Inspection on 10/08/05 for Abbeywood

This inspection was carried out on 10th 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

Abbeywood 24/10/06

Abbeywood 13/06/06

Abbeywood 19/01/06

Abbeywood 15/09/04

Abbeywood 17/05/04

Abbeywood 17/02/03

Similar services:

The Shelley

Thorndene

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Abbeywood Wharf Road Ash Vale Surrey GU12 5AX Lead Inspector Mr D Griffiths Unannounced Inspection 10 August 2005 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. Abbeywood H09 H58 s13544 Abbeywood v241167 100805 Stage 4 unn.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Abbeywood Address Wharf Road Ash Vale Surrey GU12 5AX 01252 317132 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) Anchor Homes Ms Iris Joyce-Prideaux CRH (PC) 50 Category(ies) of 1. Old age, not falling within any other category registration, with number (OP) 12. of places 2. Dementia - over 65 years of age (DE(E)) 21. 3. Physical Disability over 65 years of age (PD(E)) 15. Abbeywood H09 H58 s13544 Abbeywood v241167 100805 Stage 4 unn.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1.Service users categories of LD & LD(E) are no longer required. 2. The age/age range of the persons to be accommodated will be: 65 YEARS & OVER, with 1 (one) named resident aged 64 years. Date of last inspection 15 September 2004 Brief Description of the Service: Abbeywood is a purpose build home located in the residential area of Ash Vale. The Home is managed by the Anchor Homes Trust and is registered to care for 50 residents over the age of 65. The Registered Manager is supported by a Deputy Manager, care staff,catering,domestic, administration and maintainence staff. The Home provides five seperate living units each comprising of a lounge/dining room and a kitchen area where hot and cold drinks and snacks can be provided. Residents are accomodated in single bedrooms that are all close to communal bathroom facilities. The Home has a private courtyard garden that is secure and fully accessible to residents. Abbeywood H09 H58 s13544 Abbeywood v241167 100805 Stage 4 unn.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 7 ½ hours and was the first inspection to be undertaken in the Commission for Social Care Inspection Year of April 2005 to March 2006. Damian Griffiths, Regulation Inspector carried out this inspection and Acting Manager Mary Hunt was present as the representative for the establishment. The registered manager is presently assisting with the management of another Anchor Care Home. The service users of Abbeywood prefer to be addressed as residents and will be referred to as such throughout this report. A full tour of the premises took place and documents inspected included care plans, medication records, menu plans, staff records, and policies and procedures. The inspector met several residents and two relatives whose comments together with those received from completed comment cards will be included in the report. The inspector would like to thank the staff and residents for their time, assistance and hospitality during this inspection What the service does well: Residents stated that they received good care and were respected by the staff at Abbeywood. Residents were well dressed and presented. There were plenty of activities available for residents to choose from and these were recorded on individual care plans. Activities were listed on the notice boards situated at each of the five units and there was a part time activity organiser employed. Abbeywood is a purpose built care home and residents benefit from space for activities including a room specifically designed for sensory stimulation. Residents stated that they enjoyed the relaxed atmosphere of the hairdressing salon and there was a small shop where small items could be purchased. Residents had access to all areas of the home and there was a courtyard garden that offered a secure and quiet place to relax. Abbeywood H09 H58 s13544 Abbeywood v241167 100805 Stage 4 unn.doc Version 1.40 Page 6 The home was clean and tidy and bedrooms were well decorated and comfortable. Residents are encouraged to personalise their rooms and this was apparent at Abbeywood. Relatives and friends can visit without prior notice being given and informal social events are periodically arranged, e.g. a garden fete was due to be held the following week. What has improved since the last inspection? What they could do better: Care plans inspected need to be reviewed and updated. All units must provide evidence of residents meetings to show that residents are listened to and when necessary, suggestions are acted upon. Details of the Acting Manager should be contained on the notice board in the front reception area. Some residents did not know who the Manager was or who to talk to if they had any concerns. The Registered Manager had been away for a month managing another home. The previous inspection report required the Registered Manager to attend the home full time. Abbeywood H09 H58 s13544 Abbeywood v241167 100805 Stage 4 unn.doc Version 1.40 Page 7 The home needs to provide clear signs indicating where each of the five units is located. 50 of all staff must be trained to level NVQ 2 by the end of the year 2005. The condition of the entrance at the home needs to be improved. A concrete storage unit was stained and required attention. Back and front gardens were also untidy and required attention. 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. Abbeywood H09 H58 s13544 Abbeywood v241167 100805 Stage 4 unn.doc Version 1.40 Page 8 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 Abbeywood H09 H58 s13544 Abbeywood v241167 100805 Stage 4 unn.doc Version 1.40 Page 9 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 A new resident did not receive a complete assessment before moving into Abbeywood. EVIDENCE: The assessment for a new resident lacked the information required to complete a comprehensive assessment. The resulting care plan was unfinished and required more details about the resident’s needs. There was no risk assessment or list of preferred activities. There were incomplete cost details within the contract. When consulted, the new residents relative was satisfied that Abbeywood could meet their needs. Abbeywood H09 H58 s13544 Abbeywood v241167 100805 Stage 4 unn.doc Version 1.40 Page 10 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 and 10 Care Plans inspected were not up to date, details were inconsistent and reviews were overdue. The health care practitioners at the local health centre meet resident’s health care needs. EVIDENCE: Abbeywood uses the Anchor Trust system of care planning, which states that they work closely with residents, relatives, care managers and district nurses. Care plans and risk assessments inspected had not been regularly reviewed. One resident and their relative was distressed to discover that the residents’ late husband was still listed as next of kin. The care plan of a resident with a visual impairment did not show evidence of how staff would meet their needs and there was no evidence of any review having taken place. No residents with dementia were observed participating in activities during the inspection. Not all residents have their photographs attached to their care plans. Abbeywood H09 H58 s13544 Abbeywood v241167 100805 Stage 4 unn.doc Version 1.40 Page 11 Residents are able to access the local hospital, GP and other health practitioners when required. One resident with impaired hearing required a review and this was reported to the acting manager for action. One resident interviewed with her relative, reported that health care staff regularly assessed her health needs as she was confined to bed. Staff addressed residents by their first names and took time to listen and respond sensitively to their needs. Residents were asked if they required drinks and if they were comfortable. One resident praised a staff member for taking time to help her while she was unwell and in bed. Please see requirements and recommendations section of this report. Abbeywood H09 H58 s13544 Abbeywood v241167 100805 Stage 4 unn.doc Version 1.40 Page 12 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. Residents at Abbeywood benefit from a range of available activities but more attention must be made to the cultural needs of residents and those with dementia. Families are encouraged to visit and maintain links with their relatives and friends. There is a daily choice of food available at Abbeywood for residents. EVIDENCE: Residents were observed participating in a movement and exercise programme during the inspection. Other residents were observed following chosen leisure activities such as reading newspapers, knitting or watching TV. The activities and events held at the home help to promote quality time with friends and relatives. Relatives consulted, stated that they could come and go whenever they liked and were able to have privacy or assistance when required. The staff kept them informed and encouraged their visits. There was a part time activity organiser employed and a fete was due to be held at the home the following week. One other resident enjoyed regular shopping trips with friends. Abbeywood H09 H58 s13544 Abbeywood v241167 100805 Stage 4 unn.doc Version 1.40 Page 13 There was no evidence to show how the cultural needs of a resident speaking little English were met. It is required that the home shows how they are meeting this resident’s needs in a culturally sensitive way. It was not clear how residents with dementia had their activity needs met. No reference was made to how the special sensory room was being used. Residents enjoyed the availability and range of meals provided at the home and reported that they had enjoyed their dinner on the day of inspection. Residents were able to have salads or alternatives to the menu if required. Special diets were catered for when needed. The menu was available and comprehensively showed what was available during the coming week. Please see requirements section of this report. Abbeywood H09 H58 s13544 Abbeywood v241167 100805 Stage 4 unn.doc Version 1.40 Page 14 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 Not all residents and relatives consulted were fully aware of the complaints system in place at Abbeywood. Adult Protection Procedures were in place and are used appropriately. EVIDENCE: The inspector had received information from the home relating to two incidents that occurred in April and June 2005. This demonstrated how the Registered Manager had followed the correct procedures. Further details can be found in standard 34. Residents consulted felt safe and well cared for, however some were unsure who to complain to. The complaints procedure was available to residents in the services users guide. It is recommended that the complaints procedure should be discussed at the residents meetings and form part of a quality review. Staff receive training in adult protection under the title of Rights and Responsibilities. The Registered Manager has demonstrated that she is confident in using the Surrey Multi-Agency Procedures as required. Please see recommendations section of this report. Abbeywood H09 H58 s13544 Abbeywood v241167 100805 Stage 4 unn.doc Version 1.40 Page 15 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) 19,20,22,23, 24 and 26 Abbeywood has an active maintenance log in use. There were some hazards to be addressed that were not included in the log. The home is comfortable clean, bright and airy. Specialist equipment was available at the home but more could be done to adapt some rooms to meet individual needs. Residents have full access to all areas inside, including the inner courtyard area of the home. Residents own rooms are individually decorated and furnished. EVIDENCE: The front garden required attention and the concrete storage unit needs repair. Small conifers at the door entrance were dead and should be removed. Each residential unit has its own name: Willow, Ash, Elm, Oak and Beech. The inspector found that each unit was poorly signposted and confusing to the visitor. Abbeywood H09 H58 s13544 Abbeywood v241167 100805 Stage 4 unn.doc Version 1.40 Page 16 This particularly disadvantaged residents with short-term memory or dementia needs. New signs must be installed to make identification of each unit easier to follow. It is recommended that each unit be distinguished by means of a different colour or décor. Residents’ names are written on signs outside each resident’s door. The Acting Manager was considering improving the signs prior to the inspection. It is recommended that this is actioned. The courtyard garden was showing signs of neglect and required attention. Paving stones were loose and uneven, old containers and borders needed to be cleared and restocked. Benches needed to be maintained and trees pruned. Residents’ rooms contained their own furniture and were clean and tidy. All had fitted carpets, wardrobes and one resident benefited from an adjustable bed. Two residents interviewed were unable to see their television easily and it is recommended that adaptations be made to assist residents with limited mobility. Residents have access to lockable furniture to keep valuables in and have their own room key. The laundry room was inspected and suitable sluice facilities were in place. There were no paper towels or soap dispenser available for staff in this room, these were located across the corridor in the opposite laundry room. The smoking area was situated in the entrance lobby leading to the garden courtyard. Residents and visitors have to walk through this area to access the garden. It is recommended that an area be found that does not subject non-smokers to passive smoking. Please see requirements and recommendations section of this report. Abbeywood H09 H58 s13544 Abbeywood v241167 100805 Stage 4 unn.doc Version 1.40 Page 17 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 ,29 and 30. Abbeywood has an appropriate skill mix of staff to meet the needs of residents. The homes recruitment policy did not meet the required standard on the day of inspection. Staff receive regular training that adequately meets the needs of the residents. EVIDENCE: There was evidence that staff were trained adequately, and rotas inspected were in good order and showed that senior staff members always covered night shifts. Abbeywood was seeking to employ more permanent staff and have increased agency staffing in the meantime. Staff ratio was one staff member to six residents. A resident handyman is always available and there is a part time activities organiser employed. A new job application was inspected and contained details of the staff member’s identification together with a current criminal record bureau check. The employment history contained unexplained gaps of over 12 months duration and there was only one reference on file. New staff consulted said they had received core training covering Infection Control, Manual Handling, and Rights and Responsibilities. Safe Handling of Medication and Health and Safety were still to be completed. 50 of staff must be trained to level NVQ2 by the end of the year. Agency staff also need to be within this ratio and this needs to be monitored closely. Abbeywood H09 H58 s13544 Abbeywood v241167 100805 Stage 4 unn.doc Version 1.40 Page 18 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) 31,32,34 and 38 The arrangements for the safe keeping of resident’s finances are safeguarded. The homes overall record keeping and condition of the home indicated that the absence of the Registered Manager was not to the advantage of the residents. The acting manager has sought to address some of the issues in relation to the needs of the home. Infection control measures need to be put into place. EVIDENCE: The Registered Manager is required to work full time at Abbeywood and this is the second time this requirement has been made. Residents’ finances were inspected and a resident affected by an alleged theft in April 2005 was interviewed. The resident confirmed that she had no further concerns and was satisfied that the Registered Manager had done everything possible. Abbeywood H09 H58 s13544 Abbeywood v241167 100805 Stage 4 unn.doc Version 1.40 Page 19 Residents have lockable facilities in their own rooms and most residents manage their own money. It was recommended that the home adhere to its own policy of limiting the amount of residents’ money kept in a communal bank account. A record of resident’s accounts were stored on the homes IT system but this was not available at the time of the inspection. Records of receipts were available for funds stored on behalf of the residents. A Staff member was observed inappropriately transferring a discoloured chamber pot without out a lid. A resident’s commode was observed to be without a lid. It is requirement that the home ensures the correct procedures regarding the transfer of waste products and lids must be used to reduce the risk of infection. The Acting Manager was informed of these requirements. Abbeywood H09 H58 s13544 Abbeywood v241167 100805 Stage 4 unn.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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 x 15 3 COMPLAINTS AND PROTECTION 2 2 x 2 x 3 x 2 STAFFING Standard No Score 27 3 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 2 2 x 3 x x x 2 Abbeywood H09 H58 s13544 Abbeywood v241167 100805 Stage 4 unn.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. Standard 7 Regulation 15(a,b,c) Requirement The registered person must ensure that all residents care plans and risk assessments are kept under review every month and are available to the resident. The registered person must ensure that all residents activities are reviewed and regularley updated to accurately reflect their cultural and personal needs. The registered person must fit appropriate signs to assist residents and visitors to identify the location of the seperate units. The registered person must ensure that the premises used are of sound construction and and kept in a good state of repair externally and internally to include containers,paving,benches and gardens. The responsible person will ensure that the containers situated at the entrance of the home are removed or replaced . The registered person must ensure that suitable adaptions are made that will assist Timescale for action 08/09/05 2. 12 15 08/09/05 3. 19 23 (2)(a) 08/09/05 4. 20 23 (2)(b) 08/09/05 5. 20 23(2)(b) 08/09/05 6. 22 23(2)(n) 08/09/05 Abbeywood H09 H58 s13544 Abbeywood v241167 100805 Stage 4 unn.doc Version 1.40 Page 22 7. 26 8. 29 9. 32 10. 38 residents that are physically disabled to view their televisons with ease. 13 (3) The registered person must ensure that suitable arrangements to prevent the spread infection in the home by providing a soap and paper towel dispenser in the laundry room and to ensure that standards of hygiene are maintained. 19(4)(a) The registered person must and ensure that that the person is fit Schedule to work at the care home and 2 para 1-9 ensures that a full employment history is available for inspection. 10 (1) The registered person must 12(5)(a) manage the care home with sufficient care,competance and skill and maintain good personal and professional relationships with residents and staff. Requirement first made: 15/09/04 13 (3) The registered person must ensure that suitable procedures are followed to prevent the spread of infection in the home by providing new commode equipment. 08/09/05 08/09/05 08/09/05 08/09/05 11. 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 7 16 Good Practice Recommendations It is recommended that current photographs of residents are to be placed in their care plans. It is recommended that the manager explains the complaints procedure at the next residents meeting and makes information available to relatives and H09 H58 s13544 Abbeywood v241167 100805 Stage 4 unn.doc Version 1.40 Page 23 Abbeywood 3. 4. 5. 6. 19 19 26 34 representatives. It is recommended that the decor of each unit is changed for ease of identification. It is recommended that residents name plaques are renewed. It is recommended that the allocated smoking area does not come into contact with non smokers. It is recommended that the home assists residents with funds over Anchor Care Homes recommended limit to transfer to an appropriate bank account/savings account or seek independent financial advice. Abbeywood H09 H58 s13544 Abbeywood v241167 100805 Stage 4 unn.doc Version 1.40 Page 24 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Abbeywood H09 H58 s13544 Abbeywood v241167 100805 Stage 4 unn.doc Version 1.40 Page 25 - 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!