Inspection on 21/12/05 for Abbotsford Nursing Home

This inspection was carried out on 21st December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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 Nursing Home 04/12/08

Abbotsford Nursing Home 06/12/06

Abbotsford Nursing Home 18/08/05

Abbotsford Nursing Home 12/05/04

Abbotsford Nursing Home 30/12/03

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 Nursing Home 21 Gilbert Road Romford Essex RM1 3BX Lead Inspector Julie Legg Unannounced Inspection 21st December 2005 08:00 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 Nursing Home DS0000034878.V274171.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 Nursing Home DS0000034878.V274171.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Abbotsford Nursing Home Address 21 Gilbert Road Romford Essex RM1 3BX 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) 01708 740355 Mrs Carmel Elizabeth Dempsey Indira Sandhu Care Home 18 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (15) of places Abbotsford Nursing Home DS0000034878.V274171.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th August 2005 Brief Description of the Service: Abbotsford is a privately owned nursing home and is registered to provide accommodation and nursing care to eighteen older people. Most of the residents have moderate to high needs due to their physical frailty or dementia. The home is situated in a quiet residential area of Romford and is close to the local shopping centre. The home is well served by public transport, both buses and the main line train station are within walking distance. The home is wheelchair accessible and a passenger lift is installed. There are two single bedrooms and eight double bedrooms, none of these rooms are en-suite. The home has a large back garden and there is off street parking at the front of the house. Abbotsford Nursing Home DS0000034878.V274171.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day and lasted seven hours. The inspector spoke to a number of residents and staff. Discussion took place with the registered provider, the registered manager, the administrator and the cook. A tour of the home was undertaken and a number of care and staff records were looked at. Eight requirements set at the previous inspection were checked to see what progress had been made. This was the second statutory inspection visit in the inspection programme for 2005/6. Over the course of the two visits, all core standards have now been assessed. For one of the requirements made at the time of the last inspection, the timescale for compliance had not yet been reached, so this has been restated with the original timescale. One standard has been partly met and a revised requirements has been set to take account of this. What the service does well: What has improved since the last inspection? The home has taken action to address the requirements set at the previous inspection. All of the residents’ care plans and risk assessments are accurate and up to date, and are now being reviewed monthly or when a change in a Abbotsford Nursing Home DS0000034878.V274171.R01.S.doc Version 5.1 Page 6 resident’s needs is identified. All care and nursing staff have undertaken training to ensure that all care plans and risk assessments are completed regularly and appropriately. All areas of the home are adequately maintained and since the last inspection further redecoration and refurbishment has been undertaken. All of the remaining bedrooms, the lounge and the outside of the home have been redecorated. The new ‘rise and fall bath’ is now operational in the newly refurbished bathroom and an upstairs sluice room has been installed. The manager now has dedicated time to carry out tasks such as auditing of the care plans and risk assessments and all staff have been issued with a supervision contract and supervision has commenced. 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 Nursing Home DS0000034878.V274171.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Abbotsford Nursing Home DS0000034878.V274171.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 2,3, and 4 were not tested on this visit. However the judgement from the last inspection was that each resident, and/or their representative, know the terms and conditions attached to living in the home. The home does not offer intermediate care. EVIDENCE: Standards 2,3, and 4 were not specifically tested on this visit, as there were no outstanding requirements in relation to these standards, which were assessed at the last inspection as met. These standards will be re-tested at a future inspection. The evidence from the previous inspection found that a comprehensive preadmission assessment is undertaken for all prospective residents prior to them moving in the home. Care plans are drawn up from this assessment, ensuring Abbotsford Nursing Home DS0000034878.V274171.R01.S.doc Version 5.1 Page 9 that the needs of the resident are identified and met. This will then enable the staff to provide the right level of care to assist the resident to continue to live as full a life as possible. The home does not offer Intermediate Care therefore standard 6 does not apply. Abbotsford Nursing Home DS0000034878.V274171.R01.S.doc Version 5.1 Page 10 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, and 11 Residents’ health and personal care needs are identified in individual care plans, which accurately reflect the residents’ current needs. The care plans provide the staff with sufficient information to ensure that residents’ care needs are met on a daily basis. Standards 9 and 10 were not tested on this visit. However the judgement from the last inspection was that the home has clear medication policies and procedures for the staff to follow and the staff receive appropriate training to ensure that medication is administered safely. Residents are treated with respect and the arrangements for their personal care ensures that their right to privacy is upheld. They are also assured that their wishes regarding their death will be adhered to. EVIDENCE: Individual care plans were available for each of the residents. These care plans followed on from a full assessment of the residents’ needs. Both nursing and Abbotsford Nursing Home DS0000034878.V274171.R01.S.doc Version 5.1 Page 11 care staff have undergone training on the completion of the care plans and daily logs and evidence showed that these are now being completed appropriately. Staff spoken to were able to demonstrate that they fully understood their role in completing and regularly updating the residents’ care plans as the need arises. This was a previous requirement which has now been met. Six care plans were examined and there was evidence that all care plans and risk assessments have been reviewed and updated on a monthly basis or when there has been a change in residents’ needs. This was a previous requirement which has now been met. The inspector examined six risk assessments regarding breakdown of pressure areas, nutritional intake, continence and falls, all have been completed appropriately and are being regularly reviewed. This was a previous requirement which has now been met. Standards 9 and 10 were not specifically tested on this visit, as there were no outstanding requirements in relation to these standards, which were assessed at the last inspection as met. These standards will be re-tested at a future inspection. On examination of six residents’ files it is clearly identified who the resident wishes to be contacted at the time of their death and their wishes regarding their funeral arrangements Abbotsford Nursing Home DS0000034878.V274171.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 14 There is a varied activities programme available. However, more consideration needs to be given to planning activities which are suitable for those residents with specialist needs such as dementia. Residents are helped to exercise choice and control over their lives. Standards 13 and 15 were not tested on this visit. However, evidence from the last inspection was that visiting times are flexible and people are made to feel welcome, which ensures that residents are able to maintain contact with their friends and family as they wish. The meals in the home are well presented and nutritionally balanced. They offer both choice and variety to residents. EVIDENCE: The home has a varied activities programme, which includes, quizzes, skittles, reminiscence sessions, musical movement and art and crafts. There are regular entertainers at the home and residents have been to a local theatre. The manager is currently looking at activities that would be appropriate for residents with specialist needs such as, dementia and cognitive impairment. Abbotsford Nursing Home DS0000034878.V274171.R01.S.doc Version 5.1 Page 13 She is in consultation with other health professionals and some of the staff attended a training course in advanced dementia. This should ensure that residents with dementia and cognitive impairment can participate in appropriate activities. This was a requirement made at the last inspection, however the timescale has not yet been reached, so therefore the requirement has been restated with the original timescale. This is requirement 1. Residents’ care plans indicate their preferred name, their choice as to when and where they take their meals, whether they choose to have a bath or shower, where they would like to receive their visitors and their wishes regarding their death. Currently there are no residents that handle their own finances, however there is a clear policy and procedure, if residents wish to do so. Residents are able to bring in personal possessions with them when coming to live at the home and this was evident when the inspector visited residents’ bedrooms. Items such as radios, televisions, photographs, pictures and ornaments enabled the rooms to feel more homely. Standards 13 and 15 were not specifically tested on this visit, as there were no outstanding requirements in relation to these standards, which were assessed at the last inspection as met. These standards will be re-tested at a future inspection. Abbotsford Nursing Home DS0000034878.V274171.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Standard 16 was not tested on this visit. However evidence from the last inspection was that the home has a satisfactory complaints policy and procedure in place and residents and relatives/representatives feel confident that their complaints and concerns are listened to and acted upon. The home has a satisfactory policy and procedure regarding allegations of abuse. Staff have undertaken training in Adult Protection/Abuse Awareness to ensure that there is an appropriate response to any allegations of abuse. EVIDENCE: Standard 16 was not specifically tested on this visit, as there were no outstanding requirements in relation to this standard, which was assessed at the last inspection as met. This standard will be re-tested at a future inspection. The home has a written policy and procedure for dealing with allegations of abuse and whistleblowing. The home also has a copy of the Department of Health’s document ‘No Secrets’ and copies of the local authority (Havering) and placing authorities documentation on abuse. All staff, including ancillary and administrative staff, have undertaken the appropriate training and there is a rolling programme to ensure that all new staff attend. Staff spoken to confirmed that they had attended training and were able to inform the inspector of the action to be taken if there were any concerns about the welfare and safety of residents. Abbotsford Nursing Home DS0000034878.V274171.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21 22, 23,24,25 and 26 The home is very welcoming and provides the residents with a safe, clean and comfortable environment in which to live. There are sufficient, suitable toilets and bathrooms for the number of residents. Specialist equipment such as, hoists, mattresses and walking aids are also available to meet the needs of the residents. Residents’ bedrooms suit their needs. EVIDENCE: The home has an ongoing redecoration programme and since the last inspection the remaining bedrooms have been redecorated and where needed, carpets have been replaced. Previously there was a damp patch on a bedroom wall, this has been rectified. This requirement is now met. All of the residents’ bedrooms are appropriately furnished and have family photographs, radios and ornaments, which personalise their rooms. Some of the bedrooms have electrically operated beds, which ensure the safety and comfort of the residents. The hallway and lounge have been redecorated and a new fireplace installed. The outside of the home has also been redecorated. Abbotsford Nursing Home DS0000034878.V274171.R01.S.doc Version 5.1 Page 16 There are sufficient toilets and bathrooms on each floor. The upstairs bathroom has been refurbished and the electrically operated rise and fall bath has been installed. The registered provider has carried out alterations to the other upstairs bathroom, to ensure that the sluice is installed in a separate room. This was a previous requirement which has now been met. The home is cleaned on a daily basis and throughout the inspection all areas of the home were found to be very clean and tidy. There are adequate control systems in place to ensure that the home is free from any offensive odours. Abbotsford Nursing Home DS0000034878.V274171.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 and 30 The home’s staffing levels are satisfactory and there are sufficient staff on duty, who have the skills and training to meet the individual needs of the residents. The home’s recruitment policy and procedure is not being followed and appropriate checks are not always being undertaken. EVIDENCE: On the day of the inspection, staffing levels were seen to be appropriate to meet the needs of the residents. During the day there are three care staff and an RGN and at night one RGN and one care staff. Staff rotas were examined and the rota correlated with the number of staff duty. The inspection took place early morning and the inspector was able to observe residents getting up and having their breakfast. Some of the residents were having their breakfast in bed, some sat in their bedrooms and others sat in the lounge. One resident was seen eating her breakfast later in the morning, as this was her choice. Since the last inspection, staff files showed that staff have undergone further training in advanced dementia, infection control, pressure care and manual handling. Two members of staff are currently undertaking their NVQ2 and three staff are undertaking their NVQ3. Three staff files were examined, one of which is a new member of staff. On this file there was not a photograph of the member of staff and there was only one Abbotsford Nursing Home DS0000034878.V274171.R01.S.doc Version 5.1 Page 18 written reference. All staff files must display a photograph of the member of staff. This is requirement 2. The manager must also ensure that she receives two written satisfactory references prior to a new member of staff commencing work. This is requirement 3. Abbotsford Nursing Home DS0000034878.V274171.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 36 and 38 The manager of the home is very experienced and well qualified. The home is being managed well and provides a safe environment for the residents of the home. However, the manager needs to ensure that the home is managed in a way that puts the interest of the residents first. Staff are being supervised, however this needs to be on a regular basis. EVIDENCE: The manager is a registered nurse and has substantial clinical and management experience. She has a good understanding of the needs of the residents and the areas of the home that need to improve and develop. She has a high visible presence within the home and comments from the staff, residents and relatives were very complimentary. The registered provider also spends a considerable amount of time in the home, and she is very involved with the running of the home. Both staff and residents spoken to were very complimentary of the manager. Abbotsford Nursing Home DS0000034878.V274171.R01.S.doc Version 5.1 Page 20 Residents’ and relatives’ views are sought informally and at meetings but the registered provider needs to implement a formal quality assurance, where the views of residents, relatives and stakeholders are sought in regard to the running of the home and forward a copy of this report to the Commission. This is requirement 4. The inspector was able to examine staff rotas and there was evidence to indicate that the manager’s rota has been reviewed and she now has dedicated time to enable her to carry out tasks, such as the auditing of care plans and risk assessments, staff supervision, the development of the service and any other managerial tasks. This was a previous requirement which has now been met. There is a system in place for the regular auditing and monitoring of the standard of care plans, medication and other health related records to achieve a consistent standard throughout the home. Staff files that were examined showed that staff have been issued with a supervision contract which has been signed by both parties and supervision meetings have commenced. However, the inspector will monitor the situation to ensure that these meetings take place on a regular basis. This is a previous requirement, which has been set with a new timescale. This is requirement 5. The home has carried out all health and safety checks. Within the past year, inspections have been carried out by the fire prevention officer and the environmental health agency. Fire drills and alarm testing are undertaken regularly, and water, freezer and fridge temperatures are also recorded regularly. All staff have undertaken manual handling training and first aid training, which are updated on a regular basis. Residents’ files that were examined showed that all risk assessments are being reviewed on a regular basis or when there is a change in need. Abbotsford Nursing Home DS0000034878.V274171.R01.S.doc Version 5.1 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 3 X 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X X 2 X 3 Abbotsford Nursing Home DS0000034878.V274171.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP12 Regulation 16(2)(n) Requirement The home must provide a more varied programme of activities with consideration given to those residents with dementia and cognitive impairment All staff files should display a recent photograph of the member of staff. Two satisfactory references must be received prior to a member of staff commencing employment. Quality assurance system must be in place. This system must include seeking the views of residents, relatives and stakeholders. A copy of the report must then be forwarded to the Commission and made available to all interested parties. The manager shall ensure that staff working at the home receive supervision at least six times a year. Previous timescale 30/10/05 not met. Timescale for action 30/12/05 2 3 4 OP29 OP29 OP33 Schedule 2 (1) Schedule 2 (3) 24 28/02/06 28/02/06 30/06/06 5 OP36 18(2) 30/04/06 Abbotsford Nursing Home DS0000034878.V274171.R01.S.doc Version 5.1 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Abbotsford Nursing Home DS0000034878.V274171.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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. 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