Inspection on 20/06/05 for Abigail Lodge Care Home

This inspection was carried out on 20th June 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 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 Lodge Care Home 09/12/08

Abigail Lodge Care Home 10/12/07

Abigail Lodge Care Home 13/12/06

Abigail Lodge Care Home 14/11/05

Abigail Lodge Care Home 09/02/05

Abigail Lodge Care Home 21/07/04

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Moor House

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Mendip House

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Ann Charlton Lodge

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

CARE HOMES FOR OLDER PEOPLE Abigail Lodge Care Home Gloucester Road, Delves Lane, Consett, Co Durham, DH8 7LB Lead Inspector Stephen Ellis Unannounced 20June 2005 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. Abigail Lodge Care Home B54 S686 Abigail Lodge V223784 200605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Abigail Lodge Care Home Address Gloucester Road, Delves Lane, Consett, Co Durham, DH8 7LB 01207 502405 01207 502439 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) Tamaris Healthcare (England) Limited (wholly owned subsidiary of Four Seasons) Judith Mallaburn Care Home with Nursing 60 Category(ies) of Dementia (30), Dementia - over 65 years of age registration, with number (30), of places Old age, not falling within any other category (30), Terminally ill (3) Abigail Lodge Care Home B54 S686 Abigail Lodge V223784 200605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Terminal illness: Up to 3 persons with a terminal illness (palliative care) may be accommodated, commensurate with the homes statement of purpose and function and where appropriately qualified and competent staff are provided. Persons in the category of DE and DE(E) may be accommodated, commensurate with the homes statement of purpose and function. Date of last inspection 9th February 2005 Brief Description of the Service: Abigail Lodge is a care home with nursing. The home has two units, each with 30 beds. One is registered to provide care (including 24 hour nursing care) for persons aged 65 years or older, together with convalescence and palliative care for persons aged 55 years or older. The second accommodates clients with dementia care needs (including 24 hour nursing care).The home is located on the outskirts of Consett, close to a supermarket and a public house.The home was opened in 1995 and consists of a two-storey building. All of the home’s bedrooms are single with en-suite facilities. There is a passenger lift available in each unit.The home has large gardens that are well maintained and easily accessible. Abigail Lodge Care Home B54 S686 Abigail Lodge V223784 200605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 4 hours. The inspector looked around the building, examined a number of records required to be kept, and spoke with 16 service users, 3 relatives and four members of staff. What the service does well: What has improved since the last inspection? What they could do better: Abigail Lodge Care Home B54 S686 Abigail Lodge V223784 200605 Stage 4.doc Version 1.30 Page 6 The home is doing generally well, with good outcomes for service users and positive staff morale. It could consider introducing ‘Life story’ work with service users on both units, as discussed with the manager. It needs to monitor staffing levels between 2.00 and 8.00 pm to make sure that service users’ needs are always fully met. 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. Abigail Lodge Care Home B54 S686 Abigail Lodge V223784 200605 Stage 4.doc Version 1.30 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 Abigail Lodge Care Home B54 S686 Abigail Lodge V223784 200605 Stage 4.doc Version 1.30 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) 3 No service user moves into the home without having had his/her needs assessed and been assured that these will be met. EVIDENCE: Service users and relatives said that the care received was based on a very good understanding of service users’ needs. The care needs of service users were written in detail in the plans of care examined by the inspector. These showed a full, professional assessment of needs had been carried out, involving other agencies where appropriate, such as independent care managers and medical personnel. The manager confirmed that all service users have a comprehensive assessment of their needs before moving into the home, unless it is an emergency admission, which is a rare occurrence. The manager has to be satisfied that the home can meet the assessed needs before the admission can take place. Abigail Lodge Care Home B54 S686 Abigail Lodge V223784 200605 Stage 4.doc Version 1.30 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, 8 and 10 There are good arrangements for service users’ health and personal care, and service users feel that they are treated with respect and their right to privacy is upheld. EVIDENCE: Service users and relatives said that they had every confidence in the management and staff of the home concerning the health and personal care of service users. One relative said: “The care here is excellent, with very good standards. They do six monthly reviews and keep relatives closely informed. My mother has been here for 8 years, and has benefited from the expertise in the different units of the home.” One service user said “you couldn’t ask for anything better”. Service users and relatives felt that service users’ dignity and privacy was well respected. An examination of care plans showed that service users’ health and personal care needs were written down in detail, along with plans of care designed to meet those needs. Daily records of progress were maintained, with regular evaluations of the care plans. Records of consultations with external health and social care professionals were kept. One service user had come out of hospital one year ago with a major pressure sore; it was now nearly completely healed. Abigail Lodge Care Home B54 S686 Abigail Lodge V223784 200605 Stage 4.doc Version 1.30 Page 10 Service users’ personal clothing and appearance indicated that they were being well looked after, as did the attitudes and activities of staff. Abigail Lodge Care Home B54 S686 Abigail Lodge V223784 200605 Stage 4.doc Version 1.30 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 and 14 The arrangements for daily life and activities meet service users’ needs and expectations, including contacts with family, friends and the local community. Service users are supported to make choices in their daily lives that reflect their individuality and preferences. EVIDENCE: An activities coordinator organizes a varied programme of social and recreational activities. Service users and relatives said that there was something suitable for service users to choose each day if they wished. For example, there was a party held at the home recently to celebrate V.E. Day, with songs from the ‘sixties’ and two visiting guitarists. Another party is planned for September when the home will be 10 years old. Gardening, movement and music, board games and religious services are available. The home had its patio doors open on both wings when the inspector visited, with gazebos erected and patio furniture arranged, so that service users and their visitors could enjoy the fine weather. It was noted that the music playing was appropriate to the taste and interest of service users, and that Wimbledon tennis was being shown silently on television for those service users who liked to follow it. Abigail Lodge Care Home B54 S686 Abigail Lodge V223784 200605 Stage 4.doc Version 1.30 Page 12 Service users confirmed that they exercised choice, with support from staff when required: For example, what they wore, the times they got up and went to bed, and how they spent their time. Some enjoyed being outside in the gardens, while others preferred being in the shade in the lounges. Relatives commented that they could visit whenever they wished, so long as it was acceptable to the service users. Some visitors would help to feed a relative. They were always made welcome and often offered refreshment. Abigail Lodge Care Home B54 S686 Abigail Lodge V223784 200605 Stage 4.doc Version 1.30 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 Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. EVIDENCE: Service users and relatives said they had confidence in the management and staff to deal with any concern or complaint raised. Several relatives said that the manager in particular was someone they could talk to and trust to take appropriate action. Service users and/or their representatives were aware of the complaints procedure within the service user’s guide. The home keeps a record of all complaints, including action taken and the outcome of the complaint investigation. Abigail Lodge Care Home B54 S686 Abigail Lodge V223784 200605 Stage 4.doc Version 1.30 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 and 26 The home is well maintained and safe; it is also clean, pleasant and hygienic. EVIDENCE: There is a dedicated maintenance officer who carries out maintenance checks and takes action to correct problems at an early stage. For example, water temperatures are taken regularly along with fire safety checks. Also, forty plus emergency lights have been renewed recently. Dining furniture on the dementia care unit is due to replaced soon and six new armchairs for the ground floor dementia care lounge have been ordered. Suitable locks have been requested by the manager for the remaining rooms that require them and should be fitted later this year. Service users and relatives said the home was clean, pleasant and comfortable. They confirmed that there is on-going maintenance and redecoration within the home. Abigail Lodge Care Home B54 S686 Abigail Lodge V223784 200605 Stage 4.doc Version 1.30 Page 15 The home operates an infection control policy agreed with the Health Protection Unit, and there was evidence of wall-mounted liquid soap and paper towel dispensers in appropriate locations. Abigail Lodge Care Home B54 S686 Abigail Lodge V223784 200605 Stage 4.doc Version 1.30 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 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 and 30 There are sufficient numbers of staff on duty, with appropriate skills, that are trained and competent to meet the assessed needs of service users. EVIDENCE: There is a registered nurse on duty on each unit, on each shift, every day. In addition, there are 4 carers on duty between 08.00 and 14.00, on each unit. This number reduces to 3 carers on each unit between 14.00 and 20.00. At night (20.00 to 08.00) there are 2 carers on each unit, plus a registered nurse on each unit. At the time of inspection, there were 28 service users on the dementia care unit (14 nursing and 14 non-nursing); and 25 service users on the general, older persons’ unit (14 nursing and 11 non-nursing). These staffing levels were reported by staff and management to be sufficient, with the exception of the 14.00 to 20.00 shifts when it is desirable to have 4 carers on duty. Staff and management said that staffing levels and skill mix were satisfactory, in part due to the input of a fourth carer on the 14.00 to 20.00 shift due to current, higher dependency needs. This situation is being carefully monitored to ensure that there are always enough members of staff on duty with the right skills. Staff and management confirmed that there is a comprehensive staff-training programme, including detailed induction and foundation training. Service users and relatives said that they found staff to be skilful and competent in their work. Abigail Lodge Care Home B54 S686 Abigail Lodge V223784 200605 Stage 4.doc Version 1.30 Page 17 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) 33 The home is run in the best interests of service users. EVIDENCE: Service users and relatives expressed great confidence in the management of the home. They said that they knew that any concerns they might have would be taken seriously and acted upon. They described the home as being well run, with the manager being accessible and approachable. There is regular consultation with them. Members of staff also expressed their confidence in the way in which the home is being run. They described good morale and constructive care practice. The health and wellbeing of service users is regarded as being of paramount importance, as confirmed by numerous comments from service users and relatives. Good leadership was evident. Abigail Lodge Care Home B54 S686 Abigail Lodge V223784 200605 Stage 4.doc Version 1.30 Page 18 The manager is making good progress with her Registered Manager’s Award and has become involved in a number of learning groups whose goal is to raise standards of health and social care practice. Abigail Lodge Care Home B54 S686 Abigail Lodge V223784 200605 Stage 4.doc Version 1.30 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION 3 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 3 x x x x 3 x x x x x Abigail Lodge Care Home B54 S686 Abigail Lodge V223784 200605 Stage 4.doc Version 1.30 Page 20 No 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 OP24 Regulation 23 Requirement Timescale for action 01/12/05 2. OP27 18 Suitable locks are required to be fitted to bedroom doors in the interest of promoting privacy and choice. Service users can then safely exercise choice about whether and when to lock their doors (subject to risk assessment) knowing that staff can gain access in emergency via a passkey. Staffing levels on the 14.00 to 01/08/05 20.00 shift should be monitored carefully and incresed if rquired, in keeping with the original staffing notice agreed with the original regulator. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP31 OP33 Good Practice Recommendations The CSCI expects registered managers to achieve the RMA during 2005 if at all possible, in line with National Minimum Standards. It is desirable for the home to publish the findings of its Quality Assurance and monitoring systems in a form that is B54 S686 Abigail Lodge V223784 200605 Stage 4.doc Version 1.30 Page 21 Abigail Lodge Care Home 3. 12 accessible to service users and their relatives. Further development of quality assurance systems and processes is likely to prove beneficial. Life story work with service users should be considered as a desirable method of working, in a person centred approach. Abigail Lodge Care Home B54 S686 Abigail Lodge V223784 200605 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection No.1 Hopetown Studios Brinkburn Road Darlington DL3 3DS 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 Abigail Lodge Care Home B54 S686 Abigail Lodge V223784 200605 Stage 4.doc Version 1.30 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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