Inspection on 11/01/06 for The Abbey Retirement Home

This inspection was carried out on 11th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Abbey Retirement Home 09/04/08

The Abbey Retirement Home 22/08/07

The Abbey Retirement Home 24/01/07

The Abbey Retirement Home 14/04/05

The Abbey Retirement Home 15/12/04

The Abbey Retirement Home 25/05/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE The Abbey Retirement Home 348 Winchester Road Southampton Hampshire SO16 6TW Lead Inspector Chris Johnson Unannounced Inspection 11th January 2006 10:50 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 Retirement Home DS0000011849.V252091.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 Retirement Home DS0000011849.V252091.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Abbey Retirement Home Address 348 Winchester Road Southampton Hampshire SO16 6TW 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) 023 8070 2671 Mr Roy Clive Northover Mrs Heather Northover Mrs Jackalyn Bennett Care Home 15 Category(ies) of Dementia - over 65 years of age (15), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (15), Old age, not falling within any other category (15) The Abbey Retirement Home DS0000011849.V252091.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. No residents in the category DE (E) to be admitted under the age of 55 years 14th April 2005 Date of last inspection Brief Description of the Service: The Abbey Retirement Rest Home is a home that can accommodate up 15 older persons, some with associated dementia. Mr & Mrs Northover who are the registered persons for two other rest homes in the Southampton and Eastleigh Locality own the Abbey Retirement Rest Home. The home is situated in an affluent area of Southampton, near to the Common, popular sports centre and close to both Southampton Town Centre and Shirley High Street. There is a small parade of local shops that cater for most emergency supplies. The home is also closely situated near to the Southampton General Hospital and is on a main bus route from Shirley and Southampton allowing easy access into work for staff. The Abbey Retirement Rest Home is in keeping with neighbouring homes it is well maintained inside and has an attractive enclosed garden that attracts the sun all day in the spring and summer months. The Abbey Retirement Home DS0000011849.V252091.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second inspection carried out for the year April 2005/06. This inspection was unannounced and took place on 11th January 2006. The purpose of this visit was to carry out an inspection of the home and follow up on requirements made at the last inspection. Verbal and written feedback was given to the manager at the end of the inspection. Both reports should be read for an overview of how the home is meeting the standards. 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 The Abbey Retirement Home DS0000011849.V252091.R01.S.doc Version 5.1 Page 6 contacting your local CSCI office. The Abbey Retirement Home DS0000011849.V252091.R01.S.doc Version 5.1 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 Retirement Home DS0000011849.V252091.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,5 and 6 Improvements are needed in the assessment process to reduce the danger of someone moving into the home whose needs cannot be met. Trial periods are well managed and residents are well supported during this initial period. EVIDENCE: The Abbey Retirement Home does not provide intermediate care. The files of two residents admitted to the home since the last inspection were inspected. While there was evidence that assessments had been completed to determine whether the home could meet a persons needs, dates on one of the assessments would suggest that it was done the day that the person had moved in and for the other resident the assessment was undated. The manager said that usual practice was to invite the prospective resident into the home for a visit and assess them. This had not happened on these occasions. Improvements therefore need to be made to reduce the danger of someone moving into the home whose needs cannot be met. Care management assessments should also be obtained for any resident fully or partially funded. Residents are however given a sufficient trial period enabling the home and the resident to determine whether the placement is appropriate to their needs. Support during this period is good and all relevant professionals are consulted. The Abbey Retirement Home DS0000011849.V252091.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): 7,9 and 10 The standard of care plans has improved, providing better guidance and detail regarding residents’ needs. More regular reviews need to take place to ensure that care needs are not overlooked. EVIDENCE: Improvements had been made to the content of residents’ care plans since the last inspection. Additional information had been included as agreed at the last inspection. Details regarding residents mental health support needs and those associated with dementia had been assessed and included. Care plans now provide sufficient detail and guidance to enable staff to recognise and support residents with their mental health needs. Staff confirmed that they had full access to care plans and that they were kept informed of any changes to residents support needs. Evidence recorded in care plans would suggest that residents’ independence and privacy continue to be promoted. Discussions with staff and residents would further support this. None of the care plans looked at had been reviewed since September 2005. Whilst the manager said that some peoples support needs had not changed this was not the case for all. This presents a risk that changes in care needs may not be addressed. The Abbey Retirement Home DS0000011849.V252091.R01.S.doc Version 5.1 Page 10 Medication continues to be well managed and all medication had been removed from the kitchen since the last inspection on the advice of the pharmacist. The Abbey Retirement Home DS0000011849.V252091.R01.S.doc Version 5.1 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 the following standard(s): 12 and 14 Residents have the opportunity to engage in different activities, and make their own decisions about how they spend their time. EVIDENCE: Since the last inspection the manager had implemented changes to ensure that staff breaks were staggered. This means that residents are no longer left unsupported during meal breaks. Residents spoken with said that they were happy with the level of activities and did not feel restricted in any way and were able to make their own choices. An outside entertainer visits the home weekly and residents have the opportunity to attend communion at the home and churches within the area. Staff were observed to spend time talking with residents on a one to one basis. Residents have access to advocacy services should they require it. The Abbey Retirement Home DS0000011849.V252091.R01.S.doc Version 5.1 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Residents feel safe and adequate procedures are in place to protect them from harm. EVIDENCE: Since the last inspection one member of staff had been referred to the Protection of Vulnerable Adults list and was no longer working at the home. Since this incident all staff have received further training in adult protection procedures and the manager has introduced several new procedures to safeguard residents. Residents reported that they felt safe and well cared for and staff demonstrated that they were aware of in house policies and procedures. A copy of the Local Authority’s adult protection procedure was held in the home. Staff did not however have direct access to this document. It was agreed that this would be rectified. The Abbey Retirement Home DS0000011849.V252091.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,25 and 26 High standards of hygiene are maintained throughout the home. Improvements have been made to provide a safer environment. EVIDENCE: All requirements from the previous inspection regarding the physical environment had been acted upon within the agreed timescale. A cover had now been fitted to the radiator identified at the last inspection as posing a risk to residents’ safety. High standards of hygiene continue to be maintained and this was commented upon by residents. The home was clean and well kept throughout. It was evident that the manager and staff take pride in maintaining the cleanliness of the home. Staff were observed to follow infection control procedures such as, using gloves and aprons and these were in adequate supply. The Abbey Retirement Home DS0000011849.V252091.R01.S.doc Version 5.1 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29 and 30 Residents are provided with a consistent and reliable service. The staff team are caring and reliable. Staffing levels are maintained and the home has a good level of staff retention. Recruitment procedures need to be more robust to ensure that service users are not potentially put at risk. EVIDENCE: There had only been one new addition to the staff complement since the last inspection. The home benefits from having a high level of staff retention. Several members of staff have worked at the home for a considerable time. This proves beneficial to residents as they retain the same care workers and therefore receive a consistent and reliable service. Changes had been made to the staff rota since the last inspection with a senior member of staff now on duty at all times. This is an improvement and is a better use of resources and provides residents with access to a senior carer at all times. It was evident that staffing levels continue to be maintained and are sufficient to meet the needs of current residents. The recruitment records for a member of staff recruited since the last inspection were checked and found to be lacking in respect of references. The manager was advised to keep a record of any verbal references obtained and to refer to the latest guidance regarding recruitment checks. Staff training remains ongoing this includes NVQ’s, internal training and training delivered by outside organisations. The Abbey Retirement Home DS0000011849.V252091.R01.S.doc Version 5.1 Page 15 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): 31,35 and 38 The manager is accessible and sensitive to the needs of service users. The home is well managed and health and safety is promoted. EVIDENCE: The manager has worked at the home for several years and demonstrated a caring and sensitive approach to the needs of the residents. The manager is open and staff and residents reported that she was approachable and accessible. This is aided by, her working alongside staff and supporting residents with their needs. A requirement had been made at the last inspection that the rota be reviewed in order that the manager could fulfil all of her management responsibilities. In discussion the manager stated that this had been considered and the conclusion was that herself and the deputy should continue to work alongside each other as this proved to be the most efficient way of working. Amendments had been made to the rota to ensure that a senior member of The Abbey Retirement Home DS0000011849.V252091.R01.S.doc Version 5.1 Page 16 staff is on duty at all times and all requirements from the previous inspection had been met within agreed timescales. It has however been recommended that the manager has access to information technology such as the internet to ensure that she is able to keep abreast of changes in legislation and to be able to access guidance and information regarding recruitment practices etc. Requirements from the previous inspection had been met within agreed timescales. The home does manage and look after several residents’ money. This was found to be stored safely. Checks were made of several balances and all were correct and had been properly recorded. The inspector did advise that the manager obtained receipt books to provide a clearer audit trail. The home appeared to be safe and infection control procedures are in place and observed. Certificates were available to demonstrate that equipment and aids used in the home are regularly serviced and tested. The Abbey Retirement Home DS0000011849.V252091.R01.S.doc Version 5.1 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 3 X X X X X 3 3 STAFFING Standard No Score 27 3 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X 3 The Abbey Retirement Home DS0000011849.V252091.R01.S.doc Version 5.1 Page 18 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. 1 Standard OP3 Regulation 14 (1) Requirement The manager must ensure that assessments are completed prior to service users moving into the home. Records must be maintained and kept at the home. Care plans must be reviewed on a regularly and encompass any changes in care needs. Staff must not commence work at the home until all satisfactory checks have been made in line with the regulations. Timescale for action 11/02/06 3 4 OP7 OP29 13 (4) 19 (1) (b) 01/03/06 01/02/06 The Abbey Retirement Home DS0000011849.V252091.R01.S.doc Version 5.1 Page 19 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 OP3 OP31 Good Practice Recommendations It is advised that care management assessments are obtained for any prospective resident whom is either fully or partially funded. It is advised that the manager has direct access to information technology. To ensure that she can keep up to date with changes in legislation. The Abbey Retirement Home DS0000011849.V252091.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Retirement Home DS0000011849.V252091.R01.S.doc Version 5.1 Page 21 - 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!