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Inspection on 18/04/05 for Abbeywood Tottington Limited

Also see our care home review for Abbeywood Tottington Limited for more information

This inspection was carried out on 18th April 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home continued to provide an environment and staffing arrangements that addressed the assessed needs of resident`s admitted to the home. Positive comments were made by resident`s in respect of the respectful and caring attitude of staff and the accessibility of senior staff at the home when they had any concerns.

What has improved since the last inspection?

The range of social and recreational activities have increased and include organised trips out from the home. Staff and some resident`s were of the view that management arrangements at the home were more stable over recent months. It was also evident during the inspection that an ongoing programme of refurbishment and redecoration was being operated.

What the care home could do better:

Whilst the overall outcome of the inspection is a very positive one areas that could be improved on are; The need to update some areas of staff training. The need to provide a manager for the home who is registered with the CSCI. To improve quality assurance systems within the home by canvassing the views of resident`s and others using the questionnaire already developed by the home that has been used in the past.

CARE HOMES FOR OLDER PEOPLE Abbeywood Tottington Limited Abbeywood 104 Market Street Tottington Bury, BL8 3LS Lead Inspector Mike Murphy Announced 18 April 2005 09:30 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 Tottington Limited Version 1.10 Page 3 SERVICE INFORMATION Name of service Abbeywood Tottington Limited Address Abbeywood 104 Market Street Tottington Bury Lancashire BL8 3LS 01204 882370 01204 882370 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 Home manager appointed - requires to be processed in terms of registration with the CSCI CRH Care Home 23 Category(ies) of OP Old Age : 23 Places registration, with number of places Abbeywood Tottington Limited Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 3 September 2004 Brief Description of the Service: Personal care services at Abbeywood are provided in a large property built on two levels with a passenger lift to the first floor. The home currently provides 23 places for the care of Older people. Seventeen bedrooms are of single occupancy and three are shared. 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. Abbeywood Tottington Limited Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was the home’s first of two annual inspections for the inspection year 2005 to 2006. The inspection took place over six hours. The inspection included discussion with residents, a tour of the premises, inspection of care and other records maintained at the home, discussion with management and staff, and consideration of responses in returned questionnaires sent to various stakeholders prior to the inspection. What the service does well: What has improved since the last inspection? What they could do better: Whilst the overall outcome of the inspection is a very positive one areas that could be improved on are; The need to update some areas of staff training. The need to provide a manager for the home who is registered with the CSCI. To improve quality assurance systems within the home by canvassing the views of resident’s and others using the questionnaire already developed by the home that has been used in the past. Abbeywood Tottington Limited Version 1.10 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Abbeywood Tottington Limited Version 1.10 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 Tottington Limited Version 1.10 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) 1,2,3,4,&5. Standard 6 does not apply to this care home. Abbeywood care home enabled prospective residents and their supporters to make informed choices about the home. The home achieved this by providing detailed written information about the home and the services provided, detailed written terms and conditions of residency, and provided the opportunity for prospective residents to experience pre-admission trial visits to the home. The home was also conducting appropriate pre-admission assessments of prospective residents to ensure that the home could meet their care needs. EVIDENCE: Abbeywood care home provides a statement of purpose and service users guide that is readily accessible to all potential and existing residents and their supporters. Inspection of these documents revealed that they had recently been updated and provided appropriate information in respect of the services provided by the home. Inspection of the contract of terms and conditions issued to residents by the home indicated that this document was appropriate. Abbeywood Tottington Limited Version 1.10 Page 9 Inspection of care records revealed that all prospective resident’s undergoes a formal pre-admission assessment that is conducted by a senior member of staff from Abbeywood care home. Records of assessment revealed that all the relevant activities of daily life were assessed appropriately and any areas of need in these areas identified. Discussion with residents, management and staff, and inspection of care records indicated that the care and accommodation provided at Abbeywood were meeting residents assessed needs. Abbeywood Tottington Limited Version 1.10 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. It appeared that 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 3 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 appeared to address the health, personal and social care needs of residents and were formally evaluated on a regular basis. Appropriate risk assessments, that seek to protect resident’s health and safety were also recorded in respect of residents skin integrity, mobility, and nutrition (including weight monitoring) and other relevant areas. Inspection revealed that the arrangements for resident’s medicines were secure and appropriately documented. These arrangements are operated by senior staff at the home all of who have undergone recent training in the management and administration of medicines. Abbeywood Tottington Limited Version 1.10 Page 11 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. 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 Tottington Limited Version 1.10 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 within a risk assessed framework. The routines of daily living appear to be as flexible as possible in a communal living setting. Menus were varied, balanced and offered choice. Dining areas within the home were clean, comfortable and appropriately furnished. A programme of activities was prominently displayed in the home. This programme of activities is supplemented by a variety of entertainers coming to the home, and a range of day trips out. EVIDENCE: Discussion with resident’s indicated that they were satisfied with the personal choices and freedom they were able to exercise. They were generally satisfied with the activities provided but comments expressed a few resident’s pre inspection questionnaires expressed a wish for more variety. The home maintained a record of all activities provided. It is also noted that the activities programme is formally discussed at resident’s forums and are recorded. Residents spoke positively in respect of the food provided at Abbeywood, flexibility of meal times, and dining areas provided. Inspection of the kitchen Abbeywood Tottington Limited Version 1.10 Page 13 and records maintained in relation to foodstuffs and their preparation indicated that the kitchen was clean, adequately equipped and managed. Staff were observed to serve and assist resident’s appropriately and sensitively with their lunch on the day of inspection. This was a hot, substantial and well presented meal. Abbeywood Tottington Limited Version 1.10 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 Policies and procedures, which were well publicised and effectively implemented, provided the basis for service users to be appropriately protected. EVIDENCE: Discussion with residents and inspection of responses in pre-inspection questionnaires and the service users guide issued by Abbeywood care home indicated that there was a general awareness of how to make a complaint. A detailed and accessible complaints procedure and record was in place that included details of how complainants could contact the CSCI if desired. Resident’s spoken to felt comfortable and confident enough to raise a complaint if they felt it necessary to do so. Inspection of policies and procedures operated at Abbeywood care home and inspection of staff training records 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 Tottington Limited Version 1.10 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, 21,22,24, 25&26. Abbeywood care home was clean, warm, adequately/comfortably furnished and appeared to be well maintained at the time of inspection. Construction of an 18 places extension to the home was at the advanced stages of completion at the time of this inspection. It was noted that this construction area was appropriately sealed off from the existing home at the time of inspection. EVIDENCE: Inspection of the premises revealed that the home was very clean, warm, well ventilated, appropriately decorated, free from malodour and appropriately/comfortably furnished. All resident’s bedrooms benefited from en-suite WC and hand washbasin facilities and were appropriately equipped. Resident’s spoke positively in respect of the private accommodation provided for them at the home. Abbeywood Tottington Limited Version 1.10 Page 16 Appropriate facilities were in place to meet resident’s laundry needs. Bathing areas were appropriately equipped and adapted to meet resident’s needs. The inspector was informed that hot water temperatures were controlled by thermostatic mixer valves. Whilst it is acknowledged that staff check water temperatures before resident’s are immersed in a bath it is recommended that these temperatures are routinely monitored and recorded. Please refer to the requirements section of this report. Abbeywood Tottington Limited Version 1.10 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) 27,29,30 Abbeywood care home appeared to provide adequate and appropriate staff to meet the assessed needs of resident’s who reside at the home. Staff were subject to an appropriate recruitment process. Whilst it was evident staff received a wide range of appropriate training – including NVQ training – it was also evident that some areas of mandatory training were due to be updated. Please refer to the requirements section of this report. 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 2 recently employed staff personnel files revealed that these contained an application form (including health declaration), 2 written references, a Criminal Records Bureau check (including a ‘POVA first’ check), proof of identity (including a photograph), and evidence of induction training. Abbeywood Tottington Limited Version 1.10 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) 31,33,35,36,&38. Abbeywood care home appeared to be 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 will need to undergo a process of registration with the CSCI as is required by the Care Standards Act (2000). EVIDENCE: Discussions with resident’s, perusal of responses pre-inspection questionnaires sent to various stakeholders, and inspection of recording systems 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. Records of formal staff supervision were also maintained. Abbeywood Tottington Limited Version 1.10 Page 19 Inspection of the arrangements to manage service users personal allowances, where these are managed by the home, found that these were secure and well documented. The following safety/servicing certificates 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, servicing of lifting equipment, servicing of fire safety equipment and the fire alarm system. Accidents that occur in the home were appropriately recorded and appeared to have been appropriately managed. Abbeywood Tottington Limited Version 1.10 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 3 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 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 x 3 3 3 3 2 3 STAFFING Standard No Score 27 3 28 x 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 2 x x x 3 3 x 3 Abbeywood Tottington Limited Version 1.10 Page 21 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 30 Regulation 18 Requirement That the registerd persons provide the CSCI with a written plan of proposed updates of staff training for the next 12 months That a record of the periodic monitoring of hot water temperatures is maintained That the registered persons inform the CSCI in writing of their intentions in respect of the current manager seeking registration with the CSCI. Timescale for action 30th June 2005 30th of June 2006 30TH Of June 2005 2. 3. 25 & 38 31 13 8 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 35 Good Practice Recommendations To improve quality assurance systems in the home that residents and others views are sought through an appropriate questionnaire that canvasses their views. Abbeywood Tottington Limited Version 1.10 Page 22 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 Tottington Limited Version 1.10 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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