Inspection on 05/04/05 for Abbotsford

This inspection was carried out on 5th April 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 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 14/10/08

Abbotsford 09/07/07

Abbotsford 19/07/06

Abbotsford 16/08/04

Abbotsford 20/04/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Abbotsford 443 Wellingborough Road Abington Northampton NN1 4EZ Lead Inspector Sara Morrison Unannounced 5th April 2005 10:30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Abbotsford Version 1.10 Page 3 SERVICE INFORMATION Name of service Abbotsford Address 443 Wellingborough Road Abington Northampton NN1 4EZ 01604 636729 01604 636729 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Msaada Group Mrs Trudy-Ann Frost Care Home 18 Places = 18 Places = 18 Category(ies) of DE(E) Dementia - over 65 registration, with number OP Old Age of places Abbotsford Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: Service Users whose rooms are on the second floor, should be able to mobilize independently. Date of last inspection 16.08.2004 Brief Description of the Service: Abbotsford is a care home for 16 people over the age of 65 years who have dementia related conditions. Accommodation is set over three floors, rooms on the second floor and annex are single rooms with ensuite facitlites, rooms on the first floor are all shared and do not have ensuites. There are two lounges and a separate dining room. The home is located on a main road and is opposite a park. It is two miles to the town centre and is on local bus routes. Abbotsford Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over 4 hours and was carried out as part of the regular visits required by law. During the inspection several service users, two staff, a visitor and the manager were spoken to and a tour of the premises took place. Written comments were received from seven relatives. What the service does well: What has improved since the last inspection? What they could do better: At the time of the inspection the condition of parts of the house was not good and this must be improved. Staff were working hard to keep all parts of the home clean and tidy however they are becoming demoralised by the lack of organisation and planning about the improvements to be made. The back garden is not a pleasant place to be and it is unsafe for service users to use. The limited space in the ground floor toilet next to the kitchen and shower room in the annex is seriously affecting the privacy and dignity for service users. The condition of the rooms on the first floor is not good. Abbotsford Version 1.10 Page 6 The owners must meet the requirements of the law and visit the home to carry out their responsibilities as detailed in the Care Homes Regulations. From these visits, along with the manager they should plan the improvements that need to be made, specify a time for work to be completed and monitor that this is achieved properly. Two requirements made at the last inspection about the safety of the garden and visits by the owners have not been met and are re-stated in this report. there is an additional requirement regarding the condition of the premises. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Abbotsford Version 1.10 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Abbotsford Version 1.10 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) No standards from this section were inspected during this visit. EVIDENCE: Abbotsford Version 1.10 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 standard(s) 7,9 & 10 Improvements have been made to the care plans and medication system, providing additional information about service users and tighter controls around the stock control and administration of drugs. EVIDENCE: Care plans and risk assessments have bee improved since the last inspection and more information is now included in the documentation. Advice was given that staff should endeavour to gain as much information as possible about service users’ past lives as this will often explain particular behaviours that on their own may be difficult to understand. Service users spoken to said that the staff are very kind and helpful and meet their needs in the way they prefer. The relative of a former service user who lived at the home three years previously visited during the morning and she spoke of her satisfaction with the staff and the care her mother received. She said that there had been little change within the staff group over the years, which she felt was an indication of a good home. She said that the outlook/location of the home is good and there is a good standard of care. Abbotsford Version 1.10 Page 10 Comments from seven relatives were received and again all stated their satisfaction with the care their relative receives. Five of the people made additional comments stating how kind and welcoming the staff are whenever they visit. Improvements have been made to the medication system and the manager now carries out a weekly audit. The home have also changed from the drugs for each service user being stored in plastic wallets to the ‘NOMAD’ system whereby the pharmacist dispenses medication into individual cassettes, thus reducing the opportunity for errors. Some of the details on the administration sheet (MAR) detailed to be given ‘As directed’ but with no information for staff as to what this means. Advice was given that the manager should refer this back to the Pharmacist in order for clarification to be sought from the G.P. and exact instructions to be recorded on the MAR sheet by the Pharmacist. Abbotsford Version 1.10 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 standard(s) 12 &13 The activities programme has improved presenting more opportunities for service users to spend their time in meaningful occupation. The relationships between staff and families are good enabling service users to maintain contact with family/friends and the local community as they wish. EVIDENCE: The manager now keeps copies of leaflets, information about when and where the activities take place and seeks out other providers of activities. A plan of the activities is on the wall in the dining room for service users to read. The manager said that twice a month a lady comes in to do pottery with service users. Two service users were able to talk about this activity and said they enjoyed taking part. One service user said that there isn’t much to do and another person said she just falls in with whatever is happening. All service users have some memory problems (that may contribute to this perception) although some are still quite physically able. Advice was given regarding the person centred standards for quality dementia care in care homes published by the Alzheimer’s society that gives good ideas for meaningful activity for people with memory problems. The staff may wish to consider introducing some activities based on service users’ past life experiences Abbotsford Version 1.10 Page 12 The relative of a former service user said that when her mother lived at the home she could visit whenever she wished, and staff were always welcoming and friendly. Written comments from five current relatives said they also find the staff welcoming and pleasant. One person said,” Nothing seems to much trouble for them”. Abbotsford Version 1.10 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 standard(s) 16 Concerns are listened to and promptly resolved by the manager and staff, ensuring that residents and their families can be confident any issues will be properly dealt with. There was a lack of clarity by the Registered Providers regarding the procedure when a complaint was put to them as it was inappropriately passed to the manager for investigation. EVIDENCE: Two of the seven relatives stated that they didn’t know the home’s complaint procedure although had never needed to make a complaint. The remaining five people also said they had never had to make a complaint. Service users said that they fell confident to talk to staff or the manager if there is anything they are not happy with An anonymous complaint made earlier in the year to the inspection unit and put to the Registered Provider for investigation was unfounded. However it was concerning that the provider had delegated the issues to the manager to investigate when it was more appropriate for the provider to do this. Abbotsford Version 1.10 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 standard(s) 19 & 26 Parts of the house have been refurbished to a high standard however other areas have not been improved and do not create a pleasing and pleasant environment to live in. Several areas are unsafe for service users and the bathing and toilet facilities seriously restrict service users privacy and dignity. There is little evidence of proper planning to improve the house and maintenance is ‘ad hoc’. EVIDENCE: Some changes have been made to the layout of the home, for example an additional three rooms have been created on the 2nd floor and a ground floor bedroom has been changed into a lounge. These areas were decorated to a high standard and provided comfortable and homely surroundings. All areas of the home were clean and free from unpleasant odours. The same attention has not been paid to upgrading the rest of the house and in some areas the condition is poor. The 4 double bedrooms on the 1st floor all appeared dated and shabby. The wallpaper is old, carpets and furniture in need of improvement. One door of the cupboard under the vanity unit in one Abbotsford Version 1.10 Page 15 of the rear bedrooms was coming off it hinges and hanging off, revealing broken shelves that were not useable. The bathroom on the 1st floor is very dated and does not provide a pleasant environment. There is an old electric bar wall heater that staff said is not used. The bath has an assisted chair but the bath water outlet is tarnished with flaking metal. There is new flooring in the ensuite facilities in the annex bedrooms but the décor in the bedrooms is ‘tired’ and dated. The carpets that are original from when the annex was built 10 years ago are stained in places. The shower room in the annex is very small and is only used by two people who can manage without staff assistance. Everyone else with bedrooms in this area are taken through the dining room and transported in the lift to use the bathroom on the first floor. The kitchen is in process of being improved and work that has being going on for four weeks. There is no written plan for this and maintenance staff employed by Msaada are doing the work as and when they have available time. New cupboard units have been fitted but there are no drawers and staff are stacking cutlery etc with in the cupboards. The manager said that it is her understanding that he tiles will be covered by new ones or painted with tile paint. The lobby/hallway outside the kitchen is very dated. There is old yellowing paintwork, lots of old wires and pipes. An old style brown round light switch although no longer in use remains on the wall. Two toilets lead from this area, one has tiles missing from the wall the other has an old telephone socket situated behind the toilet. Both toilets are very small and allow little room for privacy when it is necessary for staff to assist service users in the toilet. One service user said she can’t shut the toilet door properly because there is not enough room for her zimmer frame. There is a very small wash hand basin on the wall outside the toilets. These are the closest toilets to the lounges and dining room, and are used regularly throughout the day. The staff room is in a very poor condition. There is a very old staff toilet off the staff room, the window does not open and there is no washbasin. Having used the toilet staff have to go back through the staff room to use the basin by the toilets adjacent to the kitchen. The patio courtyard area is not accessible from the annex as there is a step from the building that is not safe for service users use. Staff have closed off the door leading from the annex to the patio for the safety of service users. The path leading to the back garden is uneven with slabs that are a trip hazard. No work has been done to improve the garden, and although this could provide a safe area for service users to enjoy currently this is not Abbotsford Version 1.10 Page 16 possible as there is a square of lawn surrounded by borders that are overgrown. A gardener drew up a plan however no work has been done. A member of staff tidied up the front garden when a neighbour complained about its condition. The manager, in compliance with a requirement made at the last inspection sent a programme of redecoration to the inspection unit. However some of the items listed have not been completed, and this has been outside the manager’s control. The manager maintains a programme of improvements and re-programmes work if it is not done. It was noted from this document that with the exception of the flooring in the ensuite facilities in the annex bedrooms no other work has been achieved within the timescales set from October 2004 onwards. The manager also keeps a plan for smaller maintenance items that lists the item/issue, the date reported, who it is to be completed by e.g. internal or external contractor, a target date for completion and a signature once completed. Two items on this list that hadn’t been completed were: 1. Hall redecoration, reported 1.4.04 to be done by a member of Msaada staff, target date 24.4.04. 2. New flooring in the annex bedrooms reported 1.4.04 to be done by an external contractor, target date 16.9.04. Both the hall and the flooring in the annex bedrooms were seen to be in poor condition and require improvement. The Registered Providers must plan properly for the refurbishment of the home and ensure that work is completed within the timescales. These findings are subject to a requirement. Abbotsford Version 1.10 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 & 30 There is a good staff team who have a good understanding of the service users’ support needs. This is evident from the positive relationships, which have been formed between the staff and service users. EVIDENCE: Three care staff are on duty from 8am to 10pm with 2 waking staff throughout the night. There is a cook and domestic staff however care staff cover the laundry duties. Care staff said they have a routine for each shift and endeavour to ensure that domestic duties are not left for the night staff. Due to their dementia some of the service users are regularly up during the night and need support and supervision from staff. The commitment to training from the Registered Providers and staff is very good. Staff have recently undergone training in the Protection of Vulnerable Adults (POVA) and have also completed a 6 week course in dementia. This involved an external trainer coming into the house each week. Several staff have gained a National Vocational Qualification (NVQ) and were wearing badges to show this achievement. Service users were at ease with staff and 5 relatives commented on the positive attitude of staff who they said are welcoming, friendly and hard working. Abbotsford Version 1.10 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 & 33 The manager provides good leadership creating an open positive and inclusive atmosphere, which results in good outcomes for service users. The Registered Providers are very committed to the service in lots of ways however a lack of planning and organisation are having a negative impact on the service users in some areas. EVIDENCE: The manager’s hours are now supernumerary and she only covers care shifts in an emergency. There were clear lines of accountability between the staff and everyone was aware of their role and responsibilities. There is an on call system however staff are not paid to be on call and only receive payment if they are called out to the home. The Registered Providers may wish to re-consider this situation as if staff are not technically on duty or available as they are not being paid then it cannot be expected that they will be available to be called out in an emergency. Abbotsford Version 1.10 Page 19 The manager said that the Registered Providers do visit the home, however there is no formal system of monitoring as required by regulation 26 of the Care Homes Regulations 2001. This matter was subject to a requirement made at the last inspection and is re-stated in this report. Abbotsford Version 1.10 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 x COMPLAINTS AND PROTECTION 1 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x x 3 x 1 x x x x x Abbotsford Version 1.10 Page 21 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 19 Regulation 23 Requirement Timescale for action 27.5.05 2. 19 23 3. 26 37 All external areas of the home must be made safe. (Previous timescale of 30th September 2004 not met). The Registered Providers (not 27.5.05 the manager) must provide a written plan to the CSCI that states the action they will take to address all the issues specified in the section relating to the environment. Each action must detail a timescale for completion. 27.5.05 The Registered Provider must provide detailed visit reports in line National Minimum Standards and Care Home Regulations. (Previous timescale of 30th September 2004 not met). 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 None made. Good Practice Recommendations Abbotsford Version 1.10 Page 22 Commission for Social Care Inspection 1St Floor Newland House Campbell Square Northampton NN1 3EB 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 Version 1.10 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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