Inspection on 03/01/06 for Abbots Leigh Manor Nursing Home

This inspection was carried out on 3rd January 2006.

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

Abbots Leigh Manor Nursing Home 26/04/07

Abbots Leigh Manor Nursing Home 06/09/05

Abbots Leigh Manor Nursing Home 25/01/05

Abbots Leigh Manor Nursing Home 30/07/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Abbots Leigh Manor Nursing Home Manor Road Abbots Leigh North Somerset BS8 3RP Lead Inspector Alison Murray Unannounced Inspection 3rd January 2006 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 Abbots Leigh Manor Nursing Home DS0000020295.V271812.R01.S.doc Version 5.0 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. Abbots Leigh Manor Nursing Home DS0000020295.V271812.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Abbots Leigh Manor Nursing Home Address Manor Road Abbots Leigh North Somerset BS8 3RP 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) 01275 374669 01275 374669 Treasure Homes Limited Ms Katheryne Bauer Care Home 66 Category(ies) of Old age, not falling within any other category registration, with number (66) of places Abbots Leigh Manor Nursing Home DS0000020295.V271812.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. May accommodate up to 66 persons aged 65 years and over. Person in Charge must be a RN on part 1 or 12 of the NMC register Date of last inspection 06/09/05 Brief Description of the Service: Abbots Leigh Manor is registered to provide nursing care for up to 66 residents. Treasure Homes Limited owns the home. Mr Gillespie is the responsible individual for the home, and Mrs Bauer the registered manager. The main house is a converted and upgraded property situated in pleasant gardens with expansive views over the surrounding countryside. Accommodation is provided in mainly single rooms on four floors. All the rooms have en suite facilities. There is a wide range of communal space. A passenger lift provides easy access to all floors. The ramped corridors ensure that wheelchair users can reach all areas of the home. Abbots Leigh Manor Nursing Home DS0000020295.V271812.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the first day after the New Year holiday. Christmas decorations were still in evidence. Staff and residents were busy preparing for the ‘Management Party’ to be held that evening. All staff, residents and their families were invited. Two inspectors spent a total of 14 hours in the home. Although some records were reviewed, the main focus of the inspection was the day-to-day experience of the residents. Twenty-seven of the sixty-six residents were consulted individually. Many others chatted informally in the communal areas of the home. The inspectors spoke with 6 staff members, and observed others as they went about their work. At the end of the inspection, Mrs Bauer was given detailed feedback of the inspectors’ findings. What the service does well: Residents’ health and personal care needs are well met. Staff liaise effectively with the local surgeries to ensure that residents have access to the services they require. Residents appreciate that Mr Gillespie is ‘very get-at able’. They said that they felt comfortable raising any concerns with either him or Mrs Bauer. Although not all the management standards were assessed at this inspection, there was clear evidence that the home is effectively and efficiently managed. Mrs Bauer had already identified issues raised during the inspection, and was able to tell the inspectors her plan to address them. The standard of accommodation provided at Abbots Leigh Manor is particularly good. Rooms are spacious, and the furniture and fixtures of a high quality. Resident and staff said that this added considerably to their quality of life. Staff said that the home provides a very good working environment. Abbots Leigh Manor Nursing Home DS0000020295.V271812.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? 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. Abbots Leigh Manor Nursing Home DS0000020295.V271812.R01.S.doc Version 5.0 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 Abbots Leigh Manor Nursing Home DS0000020295.V271812.R01.S.doc Version 5.0 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 the following standard(s): These standards were not assessed at this inspection. A requirement made at the last inspection was met within the agreed timescale. EVIDENCE: Abbots Leigh Manor Nursing Home DS0000020295.V271812.R01.S.doc Version 5.0 Page 9 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): 7,8 9, 10 and 11 Residents’ health and personal care needs are very well met. They get on well with the majority of the staff. Medicine administration systems are sound. EVIDENCE: Care records are stored on the computer, and password protected. Those reviewed during the inspection were well completed and up to date. A specific care plan had been written for each identified need. These care plans had been reviewed and updated regularly. Paper copies were available to guide care staff. The advice given reflected good practice. A significant number of the residents are very frail. It was clear that they would not be able to attend to their own personal hygiene needs. All were well dressed in appropriate clothing. Attention had been paid to their hair and nail care. Several people were being nursed in bed. They looked peaceful and Abbots Leigh Manor Nursing Home DS0000020295.V271812.R01.S.doc Version 5.0 Page 10 comfortable. Care charts confirmed that staff had changed their position, and offered drinks at regular intervals. Staff were observed to address residents by their chosen name. They sought permission to enter individual bedrooms. Residents said that the majority of staff were ‘lovely’. This will be discussed further later in the report. Staff and residents said that they receive good support from the local GP practice. Several of those consulted had impaired mobility. They said that staff had helped them to access specialist equipment and wheelchairs. During the afternoons, a staff member is designated to take residents for walks around the home, to maintain and improve their mobility. Mrs Bauer said that one of the current residents is terminally ill. She described how she had accessed support for this person from the GP, the hospice team, and the local clergy. It was clear that the staff are making a commendable effort to meet the resident’s physical, spiritual and emotional needs. All the medication records were reviewed. Medicines are supplied by the local dispensing surgery. Medicine administration records are hand written by the staff. These were clearly written, and the directions had been checked and counter-signed by a second member of staff. The medicine administration procedures state that staff should indicate when a new bottle of medicine was opened. It was evident that this was not always the case. This made it difficult to carry out an audit check of medicines received into the home, and administered to the resident. Abbots Leigh Manor Nursing Home DS0000020295.V271812.R01.S.doc Version 5.0 Page 11 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 15 Residents would like the opportunity to take part in a wider range of activities. They said that the meals provided are of a good standard, but at the moment are not sufficiently varied. EVIDENCE: Residents are given the opportunity to take part in a range of activities, from music and movement, to games and bingo. A range of outside entertainers and musicians regularly visit. The local clergy offer good support. The home employs a full time activity organiser. As well as the planned group activities, she also spends time with individual residents. Mrs Bauer and the activities organiser have recently attended a course on reminiscence therapy. They hope to introduce this early in the New Year, along with a regular newsletter. Mrs Bauer said that she encourages key workers to spend one to one time, with their allocated residents. Volunteers from the local library visit the home every fortnight, and are happy to order specific books for residents. Despite this, a significant number of residents said that they would like to see more activities offered. One person’s comment ‘time weighs very heavy on my hands’ reflected the views of a number of other residents. Several people praised the efforts of the activity organiser. They said that her ‘arts and crafts’ Abbots Leigh Manor Nursing Home DS0000020295.V271812.R01.S.doc Version 5.0 Page 12 sessions were particularly good; they would like to see more of these. The inspectors noted that the residents at Abbots Leigh come from diverse backgrounds, and have a wide range of needs and expectations. In conversation although people said that they would like to do more, they were unable to suggest specific activities that they would enjoy. This was discussed in detail with Mrs Bauer. She felt that it would be a good idea to carry out a survey of residents’ interests. From this survey, she could identify common themes, and offer activities related to these. Once implemented, the success of these activities could be audited as part of the home’s quality assurance and monitoring systems. All the residents consulted said that the meals were of a good standard. They said that the senior chef visits them regularly, and they are able to discuss their likes and dislikes with him. Several commented that although they were offered a choice at each meal, there was not enough variety from week to week. One person said ‘it’s not that there is a problem with the meals; it’s just that they are not terribly exciting’. Mrs Bauer said that she and the senior chef had already identified this. The chef has devised new menus, which he plans to introduce in the New Year. He had spoken with residents, and incorporated many of their requests in these new menus. Abbots Leigh Manor Nursing Home DS0000020295.V271812.R01.S.doc Version 5.0 Page 13 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 The complaint procedure in the home is satisfactory. EVIDENCE: The home has a comprehensive complaint procedure. All those consulted said that they would have no hesitation raising complaints or concerns with Mrs Bauer. Abbots Leigh Manor Nursing Home DS0000020295.V271812.R01.S.doc Version 5.0 Page 14 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): 19, 21, 24 and 26 Abbots Leigh Manor offers very good all round accommodation. It provides an attractive and safe place for residents to live. EVIDENCE: At this unannounced inspection, all areas of the home were found to be commendably clean and tidy. The housekeeping staff demonstrated a real pride in their work. Residents were also keen to praise the efforts of the laundry staff. Clothing and bedding was well presented. Recent work to increase the number of rooms, and refurbish the communal lounges has been carried out to a high standard. All the residents consulted said that they liked their bedroom. Many praised the quality of the fixtures and fitting, whilst others commented about the ‘wonderful views’. It was clear that the re-landscaped garden, with its patio and water feature were much appreciated over the summer months. Abbots Leigh Manor Nursing Home DS0000020295.V271812.R01.S.doc Version 5.0 Page 15 Since the last inspection, the bath has been removed from the ground floor communal bathroom. This room is currently used for storage. Residents said that they would like to see it converted to a ‘wheel in’ shower. Abbots Leigh Manor Nursing Home DS0000020295.V271812.R01.S.doc Version 5.0 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): 27 Staffing levels appeared appropriate to meet the needs of the current residents. Plans are in place to monitor staff response to call bells to ensure that this is the case. EVIDENCE: Staffing levels have been recently reviewed, to take into account the increased number of residents in the home. This has made it necessary to introduce new ways of ‘team working’. Mrs Bauer said that this is still under review, but is generally working well. On the day of inspection, it was apparent that staffing levels were appropriate to meet the needs of the residents. Residents said that this was generally the case, although several commented that staff sometimes took a long time to answer call bells. They felt that this related more to specific staff, rather than time of day. Mrs Bauer felt that in the light of these comments, she would periodically monitor the length of time that it took staff to answer call bells. Abbots Leigh Manor Nursing Home DS0000020295.V271812.R01.S.doc Version 5.0 Page 17 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): 31, 32, 33 and 37 The home is effectively and efficiently managed. Systems are in place to enable staff and residents to comment on the way the home is run. Mrs Bauer has robust plans to address recent concerns about the attitude of a minority of staff EVIDENCE: Residents appreciate their regular meetings with Mrs Bauer. Others commented that Mr Gillespie was ‘very get-at able’. They said that they felt able to discuss any issues about the running of the home with them. Comments made to both inspectors suggested that the majority of staff get on well with residents, and are responsive to their needs. A significant number of these residents said that recently, they have noticed that a small number of Abbots Leigh Manor Nursing Home DS0000020295.V271812.R01.S.doc Version 5.0 Page 18 staff were less responsive. They made comments like ‘you get the impression that you are a bit of a bother’, and ‘the heart seems to have gone out of the place’. Some described ‘huddles of staff talking amongst themselves’. All these residents were at pains to point out that these comments related to a small minority of staff. They were concerned that the actions of these people undermined the efforts of the many ‘excellent’ staff who worked in the home. Mrs Bauer had just returned from holiday. She had already identified these concerns. The inspectors were impressed with her robust and creative plans to address them. Overall, there was evidence of very effective management. Both Mrs Bauer, and Mr Gillespie show a commendable commitment to improve the service offered at Abbots Leigh Manor. They have developed and implemented comprehensive quality assurance and quality monitoring systems. It was apparent that they regularly reviewed practices and procedures to reflect feedback form residents. Abbots Leigh Manor Nursing Home DS0000020295.V271812.R01.S.doc Version 5.0 Page 19 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 x 3 x 2 x x 3 x 4 STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 3 x x x 3 x Abbots Leigh Manor Nursing Home DS0000020295.V271812.R01.S.doc Version 5.0 Page 20 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 OP12 Regulation 16.(2)(m)(n) 12.-(4) 18.-(2) Requirement The programme of activities must be reviewed to ensure that it meets residents’ needs and expectation Staff must be supervised to ensure that their actions and attitude match the ethos of the home, and expectations of the residents Timescale for action 03/03/06 2 OP32 03/02/06 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 3 4 5 Refer to Standard OP9 OP9 OP15 OP21 OP27 Good Practice Recommendations Staff should indicate on the medicine administration record, when a new container of medication is started The number of tablets carried forward from one medicine administration record to the next should be recorded. Residents should continue to be regularly consulted about the meals provided at the home. A communal ‘wheel in’ shower should be provided on the ground floor The time staff take to answer call bells should be regularly DS0000020295.V271812.R01.S.doc Version 5.0 Page 21 Abbots Leigh Manor Nursing Home 6 OP32 reviewed Staff should be given the opportunity to take part in ‘team building’ exercises. 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