Inspection on 16/09/05 for Abbeywood Tottington Limited

This inspection was carried out on 16th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Abbeywood Tottington Limited 07/12/09

Abbeywood Tottington Limited 10/10/07

Abbeywood Tottington Limited 12/07/06

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 104 Market Street Tottington Bury BL8 3LS Lead Inspector Mike Murphy Unannounced 16 September 2005 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. ABBEYWOOD F56 F06 S8439 Abbeywood V232089 Stage 4 160905.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Abbeywood Tottington Limited Address 104 Market Street Tottington Bury BL8 3LS 01204 88 2370 01204 88 2370 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) Abbeywood Tottington Limited CRH PC Care Home Only 40 Category(ies) of OP Older Persons - 40 registration, with number of places ABBEYWOOD F56 F06 S8439 Abbeywood V232089 Stage 4 160905.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 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. Date of last inspection 18th April 2005 Brief Description of the Service: Care services at Abbeywood are provided in a large property built on two levels with a passenger lift to the first 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. 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. ABBEYWOOD F56 F06 S8439 Abbeywood V232089 Stage 4 160905.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was the home’s second of two annual inspections for the inspection year 2005 to 2006. The inspection took place over three hours. The inspection included discussion with residents, their relatives, a tour of the premises, and inspection of care and other records maintained at the home and discussion with the manager and staff. The home was being appropriately managed and provided residents with a clean, comfortable and homely environment in which to live. Residents were supported and cared for appropriately and encouraged to make personal choices and retain as much personal independence as possible. A number of issues were identified in relation to staff personnel records, and the availability of service records in relation to hoisting equipment within the home. These issues are addressed within this report. What the service does well: What has improved since the last inspection? The home has been significantly extended in size since the last inspection increasing its capacity from 23 residents to 40. The accommodation provided for residents both personally and communally is of a high standard and the extension to the home has been achieved in such a way as to complement the existing ‘home’. Certainly residents spoke very positively of how comfortable and homely they found the home to be. ABBEYWOOD F56 F06 S8439 Abbeywood V232089 Stage 4 160905.doc Version 1.40 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. ABBEYWOOD F56 F06 S8439 Abbeywood V232089 Stage 4 160905.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 ABBEYWOOD F56 F06 S8439 Abbeywood V232089 Stage 4 160905.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) 3,4,5. Standard 6 does not apply to this service. The home manager, which ensures that potential resident’s health, uses a method of assessment and social needs can be met by the home. The home also seek to ensure that they provide the right type of information to enable potential resident’s and their supporters to make informed choices about the suitability of the home for them. EVIDENCE: Inspection of 6 residents care records revealed that a pre admission assessment had been conducted on all 6. These assessments included consideration of prospective residents physical, psychological and social needs. The home manager had done the assessments. These assessments were supplemented by others conducted by various health and social care professionals such as doctors, nurses and social workers. Discussion with residents revealed indicated that they had been able to come to the home for trial visits to the home prior to their admission – and that these are actively encouraged by the home. They felt this was most useful ABBEYWOOD F56 F06 S8439 Abbeywood V232089 Stage 4 160905.doc Version 1.40 Page 9 because it made them more in control of their own lives as well as enabling them to make an informed choice regarding their future. Further discussion with residents also indicated that the home was meeting their needs appropriately. Comments were made by residents such ‘ they understand what needs to be done to help me’, ‘I know I am in the right place because I have got much better’. Resident’s relatives also expressed the view that the home was appropriately meeting the needs of their family member. ABBEYWOOD F56 F06 S8439 Abbeywood V232089 Stage 4 160905.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) 7,8,9,10. The health and personal care needs of residents at Abbeywood care home continue to be assessed and addressed appropriately. The arrangements for the management of resident’s medicines were appropriate and staff were observed to interact and assist residents sensitively and appropriately during the inspection. EVIDENCE: The health care records of 6 residents were inspected on this occasion. These were found to contain care plans that were initially based on the pre-admission assessment that is referred to earlier in this report. Care plans addressed the health, personal and social care needs of residents and were formally evaluated at least monthly. Appropriate risk assessments, that seek to protect resident’s health and safety, were also recorded in respect of mobility, moving and handling, and nutrition (including weight monitoring) and other relevant areas. These were also formally evaluated at least monthly ABBEYWOOD F56 F06 S8439 Abbeywood V232089 Stage 4 160905.doc Version 1.40 Page 11 Inspection revealed that the arrangements for resident’s medicines were secure and appropriately documented. It is noted a new system of dispensing was in operation at the time of this inspection. These arrangements are operated by senior staff at the home all of who have undergone recent training in the management and administration of medicines. Discussion with residents indicated that staff at the home treat them with respect and seek to maintain resident’s dignity and privacy particularly when personal care is being provided. Examples of such comments are ‘ the staff are pleasant and kind’, ‘they care for me well here’, ‘ I can go to the lounge or stay in my room as I choose’, ‘ and my family are able to visit at any time’. Residents also indicated, and this was supported in discussion with staff and inspection of care records, that residents are enabled to access health care services appropriately. All residents were registered with a local GP. ABBEYWOOD F56 F06 S8439 Abbeywood V232089 Stage 4 160905.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) 12,13,14,15. Abbeywood care home continues to enable residents to exercise as much personal freedom and choice as possible. The routines of daily living appear to be as flexible as is possible in residential home setting. Menus were varied, balanced and offered choice. Dining areas within the home were clean, and comfortably furnished. A programme of activities was prominently displayed in the home. This programme of activities included entertainers coming to the home. EVIDENCE: Discussion with resident’s showed they were happy the personal choices and freedom they were able to exercise. They were also satisfied with the activities provided. The home maintains a record of all activities provided. It is also noted that the activities programme is discussed at resident’s meetings. It was noted that bingo was one of the most popular activities. Residents spoke very positively in respect of the food provided at the home, flexibility of meal times, choice of meals and dining areas provided. Comments ABBEYWOOD F56 F06 S8439 Abbeywood V232089 Stage 4 160905.doc Version 1.40 Page 13 made included ‘ the food is very good here’, ‘I can choose something else to eat if I don’t like what is on the menu’. Menus were varied, balanced and provided extensive choice. Staff served and assisted residents appropriately and sensitively with their lunch on the day of inspection. This was a hot, substantial and well presented meal. ABBEYWOOD F56 F06 S8439 Abbeywood V232089 Stage 4 160905.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) 16,18. Appropriate measures have been taken to provide an environment where residents and their supporters feel comfortable with making a complaint if necessary, and to prevent residents becoming victims of abuse. These are important areas that are crucial to the protection of resident’s in a care home, many of whom are extremely vulnerable. EVIDENCE: Discussion with resident’s indicated that there was a general awareness and appropriate information provided that enabled people to make a complaint if they desired. Certainly residents and relatives spoken to expressed the view that they felt comfortable enough to raise concerns with the home’s management if they needed to and equally importantly were confident that any issues raised would be dealt with appropriately. Clearly such an approach by the home management means that the vast majority of concerns raised can be dealt with before they escalate into major issues – this can only be of benefit to residents at the home. A detailed and accessible complaints procedure was in place and prominently displayed in the home, which included details of how complainants could contact the CSCI if desired. ABBEYWOOD F56 F06 S8439 Abbeywood V232089 Stage 4 160905.doc Version 1.40 Page 15 Inspection of policies and procedures operated at the home and discussion with staff indicated that staff were aware of the importance of protecting resident’s from potential abuse and how to communicate any concerns they may have in this area. ABBEYWOOD F56 F06 S8439 Abbeywood V232089 Stage 4 160905.doc Version 1.40 Page 16 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) 19,20,21,22,24,25,26. The home provides an environment for residents that is of a high standard and that is appropriate to meet their needs. The home has been significantly extended since the last inspection. EVIDENCE: The 17 bed extension has had the impact of considerably improving the facilities available to resident’s within the home. Inspection of the premises revealed that the home was very clean, warm, well ventilated, appropriately decorated, free of malodour and appropriately/comfortably furnished. The new communal lounge has been decorated and furnished to a high standard and provides a comfortable and homely environment for residents. A large well maintained garden and patio area is accessible to all residents via the lounge and has been well received by residents and their visitors. The dining room situated in the pre-existing part of the home was also appropriately decorated and furnished. ABBEYWOOD F56 F06 S8439 Abbeywood V232089 Stage 4 160905.doc Version 1.40 Page 17 Residents spoke most positively in respect of the accommodation provided by the home – especially in respect of their own bedrooms describing them as ‘very comfortable’, ‘nice and private’, ’very clean’ and ‘ I am able to have my own bits and pieces around me’. 10 residents bedrooms were inspected on this occasion – these were furnished and decorated appropriately and to a high standard. Bathing areas were appropriately equipped and adapted to meet resident’s needs. The inspector was informed that the hot water temperatures are controlled by thermostatic mixer valves. Appropriate aids and adaptations were in place throughout the home that assist residents to maintain their safety and meet their physical needs. Individual aids and adaptations are provided following referral to the appropriate health care professional. A Newly equipped laundry area has also been provided in the basement area of the new extension to the home. ABBEYWOOD F56 F06 S8439 Abbeywood V232089 Stage 4 160905.doc Version 1.40 Page 18 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. The home was providing adequate and appropriate staff to meet the needs of resident’s. Staff were subject to a recruitment process that is in need of review. EVIDENCE: Inspection of staffing rotas provided by the home indicated that staffing provision at the home complied with the current minimum Department Of Health requirements that apply to care homes for older people. Discussion with senior managers at the home indicated that they were of the view that staffing levels were appropriate to meet the dependency levels of resident’s. Random inspection of 3 recently employed staff personnel files revealed that these contained an application form (including health declaration), written references, proof of identity (including a photograph), and evidence of induction training. However 1 of the files contained only one instead of the required two written references and 2 of the files did not contain a ‘POVA first’ check and although they did contain CRB checks these had been obtained whilst the members of staff had been employed elsewhere. The importance of the necessity of securing a POVA first check on all new employees prior to employment to protect vulnerable residents was emphasized by the inspector and that such checks could only be initiated by applying for a new CRB check for the individuals concerned – The inspector was informed that CRB checks had been applied for but no POVA first outcome had been received in respect of the 2 individuals concerned. The inspector was informed that these issues would be addressed as a matter of urgency. ABBEYWOOD F56 F06 S8439 Abbeywood V232089 Stage 4 160905.doc Version 1.40 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 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) 31,32,33,37,38. The home was being appropriately managed at the time of this inspection. A new manager had been recently appointed who is supervised and supported by an area manager. The new home manager has now been registered with the CSCI as the registered manager of the home – as required by law. EVIDENCE: Discussions with resident’s, their relatives, staff and inspection of records in the home indicated that the home is managed in appositive and open way. Management was said to be accessible and responsive to issues raised. Regular resident’s and staff meetings were held to seek the views of these groups within the home. The following safety/servicing certificates/records were inspected at the time of inspection and found to be up to date; Yearly gas safety certificate, 5 yearly electrical safety certificate, passenger lift certificate, fire safety training for staff, fire drills/checks, servicing of fire safety equipment and the fire alarm ABBEYWOOD F56 F06 S8439 Abbeywood V232089 Stage 4 160905.doc Version 1.40 Page 20 system. A record in respect of up to date servicing of hoisting equipment within the home was not available for inspection. Accidents that occur in the home were appropriately recorded and appeared to have been appropriately managed. ABBEYWOOD F56 F06 S8439 Abbeywood V232089 Stage 4 160905.doc Version 1.40 Page 21 ABBEYWOOD F56 F06 S8439 Abbeywood V232089 Stage 4 160905.doc Version 1.40 Page 22 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 3 3 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 4 4 3 3 x 3 3 3 STAFFING Standard No Score 27 3 28 x 29 2 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 ABBEYWOOD F56 F06 S8439 Abbeywood V232089 Stage 4 160905.doc Version 1.40 Page 23 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 29 Regulation 19 Requirement That the CSCI is provided with confirmation in writing that all staff employed in the home since The 25th of August 2004 have had a POVA first check carried out. That the CSCI is provided with confirmation in writing that 2 written references have been obtained in respect of all persons employed at the home. That a copy of the most recent service record relating to hoisting equipment within the home is forwarded to the CSCI Timescale for action 31st of October 2005 2. 29 19 31st of October 2005. 31st of October 2005. 3. 13 38 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 ABBEYWOOD F56 F06 S8439 Abbeywood V232089 Stage 4 160905.doc Version 1.40 Page 24 Commission for Social Care Inspection Turton Suite, Paragon Business Park Chorley New Road Horwich Bolton, BL6 6HG 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 F56 F06 S8439 Abbeywood V232089 Stage 4 160905.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!