Inspection on 25/08/05 for Abbeywell Court Mental Nursing Home

This inspection was carried out on 25th August 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

Abbeywell Court Mental Nursing... 16/07/07

Abbeywell Court Mental Nursing... 08/11/06

Abbeywell Court Mental Nursing... 18/01/06

Abbeywell Court Mental Nursing... 02/02/05

Abbeywell Court Mental Nursing... 02/11/04

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

CARE HOMES FOR OLDER PEOPLE Abbeywell Court Nursing Home Dragon Square Chesterton Newcastle Staffordshire ST5 7HL Lead Inspector Yvonne Allen Unannounced 25 August 2005 10:30 am th 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. 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. Abbeywell Court Nursing Home E51-E09 s26932 Abbeywell Court v246899 250805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Abbeywell Court Nursing Home Address Dragon Square Chesterton Newcastle Staffordshire ST5 7HL 01782 561769 01782 563102 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) Abbeywell Care Limited Mr Paul Hudson Care Home 30 30 30 Category(ies) of MD (E) registration, with number DE (E) of places Abbeywell Court Nursing Home E51-E09 s26932 Abbeywell Court v246899 250805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 3 DE Minimum age 50 years 3 MD minimum age 50 years Date of last inspection 2nd February 2005 Brief Description of the Service: Abbeywell Court provides nursing care for up to thirty older people with dementia care needs and mental health problems.The home is a two storey purpose built building situated within Chesterton village, Newcastle–under– Lyme. The home has twenty eight pleasantly furnished and decorated bedrooms between the two floors consisting of twenty six single and two shared rooms. All of the bedrooms have en-suite facilities consisting of a toilet and washbasin. There is a lounge, dining room, small kitchenette and appropriately adapted toilet and bathing facilities to each floor. The central kitchen and laundry is situated on the ground floor. A passenger lift provides access between floors.Externally there is a car park and enclosed gardens. Local shops and facilities are close by and the home is within walking distance of bus routes. Abbeywell Court Nursing Home E51-E09 s26932 Abbeywell Court v246899 250805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over four hours by one inspector. A tour of the home was conducted during which the inspector spoke with staff, visitors and some of the residents. Relevant records and documentation were examined. Feedback was given to the registered manager at the end of the inspection. What the service does well: What has improved since the last inspection? The previous requirements were met within the timescales set as outlined below. Risk assessments are in place for service users who are unable to use the call bells whilst in bed. No doors were observed propped open with wedges or other extraneous items. The dust behind the washing machines in the laundry room had been kept to a minimum. Abbeywell Court Nursing Home E51-E09 s26932 Abbeywell Court v246899 250805 Stage 4.doc Version 1.40 Page 6 Activity hours appeared adequate to meet the needs of the residents. Bedrail bumpers appeared clean and some had been replaced. Staff seemed to be more content with the degree of supervision they were undergoing and the inspector did not receive any comments in relation to inadequate staffing numbers. 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. Abbeywell Court Nursing Home E51-E09 s26932 Abbeywell Court v246899 250805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Abbeywell Court Nursing Home E51-E09 s26932 Abbeywell Court v246899 250805 Stage 4.doc Version 1.40 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 standard(s) 3 and 4 Residents and their representatives can be assured that this home will meet their assessed needs. EVIDENCE: Residents are individually assessed before being offered a placement at the home. Completed assessments were seen. When the inspector arrived the manager was out undertaking a pre admission assessment. The staff had the necessary skills and expertise to care for the residents. The manager was very well qualified to run the home and had a great deal of experience in the care of individuals with mental health and dementia care needs. There was evidence of other staff having received training in this area. Discussions with two visitors confirmed that they were happy with the care provided for their relatives and that they felt that their needs were being met at the home. Abbeywell Court Nursing Home E51-E09 s26932 Abbeywell Court v246899 250805 Stage 4.doc Version 1.40 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 standard(s) 7, 8, 9 and 10 The quality of care planning is inconsistent and will need improvement. The physical and mental health needs of individuals are well met with evidence of good multi disciplinary working taking place on a regular basis. EVIDENCE: A selection of individual care plans was examined. These were found to be somewhat inconsistent. Some of the plans seen were very thorough and up to date. A plan was examined in relation to a resident who was recently admitted and almost all documentation had been completed. The named nurse had been very thorough, the plan was easy to follow and risk assessments were in place. Another plan was examined; this was also in relation to a recent admission to the home. This plan was not of the same standard and documentation was inadequate. Identified risks had not always been followed up by a care plan. There were only three care plans in place for ten identified risks. The social history section had not been completed. There was no documentation in place of the resident having been weighed since admission (a period of six weeks). The assessment indicated that the resident had a high risk of falls but there was no care plan in place for this. Abbeywell Court Nursing Home E51-E09 s26932 Abbeywell Court v246899 250805 Stage 4.doc Version 1.40 Page 10 There was written evidence throughout the plans of visits by GPs, chiropody, optician and dentist on request. The nurse spoken to stated that she considered the physical and mental health care needs of individuals to be very well met by the services provided to the home. Medication administration was observed. Drug administration charts were examined and had been completed as required. Staff were seen to interact very well with residents, they appeared caring, considerate and professional. The privacy and dignity of residents was upheld in what were sometimes challenging situations. Abbeywell Court Nursing Home E51-E09 s26932 Abbeywell Court v246899 250805 Stage 4.doc Version 1.40 Page 11 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 standard(s) 12, 13 and 15 The social interests of residents are upheld wherever possible, links with the local community are good and support and enrich the lives of individuals. The meals are good offering both choice and variety and cater for special dietary needs. EVIDENCE: There is a dedicated activities co-ordinator employed by the home. She was on duty at the time of the inspection and had been working with a group of residents. There was documentation in individual care plans of a social history in relation to hobbies and interests. A separate care plan had been developed with an individual planned activity programme. Visitors were welcome at any reasonable time and were observed at the time of the inspection. Residents enjoy trips out to local places of interest on a regular basis. The lunchtime meal was observed with most residents dining in the dining rooms, one on each floor. They had a choice of main meal, the menus were on display and residents are asked what meal they prefer. Individual dietary requirements and preferences are documented on admission. Abbeywell Court Nursing Home E51-E09 s26932 Abbeywell Court v246899 250805 Stage 4.doc Version 1.40 Page 12 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 standard(s) 16 and 18 The home has a satisfactory complaints system with some evidence that residents feel that their views are listened to and acted upon. EVIDENCE: There was a clear and accessible complaints procedure in the home. The CSCI had received one complaint directly in the last twelve months, which had been unresolved. The visitors spoken to stated that they would know who to go to should they have any concerns and that concerns that they had had in the past had been dealt with appropriately. The staff spoken to stated that they were aware of the procedure for reporting bad practice and abuse. There was documentation of training in this area on induction. The systems in place at the home help to protect residents from harm. Abbeywell Court Nursing Home E51-E09 s26932 Abbeywell Court v246899 250805 Stage 4.doc Version 1.40 Page 13 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 standard(s) 19, 20, 21, 22, 23, 24, 25 and 26 The standard of the environment within this home is good providing residents with an attractive and homely place to live. EVIDENCE: A tour of the home was conducted during which all communal areas and a selection of bedrooms were inspected. The home was clean and well presented with no mal odours. Bedrooms had been personalised and adapted to meet the needs of the individual residents. The redecoration and refurbishment programme was on going and areas had been redecorated to high standards. There was a lounge and dining area on both floors, these were pleasantly furnished with a homely feel. There was also a separate activities room. Policies and procedures were in place both in the laundry and in the kitchen in keeping with infection control requirements. Abbeywell Court Nursing Home E51-E09 s26932 Abbeywell Court v246899 250805 Stage 4.doc Version 1.40 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 29 Staff morale is high resulting in an enthusiastic workforce that works positively with residents to improve their whole quality of life. EVIDENCE: At the time of the inspection there were 28 residents accommodated in the home all in receipt of nursing care. There were two registered nurses on duty, one on each floor until 2pm then one between the two floors. Upstairs there were four care staff working with the nurse until 2pm then three during the afternoon/evening shift. During the night there was one trained nurse working with two care assistants. Downstairs there were three care staff until after breakfast then two for the remainder of the day. There were 3 domestic staff on duty daily, 1 in the laundry and 1 on each floor. The kitchen was staffed throughout the day until 7pm by a cook and kitchen assistant. Abbeywell Court Nursing Home E51-E09 s26932 Abbeywell Court v246899 250805 Stage 4.doc Version 1.40 Page 15 There was a maintenance person who worked part time. There was one full time administrator employed. Trained nurses comprised of Registered General Nurses and Registered Mental Nurses. Student nurses were seconded to the home on a regular basis. The Registered Manager worked mainly supernumery covering the odd shift on the floor; he was supported by a deputy manager who worked on the floor. The inspector was informed that there were no current staff recruitment problems and the use of agency staff was minimal. The recruitment policy was robust and staff were carefully selected to work at the care home. CRB police checks were carried out and two written references were obtained. An employee file was examined and found to contained the required information. Abbeywell Court Nursing Home E51-E09 s26932 Abbeywell Court v246899 250805 Stage 4.doc Version 1.40 Page 16 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 37 and 38 The management style in the home was good and staff felt supported and received the necessary training to meet the needs of the residents. COSHH products must be locked away when not in use to protect the safety of the residents. EVIDENCE: The staff members spoken to stated that they felt very well supported by the registered manager of the home. They felt that their views and opinions regarding the home were always listened to and taken seriously by the manager. The manager keeps himself clinically updated and attends various relevant courses. Abbeywell Court Nursing Home E51-E09 s26932 Abbeywell Court v246899 250805 Stage 4.doc Version 1.40 Page 17 Records and documentation were kept secure and in accordance with data protection requirements. The bathroom on the second floor situated opposites room 25 was left open with a cleaner’s trolley inside. This contained COSHH products, which should have been locked away. On some of the bedroom doors, namely rooms 18, 20 and 28 there were no nameplates. Staff had attended the required mandatory update training sessions in moving and handling, fire safety, food hygiene and first aid. Staff members spoken to confirmed that this training had taken place. Abbeywell Court Nursing Home E51-E09 s26932 Abbeywell Court v246899 250805 Stage 4.doc Version 1.40 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 4 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 x x x x 3 2 Abbeywell Court Nursing Home E51-E09 s26932 Abbeywell Court v246899 250805 Stage 4.doc Version 1.40 Page 19 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 38 Regulation 13 (4) Requirement That coshh products are kept locked away when not in use or unsupervised. Timescale for action Immediate and on going 2. 3. 38 7 23 (4) 15 (1)(2) That residents names are Immediate displayed on their bedroom door. and on going That the standard of care Immediate planning is consistent. and on going 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 Good Practice Recommendations Abbeywell Court Nursing Home E51-E09 s26932 Abbeywell Court v246899 250805 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection Stafford - Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Abbeywell Court Nursing Home E51-E09 s26932 Abbeywell Court v246899 250805 Stage 4.doc Version 1.40 Page 21 - 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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