Inspection on 06/09/05 for Abbeymoor Nursing Home

This inspection was carried out on 6th September 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

Abbeymoor Nursing Home 20/11/08

Abbeymoor Nursing Home 18/06/08

Abbeymoor Nursing Home 23/11/06

Abbeymoor Nursing Home 21/02/06

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 NE166 3DZ Lead Inspector Tom Moody Unannounced 6 September 2005 9:30 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 B52-B02 S18165 Abbeymoor Nursing Home V217689 060905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Abbeymoor Nursing Home Address 5 Market Lane Swalwell Gateshead Tyne & Wear NE16 3DZ 0191 488 0899 0191 4888202 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) Four Seasons Healthcare (England) wholly owned subsidiary of Four Seasons Healthcare Mrs Anne Marie Reader Care Home with nursing 40 Category(ies) of PD Physical Disability (40) registration, with number DE Dementia (5) of places LD Disability (3) Abbeymoor Nursing Home B52-B02 S18165 Abbeymoor Nursing Home V217689 060905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 1 February 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 B52-B02 S18165 Abbeymoor Nursing Home V217689 060905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over one day in September 2005 and was carried out by a single inspector. Records were examined and a tour of the premises took place. The manager was on annual leave and the home was in charge of Ms Claire Kirsop, a senior nurse who has recently been promoted to Sister. The inspector spoke to service users, staff, and the senior nurse in charge. The feedback from service users and relatives was overwhelmingly positive and the home has an example 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? The home is being refurbished and the décor is being renewed. Switches are being repositioned at wheelchair user height. Abbeymoor Nursing Home B52-B02 S18165 Abbeymoor Nursing Home V217689 060905 Stage 4.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 Nursing Home B52-B02 S18165 Abbeymoor Nursing Home V217689 060905 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Abbeymoor Nursing Home B52-B02 S18165 Abbeymoor Nursing Home V217689 060905 Stage 4.doc Version 1.40 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 standard(s) 2, 3, 4 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. 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 senior nurse confirmed that service users wishes were taken into account in such areas as holiday provision and leisure activities and work or educational needs. 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. Abbeymoor Nursing Home B52-B02 S18165 Abbeymoor Nursing Home V217689 060905 Stage 4.doc Version 1.40 Page 9 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 standard(s) 6, 7, 8, 9 Service users know about their own care plans and they and relatives participate in its 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. 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. There are a wide range of clinical specialists involved in service user’s care. Staff were observed to be involving service users in decision-making. Service users spoken to confirmed they make choices about their lives and daily activities, such as the choice of entertainers visiting the home. One service user took pride in pointing out that the “garden committee” had improved the external appearance of the home with the imaginative user of container planting. Others confirmed that there was a good variety of entertainment and options for social outings. Abbeymoor Nursing Home B52-B02 S18165 Abbeymoor Nursing Home V217689 060905 Stage 4.doc Version 1.40 Page 10 Service users have a committee and, although the senior nurse does state that the participation in this is limited to a number of “activists”, this probably reflects the situation in the rest of society. Activities such as cooking are being planned and equipment has been purchased. The participation in this, and other activities is risk assessed. Staff who were spoken to were aware of permissible risks and these are recorded in care plans. Abbeymoor Nursing Home B52-B02 S18165 Abbeymoor Nursing Home V217689 060905 Stage 4.doc Version 1.40 Page 11 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 standard(s) 11, 12, 13, 14, 16, 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. Service users have access to excellent food and enjoy a good diet in very pleasant surroundings. EVIDENCE: Senior staff confirmed that service users are involved in social and educational activities outside the home i.e. local college courses and attending former work placements. Abbeymoor Nursing Home B52-B02 S18165 Abbeymoor Nursing Home V217689 060905 Stage 4.doc Version 1.40 Page 12 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 sunshades Service users spoken told the inspector they have a flexible lifestyle and told of going on outings. The nurse in charge confirmed that recent visits had been made to The Baltic Arts Centre and Newcastle Quayside. There were photographs of past social events and service users confirmed that these were held. There are some limited catering facilities that service users can use to prepare their own beverages and these facilities are being expanded to allow cooking and other life-skills to be practiced. Staff spoke of one service user who wished to holiday away from the home and the staff. This was arranged 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. The standard of catering service is to be commended. There is a good choice of meals which are taken in a very pleasant, relaxed environment. Service users commented positively on the quality of the food, one said, “The food is excellent here.” Abbeymoor Nursing Home B52-B02 S18165 Abbeymoor Nursing Home V217689 060905 Stage 4.doc Version 1.40 Page 13 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 standard(s) 18, 19 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. 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 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. They said; “The staff are brilliant,” and “The staff look after me very well.” The inspector saw that service users were being assisted in ways and at times that suited themselves. Abbeymoor Nursing Home B52-B02 S18165 Abbeymoor Nursing Home V217689 060905 Stage 4.doc Version 1.40 Page 14 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 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 has good awareness of service users vulnerability and its 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 B52-B02 S18165 Abbeymoor Nursing Home V217689 060905 Stage 4.doc Version 1.40 Page 15 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 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 kept clean. It has been modified, and is currently being refurbished to ensure it continues to meet service users needs and promote their independence. 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, and compatible with fulfilling their purpose. The home has a planned maintenance programme and refurbishment is underway. This includes re-positioning switches at wheelchair user level and updating the décor. 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. Abbeymoor Nursing Home B52-B02 S18165 Abbeymoor Nursing Home V217689 060905 Stage 4.doc Version 1.40 Page 16 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. Abbeymoor Nursing Home B52-B02 S18165 Abbeymoor Nursing Home V217689 060905 Stage 4.doc Version 1.40 Page 17 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 35 The home has staff that are experienced, well trained and qualified to meet service user’s needs. EVIDENCE: The manager is experienced and a qualified registered nurse. She has achieved the registered managers award. The nurse in charge told the inspector that staff receive in service 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. 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. Abbeymoor Nursing Home B52-B02 S18165 Abbeymoor Nursing Home V217689 060905 Stage 4.doc Version 1.40 Page 18 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 39, 42 The home is well managed by an experienced manager and the ethos is centred around service user’s needs. Health and safety issues are addressed promptly and the safety of the occupants of the home is safeguarded. 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. 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. Abbeymoor Nursing Home B52-B02 S18165 Abbeymoor Nursing Home V217689 060905 Stage 4.doc Version 1.40 Page 19 The nurse in charge told inspectors that the Registered Provider had started to carry out the refurbishments required in the home. 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. A good standard is maintained in all areas, for example, environmentally, staffing, catering and social activities Abbeymoor Nursing Home B52-B02 S18165 Abbeymoor Nursing Home V217689 060905 Stage 4.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 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 3 3 x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 x 3 3 Standard No 31 32 33 34 35 36 Score x 3 3 x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Abbeymoor Nursing Home Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score 3 3 3 x x 3 x B52-B02 S18165 Abbeymoor Nursing Home V217689 060905 Stage 4.doc Version 1.40 Page 21 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 Regulation Requirement Timescale for action 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. Refer to Standard 29 33 Good Practice Recommendations It is recommended that further environmental controls, such as automatic door opening systems, be installed to allow service users greater control and easier access. The registered provider should consider futher training for, or employment of, registered nurses with specialist skills. 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