Inspection on 08/03/06 for The Abbey

This inspection was carried out on 8th March 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

The Abbey 06/11/07

The Abbey 03/10/06

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 Jane Strawbridge Unannounced Inspection 1:00 8 March 2006 th 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.V271309.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Abbey DS0000035540.V271309.R01.S.doc Version 5.1 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 (30) of places The Abbey DS0000035540.V271309.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. The service must at all times employ a suitably qualified and experienced manager who is registered with the National Care Standards Commission. A maximum of thirty older people (OP30) may be accommodated, ten of whom may have dementia (DE(E)10). The matters detailed in the attached schedule of requirements must be completed in the specified timescales. The staffing levels in the home must meet the Residential Forum Care Staffing Formula for Older Adults by 1st April 2004. 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. 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 18th May 2005 6. 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 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 regarded as part of the local community. The Abbey DS0000035540.V271309.R01.S.doc Version 5.1 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 during one afternoon. Time was spent talking with the service users either in small groups or individually, and with the supervisors and staff on duty. Records to do with the care of the service users 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? 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 DS0000035540.V271309.R01.S.doc Version 5.1 Page 6 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.V271309.R01.S.doc Version 5.1 Page 7 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): 1, 2, 4, 5, 6 This home has procedures in place to enable potential service users and their families make important decisions about their future. On the intermediate care unit staff continue to work successfully with people after a stay in hospital. EVIDENCE: The information seen in the service users’ handbook during this inspection gives potential service users a reasonably clear idea of what to expect when they visit. However there were a few omissions and some work is necessary to bring the insert sheets up to date. For example it would be good practice for the handbook to be made more relevant to this particular home rather than giving out the generalised statements that relate to Cumbria Care. The manager or a supervisor usually visits the potential service user at home or in hospital to see if the home will be able to meet their needs. Admissions are usually planned so that potential service users have an opportunity to visit prior to moving in, which means that they can see for themselves what services are available. More often nowadays, people will have some knowledge of the home having attended the intermediate care unit or as a short term resident. New service users are offered a trial period, usually for The Abbey DS0000035540.V271309.R01.S.doc Version 5.1 Page 8 six weeks, so that they can use their experience to help them to make an informed decision about taking up permanent residence. A review is held at the end of the trial period and then service users sign a contract which includes the terms and conditions of residency. Since the last inspection the staff on the intermediate care unit have continued to work with up to four service users at any one time, who have been admitted straight from hospital. The dedicated staff team work in partnership with professional therapists to build up the service users’ confidence in preparation for going home. The Abbey DS0000035540.V271309.R01.S.doc Version 5.1 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): 11 Practices within this home mean that service users and their representatives are confident that their wishes will be respected. EVIDENCE: This home has detailed personal files that contained a wide range of information about health and personal care needs, daily routines and preferences, to enable staff working in the home to provide a consistently high level of service. Service users were encouraged to talk about their expectations and wishes after their death and these were on record. Staff had been given training on how to work sensitively with people who were in the final stages of their life and to provide support for relatives. The home’s staff members have developed an excellent relationship with local doctors, district nurses and the families of the service users in their care. One member of staff said, “They know that we’ll do our very best.” The manager and her staff listened to professional advice and would care for someone for as long as they were able to do so without compromising their health and comfort. There had been previous cases when additional night staff had been deployed to ensure that extra attention had been available to overcome a crisis. The Abbey DS0000035540.V271309.R01.S.doc Version 5.1 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): 12 An activities programme has been developed that provides a range of interesting and stimulating social activities. EVIDENCE: Members of staff in this home have developed a working partnership with a local organisation that provides horticultural work for people with learning difficulties. Together they were in the process of developing a sensory garden with pathways for wheelchair users to have easy access. The service users had been involved in the design stages and raised beds will mean that they will be able to enjoy the garden and spend time working in the open air. A member of staff had been delegated responsibilities for organising activities and she has arranged for a volunteer to come into the home twice each week to organise activities for everyone’s benefit. Service users are encouraged to go out as much as possible and to spend time with their families and friends. The Abbey DS0000035540.V271309.R01.S.doc Version 5.1 Page 11 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 The home has a satisfactory complaints procedure that protects the rights of service users to have their views taken seriously. EVIDENCE: Information about the complaints procedure was in the service user guide. People said that they were satisfied with the quality of the care they were given and had not found it necessary to complain. However if the situation changed they knew what to do and who to contact. The Abbey DS0000035540.V271309.R01.S.doc Version 5.1 Page 12 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): 26 The housekeeping in this home is generally of a high standard. However there are two specific areas that compromise the comfort of the service users. EVIDENCE: All communal areas and the majority of bedrooms had been maintained well to protect the health and wellbeing of the service users and to ensure their comfort. The housekeeping was good in most of the areas of the home and it was pleasant, clean and tidy. However there were two areas on different wings that had strong urine smells that were deeply unpleasant. The affected areas were two bedrooms and the corridors in their immediate vicinity. Staff explained that there were different medical reasons for the problem and that extensive cleaning had been done that day but had not been effective. It is recommended that the manager should take urgent action to attend to this matter so that service users, staff and visitors are not subjected to this unpleasantness. The Abbey DS0000035540.V271309.R01.S.doc Version 5.1 Page 13 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): 28, 30 This home has competent and trained staff on duty at all times. EVIDENCE: Staff members in this home are fully aware of the types of abuse that may occur against vulnerable people and how to recognise the signs. They have been given training in adult protection and are familiar with the home’s whistle blowing procedures. They said they would report colleagues if they observed any inappropriate practice. The supervisors said, “We have confident staff and we have every confidence in them.” Any concerns raised by staff were acted upon immediately and these would be followed up during individual supervision sessions and team meetings. Care staff had also been involved in training courses covering the management of challenging behaviour, dementia and principles of care. The supervisors also said that they thought they “had a good working team.” The Abbey DS0000035540.V271309.R01.S.doc Version 5.1 Page 14 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): 32, 34, 35, 36, 37, 38 The registered manager provides adequate direction, guidance and leadership for the staff so that residents are given consistent quality care. There are procedures and practices in place to protect the rights of the residents and to ensure the health and safety and wellbeing of the residents, staff and visitors. EVIDENCE: The registered manager has the necessary qualifications and experience in residential care to enable her to manage the home effectively. There was evidence that the home was run in an open, positive and inclusive manner. The supervisors said the manager is “approachable, a good leader and they had every confidence in her integrity and management style.” The manager was responsible for the monitoring and management of the home’s budget and the accounts were kept centrally. A new procurement card system for purchasing certain goods has recently been introduced to make the process The Abbey DS0000035540.V271309.R01.S.doc Version 5.1 Page 15 easier to manage and cut down on paperwork. The records of service users’ personal property and personal monies were subject to scrutiny and up to £50 for each individual were kept in the safe on their behalf if they so wished. Progress had been made to ensure that all staff had been given the appropriate levels of supervision to meet the National Minimum Standards. All records relating to the health and safety of people who live and work in the home, including the fire log had been completed correctly. Recently the fire safety procedures had been tested successfully, when an unexpected fire drill had been necessary, giving all staff on duty the invaluable experience of working with the attending fire crew. The Abbey DS0000035540.V271309.R01.S.doc Version 5.1 Page 16 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 2 3 X 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X X X X X X X X 2 STAFFING Standard No Score 27 X 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 X 3 3 3 3 3 The Abbey DS0000035540.V271309.R01.S.doc Version 5.1 Page 17 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. 1 2 Refer to Standard OP1OP1 OP26OP26 Good Practice Recommendations Work should be completed to bring the information for potential service users up to date and more specific to this home. Work should be completed to eradicate the urine smells in the two bedrooms and adjoining areas of the corridors. A continence management programme should be developed to manage the situation. The Abbey DS0000035540.V271309.R01.S.doc Version 5.1 Page 18 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 DS0000035540.V271309.R01.S.doc Version 5.1 Page 19 - 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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