CARE HOMES FOR OLDER PEOPLE
Abbeywood Abbeywood Wharf Road Ash Vale Surrey GU12 5AX Lead Inspector
Kathy Martin Unannounced Inspection 19th January 2006 09:00 X10015.doc Version 1.40 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 Abbeywood DS0000013544.V277540.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 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 DS0000013544.V277540.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Abbeywood Address Abbeywood Wharf Road Ash Vale Surrey GU12 5AX 01252 317132 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) Anchor Homes Ms Iris Joyce-Prideaux Care Home 50 Category(ies) of Dementia - over 65 years of age (21), Old age, registration, with number not falling within any other category (12), of places Physical disability over 65 years of age (15) Abbeywood DS0000013544.V277540.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. The age/age range of the persons to be accommodated will be: 65 YEARS AND OVER, with one (1) named resident aged 64 years. Up to twenty-one (21) residents may be within the category DE(E) Dementia - over 65 years of age. Up to fifteen (15) residents may be within the category PD(E) Physical Disability over 65 years of age. 10th August 2005 Date of last inspection 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. A Deputy Manager and a team consisting of care staff, catering, domestic, administration and maintenance staff, support the Registered Manager. The Home provides five separate 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 accommodated in single bedrooms that are all close to communal bathroom facilities. The Home has a private courtyard garden that is secure and accessible to residents. Car parking is available for visitors. Abbeywood DS0000013544.V277540.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. [Please note that the registered manager as named at the beginning of this report is no longer current. The new manager will need to register with the CSCI and once approved the details will change on subsequent CSCI reports] This was the second CSCI inspection this year. The first inspection took place on the 10th August 2005. This visit was unannounced meaning that the staff, residents and visitors had not been informed it was taking place. All of the key national minimum standards have now been assessed during both visits. The visit started at 9:00 am and completed at 12:00pm. The house was clean and tidy and residents were relaxed and comfortable. The residents were observed in their own daily routines or generally resting in the lounge. A few were wandering around the house and had conversations with each other and staff and with the inspector. Many are very physically frail and are not able to freely mobilise due to their illnesses and were observed taking a nap in their chairs. The inspector met the deputy manager who was new in post and was present throughout the inspection. She also provided information used in this report and assisted the inspector with documentation and also within discussions about the running of the home. The manager was not in on this day as she was at a training event. The manager has not yet made an application to register with the CSCI, which the inspector was advised would be imminent. The inspector had ample opportunity to meet with residents and staff who also provided information about their working environment. The inspector toured the premises and looked at documentation as part of the inspection. The inspector wishes to thank all those who participated in providing information for this report and for their warm welcome. In this home many of the residents were not able to communicate verbally due to their Dementia and their responses to questions asked were not always appropriate to the questions asked. However the Inspector was able to observe staff practices, their responses to residents’ behaviour and make requirements and recommendations as a result. In general the residents appeared well cared for and were dressed appropriately for the time of year (winter). Staff knew the residents and were able to care for them in accordance to their written care plans. What the service does well:
This was a pleasant and quiet environment. The home was running well during this inspection. The inspector met several residents and one visitor and was able to ascertain that the residents were generally happy. The staff were very courteous and responded well to the residents’ needs. Residents actually
Abbeywood DS0000013544.V277540.R01.S.doc Version 5.1 Page 6 stated that they had no complaints and thought highly of the care they received. What has improved since the last inspection? What they could do better:
Following this inspection 4 requirements were made: A few of the residents expressed boredom, which was later explored with the activities organiser and the deputy manager. In fact during the tour of the building, the inspector noted some residents asleep and sitting down with not much to do. Requirements have been made as follows under Standard 12 and 30: 1. To provide a clear daily activities programme including Dementia related activities. 2. To provide the activities organiser with training specific to her job, including working in activities for persons with Dementia and working with older people. A further requirement was also made for the registered persons to provide training in recruitment/ staff selection and interviewing to all those who are involved in staff recruitment and interviewing new staff. This requirement was made as a direct result of inappropriate staff interviewing on behalf of the management team. This practice weakens the position of the home in regard to the National Minimum Standards and Regulations that should be followed when recruiting staff to ensure residents safety. (Standard 29, 30 and 36) The fourth requirement was made under Standard 38:
Abbeywood DS0000013544.V277540.R01.S.doc Version 5.1 Page 7 To remove the temporary chair lift in the fire exit staircase because the lift has now successfully been installed. The chair lift and railings are partially restricting the passages on the staircase. Two recommendation were made: 1. To increase the details in the care plans as per the comments under Standard 7. 2. For the staff to make contact with other similar organisations/ homes for sharing information on the provision of activities for older people and for those with Dementia and to access training. 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 DS0000013544.V277540.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Abbeywood DS0000013544.V277540.R01.S.doc Version 5.1 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 the following standard(s): This section was assessed during the previous inspection in August 2005. However the staff are working on a more comprehensive assessment tool. EVIDENCE: The new assessment tool was shown to the inspector but was not yet in use. This new form would provide necessary information about any new applicant to later form the basis of the care plans. This will be looked at the next inspection. Abbeywood DS0000013544.V277540.R01.S.doc Version 5.1 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 the following standard(s): 7 and 9 The care plans provided information about areas of needs and how these were being met although it was recommended that the details be more thorough. The procedures for the management of medication were followed. EVIDENCE: Standard 7: Three care plans were selected at random and on the whole found to offer relevant information about the assessed needs of residents and demonstrated how these were being met. The care plan details were being transferred to the Anchor Trust systems, which so far was proving a lengthy process, as there are several left to convert. Senior carers were responsible to update care plans regularly with the assistance of the key workers. A recommendation was made for the staff to increase the details in the care plans to provide a fully comprehensive picture of the residents’ life. This should then include any previous history, family life, previous life/ experiences (especially for those with Dementia), physical and emotional needs, cultural and religious needs together with their physical and psychological needs. Abbeywood DS0000013544.V277540.R01.S.doc Version 5.1 Page 11 All relevant risk assessments were maintained including moving and handling, falls assessments and taking medication. Standard 9: The procedures for the management of medicines were clear and were followed. The Medication Administration Records (MARs) inspected contained no unexplained gaps. Staff were offered training in medication administration. The staff reported that they had a good working rapport with the supplying chemists and the doctors. Storage and returns of medication was appropriate. Abbeywood DS0000013544.V277540.R01.S.doc Version 5.1 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 the following standard(s): 12 and 14 The provision of activities needed more structure and the staff who provided the activities needed to be equipped with updated knowledge and skills. Residents were able to exert choice and express themselves. They were encouraged to maintain independence. EVIDENCE: Standard 12: This section was assessed during the previous inspection in August 2005 for the exception of Standard 14. The home did still provide activities although this needed to be more structured. The home employs an activities organiser who has recently increased her hours to provide 40 hours of work. During the inspection the inspector observed that any planned organised activities/ events were not clearly advertised for residents and visitors. The inspector also spoke to residents and at least 2 made reference that they were bored and had nothing to do. This was backed up by the inspector’s own observation of several residents asleep in their chairs, some were chatting to each other but generally the environment was very quiet and did not offer much stimulation during the inspection. The staff however did state that activities were offered. The home needed to be able to evidence this. The activities organiser kept notes on her activity and also residents who received either group or one to one sessions
Abbeywood DS0000013544.V277540.R01.S.doc Version 5.1 Page 13 which is good practice. Two requirements were made regarding the provision of activities: 1. To provide a clear daily activities programme including Dementia related activities. 2. To provide the activities organiser with training specific to her job, including working in activities for persons with Dementia and working with older people. This requirement was made as the activities organiser had no previous experience with working with older people and had not been offered training in organising activities for older people especially those with Dementia but had worked in the home for several months already. Relevant training would equip her with the knowledge and skills to ensure appropriate activities are organised to suit the client group. The inspector also advised interactions with other similar homes and organisations such as NAPA for information sharing which will benefit the staff who assist in the provision of activities and also access training. Standard 14: There are areas where residents can sit without having to hear the television or the music if they chose not to or stay in their rooms for privacy. Each unit had a lounge and there are ample spaces in the home for quiet gathering. Residents go out with relatives and friends as able. They can receive visitors as they wished. One relative was present and talked with the inspector. Her feedback was very positive. Staff would facilitate keeping in touch via telephone calls or written communication on behalf of residents to their request and help them with their mail. It is acknowledged that a lot of residents who live in the home are also very physically frail and are not able to go out into the community by themselves. They are often dependent on visitors and staff providing the link with outside and rely on television or newspapers to keep informed. The home would provide transport to shops, and visits to the hospital appointments if needed. Residents are able to choose a meal from a menu, wear their own clothes and participate in any activity if they choose to. Staff received an induction training, which covered the principles of care such as choice and respecting dignity further monitored by everyday practice to ensure these rights were observed. Abbeywood DS0000013544.V277540.R01.S.doc Version 5.1 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 the following standard(s): 16 and 18 The home has a complaints procedure that is effective and used in most cases. The approach to responding to complaints seemed pro-active. The home has procedures for dealing with abuse. EVIDENCE: The complaints procedure is offered to all residents and those who wish to be given a copy. The home is not currently dealing with any complaints. A log of any comments received is maintained and dealt with promptly. The comments made by residents during the inspection indicated that they were happy with the care they received. Staff received training in the procedures for dealing with abuse and prevention of abuse, which is considered mandatory (which means that the staff have to do it). There is a case referred under these procedures although this relates to the management of one resident’s behaviour. Abbeywood DS0000013544.V277540.R01.S.doc Version 5.1 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 the following standard(s): This section was assessed during the inspection in August 2005. EVIDENCE: Abbeywood DS0000013544.V277540.R01.S.doc Version 5.1 Page 16 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29, 30 This section was assessed during the inspection in August 2005. However issues were raised regarding the recruitment process, which was not appropriate in view of staff competency to hold interviews and delegating tasks. EVIDENCE: These issues were raised regarding the provision of training in specific areas. This included these two requirements under Standards 29 and 30: 1. To provide the activities organiser with training specific to her job, including working in activities for persons with Dementia and working with older people. 2. A further requirement was also made for the registered persons to provide training in recruitment/ staff selection and interviewing to all those who are involved in staff recruitment and interviewing new staff. This requirement was made as a direct result of inappropriate staff interviewing on behalf of the management team. Staff should not be delegated tasks that they are not competent/ trained to undertake. The management team must ensure staff’s abilities before delegating tasks to other members of staff. This practice weakens the position of the home in regard to the National Minimum Standards and Regulations that should be followed when recruiting staff. Abbeywood DS0000013544.V277540.R01.S.doc Version 5.1 Page 17 Abbeywood DS0000013544.V277540.R01.S.doc Version 5.1 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35, 36 and 38 There are procedures in place to ensure residents financial interests are safeguarded. Staff were supervised but it was unclear if there were clear definition of roles established. The home has procedures to deal with all aspects of health and safety for residents and staff. One issue needs to be actioned regarding the fire exit staircase. EVIDENCE: Standard 35: The home had procedures to deal with residents’ finances. As much as possible they were encouraged to take responsibility for their own finances. The administrator maintained accounts for residents who leave a small sum of money to pay for hairdressers or small purchases and receipts are maintained. All residents have the use of a locked drawer in their own bedrooms. Standard 36:
Abbeywood DS0000013544.V277540.R01.S.doc Version 5.1 Page 19 A requirement was also made for the registered persons to provide training in recruitment/ staff selection and interviewing to all those who are involved in staff recruitment and interviewing new staff. This requirement was made as a direct result of inappropriate staff interviewing on behalf of the management team. This practice weakens the position of the home in regard to the National Minimum Standards and Regulations that should be followed when recruiting staff. It was also apparent that staff roles needed clarification as tasks should be delegated with precaution to avoid anyone undertaking jobs that they are not competent/ trained to do. Therefore staff supervision was not adequate in this particular instance. Standard 38: The home has policies and procedures to ensure health and safety practices for staff and residents. There are now regular maintenance checks internally and externally. The home was seen as generally well maintained although some jobs are waiting to be done and planned and budgeted for. It is in a reasonable decorative order and there is a plan for further improvement. The equipment is serviced regularly including fire, disability, bathroom and kitchen equipment and appliances. Breakages are reported and repairs are undertaken. All accidents and incidents are reported appropriately and care managers, next of kin and the CSCI are kept informed under Regulation 37. There were no issues regarding health and safety reported to the inspector but one was noted during the visit. A temporary chair lift and railings in the fire exit staircase needs to be removed as a lift has now been installed successfully. This is a requirement as it is restricting the fire exit passages at the moment. There are regular visits to the home from the registered providers very and it is reported that there was a good rapport with the staff, and senior management was supportive and helpful. Abbeywood DS0000013544.V277540.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 2 X 2 Abbeywood DS0000013544.V277540.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? No 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 12 Regulation 16 (2) (m) (n) 18 (1) (c) Timescale for action To provide a clear daily activities 27/02/06 programme including Dementia related activities. To provide the activities 27/03/06 organiser with training specific to her job, including working in activities for persons with Dementia and working with older people. To provide training in 27/03/06 recruitment/ staff selection and interviewing to all those who are involved in staff recruitment and interviewing new staff. To remove the temporary chair 27/02/06 lift and railings from the fire exit staircase. Requirement 2. 12, 30 3 29, 30, 36 18(1)(a), 18 (1)(c) 4 38 13 (4), 23 (4) Abbeywood DS0000013544.V277540.R01.S.doc Version 5.1 Page 22 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 12 Good Practice Recommendations To increase the details in the care plans to provide a fully holistic picture. Staff to make contact with other similar organisations/ homes for sharing information on the provision of activities for older people and for those with Dementia and to access training. Abbeywood DS0000013544.V277540.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Surrey Area Office 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
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