Inspection on 13/02/06 for Abbotsford

This inspection was carried out on 13th February 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Abbotsford 20/11/07

Abbotsford 13/02/07

Abbotsford 12/10/05

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 Gail Freeman Unannounced Inspection 13th February 2006 07:45 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.V281485.R01.S.doc Version 5.1 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.V281485.R01.S.doc Version 5.1 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.V281485.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th October 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 were 23 people living at the home at the time of inspection but two were in hospital. 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.V281485.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place in the morning of a cold February day and lasted for four and a quarter hours. The inspector talked with a number of residents and staff, looked at some policies and records, and viewed parts of the premises. The Inspector briefly met the Manager and had a telephone discussion with her later. The inspector also considered the fourteen comments cards received about the home from residents or their relatives or friends. The Inspector would like to thank everyone at the home for their kind assistance and co-operation during the visit. 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.V281485.R01.S.doc Version 5.1 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.V281485.R01.S.doc Version 5.1 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): These standards were not assessed at this inspection. EVIDENCE: Abbotsford DS0000017515.V281485.R01.S.doc Version 5.1 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, 9 and 10 were partially inspected. Medication administration records are not always completed which potentially compromises the safety of residents Not all residents can make private phone calls without staff assistance. EVIDENCE: Standards 9 and 10 were assessed at the last visit. At this visit the Inspector followed up on progress in meeting the requirements from that inspection. At the last visit the Inspector noted gaps in the signing of medication administration records. At this visit the Inspector also noted occasions for two residents when signing had not happened. Staff confirmed that they had attended medication administration training. The records of care for one resident noted the request for an occupational therapist assessment but also a number of falls subsequent to this request.The risk assessment for that person did not refer to these incidents. Staff said that nine residents have their own phone in their room. One resident the Inspector visited in their room had a phone. The communal phone is in the corridor near the front door. The area is quiet but privacy cannot be assumed. Abbotsford DS0000017515.V281485.R01.S.doc Version 5.1 Page 9 Nobody spoken with saw this as an area for concern and the resident comment cards noted without exception that their privacy was respected. Abbotsford DS0000017515.V281485.R01.S.doc Version 5.1 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): 12 and 14. The home provides an environment that works positively to provide residents with a lifestyle that matches their preferences and expectations and help them to exercise choice and control over their lives. EVIDENCE: Of the 14 comment cards received 13 people did not want more involvement in the decision making process in the home and one person did sometimes. Comments made included ‘totally satisfied’, ‘good standard’ and ‘first class’. Every one said they felt safe and that they knew who to speak to if they were unhappy about the care. All but one resident said they liked living at the home; one person said they did sometimes. Residents spoken with included people who had lived in the home for a number of years, someone who was quite new and a person on a short stay. All expressed positive comments about the home. Most people knew who to speak to if they had a concern or worry and all residents said staff were approachable. Staff said that 14 residents had a daily newspaper delivered to the home and the Inspector saw residents reading their paper. The Inspector spent the first part of the visit in the communal lounge and noted that staff were taking breakfast trays to and from resident rooms during the first hour or so. Staff Abbotsford DS0000017515.V281485.R01.S.doc Version 5.1 Page 11 confirmed that all residents had their breakfast in their room. It was well into the morning before there were many residents in the lounge. Staff said that most residents at Abbotsford are able to move around the home without staff assistance and care records inspected and observations confirmed this. Some residents when asked about activities available at the home said that they go out with their families or they visited. They also mentioned the musical entertainment that happened on a regular basis and some people found the company of other residents a positive aspect of life at the home. Two people spoke about the visiting library service which was seen to be good. Comment card responses from most people noted that the home provided suitable activities but three people said that this sometimes happened. One person commented that ‘ they provide entertainment some afternoons and evenings’. Care records inspected confirmed that care planning includes peoples’ preferences and routines in relation to activities and daily living and staff usually record what happens. Discussions with staff and observation provided evidence that staff are well informed about residents needs and wishes in this regard and what happens is usually in accord with care plans. There are notices about recent activity events planned by the home in communal areas. The Manager confirmed that she is considering employing an activities coordinator for the homes. The Inspector noted that there was information about an advocacy service in the front hall. The home does not manage residents’ money. Abbotsford DS0000017515.V281485.R01.S.doc Version 5.1 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): 16 The home staff and management listen when residents and their relatives and friends express concerns and act appropriately. EVIDENCE: The Inspector noted a copy of the home’s complaint procedure in the hall which included details of how to contact CSCI. Comment cards and residents spoken with confirmed that residents and their families know whom to contact if they have a concern or worry about care. They also confirmed that if any issues were brought to the home’s attention they were dealt with satisfactorily. The homes policy file included the complaints policy and procedure but the protection of vulnerable adults policy was not up to date and did not include the appropriate information about involving the local authority and CSCI. There were no records of complaints and the Manager said that there had not been any complaints. Abbotsford DS0000017515.V281485.R01.S.doc Version 5.1 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 and 25 were partially assessed. The home is a comfortable and homely environment but is in need of some repair and up dating. EVIDENCE: The inner front door still had a pane of glass missing with a temporary repair in place. The toilet seat in the downstairs toilet had been repaired since the last inspection. The manager explained that the premises improvement work was being implemented and that the laundry flooring was to be done as soon as other work in progress in the laundry was completed that week. The manager said that radiator covers were also part of this planned work and the Inspector noted that care records inspected included risk assessments in relation to uncovered radiators. Access to radiators in the communal lounge was blocked by furniture. Abbotsford DS0000017515.V281485.R01.S.doc Version 5.1 Page 14 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): 27,28 and 30 Residents’ needs are met by staffing levels provided by the home. Staff provide a safe and caring environment for residents. EVIDENCE: All resident and relatives comment cards noted that staff treated them well and that there were enough staff available to them. Residents spoken with talked about staff being kind and always doing what was needed. Staff were observed to be carrying out their work in an organised and calm way. Staff spoken with were knowledgeable about residents’ care needs and wishes. The staff rota book included delegation of tasks, e.g. cooking, rooms and care, and the resident appointment book included medical appointments, district nurse visits and assessment visits. Records and conversations with residents and staff as well as observations confirmed that these arrangements were carried through appropriately. The Manager had arranged to escort a resident to a hospital appointment that morning and did this. Staff talked about training carried out. They said that six staff were about to start on NVQ training arranged by the home, and that some staff had already completed level two. The Manager confirmed this. Staff records showed that new staff undertake an in house induction programme which is signed off. Staff confirmed that they are paid when they attend staff training. Staff confirmed that first aid, manual handling and medication training had happened in the last year. Speaking with staff and staff records provided evidence that staff do not have a written staff development plan. Abbotsford DS0000017515.V281485.R01.S.doc Version 5.1 Page 15 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): 35. Standard 38 was partially assessed. The home is not involved in the management of residents’ money but does provide a support for residents’ day-to-day spending that is appropriate and safe. EVIDENCE: The Inspector noted that food in the fridge was appropriately labelled and dated and that staff used an appropriate format for daily monitoring of the standard of health and safety in the kitchen. However records of the temperatures of fridges and freezers were not up to date with the last entry dated 6th February 06. The home does not manage residents’ money. The home does provide support to manage day-to-day small sum spending and this is used by some residents. This process is recorded clearly and appropriately and managed by one member of staff. The staff explained that the Manager monitors the process regularly. It is recommended that the monitoring process is also recorded and that this could be by signature. Abbotsford DS0000017515.V281485.R01.S.doc Version 5.1 Page 16 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 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 2 X 2 X X X 2 X STAFFING Standard No Score 27 3 28 3 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X 2 Abbotsford DS0000017515.V281485.R01.S.doc Version 5.1 Page 17 Yes 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 OP9 Regulation 13(2) Requirement Medication sheets need to be up to date, current and accurate. (previous timescale of 12/10/05 not met) Residents must have access to a telephone for use in private. (previous timescale of 1/02/06 not met) The policy on death and dying needs updating. (not inspected) The Abuse Policy must include reference to notifying CSCI of any incident. (previous timescale of 01/01/06 not met) A pane of glass needs replacing at the inner door entrance. (previous timescale of 01/12/05 not met) Several carpets needed replacing in bedrooms either because of being stained or being worn and a tripping hazard. DS0000017515.V281485.R01.S.doc Timescale for action 31/03/06 2. OP10 16(2)(b) 30/06/06 3. OP11 37(1)(a) 01/01/06 4. OP18 37(1) 31/03/06 5. OP19 23(2)(b) 31/03/06 6. OP19 23(2)(b) 30/06/06 Abbotsford Version 5.1 Page 18 (previous timescale of 01/12/05 not met) 7. OP21 16(2)(c) The ground floor bathroom flooring that has been resealed where it is lifting needs further remedial work. (previous timescale of 01/01/06 not met) Radiator covers must be fitted to all exposed radiators. (Previous timescale of 01/09/05 not met). Records of temperatures of the fridges and freezers must be accessible at all times. (previous timescale of 13/10/05 not met) Risks assessments must be up to date. Individual staff must have a written training and development. assessment and profile 30/06/06 8. OP25 13(4)(a) 23(2)(a) 31/03/06 9. OP38 23(2)(c) 31/03/06 10 11 OP7 OP30 12 18 (1) © 31/03/06 30/06/06 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. Refer to Standard OP35 Good Practice Recommendations The process of monitoring process of recording home’s cash transactions on behalf of the resident should be recorded. Abbotsford DS0000017515.V281485.R01.S.doc Version 5.1 Page 19 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.V281485.R01.S.doc Version 5.1 Page 20 - 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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