Inspection on 14/04/05 for The Abbey Retirement Home

This inspection was carried out on 14th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 Retirement Home 09/04/08

The Abbey Retirement Home 22/08/07

The Abbey Retirement Home 24/01/07

The Abbey Retirement Home 11/01/06

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 SO16 6TW Lead Inspector Chris Johnson Unannounced 14 April 2005 9:30 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 Retirement Home Version 1.10 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 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 C Northover and 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 Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: No resident in the category DE (E) to be admitted under the age of 55 years Date of last inspection 15/12/04 Brief Description of the Service: The Abbey Retirement Rest Home is a home that can accommodate up 15 elderly ladies and gentleman, 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 Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over 6 and half hours. The purpose of this visit was to carry out an inspection of the home and follow up on requirements made at the last inspection. A tour of the premises took place that included looking at service users’ bedrooms. Staff and care records were inspected. Five of the thirteen service users currently living at the home were spoken to. What the service does well: What has improved since the last inspection? What they could do better: Care planning must improve to ensure that staff are able to know how to meet all resident’s individual needs. To ensure that the home is safe all risks must be taken into account and more prompt action must be taken to minimise these. The manager must also make sure that she and her staff undertake regular checks to make sure that risks to residents are kept to a minimum. There is a good mix of skills within the staff team. Unfortunately this is not managed very well and results in less experienced staff working with minimum supervision. Time management is another area that is not well managed current demands on the manager mean that some issues relating to the safe running of the home are not given priority. The Abbey Retirement Home Version 1.10 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Abbey Retirement Home Version 1.10 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 Retirement Home Version 1.10 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) 2, Service users and or their representatives are made aware of their rights and of the terms and conditions, including the cost of living at the home. EVIDENCE: Service users had been issued with revised contracts detailing fee increases for the current financial year. The manager had complied with the previous requirement to issue each service users with a contract that specified the room that they would occupy and any breaches of conditions that could result in their residency being terminated. Service users sign to say they that they agree with these conditions wherever possible. Relatives or a representative of the service users sign and agree contracts where it would not be appropriate to ask the service user to do so. The Abbey Retirement Home Version 1.10 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9 and 10. Support with personal care needs is offered in such a way as to promote service users privacy, dignity and independence. However an improvement is needed in ensuring that all needs are fully assessed and addressed. EVIDENCE: Each service user has an individual plan of care. These provide detailed information, with clear and specific guidance as to the level of assistance that service users require with their personal care needs. The information recorded in the care plans addressed service user’s abilities with regard to personal care and would suggest that service users’ independence is promoted. In discussion with service users their description of their personal care needs matched with the details recorded in the care plans. Service users reported that they considered that their personal care needs were being met. Care plans did not however provide sufficient detail regarding service users’ mental health needs or how these were to be met. Although pre admission assessment documentation did refer to specific mental health needs such as depression, there was not any evidence that this was being addressed. Several of the care plans looked at had not been reviewed on a regular basis which presents a risk that changes in care needs may not be addressed. The Abbey Retirement Home Version 1.10 Page 10 No improvement had been made since the last inspection in assessing the risk to service users from falls and the use of bedsides. Service users told the inspector that they had access to a range of healthcare support as and when necessary and written documentation supported this. Service users also confirmed that they were happy with the way that their medication was managed. The manager had implemented changes since the last inspection to ensure that administration records were accurate. Systems are now in place to monitor staff to ensure that they deal with medication safely and appropriately and all staff had received further training. Advice will need to be taken however regarding the storage of medication in the kitchen to ensure that any fluctuations in temperature do not have an adverse effect on the medicines. Service users told the inspector that staff respected their privacy. This was supported by the guidance in care plans, the use of screens in shared rooms, door locks and observations during the inspection. The Abbey Retirement Home Version 1.10 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,and15. The meals in the home are good, offering both choice and variety. The current organisation of staff duties and breaks does not provide sufficient time for staff to be engaged with service users. EVIDENCE: Service users told the inspector that they were free to please themselves how they spent their day and that they did not have any restrictions placed upon them regarding what time they should get up or go to bed. The home does provide activities such as books from a mobile library and one service user helps with light domestic chores such as washing up. However the majority of service users were observed to spend a large proportion of the day without much to do other than watch television. Whilst it was unclear whether they wished for more activities and also the possibility that the inspection process had interfered with the daily routine there were times of the day that staff could have been engaged with service users such as during the staff meal break. All three members of staff took their lunch break together. Not only did this mean that service users were largely unsupervised during this period, they were not able to engage with staff in any meaningful activity. This is especially pertinent to service users with higher dependency needs such as those with dementia. The Abbey Retirement Home Version 1.10 Page 12 All service users spoken with confirmed that they were free to receive visitors and expressed their satisfaction with the food. Service users comments included, “ the food is very nice” and “ appetising”. The home uses mainly fresh produce. Menus were inspected and found to be varied and balanced. Alternatives to the main meal are always available and service users can choose from a range of different things for breakfast and evening meal. The Abbey Retirement Home Version 1.10 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 Satisfactory systems are in place for service users to address any concerns or complaints that they may have. EVIDENCE: There had not been any complaints made about the home since the last inspection. A complaints procedure is displayed within the home informing service users of their right to complain and how they can go about this. All service users spoken with said that they would tell a member of staff or the manager if they were unhappy with anything and that they were confident that it would be dealt with. The Abbey Retirement Home Version 1.10 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) 19,22,24,25, and 26. High standards of hygiene are maintained throughout the home and safety equipment is provided. However the home is slow to respond to some environmental risk factors. EVIDENCE: The home was clean and well kept throughout. Staff were observed to follow infection control procedures such as, using gloves and aprons. Service users remarked on the standard of cleanliness throughout the home. One commented, “ My room is done daily, hoovered and dusted, including Sundays. It is spotlessly clean”. Adequate adaptations and equipment are available to meet the needs of the current service users. These include a passenger lift to enable service users to access all floors; bath hoists to enable safe use of the bath and call bells were fitted in all bedrooms seen. Service users reported that staff responded to call bells promptly. The Abbey Retirement Home Version 1.10 Page 15 All bedrooms contained adequate furnishings and service users had been able to personalise them with their own belongings. There were however several issues outstanding from the previous inspection that had not been adequately addressed. The inspector was informed that a new washing machine had recently been fitted. Documentation was not available to demonstrate that this installation complied with water supply regulations that would prevent foul water from contaminating the mains. Nor was there a certificate to demonstrate that the home’s water system is checked for legionella. The inspector was informed that this was due to be done in the near future. A further point of concern was that safety issues highlighted during an environmental risk assessment of the premises in November 2004 had not been addressed this included the covering of a radiator in a downstairs toilet to minimise the risk of burns. The Abbey Retirement Home Version 1.10 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) 27,28 and 29. Staffing levels are maintained and care is delivered by a caring and responsive team. The home does not however utilise staff resources and skills in the best interests of service users. EVIDENCE: There had not been any changes to the staff complement since the last inspection and it was evident that staffing levels are being maintained. On the day of the inspection the staff team consisted of, the manager, the deputy manager, a senior carer and a cleaner/carer. Additional staff provide evening and nighttime cover and on-call arrangements are also in place to deal with emergencies. The manager, deputy and most senior carers work alongside each other on a daily basis. This would not seem the best use of staff skills and resources as this means that during other periods in the day the home is staffed by less senior and experienced staff with limited supervision. Currently the preparation and cooking of the main meal is shared between the manager and deputy, with each taking responsibility on alternate days. It was reported that this takes an average of 4 hours a day. Again this would seem a task that would be better undertaken by a cook to allow for staff time to be spent engaged with service users. All service users spoken with reported that staff were helpful, obliging, responsive to their needs, and friendly. The inspector observed this to be the case. Staff training remains ongoing with the majority of staff enrolled in NVQ level 2 courses and both the manager and the deputy undertaking level 4 in The Abbey Retirement Home Version 1.10 Page 17 management. Additional training such as moving and handling has also taken place. Although there had not been any additional staff employed since the last inspection, the manager had ensured that she was familiar with the up to date legislation regarding pre employment checks that must be carried out to safeguard service users. The Abbey Retirement Home Version 1.10 Page 18 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) 31,32 and 38. The manager is accessible and sensitive to the needs of service users. The current demands on the manager’s time do not however enable the manager to ensure that all issues relating to the safe running of the home are fully addressed. EVIDENCE: The manager has worked at the home for several years and demonstrated a caring and sensitive approach to the needs of the service users. Service users told the inspector that they felt confident in the manager. It was evident that she was accessible to deal with any issues that may arise and adopted a ‘hands on approach’. The manager had taken action to address several of the requirements made at the last inspection. However some remain outstanding. From discussion with the manager it would appear that more time is needed to focus on management responsibilities and ensuring compliance with all requirements. The home appeared to be safe and from inspection of the fire log book regular and thorough testing of the homes fire detection equipment had taken place. The Abbey Retirement Home Version 1.10 Page 19 Staff are trained regularly in evacuation procedures and general health and safety issues. It was found that one radiator in a downstairs toilet remained uncovered. This does present a risk to service users and will need to be addressed. The Abbey Retirement Home Version 1.10 Page 20 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 2 x x 3 x 3 2 3 STAFFING Standard No Score 27 2 28 3 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 2 3 2 x x x x x The Abbey Retirement Home Version 1.10 Page 21 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. Standard 7 Regulation 13 (4) Requirement The Registered Manager must ensure risk assessments include:Risk of falls and the Use of bedsides.(Previous timescale of 28/2/05 not met) Care plans must address mental health needs and be reviewed regularly. You must consult the pharmacist regarding the suitability of the current location of the medication cabinet and take action accordingly. Staff breaks must be staggered and structured to meet the needs of service users. An action plan must be submitted detailing the plans to address the outstanding issues identified in the environmental risk assessment. The Registered Manager must provide certificated evidence that the home’s washing machine has been installed under the 1999 Water Regulations. The radiator in the downstairs toilet must be covered. The rota must be reviewed to enable the manager to fulfill her management role and Version 1.10 Timescale for action 15/5/05 2. 3. 7 9 13 (4) 13 (3) 15/5/05 15/5/05 4. 5. 12 & 27 19 & 38 18 13 (4) 15/6/05 15/5/05 6. 25 13(4)(c) 15/5/05 7. 8. 25 & 38 27 & 31 13(4)(c) 15/5/05 15/6/05 The Abbey Retirement Home Page 22 responsibilities. 9. 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 Retirement Home Version 1.10 Page 23 Commission for Social Care Inspection 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 Version 1.10 Page 24 - 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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