Inspection on 25/01/06 for Abigail House

This inspection was carried out on 25th January 2006.

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 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

Abigail House 18/06/07

Abigail House 15/02/05

Abigail House 03/11/04

Abigail House 08/03/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Abigail House 173 West Avenue Westerhope Newcastle Upon Tyne Tyne & Wear NE5 5JH Lead Inspector Alan Baxter Unannounced Inspection 25th January 2006 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 DS0000000431.V258848.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. DS0000000431.V258848.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Abigail House Address 173 West Avenue Westerhope Newcastle Upon Tyne Tyne & Wear NE5 5JH 0191 286 2468 0191 214 6364 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) Manor Care Home Group Mrs Kath Gordon Care Home 29 Category(ies) of Dementia - over 65 years of age (19), Old age, registration, with number not falling within any other category (10) of places DS0000000431.V258848.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th August 2005 Brief Description of the Service: Abigail House is a care home situated in a quiet residential area of Westerhope. The home is close to the village that provides all amenities. The home is a twostorey building providing 19 places for service users with Dementia Care needs and 10 places for service users requiring 24-hour personal care. The home cannot provide nursing care. The home has bedrooms over two floors, only one is en-suite. There is ample lounge and dining room space and the home has a pleasant secure garden area. DS0000000431.V258848.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection of Abigail House, which took place in January 2006. The main focus of the inspection was to check that the home had carried out the requirements and recommendations of the last inspection, which took place in November 2005. All but one were found to have been complied with. Time was spent studying care records and other relevant documentation. Lunch was taken with the residents. The inspection took approximately three and a half hours. What the service does well: Residents are given a healthy and varied diet, with a degree of choice. The home takes all complaints and concerns very seriously and deals with them quickly and positively. Residents are encouraged and supported to take decisions for themselves, as much as possible, and to exercise choice. Residents are protected from abuse. The home is kept clean and hygienic, and provides a pleasant living environment for the residents. The home is well staffed. All staff are qualified to NVQ level two (and most, to NVQ level three). Residents’ finances are protected by clear and thorough accounting. (For other areas where the home does well, please see the last inspection report.) DS0000000431.V258848.R01.S.doc Version 5.0 Page 6 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. DS0000000431.V258848.R01.S.doc Version 5.0 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 DS0000000431.V258848.R01.S.doc Version 5.0 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): These standards were not inspected, but standards 1 and 3 were met on the last inspection. EVIDENCE: DS0000000431.V258848.R01.S.doc Version 5.0 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 the following standard(s): These standards were not inspected, but standards 7,8,9 and 10 were met on the last inspection. EVIDENCE: DS0000000431.V258848.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): 14,15. 14) Residents are helped to exercise as much choice and control over their lives as possible. 15) Residents have a good balanced diet and enjoy their food. EVIDENCE: 14) Study of residents’ care plans and discussion with the manager confirmed that residents are given as much choice and control of their lives as possible. Examples included the freedom to move around the home; to go out (alone, subject to a risk assessment; otherwise with a staff or family member to escort); when to get up and go to bed; what to eat and when; and how often and when to bathe. Residents may choose which visitors they wish to see, and may see them in private. They may smoke in a designated area. Although none of the current residents is able to fully handle their own financial affairs, staff make sure that they have small amounts of their own money, if they so choose. DS0000000431.V258848.R01.S.doc Version 5.0 Page 11 Advocacy services are arranged for residents when necessary, and information about the Alzheimers Society advice service and the Newcastle Advice Service is displayed in the home. Residents may bring some furniture and other personal possessions with them when they come into the home. The home is aware of its responsibilities under the Data Protection Act, and the manager gave a number of examples of residents’ personal information being protected by the home. 15) The menus were examined. They have an eight-week cycle, giving more variety than most homes. A cooked breakfast is available every day. There is a choice of main meal at lunchtime and vegetarians are catered for daily. The chef is well qualified and very experienced. He has introduced the good practice of showing photographs of the menu choices to residents who cannot verbally communicate their choices. Also, of processing fruit and vegetables into easily taken and digested juices, which are apparently popular with the residents. A meal was taken with the residents. A number of practice issues were discussed with the manager, afterwards. Residents are weighed every month. Any weight problems are properly addressed, with the introduction of a specific care plan, with weekly summaries, and the use of weekly weighing, and of food charts. The latter were found to be always fully completed, including the quantities eaten, and are signed and dated. This is good practice, and staff are commended for taking this important area of care so seriously. DS0000000431.V258848.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): 16,18. 16) Residents and their relatives can be confident that their complaints will be listened to, taken very seriously and acted upon. 18) Residents are protected from abuse. EVIDENCE: 16) The complaints book was examined. It was clear from the number of entries that the home takes all complaints or expressions of concern very seriously, even though most were minor complaints, of the “no bran flakes for breakfast today” kind. All are looked into, promptly, and the findings/outcomes recorded in good detail. There is space for recording whether or not the complainant is happy with the outcome of their complaint. It is clear from the complaints record that any identified shortcomings in the service are quickly addressed (examples included fixing plumbing problems, finding missing clothes, and replacing clothing damaged in the laundry). The home is complimented on its positive approach to complaints, its speedy response in terms of recording and dealing with the complaint, and the sensitivity and respect shown to residents and their families when dealing with complaints. DS0000000431.V258848.R01.S.doc Version 5.0 Page 13 18) The home has suitable policies and procedures for protecting residents from abuse, and for responding appropriately, should an allegation of abuse be received. There has been a recent example of the home responding speedily and proactively to a situation that was potentially abusive. The home contacted social services and the Commission immediately and co-operated fully with the subsequent investigation. Appropriate disciplinary action was taken against a member of staff, and a referral was made to the Protection of Vulnerable Adults (POVA) list. All staff have received POVA training. The home has a ‘no restraint’ policy. DS0000000431.V258848.R01.S.doc Version 5.0 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 the following standard(s): 19,23,26. 19) Residents live in a safe and well-maintained environment. 23) Residents’ rooms generally suit their needs. 26) The home is clean, pleasant and hygienic. EVIDENCE: 19) It was a requirement of the last inspection report that water must be delivered to outlets at close to 43oC.; and that the laundry flooring must be replaced with an impermeable surface. Both of these issues have now been implemented. 23) It was a requirement of the last inspection report that bedroom no. 21 must be given adaquate window area by opening up the currently blocked second bedroom window. DS0000000431.V258848.R01.S.doc Version 5.0 Page 15 This requirement has not been implemented, apparently because it was felt that such building work would be too disruptive to the resident. However, there was no evidence that the resident and her family have been consulted on this issue. This requirement is, therefore, repeated in this report. 26) All areas of the building seen were very clean and hygienic. DS0000000431.V258848.R01.S.doc Version 5.0 Page 16 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): 27,28,29. 27) Staffing levels are high enough to meet residents’ needs. 28) Staff are well trained. 29) The home has recruitment practices that keep residents safe. EVIDENCE: 27) Staff rotas were examined. The staffing levels are unchanged from the last inspection, and meet the agreed minimum staffing levels for a home of its size and client groups. These are: six staff (seniors and carers) between 8am and 2pm; five between 2pm and 8pm; and three at night. Domestic cover is provided between 8am and 4pm, and laundry cover between 8am and 3.30pm, seven days per week. The cook works between 7am and 5pm, and his assistant between 7.30am and 3pm. The manager is supernumerary to the rota. The manager has the delegated power to call in agency staff, where necessary, and this has been demonstrated in practice. 28) All care staff have now achieved National Vocational Qualification (NVQ) level two in care. Approximately 60 of staff have gone on to achieve NVQ level three in care. This shows a commendable degree of commitment and motivation by staff, and they are congratulated. DS0000000431.V258848.R01.S.doc Version 5.0 Page 17 All care staff are doing an ASET level two qualification in Dementia Care; again, good practice. The manager holds NVQ level four in care and management and the Registered Manager Award. All new staff are put on a TOPSS-certified induction and foundation course. 29) It was a requirement of the last inspection report that evidence of CRB checks must be held on staff files. This has been implemented. The CRB file was examined, and all new CRBs were signed off by the inspector. It was a recommendation of the last inspection report that staff job interviews are minuted, to demonstrate that application forms and work histories are thoroughly vetted in interview. This has been implemented. DS0000000431.V258848.R01.S.doc Version 5.0 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 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): 33,35. 33) The home is run in the best interests of the residents, but quality assurance systems must be kept up to date. 35) Residents’ financial interests are safeguarded. EVIDENCE: 33) Quality assurance systems were examined. The most recent quality audit undertaken by the home was in 2004. It is a requirement that there is an annual audit of the views of residents, relatives, staff and visiting professionals, and that this information is collated and is published in the service user guide. DS0000000431.V258848.R01.S.doc Version 5.0 Page 19 The home has some other audit forms (for the building, care records etc.) but these need to be expanded. The home’s activities co-ordinator holds meetings with the residents and feeds back their views. There are monthly visits to the home by its line manager. The complaints book confirms the openness and responsiveness of the home’s management. There is an ‘open door’ policy, which is well used. There was anecdotal and documentary evidence of residents being helped to lead normal lives. The home usually meets the requirements made of it in inspection reports within the timescales set down. The home must draw up an annual development plan. 35) A spot check of a number of residents’ financial accounts was undertaken. They were found to be accurate. Receipts are kept for all transactions involving residents’ monies. These receipts are numbered and cross-referenced. There are always two staff signatures for each entry (and the resident is also encouraged to sign themselves). There is a weekly internal audit by the manager and deputy manager; and occasional audits by line management. Residents and their relatives/representatives can access their own financial records. DS0000000431.V258848.R01.S.doc Version 5.0 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. 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 X 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X 2 X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 X X X DS0000000431.V258848.R01.S.doc Version 5.0 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 OP23 Regulation 23 Requirement The resident of bedroom 21 and her family must be consulted as to whether they wish to have the (currently inadaquate) window area improved by opening up the blocked second bedroom window. Work to be carried out if agreed. 2 OP33 24 An annual audit of the views of residents, their families or representatives, staff and visiting professionals about the running of the home must take place. The results of such audits must be published in the service user guide. An annual development plan must be drawn up for the home. 31/03/06 Timescale for action 28/02/06 3 OP33 24 31/03/06 DS0000000431.V258848.R01.S.doc Version 5.0 Page 22 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 DS0000000431.V258848.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 DS0000000431.V258848.R01.S.doc Version 5.0 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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