Inspection on 01/03/07 for Abbotsbury

This inspection was carried out on 1st March 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Abbotsbury 20/02/09

Abbotsbury 24/10/05

Abbotsbury 17/06/05

Abbotsbury 27/01/05

Abbotsbury 16/07/04

Abbotsbury 06/02/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Abbotsbury Mead End Biggleswade Bedfordshire SG18 8JU Lead Inspector Mr Pursotamraj Hirekar Unannounced Inspection 12:20 01st March 2007 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 Abbotsbury DS0000014873.V330490.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. Abbotsbury DS0000014873.V330490.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbotsbury Address Mead End Biggleswade Bedfordshire SG18 8JU 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) 01767 313366 01767 312822 wilsona@bupa.com BUPA Care Homes (Bedfordshire) Ltd Mr Colin Bunyan Care Home 32 Category(ies) of Dementia - over 65 years of age (32), Old age, registration, with number not falling within any other category (32), of places Physical disability over 65 years of age (32) Abbotsbury DS0000014873.V330490.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th October 2005 Brief Description of the Service: Abbotsbury is a purpose built home for older people; it is a part of BUPAs Partnership Homes. The home is situated in a residential area of Biggleswade on the outskirts of the town centre; it is within walking distance of local shops and close to a local bus route. The A1 and the main line railway allow easy access for those travelling to the home from a distance. A car parking facility is available on site for visitors and staff. The building is all on the ground floor and offers single occupancy for up to 32 service users including four respites care beds. All rooms are attractively decorated and personalised and have a 24- hour call system. The home has six day/quiet rooms and a smaller communal dining area. The home also has a large, enclosed garden. There is a local mobile library service, which calls at the home, and a hairdressing service is available on site. Support services are in place with a choice of general practitioners, and visits from the district nurses, chiropodist, dentist, and opticians. The community psychiatric nurse, occupational therapist, physiotherapist, and dietician are accessed when required. Abbotsbury DS0000014873.V330490.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the report of the unannounced inspection carried out on 01/03/07 over 4 ½ hours by Pursotamraj Hirekar. The deputy manager coordinated the inspection through out. The method of inspection included study of care plans, risk assessments, personnel records, staff deployment duty rota, relevant care delivery documents, discussions with deputy manager, staff, visiting doctor, conversation with service users’ and partial tour of the building. This inspection report also includes information from the service users’ survey carried out by the commission and pre-inspection information provided by the home. What the service does well: 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. The summary of this inspection report can be made available in other formats on request. Abbotsbury DS0000014873.V330490.R01.S.doc Version 5.2 Page 6 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 Abbotsbury DS0000014873.V330490.R01.S.doc Version 5.2 Page 7 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 and 6 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home had made appropriate arrangements for the assessment of needs of the service users’ and the service users’ were aware of the care and services they would receive from the home prior to their admission. EVIDENCE: The home had made appropriate arrangements for the assessments of the respite as well as long term stay service users’ prior to their admission. The respite service users’ areas of assessments included; hearing, communication, sight, mobility, transfer assistance, housework, accommodation, family history, food preparation, personal care, eating and drinking, lifestyle, safety, finance, mental health, breathing, medication, oral hygiene, skin pain, foot care, sleeping pattern, continence, vulnerable adult, current equipment, and falls risk assessment. The long stay service user preadmission assessment covered Abbotsbury DS0000014873.V330490.R01.S.doc Version 5.2 Page 8 presenting conditions, past medical history, oral health, foot care, mobility and dexterity, history of falls, skin integrity, continence, medication usage, mental stage and cognition, personal safety and risk, personal care and well being, diet and weight, sight, hearing, communications, hobbies, religious and cultural, family and friends. The commission had undertaken service users’ survey prior to this inspection, to get the feedback from the service users’ and their family members about the care and services they get from the home. A pre-inspection questionnaire was also used for the responsible individual/manager to provide information to the commission with regard to various aspects of care provision and delivery they undertake. 16 service users’ have responded to the service users’ survey undertaken by the commission, of which 13 service users have said that they had prior information about the home, before they moved in and had signed the contract of services. However, 3 service users said they were not aware. Some quotes in the words of the service users’: Service user – 1 said ‘Happy to be here as was falling at home’. Service user – 2 said ‘Family assisted with move’. Service user – 3 said ‘Don’t remember as was ill when I first arrived’ Service user – 4 said ‘Had respite and was happy to come live here’. Service user – 5 said ‘No information was given to me, but I am pleased I’m here’. Service user – 6 said ‘Happy with information’. Abbotsbury DS0000014873.V330490.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home had made appropriate arrangement s for the delivery and care of the personal and health care needs of the service users’. EVIDENCE: The home had made appropriate arrangements for preparation of care plans taking into account from various assessments; the map of life, risk assessments, the behavioural assessment scale of later life tool and the activity profile. The areas of assessments included; self-care, memory and orientation, challenging behaviours, mood, sensory abilities, and mobility, moving and handling, psychological hazards, environmental hazards, physical hazards, movement in the bed, sitting balance, commode/toilet, bathing showering, stairs, dressing, pressure sore, nutritional screening, falls, mealtimes, memory, communication, restlessness, cooperation, motivation, behaviour, personal care, fulfilment, decision making, reasoning and logic, hearing sight, and social relations. Abbotsbury DS0000014873.V330490.R01.S.doc Version 5.2 Page 10 On this inspection 5 service users’ care plans were seen and found that the home had prepared care plans in response to the needs assessments and risk assessments. These care plans were reviewed monthly on a regular basis and updated were necessary. The home had maintained medical log and professionals’ visits record in relation to the service users health needs. The pre-inspection questionnaire indicated that the home had made arrangement s to the following support services in response to the assessed needs of the service users’. They included access to GP, district nurse, pharmaceutical service, community psychiatric nurse, OT, optician, and chiropodist. The home had 18 staffs trained for administration of medication. The pre-inspection questionnaire indicated that the home had made arrangement s to the following support services in response to the assessed needs of the service users’. They included access to GP, district nurse, pharmaceutical service, community psychiatric nurse, OT, optician, and chiropodist. The home had made appropriate arrangements to meet the personal and health care needs of the service users’. This was evident from the various responses the service users’ have provided to the service users’ survey and spoken to on this inspection. However, there are few areas that are quoted in this section, that the home needs to take cognisance of and make improvements. Of the total 16 service users’ 9 service users have said that they always receive the care and support they need and 6 service users said they receive usually. However, when asked do they receive medical support they need, 15 service users’ said they received medical support always. 1 service user said usually. Some quotes from the survey in the words of service users’: Service user - 1 said ‘But I feel sometimes staffs are stretched’. Service user – 2 said ‘Don’t feel I see my GP enough’. Service user – 3 said ‘Not enough of staff to be able to assist all of us always staff listen well’ Service user – 4 said ‘Staff do their best’ Service user – 5 said ‘Staff listen and act on what I say – really very good’ Service user – 6 said ‘Medical support I receive is very good No fault to find with this’. Abbotsbury DS0000014873.V330490.R01.S.doc Version 5.2 Page 11 Service user – 7 said ‘Staff were available – when I personally have needed help they have been there for me’. Service user – 8 said ‘Staff are not available always as others need help too’ Service user – 9 said ‘Receive medical support always and on time’. Service user – 10 said ‘No problem with amount of care’. Service user – 11 said ‘Staff levels do not accommodate for them to always see to me straight away’. Abbotsbury DS0000014873.V330490.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. The service users’ dietary needs were assessed and choice of menu and timings were maintained, in the interest of the service users’. However, regular review and consultations with all the service users’ regarding their choice of food would help situation further improve and ensure satisfaction of all the service users’. EVIDENCE: The home had developed variety of activities in response to the activity profile of the service users’. Of the 16 service users’ who responded to the commission’s survey, of which 3 service users said they always participate in the activities and 10 service users’ said they usually participate in the activities the home conducts. The kitchen was clean and neat. The food menu was prepared in consultations with the service users and each and every service users dietary needs were taken into account. The menu was displayed in the dinning room. The recent meeting of 27/11/07 identified few areas of improvement in the home Abbotsbury DS0000014873.V330490.R01.S.doc Version 5.2 Page 13 particularly with regard to the choice of food. The deputy manager had said on this inspection that the changes recommended by the service users’ have been implemented now. Of the 16 service users’ who responded to the commission’s survey, of which 7 service users’ have said to the survey that they always like the meals at the home, and 6 service users’ said they usually like the meals at the home. Some quotes for the survey in the words of service users’: Service user – 1 said ‘I don’t like all the foods offered’. Service user – 2 said ‘I think things have deteriorated some since I first came’. Service user – 3 said ‘Don’t feel they are like they used to be’ Service user – 4 said ‘Need a diet free from some foods’ Service user – 5 said ‘Like the meals at the home – very much so’. Abbotsbury DS0000014873.V330490.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. The service users’ were aware of the complaints procedure and were confident to use the same when necessary. EVIDENCE: The home had a comprehensive complaints policy and procedures in place. All the service users’ and visitors had access to the displayed complaints procedure in the communal areas. Of the 16 service users who responded to the commission’s survey, of which 14 service users’ have said that they always speak to if they were not happy with any of the service at the home and 10 service users’ said they were aware how to make a complaint. The information provided in the pre-inspection questionnaire indicated that the home had 1 complaint in the past 12 months and has dealt with satisfactorily. Abbotsbury DS0000014873.V330490.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, 25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was maintained clean and tidy and the service users’ were happy about it. EVIDENCE: The partial tour undertaken on this inspection found that the home was maintained clean and tidy without any offensive odours. The pre-inspection questionnaire indicated that, the home had carried out the maintenance and completed the associated records of fire equipment, fire drill, fire alarm test, central heating system, water temperature checks, hoist/adaptation, and COSHH. Water temperature was recorded monthly. However, the water temperature record provided on this inspection indicated that the temperature was not recorded unit wise. Toilet has been refurbished and fitted with the disabled toilets. Abbotsbury DS0000014873.V330490.R01.S.doc Version 5.2 Page 16 Of the total 16 service users’ those who have responded to the service users’ survey, of which 13 have said that the home is always fresh and clean and 3 service users’ have said usually. Quotes from the survey the words of service users’: Service user – 1 said ‘Very well cleaned’. Service user – 2 said ‘always clean’ Abbotsbury DS0000014873.V330490.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 adequate. This judgement has been made using available evidence including a visit to this service. The home’s policy on staff recruitment was comprehensive. The home needs to improve staff ratio with appropriate skill mix, to match with the current and changing needs of the service users’. EVIDENCE: The home has had 19 service users’ with physically disability of which 2 were immobilised, 10 service users’ with dementia, and 1-service users’ with learning disability. The staff deployed to meet the needs of the above service users’ were as follows: the home operated a 3 shift system; shift – 1 had 6 staffs’ on duty, shift – 2 had 6 staffs’ on duty and for the night shift there were only 2 staffs on duty. Given layout of the home and the current service users’ category and their needs, the night shift had low level of staffs’ deployment and this was discussed with the deputy manager on duty the need to increase the number to a minimum of 3 staffs for the night shift. The deputy manager was in agreement on this inspection. As part of the feedback, operational manager was appraised over phone on the 02/03/07 regarding the service users category and their needs in relation to the staffing levels for the night shift. The operational manager was in agreement to improve the staffing levels for the night shift. Abbotsbury DS0000014873.V330490.R01.S.doc Version 5.2 Page 18 The home had made arrangements for staffs’ training and their regular update, the core areas of training included; fire training, first aid, basic food and hygiene, moving and handling, infection control, Parkinson’s disease, dementia, safe bathing, urinary tract infection training, nutrition and swallowing, and health and safety. The staffs’ appeared to have good working relations with the service users’, service users families, and external professionals. 16 service users’ those who have responded to the commissions’ survey of which 14 have said that the staff listen and act to what the service users’ say and 13 service users’ said that staffs’ are usually available when they need them. Quotes from the survey in the words of service users’: Service user –1 said ‘Staff are very accommodating’ Service user – 2 said ‘Staff are very busy’ Service user – 3 said ‘Staff listen and act on what you say – ‘hope it stays this way’ Service user – 4 said ‘Staff always helpful’ Abbotsbury DS0000014873.V330490.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. The home had maintained good standards of care delivery and good working relations with the service users’ and their family members, staffs and relevant professionals which had been useful for appropriate care delivery and in meeting the service users’ assessed needs. EVIDENCE: As part of the quality assurance system the home had quarterly service users’ meetings in place. The recent meeting of 27/11/07 identified few areas of improvement I the home particularly with regard to the choice of food. The deputy manager had said on this inspection that the changes recommended by the service users’ have been implemented now. The home also had an inbuilt Abbotsbury DS0000014873.V330490.R01.S.doc Version 5.2 Page 20 audit mechanism to ensure that the quality of care delivered and records maintained were appropriate. The internal records audit covered areas such as; preadmission assessment, initial assessment and risk assessment, manual handling, falls, bed rails, water low, nutritional, weight, BASOLL, continence. The core care plan covered mobility, personal hygiene, elimination, pressure risk, nutrition, wound, social, safety/falls, communication, and behaviour. Service users’ finances were not seen on this inspection. The assessed healthcare and personal needs of the service users’ were met with good standards as reported under various outcome groups of this report. The staffs’ supervision was carried out regularly that helped both the staffs as well as service users’. It was observed during the interaction with the service users’ on this inspection that, the service users’ were neatly dressed, clean, and have expressed satisfaction with the care and services they received at the home. The home had provided information to the commission with regard to various policies, procedures, and codes of practice that would impact upon the life of the service users’. They included adult protection, administration of medication, fire safety, equal opportunities, food safety, and nutrition, management of money, racial harassment, record keeping, recruitment, privacy, and dignity at work place. Abbotsbury DS0000014873.V330490.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 4 X X 4 HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 4 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X 2 3 STAFFING Standard No Score 27 2 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 Abbotsbury DS0000014873.V330490.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 OP27 Regulation 18 (1) (a) Requirement The home must ensure the ratio of care staff to service users must be determined according to the assessed needs of the service users’. Timescale for action 15/04/07 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 OP25 Good Practice Recommendations The home should maintain record of checks carried out for the entire water points, unit wise separately. Abbotsbury DS0000014873.V330490.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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 Abbotsbury DS0000014873.V330490.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. 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