Inspection on 10/10/07 for Abbeywood Tottington Limited

This inspection was carried out on 10th October 2007.

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

Abbeywood Tottington Limited 07/12/09

Abbeywood Tottington Limited 12/07/06

Abbeywood Tottington Limited 16/09/05

Abbeywood Tottington Limited 18/04/05

Abbeywood Tottington Limited 03/09/04

Abbeywood Tottington Limited 11/05/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Abbeywood Tottington Limited Abbeywood 104 Market Street Tottington Bury Lancs BL8 3LS Lead Inspector Mike Murphy Unannounced Inspection 10th October 2007 09:30 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 Tottington Limited DS0000008439.V337604.R01.S.doc Version 5.2 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 Tottington Limited DS0000008439.V337604.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbeywood Tottington Limited Address Abbeywood 104 Market Street Tottington Bury Lancs BL8 3LS 01204 882370 01204 882507 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) Abbeywood Tottington Limited Mrs Irene Elaine Farnworth Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Abbeywood Tottington Limited DS0000008439.V337604.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Within the maximum registered number 40, there can be: 40 Older People (OP). The service should employ a suitably qualified and experienced manager, who is registered with the Commission for Social Care Inspection. 12th July 2006 Date of last inspection Brief Description of the Service: Care services at Abbeywood are provided in a large property built on three levels with passenger lifts to each floor. The home provides 40 places for the care of Older people who are in need of personal care. The home does not provide nursing care – if residents develop nursing needs these are addressed by visiting district nurses. All bedrooms are provided with en-suite facilities. The home is situated within walking distance of Tottington village centre, and is close to main bus routes. Decoration and furnishing is to a high standard. Current fees are £405 per week (figures supplied by provider at time of this inspection). Please contact the home for further details. Abbeywood Tottington Limited DS0000008439.V337604.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection, which the home did not know was going to happen, took place on the 10TH of October 2007. The inspection took place over six hours. The inspector was accompanied by an ‘expert by experience’ – this is a person who has experience using care services and participates in the inspection by seeking the views of those who use the service about how well they feel they are cared for and supported. The inspection process included discussion with residents, their relatives, a tour of the premises, inspection of care and other records maintained at the home and discussion with the registered manager and care staff. What the service does well: What has improved since the last inspection? What they could do better: The home needs to comply with new guidance and make suitable arrangements to securely store ‘controlled ‘ medicines. Also the recruitment process needs to ensure applicants provide a detailed work history to help ensure residents (who are all potentially very vulnerable) are being cared for by people suitable to do so. Abbeywood Tottington Limited DS0000008439.V337604.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Abbeywood Tottington Limited DS0000008439.V337604.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Abbeywood Tottington Limited DS0000008439.V337604.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 does not apply to this service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. No prospective residents are admitted to the home without their care and support needs being assessed appropriately. EVIDENCE: Prior to residents being admitted to the home the registered manager carries out an assessment of the prospective resident’s needs in consultation with the resident, their relatives and relevant health (for example doctors) and social care professionals (for example social workers). The purpose of such an assessment is to assist the prospective resident (and their relatives) in their considerations of how appropriate a placement at the home would be and enable the person conducting the assessment to judge if the home will be able to meet the prospective resident’s needs appropriately. Abbeywood Tottington Limited DS0000008439.V337604.R01.S.doc Version 5.2 Page 9 3 recently admitted residents pre-admission assessments were inspected. The records identified that pre-admission assessments had been carried out by the home and were supplemented by assessments conducted by Social Services. Abbeywood Tottington Limited DS0000008439.V337604.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care provided for residents is suitable, well organised and meets their needs as well as the expectations of their relatives. EVIDENCE: The care records of three residents were inspected. These contained care plans that were initially based on the pre-admission assessment that is referred to earlier in this report. Care plans addressed the health and personal care needs of residents in a clear, organised way and were evaluated at least monthly. Risk assessments, that seek to protect resident’s health and welfare are recorded individually or incorporated into the care plans in respect of residents skin integrity (assessing the risk of pressure sores), mobility and moving and handling, nutrition, (including weekly weight monitoring) and other areas of potential risk for individual residents were also assessed at least monthly. Daily statements regarding resident’s progress are also recorded. Care records have been reviewed by the manager since the last inspection and have significantly Abbeywood Tottington Limited DS0000008439.V337604.R01.S.doc Version 5.2 Page 11 improved. The manager stated to the inspector that she intends to continue that review to further improve them. All residents are registered with a local GP and it was evident that they were enabled to access dieticians, opticians, chiropodists, dentists, district nurses and other specialist services as individual residents needed. Pre-inspection comment cards completed by relatives and discussion with relatives on the day of inspection indicated that they are kept informed of all changes in their relation’s health. The practices for the receipt, recording, storage, handling, administration and disposal of resident’s medicines were appropriate and safe. Staff responsible for the management of resident’s medicines have all received recent appropriate training. Medicine records had been completed properly. However to comply with new guidance it is required that more suitable arrangements are made for the storage of ‘controlled’ medicines at the home. Discussion with residents and staff (and responses in Pre-inspection comment cards completed by residents and relatives) revealed that residents were treated with respect and that their right to privacy was upheld. Comments made included; ‘all the staff are very respectful and caring’, ‘the girls are lovely and speak to me with respect and treat us all decently’, ‘My mum says the staff are kind and considerate particularly when very personal care is being given’, ‘ I am able to have a good laugh with them all [the staff] but they never step over the mark’. On the day of inspection staff were observed to interact positively with residents and show them respect, protect their dignity and assist them appropriately throughout the day. Residents and relatives all spoke very positively in respect of the care and attention provided by the manager and her staff. Abbeywood Tottington Limited DS0000008439.V337604.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are being supported by staff to participate in social activities and are able to retain the ability to make personal choices. There was a general satisfaction with meals provision at the home. EVIDENCE: Discussion with residents and relatives and observations made on the day of inspection indicate that the routines of daily life in the home are as flexible as possible in a group setting. Residents stated that they are able to choose what time they get up and go to bed, what activities to engage in and feel that staff inform and consult them about the care and support they need. Clearly this is very important in enabling residents to retain as much control over their life as possible. The visiting ‘expert by experience’ observed that ‘Activities and entertainment for all appeared to be well-organised including trips out which are funded by proceeds from a weekly bonus ball lotto and raffles. Bingo and dominoes were a daily highlight for those who enjoy the games. Making Abbeywood Tottington Limited DS0000008439.V337604.R01.S.doc Version 5.2 Page 13 greetings cards, and also scheduled entertainment was available. Religious practices were catered for and assisted by volunteers and relatives’. An entertainer came in the afternoon of this unannounced inspection. Clearly he is very popular and knows the residents well – encouraging their participation throughout. Group activities are the main focus in respect of leisure and social activities at the home. The inspector and visiting ‘expert by experience’ are of the view that this good practice could be further enhanced by the addition of more individualised activities – for example individual craftwork for the more active residents and short period 1 to 1 activities for the more passive less orientated residents. To achieve this it may be helpful to designate a member of staff to co-ordinate social activities as part of their duties. The home has an open visiting policy. There are no restrictions on the time people visit. Evidence of this was highlighted in the visitor’s book where entries showed residents friends and relatives visiting at different times during the day and evening. The only time restrictions would be imposed is when requested by residents. Relatives spoken to during the inspection said they were always made welcome at the home and were able to see their relatives in the privacy of their own room or in a quieter lounge area. Residents spoken to expressed satisfaction with care provided and organisation of life at the home. Observation of care practice and information in care plans indicated residents are encouraged to make choices. For example in respect to where they spend their day. While some residents chose to sit in the lounge a number were observed to spend their time in their own rooms. Meals are cooked on site in the home’s kitchen. Menus are varied and balanced and provide choice. Meals are served in designated dining rooms – These were appropriately furnished and provide comfortable and pleasant areas for residents to have their meals. Residents’ meal times are as reasonable and as flexible as they can be in a communal setting. Lunch was observed on the day of inspection. This was a hot and substantial meal and staff assisted and served residents their meals appropriately. Discussion with residents revealed a general satisfaction with the meals provided. Abbeywood Tottington Limited DS0000008439.V337604.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and relatives felt comfortable enough to and knew how to make a complaint if they felt it necessary. Written guidance and training arrangements ensure that staff members have a good knowledge of abuse and protection arrangements and safeguards were in place to protect the welfare of residents. EVIDENCE: The complaints procedure was prominently displayed in the home and included details of how to contact the CSCI if it was felt necessary by the complainant. Relatives said in Pre-inspection comment cards and on the day of inspection that any concerns or worries brought to the manager’s attention are responded to quickly and don’t become formal complaints. A complaints log is maintained. No complaints have been made to the CSCI in respect of the home since the last inspection. Policies and practices aimed at protecting residents from abuse are in place. Also Bury’s Inter agency protection procedure is held on site. Staff spoken to confirmed that they had received adult protection training (this was also reflected in training records maintained by the home) and were aware of the whistle-blowing policy. Abbeywood Tottington Limited DS0000008439.V337604.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20, 21,22, 24 and 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are cared for and supported in an environment that is comfortable and maintained to a high standard. EVIDENCE: Abbeywood is situated near the centre of Tottington The home has a pleasant large gardenand patio area which accessible to residents. A tour of the premises as part of this unannounced inspection revealed that the home was very clean and free of malodour throughout. Discussion with residents and visitors indicated this was the norm for the home. The lounges and dining rooms provide spacious, appropriate, comfortable and warm communal areas for residents. These rooms were decorated and furnished to a high standard. WC and bath and shower rooms were appropriately equipped and adapted to meet the health and safety needs of Abbeywood Tottington Limited DS0000008439.V337604.R01.S.doc Version 5.2 Page 16 residents. Seven bedrooms were inspected on this occasion – these were clean, warm, suitably ventilated, personalised, comfortable and appropriately furnished and equipped. They were also decorated and furnished to a high standard. A programme of maintenance and refurbishment has been developed and implemented. Residents are encouraged to bring personal items into the home and this creates a more personalised atmosphere in resident’s own rooms. Discussion with residents and their relatives revealed a very high level of satisfaction with the bedroom and communal accommodation provided at Abbeywood. Comments made included ‘my room is lovely, it is comfortable and clean and I am able to display my family photos and favourite ornaments’,’ my mum’s room is always spotlessly clean, but it is also comfortable and homely for her’. Appropriate measures to prevent the spread of infection were in place – including adequate hand washing and cleaning facilities, laundry and sluicing arrangements, provision of disposable gloves and aprons for staff, adequate provision of house keeping staff and appropriate arrangements for the disposal of clinical and other waste. Abbeywood Tottington Limited DS0000008439.V337604.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are being appropriately recruited and trained, ensuring that residents are safe and well cared for. EVIDENCE: Inspection of staffing rotas indicated that staffing provision at the home complied with the current minimum requirements that apply to care homes for older people. Discussion with manager and staff at the home indicated that they were of the view that staffing levels were appropriate to meet the dependency levels and needs of resident’s. There is also adequate provision of housekeeping, catering and ancillary staff at the home. Inspection of 3 staff personnel files revealed that these contained an application form (including health declaration), 2 written references, details of work permits (where applicable), a Criminal Records Bureau check (including a ‘POVA first’ check), proof of identity and evidence of induction training. However the application form of 1 staff member lacked detail of the applicant’s work history – obtaining this information helps (along with the other screening measures in place) to ensure that staff that care for vulnerable people are suitable to do so. This was discussed with the registered manager on the day of inspection. There is a strong commitment to NVQ, mandatory and other training provision for all staff at the home. Training records are detailed and well organised and discussion with staff indicated that they are enabled and supported in Abbeywood Tottington Limited DS0000008439.V337604.R01.S.doc Version 5.2 Page 18 accessing appropriate training to look after their residents effectively and safely. All staff employed at the home are provided with appropriate induction training. A review of staff training is conducted as part of the regular individual staff appraisal and supervision conducted by the registered manager. Abbeywood Tottington Limited DS0000008439.V337604.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Abbeywood is effectively managed ensuring the health, safety and welfare of residents is promoted and protected EVIDENCE: The registered manager has the required qualifications and experience and manages the home in such a way that seeks to meet the aims and objectives of the home. Discussion with residents and staff indicate that the manager and senior staff are accessible and operate an ‘open door’ policy that enables any issues to be easily discussed. Management policies are effectively implemented and monitored. Abbeywood Tottington Limited DS0000008439.V337604.R01.S.doc Version 5.2 Page 20 The inspector is of the view that the home is run in the best interests of the residents and this was confirmed through discussion with residents, relatives and staff. The home has developed a quality assurance system to measure residents and their relative’s satisfaction, with the level of care and accommodation provided. This is essential as such information will enable a quality improvement plan to be fully developed and implemented to further improve the quality of life for residents. The manager and area manager responsible for the home informed the inspector that they intend to further develop the quality assurance system to incorporate the views of visiting doctors, nurses, social workers and others who regularly come to the home. And to develop a system of checks (for example of care records, medicines, social activities, catering, complaints and protection, the home environment, staff training and management processes generally) to ensure practices in the home are of as a high a standard as possible. The owners representative regularly visits and produces written reports on the running of the home. Measures were in place to ensure that residents’ financial interests are safeguarded. Residents are encouraged to control their own money. However where they are unable (or choose not to) personal allowances are managed by the home. The health, safety and welfare of residents and others are promoted and protected. For example staff are provided with regular training and appropriate equipment to ensure resident’s moving and handling needs are met – an example of this would be for a resident who needs to be safely moved with the aid of a hoist. Fire safety training is regularly provided. Documentary evidence was seen of the fire alarm system/fire fighting equipment and gas and electrical safety inspections and servicing. The passenger lifts that enable residents and others to access all areas of the home have been serviced as has all hoisting equipment used in the home. All significant events in the home – including accidents and illness and monitoring visits by the home’s owners – are recorded and reported (as required legally) to the CSCI. Abbeywood Tottington Limited DS0000008439.V337604.R01.S.doc Version 5.2 Page 21 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 3 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 4 4 3 x 4 x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 Abbeywood Tottington Limited DS0000008439.V337604.R01.S.doc Version 5.2 Page 22 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 OP9 Regulation 13(2) Requirement Timescale for action 31/01/08 2 OP29 That provision is made to store ‘controlled’ medication in a suitable locked cabinet That the CSCI is informed of this in writing 19 (1)(b) You must confirm to the CSCI in Schedule writing that prospective 2 employees are safely recruited paragraph which includes checks on their 6 employment history and any gaps in it. 31/01/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Abbeywood Tottington Limited DS0000008439.V337604.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Tottington Limited DS0000008439.V337604.R01.S.doc Version 5.2 Page 24 - 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!