Inspection on 18/05/05 for The Abbey

This inspection was carried out on 18th May 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

The Abbey 06/11/07

The Abbey 03/10/06

The Abbey 08/03/06

The Abbey 17/01/05

The Abbey 13/09/04

The Abbey 15/03/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE The Abbey Main Street Staveley Kendal, Cumbria LA8 9LU Lead Inspector Jane Strawbridge Unannounced 18 May 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. The Abbey F58 F10 s35540 the abbey v225820 180505 ui stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Abbey Address Main Street Staveley Kendal Cubmria LA8 9LU 01539 821342 01539 822837 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) Cumbria Care Ann Elizabeth Dent Care Home 30 Category(ies) of OP - Old Age registration, with number DE(E) - Dementia, over 65 of places The Abbey F58 F10 s35540 the abbey v225820 180505 ui stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service must at all times employ a suitably qualified and experienced manager who is registered with the National Care Standards Commission. 2. A maximum of thirty older people (OP30) may be accommodated, ten of whom may have dementia (DE(E)10). 3. The matters detailed in the attached schedule of requirements must be completed in the specified timescales. 4. The staffing levels in the home must meet the Residential Forum Care Staffing Formula for Older Adults by 1st April 2004. 5. When single rooms of less than 12 sqm usable floor space become available they must not be used to accommodate wheelchair users, and where existing wheelchair users are in bedrooms of less than 12 sqm they must be given the opportunity to move to a larger room when one becomes available. 6. Two service users may share a bedroom of at least 16 sqm usable floor space only if they have made a positive choice to do so, and when one of the shared spaces becomes vacant the remaining service user has the opportunity to choose not to share, by moving to a different room if necessary Date of last inspection 17 January 2005 Brief Description of the Service: The Abbey is a residential home for older people situated in the centre of Staveley which is a village near to Kendal. The home is owned by Cumbria Care and is managed by Mrs. Ann Dent. The Abbey is registered to provide care and support for thirty older people aged over 65 years including 10 who have dementia. The home is a large Victorian building that was fully refurbished approximately six years ago. The living accommodation is on two floors with a passenger lift servicing the upper floor. The bedrooms vary in size and are currently used for single occupancy but there are two bedrooms that can be used for two people sharing. The homes living space has been divided into three units each of which contain a living room and kitchen / dining area and there are other sitting rooms for service users and their visitors to use if they wish. A wing has been adapted to provide up to four people with short term intermediate care following a stay in hospital. The home has established firm links with the people in the village and its residents are viewed as part of the local community. The Abbey F58 F10 s35540 the abbey v225820 180505 ui stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection of the home that took place over one day. The inspector spent time talking with the residents either in small groups or individually and with the manager and staff on duty. Records to do with the care of the residents and the day to day running of the home were looked at and the inspector visited all parts of the home. What the service does well: What has improved since the last inspection? A number of bedrooms have been redecorated since the last inspection and all of the bedrooms seen by the inspector were personal to each occupant with plenty of pictures, photographs and ornaments. There had been a requirement made as a result of the previous inspection that formal staff supervision must take place every two months and records of this kept on file. The supervisors who have the responsibility for supervising care staff and ancillary staff had managed to implement regular formal supervision and the care staff members who spoke to the inspector said that they had found it to be a positive improvement. The Abbey F58 F10 s35540 the abbey v225820 180505 ui stage 4.doc Version 1.30 Page 6 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. The Abbey F58 F10 s35540 the abbey v225820 180505 ui 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 The Abbey F58 F10 s35540 the abbey v225820 180505 ui 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 and 6 The home provided service users and their family carers with a comprehensive range of information about the home to help them to make an informed decision whether the home would be able to meet their needs. The staff working on the intermediate care unit had enabled people to become sufficiently independent so that they could return to their own home following a stay in hospital. EVIDENCE: There was a clear admissions procedure to the home that included a full assessment of need being carried out. The managerial staff team working in the home were aware of the registration categories and had been careful not to admit anyone into the home whose needs were outside the categories. All service users were issued with an individual contract and terms and conditions. The contracts clearly stated the terms of residency that included trial periods. The four - bedded intermediate care unit had been designed to be as near to a domestic setting as possible. There was a dedicated staff team who worked on the unit and this had resulted in a consistent approach to record keeping and assessments. The staff had developed a close working relationship with the The Abbey F58 F10 s35540 the abbey v225820 180505 ui stage 4.doc Version 1.30 Page 9 health service Intermediate Care Team and their rehabilitation workers visited the unit daily. The majority of the service users who had spent time on the unit had been enabled to develop sufficient confidence to be able to return to their own home. In other cases the service users had been assessed as suitable for longer term care and had moved to a home that would be able to meet their needs. The Abbey F58 F10 s35540 the abbey v225820 180505 ui stage 4.doc Version 1.30 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 standard(s) 7,8,9,and 10 The home used a clear and consistent care planning system which ensured that the health and social care needs of the people who lived in the Abbey were met in a dignified way. EVIDENCE: The home used their initial assessment of the needs and capabilities of new service users as the basis for their individual ongoing plan of care. The care plans provided staff with the necessary information to ensure that they were able to meet the needs of the service user. Each plan of care had been reviewed on time and the service users had signed them to confirm that they had been involved. Records of visits by GPs and other health care appointments had been kept. Service users who spoke to the inspector confirmed that the staff assisted them to keep appointments to see the chiropodist, dentist and optician. Medication procedures were followed and ensured the safety and well being of service users. Staff members spoke to service users in a polite way and knocked on bedroom doors before gaining permission to enter. Service users said that staff spoke to them in a courteous manner and said that “staff were very kind” and that their personal care was handled in a way that preserved their dignity. The Abbey F58 F10 s35540 the abbey v225820 180505 ui 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, 14, 15 Service users were provided with a range of choices at mealtimes and opportunities for social activities on a daily basis. EVIDENCE: The service users who spoke to the inspector were very positive about their experiences of living in the Abbey. Some said that they were “free to do whatever they liked and at times to suit themselves.” Another said that the Abbey was an ”older building that had character more like my old home” and therefore preferred living there rather than in “a modern box.” On the day of the inspection most meals were being taken in the dining room although service users and staff confirmed that it was possible for them to be served in service users’ own rooms if people preferred to do so. The staff members who worked on the Intermediate Care unit encouraged service users to help to prepare snacks and light meals as part of their preparation for returning home. Service users confirmed that they were able to receive visitors and go out whenever they wished. The Abbey is situated in the centre of Staveley and has firmly established links with the local community and the church. Local volunteers visit the home regularly, ensuring service users are able to maintain active links with the community. The Abbey F58 F10 s35540 the abbey v225820 180505 ui stage 4.doc Version 1.30 Page 12 The home has menus that offer a choice at all meals. Service users told the inspector that the food was “very good and varied.” The Abbey F58 F10 s35540 the abbey v225820 180505 ui 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, 17, 18 The home has a satisfactory complaints procedure in place and service users are protected from abuse. EVIDENCE: Service users had been given information about how to complain when they moved into the home and the complaints procedure had been included in the Service Users’ Guide. All the service users who spoke to the inspector said they would take up any complaint with manager or supervisor if necessary although they said that they had no reason for concern. The home had contacts in Age Concern and had used their advocacy service on previous occasions. Service users who wished to vote in the recent general election had maintained that right by registering for a postal vote. The home’s “whistle blowing” policy was clearly understood by staff who knew what their responsibilities were in order to protect vulnerable people in their care. The Abbey F58 F10 s35540 the abbey v225820 180505 ui 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, 23, 24, 25, & 26 The home provides a clean and homely environment for the people who live there. EVIDENCE: The home was generally well maintained and provided a safe environment for its residents. Since the previous inspection eight of the bedrooms had been decorated to provide a more homely and pleasant environment for service users. However the inspector identified trip hazards and therefore requires that these areas of carpet be repaired as a matter of urgency. The private bedrooms seen by the inspector were clean and tidy and had been furnished to provide a comfortable environment. All had many pictures and personal possessions and ornaments that made them very personal and individual. There were ramps and handrails fitted to assist people to move around independently. The home also had a passenger lift to allow easy access to all The Abbey F58 F10 s35540 the abbey v225820 180505 ui stage 4.doc Version 1.30 Page 15 floors. The bathrooms were pleasantly decorated and equipment had been installed in them to assist service users to take baths in safety. The Abbey F58 F10 s35540 the abbey v225820 180505 ui 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, 29 &30 Competent members of staff had been appointed to care for service users. EVIDENCE: On the day of the inspection there were sufficient members of staff members and a supervisor on duty to meet the needs of service users. During the morning a supervisor was in charge until the manager returned form a training course at lunchtime. Staff members were seen to respond to the requests from service users in a prompt and efficient manner. The home was clean and lunch was served on time. The home operated a recruitment policy that had been designed to protect service users. Although it was sometimes difficult to recruit suitable staff due to the low unemployment levels in the area the manager had ensured that standards had been maintained. The procedures were thorough and contributed towards the protection of service users. On the day of the inspection the manager and three care staff had attended a training session on the protection of vulnerable adults. On the previous day four members of staff had attended a training course on the safe administration of medication. All care staff are required by the home to attend these courses. The Abbey F58 F10 s35540 the abbey v225820 180505 ui 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) 31, 33, 36 & 38 The home was managed effectively to ensure that staff provided the best possible quality of care for the service users. However there was a shortfall in the way that senior staff were formally supervised. EVIDENCE: The registered manager has many years’ experience and had worked at the Abbey in a variety of roles before being promoted to her current post. This meant that she understood what was required of each person in the team. Both staff and service users had the utmost respect for her and spoke warmly about her commitment and the way she managed the home. Formal staff supervision between the supervisors and the care staff had been implemented and the system was working well and had been well received. However the formal supervision sessions between the manager and the supervisors was not yet in place. This shortfall is partly due to the manager The Abbey F58 F10 s35540 the abbey v225820 180505 ui stage 4.doc Version 1.30 Page 18 having to cover a supervisor’s vacant post in addition to doing her own job. The requirement that was made at the previous inspection will remain in place until the supervision programme has been fully implemented. The records showed that the home’s staff group are committed about ensuring the health and safety and wellbeing of the service users, themselves and colleagues. The Abbey F58 F10 s35540 the abbey v225820 180505 ui 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 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION 2 x x x 3 3 2 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 x 3 x x 2 x 3 The Abbey F58 F10 s35540 the abbey v225820 180505 ui stage 4.doc Version 1.30 Page 20 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. 2. Standard OP19 OP36 Regulation 23,(2b) 18(2) Requirement The worn carpets on the corridor floors must be repaired. Formal staff supervision for the supervisors must take place at least every two months and records of the meeting kept on file. Timescale for action June 30 2005 June 30 2005 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 Good Practice Recommendations The Abbey F58 F10 s35540 the abbey v225820 180505 ui stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith, Cumbria CA11 9BP 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 The Abbey F58 F10 s35540 the abbey v225820 180505 ui stage 4.doc Version 1.30 Page 22 - 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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