Inspection on 06/11/07 for The Abbey

This inspection was carried out on 6th November 2007.

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

The Abbey 03/10/06

The Abbey 08/03/06

The Abbey 18/05/05

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 Mrs Margaret Drury Unannounced Inspection 6th November 2007 09:45 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 The Abbey DS0000035540.V350012.R01.S.doc Version 5.2 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. The Abbey DS0000035540.V350012.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Abbey Address Main Street Staveley Kendal Cumbria LA8 9LU 01539 821342 01539 822837 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) www.cumbriacare.org.uk Cumbria Care Mrs Ann Elizabeth Dent Care Home 30 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (29), of places Physical disability (1) The Abbey DS0000035540.V350012.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 30 service users to include: - up to 10 service users in the category of DE(E) (Dementia over 65 years of age) - up to 29 service users in the category of OP (Old age not falling within any other category) - 1 service user in the category of PD (Physical Disabilities) 3rd October 2006 Date of last inspection Brief Description of the Service: The Abbey is a residential home for older people situated in the centre of Staveley 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 although 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 regarded as part of the local community. The fees charged at this home range from £363.00 to £422.00, as at the date of the visit, with extra charges for hairdressing, newspapers, magazines, personal toiletries hairdressing, private chiropody and some outings. The Abbey DS0000035540.V350012.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit, during which an expert accompanied the inspector, forms part of a key inspection. It took place over one day and we ( The Commission for Social Care Inspection) were in the home for five and a half hours. Information about the service was gathered in different ways: • Annual Quality Assurance Assessment document completed by the manager • Interviews and a report from the expert by experience who was present during the visit. • The service history • Interviews with residents, visitors and staff on the day of the visit. • Completed questionnaire survey forms We looked at care planning documentation to ensure the level of care provided met the needs of those living in the home and a tour of the building to inspect the environmental standards was undertaken. Staff personnel files were examined. What the service does well: Feedback from residents and staff about this service was very positive. Comments such as “ I come to the home for short periods and am looked after very well” and “the staff are lovely and very kind” were made. There is a stable staff team that promotes and encourages the residents to remain as independent as possible and to exercise choice and control over their lives as far as they are able. Some activities are made available to residents if they wish to join in and special events are celebrated. Care plans are in place to ensure the staff have the information to meet the assessed needs. Residents are provided with a safe, clean, and comfortable place to live. Meals served at the home are of a very good standard and are very well received. The Abbey DS0000035540.V350012.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. The Abbey DS0000035540.V350012.R01.S.doc Version 5.2 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 The Abbey DS0000035540.V350012.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4, 5 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service and their representatives have the information they require to make an informed choice about moving in. EVIDENCE: Information about this home and the services it provides are made available to all who visit to look at available rooms. There is a statement of purpose and resident’s guide, copies of which are on display at the front of the home. A copy of the latest inspection report is also available. The home manager ensures that individual care needs assessments are carried out for each prospective resident. Admissions do not take place without this information and consideration is also given to the needs of those people already living in the home before a place is offered. The Abbey DS0000035540.V350012.R01.S.doc Version 5.2 Page 9 Discussion with the manager evidenced that the assessments are carried out in a professional and sensitive manner involving the individual, their family or representative where appropriate. Residents who spoke to us during the visit said they were able to visit the home to look around prior to moving in. if they were not able to do so, a family member or friend visited on their behalf. They agreed that this gave opportunity to meet the staff and others who live at The Abbey. During the visit the expert by experience was able to spend some time in the intermediate care unit that is situated on the ground floor. Her comments included, “The home offers respite care and I was able to speak with a client who was in the home for a week to give her husband some respite and she said that she loved the place. I met her in the lounge where there were other clients watching the television. The kitchen and dining room looked similar to other areas in the home. Residents have visits from the physiotherapist and occupational therapist every day to help them regain their confidence after a spell in hospital. Each resident has a maximum of 6 weeks care and rehabilitation during which time they have home visits to see if they can manage at home. The resident I spoke to said that the Unit was “like a 5 Star Hotel” and the staff were “marvellous”. The Abbey DS0000035540.V350012.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs. Privacy and dignity are respected at all times. EVIDENCE: We looked at the care plans for five people and the information provided covered areas such as mobility, diet, health and personal care. The care plans are reviewed monthly but recently during a period when members of the senior team were away from the home the reviews were not always kept up to date. However, since the registered manager’s return the staff have worked hard to ensure they are now reviewed with the timescale. Records of healthcare visits are kept and the manager confirmed that the nurses at the local practice are extremely helpful and supportive. The care plans could be improved if the The Abbey DS0000035540.V350012.R01.S.doc Version 5.2 Page 11 changes noted during the reviews were shown in more detail. It is important for all staff to know exactly what the changing needs of the residents in order to provide the highest level of care. Despite this it was obvious the staff knew the residents well and provided a high level of support. Cumbria Care is currently making changes to the format of the care plans that will improve the care planning system. A more person-centred approach is being introduced with more information regarding personal history, likes and dislikes being noted. . We observed the delivery of personal care during the visit and found it to be varied to meet the individual needs and preferences. Staff respected the privacy of the residents and were seen to listen attentively when residents spoke to them. One resident said, “the staff are always so polite and kind”. All residents are asked how they wish to be addressed and are supported and encouraged to remain as independent as possible. From discussions and observations it was evident that the staff understood the needs of the residents and supported them whilst meeting those needs. The Abbey DS0000035540.V350012.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service are able to make choices about their lifestyle and are supported to maintain their independence. The dietary needs of the residents are well catered for. EVIDENCE: The routines in this home are flexible and meet the needs of those people living there. As the home has no designated activities organiser the manager and staff currently organise any activities that take place. It is difficult, due to staff shortages, to have a full programme of regular activities but there are the usual bingo and other games are available. The manager hopes to address this issue in future in order to provide more meaningful activities for those living in the home. The hairdresser visits and staff arrange “pamper afternoons” for the ladies when they have hand massages and manicures. There is a church service held each month with Communion for those residents who wish to take it. All the residents enjoyed the recent Halloween party and bonfire celebrations when the staff dressed up in fancy dress costumes. Family members recently The Abbey DS0000035540.V350012.R01.S.doc Version 5.2 Page 13 organised a “reminiscence night” in the local village hall when £800 was raised for residents’ funds. There was a lovely photographic record of this event on display. One resident told the visiting expert by experience “everything about this place is perfect”. All the residents enjoy the regular visits made by the “pets as therapy dogs” as many of them had pets before they came to live in The Abbey. Some residents are able to go into Stavely village to do some shopping or pick up a newspaper if they wish. Visitors to the home are welcome any time and when we discussed this with the residents they said their visitors “are always offered tea and coffee when they come to see me”. We observed lunch being served and obviously enjoyed by the residents. Meals are served individually from heated trolleys in each dining room, which gives the residents the opportunity to choose what and how much they want. Lunchtime was seen to be a social and relaxed time with the residents and staff enjoying a chat. All residents appeared to have their own places in the dining room and were placed there by the staff at mealtimes if the were unable to go to the dining room by themselves. There were four members of staff on duty in the lower dining room at lunchtime. All washed their hands and put on aprons before serving the meal to the residents. We saw 2 members of staff helping a gentleman out of his chair into a wheelchair to be moved into the dining room and they took great care not to rush him in this movement and also encouraged him to help himself. The medicine trolley was placed in the doorway of the dining room when the medication was being administered. This could be an impediment to movement through the doorway. The menus are varied and nutritious and we had the opportunity to speak to the cook during the visit. She is currently working towards her National Vocational Qualification (NVQ) in catering and said she was enjoying it very much. There is a choice at all meals and vegetarian and diabetic dies can be catered for. When we asked the residents if they enjoyed their meals they all said they did and that there was “always plenty to eat The Abbey DS0000035540.V350012.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service are able to express their concerns knowing they will be listened to and acted upon. They are safeguarded from abuse by robust policies and procedures. EVIDENCE: The home has policies and procedures in place in relation to complaints and concerns, with details on display in the hall. The complaints procedure is also contained in the resident’s guide that is given to all new residents. Those who spoke to the inspector all said they would speak to the manager or one of the supervisors if they had any concerns to discuss. They did also say that they “had no complaints anyway”. There is a complaints log in place although there have been none to record and none have been received by The Commission for Social Care Inspection. We discussed with the manager the fact that concerns or “niggles” are not recorded. It is good practice to record all concerns and the way in which even the smallest is dealt with. Some adult protection/mistreatment of vulnerable adults training has been provided for the staff and there are policies and procedures in place covering this subject. This subject forms part of the induction programme introduced by The Abbey DS0000035540.V350012.R01.S.doc Version 5.2 Page 15 Cumbria Care. The home also has a copy of Cumbria Council’s protocol that is available for the staff to read. There have been no such incidents to report. The Abbey DS0000035540.V350012.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 24, 25 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents enjoy a comfortable and homely living environment. The premises are reasonably well maintained and kept to a good standard of cleanliness EVIDENCE: We conducted a tour of the building looking at the environmental standards within the home. All the residents have single rooms although there are two that are registered to accommodate two people if they wish to share. The rooms vary in size with some of them being quite large. Although many of them are rather small, all who spoke to us were pleased with their accommodation. There are sufficient bathrooms and toilets to meet the The Abbey DS0000035540.V350012.R01.S.doc Version 5.2 Page 17 assessed needs and all are suitable for anyone who may have a physical disability. There are handrails on the corridors to assist with mobility around the home. A passenger lift ensures residents have access to all parts of the building. Communal space is found on all floors with a large lounge on the ground floor and a lounge/diner on the first floor. There are also lounge, dining and kitchen facilities situated in the intermediate care unit Due to financial constraints within the organisation there has only been some redecoration but more is needed to ensure the home’s environmental standard remains high. The manager has applied to the organisation’s estates manager for shower facilities to be made available in the home, as this has been requested by one of the residents. As far as she is aware this request is being favourably considered. New carpet has been laid on one of the ground floor corridors and there is now money available to purchase new soft furnishings. The Abbey DS0000035540.V350012.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are good staff recruitment processes in place and the manager is mindful of the need for staff training and development. This means that those living at the home are supported by suitable staff. EVIDENCE: We discussed the staffing arrangements with the manager in the light of the current staff shortages. These are due, in the most part to staff sickness and some holidays. At the moment existing staff are covering to ensure continuity of care but there has been the need to use agency staff. This has worked because, as far as possible the same agency staff cover the vacant hours. This does mean that there is, for the most part, continuity of care for the residents. Comments from residents about the staff included, “the staff are lovely and always kind and considerate” and “ I really like the staff that look after me”. The expert by experience noted that the staff were very attentive to the residents’ needs and treated them with dignity at all times. The Abbey DS0000035540.V350012.R01.S.doc Version 5.2 Page 19 We looked at the staff files and recruitment process for 4 members of staff. These were very well maintained and contained all the necessary checks including Criminal Records Bureau (CRB) checks and references. Staff training is on going and must be continued to ensure the home continues to meet the target of 50 qualified to NVQ level 2 or above. Cumbria Care provides an annual training programme and the manager ensures, as far as possible, that the staff are able to attend all available training courses. Training has been completed in, food hygiene, medication appraisals, infection control and moving and handling. The Abbey DS0000035540.V350012.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 37 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a home that is run in their best interests by a qualified and experienced manager. EVIDENCE: The manager has worked for Cumbria Care for many years and has completed the registered manager award and NVQ level 4 in management. She is currently working towards her NVQ level 4 in care with only a couple of units to complete. She has an open and positive style and comments from the staff evidenced that she is very supportive to the residents and staff team. The Abbey DS0000035540.V350012.R01.S.doc Version 5.2 Page 21 The residents who talked with us said that they “saw Ann every day” and that she “was available to speak to at any time”. The home is responsible for small amounts of residents’ monies used to pay for hairdressing, chiropody or newspapers. Records are kept with all receipts held on file and expenditure signed out by two members of staff as a safeguard for the residents. The manager has systems in place to ensure the home is run safely. Water temperatures are checked, fire safety equipment is tested and risk assessments are completed and reviewed. Cumbria Care carries out annual heath and safety checks and a report is forwarded to the manager outlining any work that needs to be completed. All equipment is serviced under annual contracts. The Abbey DS0000035540.V350012.R01.S.doc Version 5.2 Page 22 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 3 X 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 X 3 3 The Abbey DS0000035540.V350012.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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 The Abbey DS0000035540.V350012.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith Cumbria CA11 9BP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000035540.V350012.R01.S.doc Version 5.2 Page 25 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!