Inspection on 09/04/08 for The Abbey Retirement Home

This inspection was carried out on 9th April 2008.

CSCI found this care home to be providing an Adequate service.

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 22/08/07

The Abbey Retirement Home 24/01/07

The Abbey Retirement Home 11/01/06

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 Neil Kingman Unannounced Inspection 9 April 2008 09:55 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.V361000.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 Retirement Home DS0000011849.V361000.R01.S.doc Version 5.2 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 Natasha Jane Ball 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.V361000.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. A maximum of 3 service users in the categories DE and MD may be accommodated between the age of 55-64 years at any one time 22nd August 2007 Date of last inspection Brief Description of the Service: The Abbey Retirement Home is a registered care home providing care and accommodation for up 15 older people. It provides a service for people with mental frailty and illness associated with dementia. Natasha Ball manages the home on behalf of the proprietors Roy and Heather Northover who are also responsible for other similar services in the area. The home is situated in a residential area, on public transport routes to both Southampton Town Centre and Shirley High Street, and within about three hundred yards of a small parade of local shops. The accommodation, comprising both single and shared rooms is arranged over two floors with a passenger lift affording access to rooms on the first floor. All parts of the home and garden are accessible to residents including those who use a wheelchair. There is a car park at the rear with spaces for about four vehicles. At the time of the inspection fees ranged between £385 and £415 per week. The Abbey Retirement Home DS0000011849.V361000.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report details the results of an evaluation of the quality of the service provided by The Abbey Retirement Home and brings together accumulated evidence of activity in the home since it was last inspected on 22 August 2007. Included in this inspection was an unannounced site visit to the home by an inspector on 9 April 2008. The registered manager Natasha Ball was available throughout the day. At the visit we had an opportunity to speak with the staff on duty and several visiting relatives. Due to the needs of the residents it was only possible to fully engage with only a minority of individuals. We also toured the building and looked at a selection of records. Prior to the site visit the manager sent to the Commission a detailed selection of information about the service including an Annual Quality Assurance Assessment (referred to as ‘the assessment’ during the report), which has been used with other information to inform the various judgements made about the service. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. What the service does well: The home provides a comfortable, clean and safe environment for the people who live there. The rooms are spacious, well decorated and furnished and people enjoy occupying them. The interactions between the staff and the residents are warm and friendly and staff pay a good deal of attention to respecting peoples’ dignity and privacy. The home accommodates a person with an ethnic background and arrangements have been made for staff to learn basic communication skills to better understand the person’s needs and wants. Picture cards and gestures have been introduced. Overall the home has substantial strengths. Where areas for improvement are identified the service recognizes and manages them well. The management and staff are committed to promoting dignity. The Abbey Retirement Home DS0000011849.V361000.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 Retirement Home DS0000011849.V361000.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 Retirement Home DS0000011849.V361000.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): 3 and 6 - People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. The home does not provide dedicated accommodation for short-term intermediate care or specialised facilities for rehabilitation. EVIDENCE: Pre-admission assessment People should know that their needs will be met when they move into a home. An important part of ensuring this happens is the pre-admission assessment process. The Abbey Retirement Home DS0000011849.V361000.R01.S.doc Version 5.2 Page 9 The manager described the home’s admissions process in general, and specifically in relation to the newest person to be admitted: • Typically the manager and her deputy or senior carer would visit the person who may want to use the service either at their home address or hospital where applicable. An assessment of care needs would take place at that point. The home always prefers the individual and/or their representative to come in for a pre-admission visit wherever possible. The most recently admitted person moved in from another care home just two weeks before our visit and, according to the manager was an emergency situation, which meant that she was unable to carry out as full an assessment beforehand as she would have liked. The individual’s guardian was already familiar with The Abbey so the manager was able to gather information from this person. A full assessment of needs was carried out in the first forty-eight hours after admission. The information was then used to draw up a care plan. The manager showed a good understanding of the importance of a thorough pre-admission assessment in the process of choosing the right home. • • • A copy of the initial admission assessment was available on this person’s file and assessments were also noted on other care files looked at during our visit. Intermediate care People who live at The Abbey Retirement Home tend to be long term. The home does not provide dedicated accommodation for short-term intermediate care or specialised facilities for rehabilitation. However, respite care is provided if there is a room available. Provider’s Annual Quality Assurance Assessment The assessment identified what the service does in this area: • • • • • Have good communication with potential service users and their representatives. Provide the information that they will need to make an informed choice about where they would like to live. Each potential service user has an initial assessment to ensure that their needs can be met. Service users have a written contract with terms and conditions. Enable service users to have a visit to the home for the afternoon to assess the service we provide. DS0000011849.V361000.R01.S.doc Version 5.2 Page 10 The Abbey Retirement Home • • Have improved the assessment process both prior and after admission. Added the service users guide into both audio and large print. The Abbey Retirement Home DS0000011849.V361000.R01.S.doc Version 5.2 Page 11 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 and 10 - People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: Care planning – The home has a system of care planning with an individual personal plan for each resident. We looked at a sample of three plans. The intention was to look at the outcomes for people who use the service in general by assessing all areas of care for those sampled. The sample included a female resident with an ethnic background; a person who had been at the home for about two years and was able to fully engage with us, and the newest admission to the home. The Abbey Retirement Home DS0000011849.V361000.R01.S.doc Version 5.2 Page 12 Plans provide information about how peoples’ needs are to be met and have good references to staff respecting their dignity and privacy. They identify their abilities and problems and set out the aims of the care and the method. However it was noted that information was limited, even though the computerised system enables areas to be expanded. Some areas of the plans were not person centred as very similar descriptions were used on all three plans viewed. We had a discussion with the manager who recognised that plans could be improved by taking a person centred approach to all areas so that they became personal to the individual concerned. On the positive side it was noted that the sampled plan for one person had a separate communication care plan with picture cards, drawn up by a speech therapist. The manager said that they had involved the person’s family to aid with translation. The plan drawn up for the person newly admitted to the home had their preferences clearly recorded, e.g., the times they liked to rise and go to bed, what they liked to do throughout the day etc. However, this information was lacking on one of the other plans viewed. Risk assessments were noted in the sample plans with headings; ‘risks’, ‘actions taken’ and ‘to be reviewed’. As covered later in the report risk assessments are not consistently developed for all people with identified risks. Health and access to care services The manager confirmed, and records evidenced the regular contact with GPs, optician, dentist, chiropodist and mental health specialists. Records showed and discussions with the manager and care staff confirmed that the risk of pressure sores was currently low. The manager made the point that staff are always vigilant and at the first sign of a red mark staff bring it to her attention and the Community Nurse is contacted. Staff spoken with were very clear about what was required to ensure that pressure sores did not develop, i.e., suitable equipment, good liaison with the Community Nurse and care practices. The manager said, that people are able to continue with their GP and dentist of choice if they happen to be local. However, with four GP practices in the area there is no problem with lack of choice. There is a choice of two dentists who will pay a visit to the home to see people. Other healthcare professionals including the more specialist ones e.g., Community Psychiatric Team are called upon as and when required. The Abbey Retirement Home DS0000011849.V361000.R01.S.doc Version 5.2 Page 13 Medication Medication is given to the residents by means of a cartridge system, known as the Nomad system, which has separate compartments for regular times throughout the week. This hygienic method is designed to simplify the procedure for giving out medication. The manager said only staff who have completed the safe handling of medication training and are competent are permitted to give out medication. The home has a policy and system to ensure residents’ medication is stored, administered and recorded safely. During the site visit we looked at the arrangements in place and noted medicines were stored under secure conditions in a locked cabinet, and accurate records of receipt, administration and disposal of medicines were maintained. Privacy, dignity and respect The importance of treating people who use the service with dignity and respect is covered in the induction training for new staff. Also, it was an important feature of all care plans viewed. On the day of the site visit we toured the building and spent time with residents in the communal areas. There were opportunities to observe staff at work. Staff spoke kindly to people and showed patience with them. We saw staff deal sympathetically and professionally with one person whose actions were quite challenging. There were many signs of well being amongst the residents in the lounge, especially the newest person to be admitted, who according to the manager had settled well in such a short time. During the afternoon we had an opportunity to speak with staff who showed a good understanding of how individuals needed to be treated. Staff address people by the names that they prefer and knock on doors and wait for an answer before entering rooms. All residents have locks on their room doors and while they can come and go as they please, in reality staff are attentive and provide support where needed. Residents can use the facility of the home’s portable telephone to make and receive calls, in private if they wish. The home will arrange for private installations in bedrooms on request. The Abbey Retirement Home DS0000011849.V361000.R01.S.doc Version 5.2 Page 14 Provider’s Annual Quality Assurance Assessment The assessment identified what the service does in this area: • • • • • • • Set out a service user’s health, personal and social care needs in an individual plan of care. Ensure that the service user’s health care needs are met. Service users are protected by the homes policies and procedures for the dealing with medicines. Ensure that service users are treated with respect and their right to privicy is upheld. Assure our service users that at the time of their death, staff will treat them and their families with care, sensitivity and respect. Computerised care plans and expanded the areas that they cover. Gone through more regularly with the staff the core values. The Abbey Retirement Home DS0000011849.V361000.R01.S.doc Version 5.2 Page 15 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 and 15 - People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are able to make choices about their lifestyle and activities are offered to suit their individual needs and expectations. Friends and family are made to feel welcome and can visit at any time. Residents’ nutritional needs are satisfied with a varied and balanced diet of good quality food. EVIDENCE: Routines and activities – The home’s assessment shows and the manager confirmed that residents are encouraged and supported to exercise choice and control in their lives according to their abilities. Routines for residents are kept as flexible as possible, e.g., they have choice over where and when they have their food served, what time they like to be woken and the time they like to retire, where and when they like their breakfast served etc. This was confirmed in discussions with those who were able to give informed views. The Abbey Retirement Home DS0000011849.V361000.R01.S.doc Version 5.2 Page 16 The home has a weekly programme of in-house activities, such as games, videos, music and visiting entertainers. Some residents regularly go out with their families and the manager said that staff take individuals out to the shops or the common on a one-to-one basis. Apart from the activities detailed above the home will arrange regular visits from local clergy who conduct services in the home. However, staff confirmed that currently none of the residents currently have an identified wish for religious observance. The person from an ethnic background has family close by who in liaison with the home cater for their needs in that respect. Visiting arrangements – Details of visiting arrangements can be found in the service user’s guide and on display in the hall. Visits are generally unrestricted but the home asks people to avoid mealtimes wherever possible. Family and friends are encouraged to visit and this was very much in evidence on the day of our visit with opportunities to speak with families in the lounge. People can receive visitors in their own rooms or either of the two communal areas. All visitors spoken with said they were always made welcome by staff. Personal autonomy and choice – Residents were spoken with individually in the lounge and in a group. Those who were able to express views said they were given choices regarding routines in the home, e.g., times of rising, going to bed, activities, meals, personal care, going out etc. The families we spoke with supported this view. The manager confirmed that all residents have someone independent of the home to support them. Family are able to assist people with their financial affairs and several residents are able to control their own monies. However, the manager said that since the last inspection she had made information about the advocacy service available to the residents and their representatives. People are encouraged to bring with them pictures, ornaments and personal items for their room. During the tour of the building it was noted that most rooms were very well personalised, according to peoples’ individual tastes and preferences. The manager said that some individuals had brought canaries or budgerigars with them and this had been most acceptable. The management of residents’ finances is covered later in the report but in a general sense they are encouraged, with support from family or a representative, to handle their own financial affairs for as long as they are able. The Abbey Retirement Home DS0000011849.V361000.R01.S.doc Version 5.2 Page 17 Meals and mealtimes – Menus are arranged on a two-week rota and those seen showed that food is generally varied, nutritious and appealing. The home uses a mix of frozen and fresh vegetables. Staff take turns to cook the meals as well as the domestic and care work, as part of their overall duties in the home. This was explored in our discussions with staff. They were very clear that in what was a relatively small-scale environment they were able to cope well with the arrangements as they worked well as a team. Staff said they had a good knowledge through experience of peoples’ likes and dislikes as nearly all had worked in the home for some years. In discussions they said they were able cater for special diets. They described two individuals as examples of how they managed their diabetic needs. In discussions about the variety of food on offer staff said that while they produce a main meal of the day at lunchtime it was based on what they knew residents enjoyed. Alternatives to the main meal were always available. Residents were able to have exactly what they wanted at teatime, either a hot or cold meal. At lunchtime we noted that nearly all the residents ate together in the dining room. The atmosphere was relaxed and unhurried. Staff were available to assist at all times. Choice was very evident, a good example being one individual who likes their lunch at varied times. The kitchen has been refurbished since the last inspection to create a modern, clean and pleasant place to work. Provider’s Annual Quality Assurance Assessment The assessment identified what the service does in this area: • • • • • • Making sure that service users find the lifestyle experienced in the home matches their expectations and preferences. Helping service users to maintain contact with families, friends, representatives and the local community as they wish. That service users receive a wholesome, appealing, balanced diet in pleasing surroundings at a time conveinient to them. Help service users to exercise choice and control over their lives. Easier to enable service users to acess their friends in the outside community. Accessing better information to help a service user make informed choices. The Abbey Retirement Home DS0000011849.V361000.R01.S.doc Version 5.2 Page 18 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 and 18 - People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home treats residents’ complaints seriously and responds appropriately. While the home’s policies, procedures and practices ensure that residents are safeguarded from abuse the home would benefit from some structured Safeguarding training for staff. Procedures for responding to suspicion or evidence of abuse are robust. EVIDENCE: Complaints – The home has a complaints policy and procedure, summarised in the service user’s guide, which is given to all residents or their representatives. The procedure for making a complaint is also prominently displayed in the hall and includes contact details for the Commission for Social Care Inspection. Information provided by the home prior to the inspection shows that there have been no complaints since the last inspection. The manager was very clear that in the event of a complaint being made a record would be kept to include details of any outcome. People spoken with on the day of the site visit were not familiar with the detail of the complaints procedure, but were very confident about raising any concerns with the manager. The Abbey Retirement Home DS0000011849.V361000.R01.S.doc Version 5.2 Page 19 Safeguarding adults – The home has an Adult Protection policy and procedure in place, which follows local authority guidance. In discussions with the manager and the staff we understood that no formal training is provided for staff in safeguarding adults from abuse. Instead the manager goes through the home’s policy and procedure with them. It is essential with such an important subject that staff training is formalised. However, in terms of outcomes for the people who use the service there had been no safeguarding referrals in the home and staff were very clear about their responsibilities to report any issues of concern without delay. They also were aware of the home’s “whistle-blowing” procedures. It must also be said that adult protection is a subject covered in the National Vocational Qualification (NVQ) training programme, which most staff have completed. Provider’s Annual Quality Assurance Assessment The assessment identified what the service does in this area: • • • • • • That service users and thier 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. Comments box for issues now at the enterance of the home. Advocate service information given to all service users. Complaints procedure included in the service users guide. The Abbey Retirement Home DS0000011849.V361000.R01.S.doc Version 5.2 Page 20 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 and 26 - People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The physical design and layout of the home enables residents to live in a safe, well-maintained and comfortable environment, which encourages independence. All areas of the home are kept clean, hygienic and there are no unpleasant odours EVIDENCE: Environment The Abbey Retirement Home has been a residential care home for older people in Southampton for many years and while not purpose built has been developed and adapted over the years to be suitable for its stated purpose of providing a safe, manageable and comfortable environment for the people who live there. The home is located in Winchester Road, near to the junction with Hill Lane and a small parade of shops. All areas of the building are accessible to the people who use the service, including the rear garden, which is mainly laid to lawn with flowerbeds and The Abbey Retirement Home DS0000011849.V361000.R01.S.doc Version 5.2 Page 21 shrubs. There is a large patio area where residents can sit when the weather is fine. The home is generally comfortable, well furnished and decorated. Communal areas are bright and airy. Good signage is used throughout the home to help those who are confused to find their way around. During the visit we toured the building with the manager. While the home provides a higher percentage of shared room accommodation than single it has done so since before 2002 when the National Minimum Standards were introduced. We had an opportunity to speak with some of the residents about their experience of sharing a room. There were no negative views given. Two seated together in the lounge said they were best friends and would not want it any other way. One visiting family said they had visited several other homes in the locality and knew The Abbey was the right place for their relative as soon as they came in to view. People commented on the homely and friendly feel to the environment. There was evidence of continued improvements with ongoing redecoration. Almost all the bedrooms have now been redecorated and new carpets have been ordered for the hallways and stairs. The home’s assessment confirms that plans to update the lounge are in place for the coming year. People who live in the home have rooms on the ground and first floors. There is a passenger lift, which affords access to all rooms on the first floor. Assisted bathing and toilet facilities on both levels are adequate for the needs of people who use the service. We noted they are well equipped and clean and have plants and pictures, which give them a homely, domestic feel. Cleanliness All areas of the home were found to be very clean and free from unpleasant odours. As already mentioned all staff are involved with domestic duties and they ensure the standard of hygiene is maintained. There is a laundry sited on the first floor with a machine capable of washing articles at appropriate temperatures. The home’s assessment confirms it has policies and procedures for preventing infection, managing infection control and soiled waste disposal. During the tour of the building it was noted that all bathrooms and WCs were equipped with liquid soap and disposable towels. Provider’s Annual Quality Assurance Assessment - The Abbey Retirement Home DS0000011849.V361000.R01.S.doc Version 5.2 Page 22 The assessment identified what the service does in this area: • • • • • • • • • Service users live in a safe, well maintained environment and have access to safe and comfortable indoor and outdoor communal facilities. Ensure there are suitable lavatories and washing facilities. Making sure that service users have the equipment they require to maximise their independence. Helping service users make their own rooms suit their own needs, making sure that they can have their own possessions around them. That service users live in safe, comfortable surroundings that are clean, pleasant and hygienic. All of the bedrooms have been redecorated. Hallway, bathrooms and dining area have been redecorated. Some of the older furniture has been replaced in the home. Bedding replaced with new. The Abbey Retirement Home DS0000011849.V361000.R01.S.doc Version 5.2 Page 23 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 and 30 - People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff in the home are deployed in sufficient numbers, are trained and given the necessary skills and experience to meet the needs of the people who live there and support the smooth running of the service. EVIDENCE: Staffing levelsThe home employs eight care staff and a manager. There are two main shifts throughout the day when a minimum of three care staff are on duty at all times. Four staff are deployed in the morning up to 2 pm. Overnight there is one waking care assistant and one asleep in the home on call. The home does not employ additional catering and domestic staff. The manager works in the home each weekday and is included in the care team, except, since the last inspection, on Thursdays and Fridays when an additional staff member is deployed so that she can carry out admin/management tasks. At the last inspection a requirement was made for the home to review the deployment of staff to ensure there are sufficient staff on duty to meet residents’ needs at all times. The issue being that staff do the cooking, cleaning and laundry as well as the care for the residents, which reduces the number of staff available to assist and support residents. The Abbey Retirement Home DS0000011849.V361000.R01.S.doc Version 5.2 Page 24 At this inspection we spoke to residents, visitors, the manager and staff specifically about the numbers of staff available to provide care and support for people. There were no indications that peoples’ needs were not being met and additional evidence to support this is: • • • • • • Residents and visitors felt there are enough staff on duty. Staff said they work well as a team in what they consider a family style environment, and additional staff are brought in if people’s needs increase. The home was very clean and tidy. There were very complimentary remarks about the food provided. There were positive signs of well being amongst the residents. Staff rotas showed levels to be consistent over the period viewed. Therefore staffing levels were considered currently sufficient to meet the needs of the fifteen residents accommodated. NVQ training – Records showed and the manager confirmed that currently five of the eight care staff have achieved the National Vocational Qualification (NVQ) at level 2 (62.5 ) with the remaining three currently undertaking the training. The home’s NVQ training programme ensures the standard of 50 qualified staff is maintained. Recruitment Individual staff recruitment files were available for inspection. The home has a very stable staff group and only one new staff member has been recruited since the last inspection. An audit was carried out on this person’s recruitment file, which was found to be in order. Two written references and Criminal Record and Protection of Vulnerable Adults (POVA) checks are carried out on all staff before they commence working in the home. Staff training – The home continues to move forward with training opportunities for staff. Since the last inspection the manager has produced an individual training profile for each staff member, giving details of training achievements. We had an opportunity to view a sample of these training records during our visit. The induction programme for new staff now follows the Common Induction Standards required by ‘Skills for Care’. Induction workbooks have recently been introduced and one was being completed for the most recently recruited staff member. The Abbey Retirement Home DS0000011849.V361000.R01.S.doc Version 5.2 Page 25 Staff training includes: Manual handling Food hygiene First aid (appointed persons) Health and safety Dementia awareness Medication Fire safety Infection control Managing challenging behaviour The issue of safeguarding adults training has been covered earlier in the report. Provider’s Annual Quality Assurance Assessment The assessment identified what the service does in this area: • • • Making sure that the service users needs are met by the number and skill mix of staff. Staff are trained and competent to do their job, also ongoing training at all times. Two more courses taken on by staff and completed The Abbey Retirement Home DS0000011849.V361000.R01.S.doc Version 5.2 Page 26 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, 33, 35, 36 and 38 - People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service The management and administration of the home is based on openness and respect, has effective quality assurance systems developed by a qualified, competent manager. However, attention needs to be paid to the development of risk assessments to ensure that the correct measures are taken to minimise risks to people who use the service. EVIDENCE: Management – The registered manager Natasha Ball has managed the home since January 2007 and has achieved the Registered Managers Award (RMA). She confirmed that she intends to enrol on a course to achieve the NVQ at level 4 in care. Ms Ball has many years experience at The Abbey as the deputy manager. The Abbey Retirement Home DS0000011849.V361000.R01.S.doc Version 5.2 Page 27 She states that she updates her knowledge, skills and competence with periodic training in the same mandatory subjects taken by the rest of her staff and also care related subjects specific to the service provided by the home. Staff spoken with during the site visit confirmed that regular staff meetings and formal supervision sessions were taking place. They felt the home was well managed; staff morale was high and communication was good. During the site visit we had an opportunity to observe in a general sense the way the home functions. Comments from residents and visitors show that the manager is held in high regard and they had confidence in her ability to manage the home. Quality assurance – The home has a system of seeking the views of people who use the service by way of a survey questionnaire to residents and visitors. In addition, there is a box in the hall inviting people to put in comments about their views of the service. While residents meetings take place periodically the manager explained that it tends to be difficult to motivate them to give their opinions in a group setting. However, given the size of the home visitors and residents feel relaxed about giving their views about the service to staff and the manager. Other areas that inform the home’s quality assurance are: • • • • Regular in-house care plan reviews. Regular staff meetings and supervision sessions. Maintenance and renewal records, although there is no formal planned programme. Monthly visits on behalf of the provider to monitor the conduct of the home. Residents’ monies – The home prefers the residents’ representatives to take responsibility for their financial affairs. However, with the needs of the current resident group it is appropriate to have in place a system to safeguard the monies of those who are unable to make other arrangements. At the site visit we checked the system by way of dip sample and found it to be in good order, with receipts for purchases kept. Transactions were accurately recorded and balanced against expenditures. The Abbey Retirement Home DS0000011849.V361000.R01.S.doc Version 5.2 Page 28 Health and safety – The home’s pre-inspection information sent to the Commission by the manager confirmed that policies and procedures are in place to ensure safe working practices in the home. A sample of records was viewed during the site visit including fire alarm tests, public liability insurance, service of hoist and gas and electrical tests, all of which were in good order. We asked to view the home’s accident records. There was initially some confusion as a new book had not yet been started and the old one was not readily available. Other records showed one person had fallen overnight the previous day but the incident had not been entered into the new accident book. The manager located the old book, which had a recorded incident involving the same person the week before. The record described this individual having fallen and injured them self. The record gave minimal information and nothing about the action taken by staff. In discussions with the manager we were shown the daily record, which showed the person was taken to hospital and the correct aftercare given. It is important in circumstances where a risk is identified, as in this case, that an assessment is carried out and a record kept of the measures taken to minimise the risk. The manager and the care plan confirmed that no risk assessment was in place. In addition the Care Homes Regulations require serious injuries to be reported to the Commission, which in this case had not been done. The accident/incident records also identified a death in the home, which similarly must be reported to the Commission. Staff training records showed, and staff confirmed that statutory training is scheduled and updated in manual handling, first aid, fire training, infection control and food hygiene. Provider’s Annual Quality Assurance Assessment The assessment identified what the service does in this area: • Service users benefit from the ethos, leadership and management approach of the home and the home is run in the best interests of the service users. Service users financial interests are safeguarded. Staff are supervised. Service users rights and best wishes are safeguarded by the homes recorded keeping, policies and procedures. DS0000011849.V361000.R01.S.doc Version 5.2 Page 29 • • • The Abbey Retirement Home • The health and safety and welfare of service users and staff are promoted and protected. The Abbey Retirement Home DS0000011849.V361000.R01.S.doc Version 5.2 Page 30 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 3 x x N/A 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 2 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 2 The Abbey Retirement Home DS0000011849.V361000.R01.S.doc Version 5.2 Page 31 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 OP18 Regulation 13 Requirement Formal training in safeguarding adults from abuse must be provided for staff. This is to ensure that vulnerable people are safeguarded from all forms of abuse. Timescale for action 31/07/08 2. OP38 13 & 15 Where risks to vulnerable people 05/05/08 are identified with particular reference to falls, a risk assessment must be completed to set out the measures taken by the home to minimise the risk. This is to ensure that risks to vulnerable people are kept to a minimum. All events listed under Regulation 37 of the Care Homes Regulations must be notified to the Commission without delay, with particular reference to serious injuries and deaths. 05/05/08 3. OP38 37 The Abbey Retirement Home DS0000011849.V361000.R01.S.doc Version 5.2 Page 32 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 Retirement Home DS0000011849.V361000.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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. 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