Inspection on 12/10/05 for Abbotsford

This inspection was carried out on 12th October 2005.

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

Abbotsford 20/11/07

Abbotsford 13/02/07

Abbotsford 13/02/06

Abbotsford 27/01/05

Abbotsford 01/07/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Abbotsford 53 Moss Lane Pinner Middlesex HA5 3AZ Lead Inspector Richard Adkin Unannounced Inspection 12th October 2005 11:30 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 Abbotsford DS0000017515.V258303.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. Abbotsford DS0000017515.V258303.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Abbotsford Address 53 Moss Lane Pinner Middlesex HA5 3AZ 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) 0208 866 6030 020 8426 2257 Mrs J Spanswick-Smith Mr Derek Spanswick-Smith Mrs J Spanswick-Smith Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Abbotsford DS0000017515.V258303.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th January 2005 Brief Description of the Service: Abbotsford is a care home providing personal care and accommodation for up to 24 older people. One room was registered as a double room, but is now used only by one person. The group of people living at the home at the time of the inspection were of mixed gender. There was one vacancy at the time of the inspection. The home is a family-run business, having been established by the owners in the 1960’s. Mrs Spanswick-Smith, one of the owners, manages the home. The family own a similar care home, Glengariff at 59 Moss Lane. Service users with lower dependency care needs are accommodated in Abbotsford. The home is situated in a quiet residential area of Pinner, fifteen minutes walk from local shops and public transport links. The forecourt has parking for a maximum of eight cars. The building has a ground and a first floor. Access is by passenger lift or stairs. All bedrooms are fully furnished, with some on the ground floor. The home has three communal bathrooms, one of which has facilities to support with getting in and out of the bath. There are other individual toilets available. The home has a large lounge that is split into a number of interconnected areas, one of which doubles as the dining area. The home also has a goodsized well-maintained garden. References to the manager in this report refer to Mrs Karen Spanswick-Smith, the daughter of the registered manager, who oversees most aspects of day-today management at this home. She is also registered as the manager of the sister home at Glengariff. Abbotsford DS0000017515.V258303.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place at a midweek lunchtime and afternoon in October. Besides looking at policies, procedures and records, the Inspector had the opportunity to look around the home and meet with staff, a number of residents, visitors and relatives. The manager kindly made herself available for the inspection. The Inspector is grateful for the contribution made by everyone at the home during the course of the inspection. 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. Abbotsford DS0000017515.V258303.R01.S.doc Version 5.0 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 Abbotsford DS0000017515.V258303.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3 Information has been updated in order that there is clarity about the contract. New residents are admitted on the basis of a full assessment to ensure that their needs are met. EVIDENCE: The requirement from the previous inspection concerning the updating of the contracts between the registered provider and each resident (or their representative) for any privately funded services received at the home is being addressed and finalised and is on the point of being re-issued by the proprietor’s Solicitors. Assessment of potential residents were seen to be comprehensive and are usually undertaken by the manager. The needs assessment of residents who are self funding was looked at for two of the residents. These assessments covered a wide range of issues around physical care, risk of falling, social and familial needs and how the resident wished to be addressed. Abbotsford DS0000017515.V258303.R01.S.doc Version 5.0 Page 8 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 Risk assessments reflect the changing needs of residents. The home’s procedures for dealing with medicines potentially puts residents at risk. EVIDENCE: The residents’ current health, personal and social care needs are set out in that individual’s plan of care. The general risk assessments of a number of residents were checked on during the inspection. These were all up to date and reflected the changing risks and needs of residents. The requirement from the previous inspection has been addressed concerning continence and medication reviews. The records of continence reviews and medication reviews are made in each applicable resident’s summary health sheets. Evidence was seen in three files looked at, of a dated, signed write up and the continence advisor being involved where there were continence issues. The CSCI Pharmacist had made a follow up visit the previous week, following an assessment of the home’s medication systems as part of the previous inspection. Abbotsford DS0000017515.V258303.R01.S.doc Version 5.0 Page 9 There was a covering sheet of staff signatories name and initials and training undertaken in the giving of medication. The MAR sheets had run out on the day of the inspection. No record of signing for medication had been made for the morning though it had been given; lunchtime staff had signed the sheet for the medication given in an additional column. New MAR sheets were being delivered during the course of the inspection – there had been a delay because of the chemist not being well. Clearly this is an oversight leading to poor practice that must be avoided – medication sheets must be up to date and accurate. Abbotsford DS0000017515.V258303.R01.S.doc Version 5.0 Page 10 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): 13, 15 Residents maintain strong links with their community and their families. Wholesome and nutritious food is provided. EVIDENCE: There are strong links with the local community and a number of residents are from the Pinner area and are able to maintain or renew connections. Residents and relatives spoken to have made personal recommendations about the benefits of becoming a resident of the home. Several residents spoke of the pride they felt in the home. One senior resident was collected and taken to church during the course of the inspection, which was an established pattern. A hairdresser was also present during the inspection and contributed to the expression of pride that residents showed in their appearance. Relatives spoken to expressed ‘peace of mind’ and trust that they felt in the care provided to family members. The inspector observed an animated level of interaction between residents and residents and family members. Abbotsford DS0000017515.V258303.R01.S.doc Version 5.0 Page 11 The serving of lunch was observed and positive feedback received from residents about the quality of food provided. Two cooks are employed at the home. The food looked wholesome and nutritious. There were gaps on the list for breakfast food and drinks for several of the residents which should be rectified for consistency. The manager has undertaken a food questionnaire at the home recently and meets regularly with the cook to discuss quality, nutrition and any comments received. Abbotsford DS0000017515.V258303.R01.S.doc Version 5.0 Page 12 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): 18 Residents are protected from abuse and their views are taken seriously. Policies need to reflect the role of the CSCI. EVIDENCE: The complaints policy and procedure was looked at and the policy was displayed. Copies displayed in each bedroom had not been updated and did not refer to CSCI. Likewise, the policy on abuse did not make reference to informing CSCI of any significant incidents, otherwise the home’s own guidelines were comprehensive. London Borough of Harrow’s POVA guidelines were accessible and staff were familiar with these. There have been no incidents of reported abuse. Relatives spoken to as well as residents spoken to, all felt their comments were taken on board positively and acted upon if necessary. Abbotsford DS0000017515.V258303.R01.S.doc Version 5.0 Page 13 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, 22, 26 Residents live in a comfortable homely, spacious environment. A necessary building programme needs to be undertaken to ensure that the surroundings remain safe and comfortable. EVIDENCE: The Inspection included a tour of the building and a visit to a number of the bedrooms. There is a significant programme of work about to be undertaken. This includes the covering of radiators (some of which have happened), the replacing of rotten window sills, the refurbishment of the kitchen, and upgrading of the upstairs bathroom where there is a hole in the floor and exposed pipework. The home is comfortable and warm clean and tidy with a homely feel. A number of residents spoken to liked the space and layout of the home and the actual location. There were new curtains in the living room. Abbotsford DS0000017515.V258303.R01.S.doc Version 5.0 Page 14 There were a number of specific repairs needed besides the broader building work programme. - a broken pane of glass needed replacing at the inner door entrance. - some carpets in bedrooms needed replacing because of being stained or being a potential tripping hazard (the details of these rooms was discussed with the manager.) - the unstable toilet seat in the downstairs toilet needed securing. - the ground floor bathroom flooring recently resealed was still lifting. Random bell tests have taken place throughout the home and are recorded. The bath chair has been inspected (expires December 2005). The home is having new washing machines delivered with sluicing functions. Abbotsford DS0000017515.V258303.R01.S.doc Version 5.0 Page 15 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): 29 Employment procedures are adhered to, to ensure the protection of residents. EVIDENCE: At the previous inspection two new members of staff only had one reference in place instead of the required two references, this was rectified. The personnel file of a new member of staff was looked at. Two references were on file, along with all the necessary paperwork. Abbotsford DS0000017515.V258303.R01.S.doc Version 5.0 Page 16 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, 33, 38 The home is run by a person competent to carry out the task. Some domestic practice needs improving to promote the health and safety of residents. EVIDENCE: The manager of the home has a number of years experience of running the home and the home next door as part of a longstanding family business. The inspection looked at the ‘Quality Assurance Policy’ (February 2005) and the practice around quality is being developed in the home. A food questionnaire was recently undertaken and feedback from residents acted upon. An annual review sheet is now in place in each resident’s file. The views of stakeholders will be captured during the course of December 2005. Abbotsford DS0000017515.V258303.R01.S.doc Version 5.0 Page 17 There were several containers in the fridge with food that were not labelled or dated as would be expected. Records were not accessible of temperatures for the fridge and freezer. Equipment was now available to check the temperature of the fridges and the freezers. A number of fire related practices were in place. Fire fighting equipment was checked 17/5/05, a fire department inspection took place 8/7/05. Weekly fire bell tests are taking place and fire drills are regular and dated and capture the time of the drill. Abbotsford DS0000017515.V258303.R01.S.doc Version 5.0 Page 18 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 3 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 4 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 X 2 X 2 3 X X X 3 STAFFING Standard No Score 27 X 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X X 2 Abbotsford DS0000017515.V258303.R01.S.doc Version 5.0 Page 19 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 2 3 4 5 6 7 Standard OP9 OP10 OP11 OP16 OP18 OP19 OP19 Regulation 13(2) 16(2)(b) 37(1)(a) 22(7) 37(1) 23(2)(b) 23(2)(b) Requirement Medication sheets need to be up to date, current and accurate. Residents must have access to a telephone for use in private. The policy on death and dying needs updating. An up to date complaints policy must be accessible for each resident. The Abuse Policy must include reference to notifying CSCI of any incident. A pane of glass needs replacing at the inner door entrance. Several carpets needed replacing in bedrooms either because of being stained or being worn and a tripping hazard. The ground floor bathroom flooring that has been resealed where it is lifting needs further remedial work. The toilet seats needs securing in the downstairs toilet by the entrance. Radiator covers must be fitted to all exposed radiators. (Previous timescale of 01/09/05 not met). DS0000017515.V258303.R01.S.doc Timescale for action 12/10/05 01/02/06 01/01/06 01/01/06 01/01/06 01/12/05 01/12/05 8 OP21 16(2)(c) 01/01/06 9 10 OP21 OP25 23(2)(b) 13(4)(a) 23(2)(a) 01/12/05 31/03/06 Abbotsford Version 5.0 Page 20 11 12 OP38 OP38 23(2)(c) 13(3) Records of temperatures of the fridges and freezers must be accessible at all times. Food in the fridge must be labelled and dated. 13/10/05 13/10/05 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 Refer to Standard OP15 OP22 Good Practice Recommendations The recording of resident’s preferences for drink and food for breakfast should be comprehensive. The few stairs in the upstairs hallway would benefit from visibility strips. Abbotsford DS0000017515.V258303.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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 Abbotsford DS0000017515.V258303.R01.S.doc Version 5.0 Page 22 - 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!