1 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 Nursing Home DS0000018165.V273779.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Abbeymoor Nursing Home DS0000018165.V273779.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 4, 5 The home provides a good level of information to prospective service users, and service users are able to visit the home in advance of any placement, if they are able to do so. This enables them to make an informed choice about the home. Comprehensive assessment information is received by the home before making a decision to accept a referral, which ensures the home, can meet the needs and there preferred lifestyle of the service user. Service users have contracts for each individual and these are explicit as to the level of service provision that can be provided. EVIDENCE: Care management assessments are made available to the home prior to the service user’s admission and these are contained in care plans. The assessment material seen in care plans provided excellent detail regarding the service user’s needs, which allowed staff to have a good picture of the person and their needs. The care plans indicate that progress is made towards meeting service user’s needs and aspirations. The manager stated that service users can visit in advance of a stay and sample life at the home. She confirmed that service user’s wishes were taken into account in such areas as holiday provision and leisure activities and work or educational needs. Abbeymoor Nursing Home DS0000018165.V273779.R01.S.doc Version 5.1 Page 9 Staff who were spoken to showed a good awareness of service user’s needs and confirmed that the service user’s needs and aspirations are taken into account as well as other aspects of their physical emotional and spiritual care. Service user’s comments confirm a high level of satisfaction with the home’s performance. Contracts and terms and conditions were available and matched service user’s needs. Abbeymoor Nursing Home DS0000018165.V273779.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9, 10 Service users know about their own care plans and they and relatives participate in it’s creation and review. Service users are consulted on the homes running and they are well supported in decision making by the home’s staff. Risk assessment takes place and service users can take part in activities that are fulfilling and without being unduly restricted in their lifestyle choices. Records and other information about service user’s is kept securely. EVIDENCE: Service user care plans are well written and contain comprehensive information. A multi-disciplinary approach is evident and the involvement of service users is apparent in the recording of assessments. Care plans are reviewed regularly and the examples seen had been updated in line with service user’s changing circumstances. There are a wide range of clinical specialists involved in service user’s care. Staff were observed to be involving service users in day to day decisionmaking. Social activities were tasking place in the home including a classical music appreciation session, followed by cheese and wine. Abbeymoor Nursing Home DS0000018165.V273779.R01.S.doc Version 5.1 Page 11 Service users spoken to confirmed they make choices about their lives and daily activities, such as the choice of entertainers visiting the home. The manager spoke of the “garden committee” improving the external appearance of the home with the imaginative user of container planting. Service users confirmed their involvement in this. Others confirmed that there was a good variety of entertainment and options for social outings. There was a notice listing proposed trips out of the home. Service users have regular meetings. Staff who were spoken to were aware of permissible risks and service user’s capabilities. These are recorded in care plans. Records are kept securely and staff were careful not to discuss service users capabilities or problems when this could be overheard. Abbeymoor Nursing Home DS0000018165.V273779.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 17 Service users engage in a wide range of social events, within and outside of the home, that meet their needs and preferences. Service users are encouraged to participate in decision-making and to take responsibility for decisions making in the home. Staff are aware of service user’s personal relationships and they ensure these are appropriate and that vulnerable service user’s are safeguarded. Service users have access to a variety of food and enjoy a good diet in very pleasant surroundings. Unfortunately the cleanliness of the kitchen was below the home’s normal standards and this could affect the quality of the meals served. EVIDENCE: The manager confirmed that current and past service users can be involved in social and educational activities outside the home i.e. local college courses and attending former work placements. Abbeymoor Nursing Home DS0000018165.V273779.R01.S.doc Version 5.1 Page 13 The home has television, DVD and video equipment, games and a pool table. The patio area of the garden is pleasant and well used by service users. It is equipped with appropriate furniture and is accessible. Service users spoken told the inspector they have a flexible lifestyle and told of going on outings. There were photographs of past social events and service users confirmed that these were held. Staff spoke of one service user who wished to holiday away from the home and had been able to do this using the Calvert Trust facility at Kielder. Service users have a regular forum where they can meet and suggest improvements or air any concerns they have. This is recorded and indicates service users are listened to and their suggestions are acted upon. Two service users run a small shop as a result of suggestions from this forum. There is a good choice of meals in the home. These are taken in a very pleasant, relaxed environment. The manager spoke of the timing of meals being changed at the request of the majority of service users. The midday meal is now of a “snack” type and a more substantial meal is served in the evening. Even some of the “snack” meals, seen by the inspector, were cooked and looked quite substantial. Service users commented positively on the quality of the food. “The food is good” was typical of service user’s comments. Abbeymoor Nursing Home DS0000018165.V273779.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 The service users receive appropriate support from staff to meet all of their needs and preferences. Service user physical and mental wellbeing is promoted by the home. The home has appropriate medication policies to protect service user’s but staff may not always stick to these. The physical condition of the clinical areas does not support a safe system of medication. EVIDENCE: Discussions with staff, and an examination of care plans, highlight the range of support that the home can give. It is evident from the care plan that this is tailored to individual needs. The homes philosophy of care also supports this. Care plans are comprehensive and include good clinical details as well as social and aspirational needs. They record that other health and social care professionals are involved in meeting service users needs. The manager confirms that the home has good relationships with, and consults with other healthcare professionals, such as Hunters Moor Hospital and The Janey Hepple unit at Prudhoe Hospital. Service users feel well supported and have a good relationship with staff. The inspector saw that service users were being assisted in ways and at times that suited themselves. Abbeymoor Nursing Home DS0000018165.V273779.R01.S.doc Version 5.1 Page 15 The home has appropriate medication policies and procedures unfortunately gaps in recording indicate that staff may not always adhere to the policy. The cleanliness of the clinical area was of concern. Medication trolleys had not been cleaned. The floor and surfaces had accumulated pieces of litter and debris. Some surfaces were dusty and machines, such as feed pumps, had not been cleaned. The homes British National Formulary is very out of date (1999) and other professional guidance documents were also dated. Staff took steps to address the physical problems as soon as they were pointed out by the inspector. Abbeymoor Nursing Home DS0000018165.V273779.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 The home has mechanisms that allow service users to express their views and the practice in the home is modified by this. Protection of service users is a high priority for the staff and manager. The home’s staff have good awareness of service users vulnerability and it’s systems protect service users. EVIDENCE: The home has appropriate policies and procedures to protect service users. Staff said that they receive appropriate training. The staff were aware of issues relating to some service users risks of self harm or unhealthy lifestyle choices. Any behaviour modification strategy, such as “Time Out On The Spot” (TOOTS), is carried out under the advice of consultant medical staff and with reference to agreed multi-disciplinary strategies. The “No Secrets” document is available and prominently displayed in the manager office. Meetings take place with service users on a regular basis and the comments recorded indicate that service users are able to raise issues. It is also apparent that these comments are acted upon and outcomes are recorded. Service users told the inspector that they feel comfortable raising issues with the staff or the manager. Abbeymoor Nursing Home DS0000018165.V273779.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29, 30 The home is furnished, decorated and equipped to an acceptable standard. It is well maintained and bedrooms are comfortable. The home has some modifications that meet service user’s needs but it is lacking other basic modifications that would be expected in a home of this nature. Such modifications are necessary to ensure service users can control their own environment. Although areas occupied by service users are clean, areas such as the kitchen, laundry and clinical areas were not cleaned to a standard that would ensure service user’s well being. EVIDENCE: Overall, the home was clean, tidy and comfortable. The premises are generally accessible to service users but greater use could be made of automatic door opening and environmental controls. Furnishings, fittings and adaptations in the home are generally of good quality but the home lacks some basic adaptations, such as a loop system for hearing aid users. The home has a planned maintenance programme and the manager spoke of a refurbishment that is planned to upgrade the home. This should include re-positioning switches, and sinks at wheelchair-user level and updating the décor. Abbeymoor Nursing Home DS0000018165.V273779.R01.S.doc Version 5.1 Page 18 Bedrooms reflected the taste of the occupant and most service users had a strong sense of ownership of their rooms and the home in general. The home provides several communal areas, which service users can use as well as their visitors. All these areas provide a comfortable sitting areas and recreational space. A pool table is available in one lounge. Although some of the fabric of the building is showing signs of wear refurbishment was taking place at the time of this visit. The gardens were being used by service users and the patio area was particularly popular. The service users have taken great efforts to plant containers and this brightens and enhances the gardens and grounds. Service users display a justifiable pride in this achievement. Cleaning is satisfactory in most areas of the home but the lack of basic cleanliness in the kitchen, laundry and clinical areas was of concern. Although staff were contrite, and reacted quickly to rectify the situation, it should not have been allowed to develop. Abbeymoor Nursing Home DS0000018165.V273779.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 The home has job descriptions and staff are clear about how their role relates to service user’s wellbeing. The home has staff that are experienced, well trained and qualified to meet service user’s needs. The homes recruitment policy is appropriate and is carried out thoroughly to ensure the safety of service users. EVIDENCE: The manager is experienced and a qualified registered nurse. She has achieved the registered managers award. The manager spoke of staff receiving inservice training appropriate for their roles and designed to meet service user’s needs. The staff confirm this and state that they receive induction training and good support from the company. Records of staff training confirm this. The home has not yet got staff who have any formal qualifications in looking after service users with learning disability. It was suggested that this is pursued. Staff can confirm what their role is and how they contribute to service users welfare and the aims of the home. All staff have appropriate job descriptions. Abbeymoor Nursing Home DS0000018165.V273779.R01.S.doc Version 5.1 Page 20 The manager stated that the companies policy on recruitment was carried out and staff records confirm this. Abbeymoor Nursing Home DS0000018165.V273779.R01.S.doc Version 5.1 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 40, 42, 43. The home is well managed by an experienced manager and the philosophy of the home, and it’s policies and procedures, are centred around service user’s needs. Health and safety issues are usually addressed promptly but the lack of cleanliness in some areas could adversely affect the safety of the occupants of the home. EVIDENCE: The manager has a substantial number of years experience both as a nurse and in a managerial role in the private care sector particularly with young adults who have a physical disability. She has completed the Registered Managers Award programme. Abbeymoor Nursing Home DS0000018165.V273779.R01.S.doc Version 5.1 Page 22 She is supported by senior nurse who is also experienced in caring for the service users who live in this home. The staff told the inspector that the manager is approachable and it is apparent from discussions that she has a good relationship with staff and service users. Service user suggestions have been acted upon and practice in the home has changed to accommodate this. There is no reason to doubt either the management ethic, or the professional values that underpin the operation of this home. This is reinforced by appropriate policies and procedures and records such as care plans and meeting notes confirm service user involvement in decision making. The home is well maintained and a good standard of hygiene is maintained in most areas, use by service users. Unfortunately the service areas of the home were not as clean as they should have been. Abbeymoor Nursing Home DS0000018165.V273779.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 2 26 2 27 3 28 3 29 2 30 2 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 X 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 3 X 3 X 2 3 Abbeymoor Nursing Home DS0000018165.V273779.R01.S.doc Version 5.1 Page 24 No 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 YA30YA17 Regulation 13(3) 16 Requirement Timescale for action 21/04/06 2 3 The home must maintain an adequate level of hygiene in kitchen and laundry areas to ensure service user’s safety YA20 13(2) The must ensure medication procedures are adhered to and that the clinical areas are kept clean. YA29YA26YA24 16(2)(c) The home must ensure that 23(2)(a)(n) environmental controls and adaptations, such as automatic door opening systems, loop induction systems and variable height sinks, and work-tops, be installed to allow service users greater control and easier access. 21/04/06 21/04/06 Abbeymoor Nursing Home DS0000018165.V273779.R01.S.doc Version 5.1 Page 25 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 YA33 Good Practice Recommendations The registered provider should consider further training for, or employment of, registered nurses with specialist skills in learning disabilities. Abbeymoor Nursing Home DS0000018165.V273779.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection South of Tyne Area Office Baltic House Port of Tyne Tyne Dock South Shields NE34 9PT 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 Nursing Home DS0000018165.V273779.R01.S.doc Version 5.1 Page 27 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!