Inspection on 11/11/05 for The Abbeys

This inspection was carried out on 11th November 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 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 Abbeys 01/05/07

The Abbeys 09/05/06

The Abbeys 12/05/05

The Abbeys 28/10/04

The Abbeys 11/05/04

The Abbeys 27/01/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE The Abbeys High Street Rawmarsh Rotherham South Yorkshire S62 6LT Lead Inspector Ms Stephanie Kenning Unannounced Inspection 11th November 2005 09:45 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Abbeys DS0000003069.V261347.R01.S.doc Version 5.0 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 Abbeys DS0000003069.V261347.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Abbeys Address High Street Rawmarsh Rotherham South Yorkshire S62 6LT 01709 719717 01709 710149 theabbeys@highfield-care.com 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) Southern Cross Operations Limited Alison Tripp Care Home 80 Category(ies) of Old age, not falling within any other category registration, with number (80) of places The Abbeys DS0000003069.V261347.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Nursing clients are admitted to the Abbeyhill Unit only. Date of last inspection 12th May 2005 Brief Description of the Service: The Abbeys is situated just off a main road in Rawmarsh, Rotherham. It comprises of two separate buildings, both built as residential care homes. Abbeyhill is a two storey building providing care for older people, including those who need nursing care. Abbeydale is a three storey building for older people who do not require nursing care. In total up to 80 people can be accomodated. All of the rooms accomodate one person and a few have an ensuite toilet. There are a variety of communal areas within the home and sitting areas in the garden. The home has recently been aquired by Southern Cross, a national care home provider. The Abbeys DS0000003069.V261347.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 7 hours during the daytime. It was the second inspection during this year and any of the key standards not assessed at this inspection would have been assessed at the previous inspection. The inspector had discussions with the staff on duty, examined staff rotas, spoke to service users and relatives, did a partial tour of the building, examined 5 care plans, checked 3 service user accounts against the records, and checked many other documents. Service users and relatives completed questionnaires that were left following the inspection to gain more views about life at the home. What the service does well: What has improved since the last inspection? Progress had been made towards meeting the requirements of the previous inspection, including the immediate requirement issued for the repair of the sluicing washing machine. Staffing levels have been under review according to dependency of service users and a meeting has been planned to discuss some proposals. Monthly Health and Safety meetings with the heads of departments have been started and these have helped to identify issues and problems, and plan action to put them right. The Abbeys DS0000003069.V261347.R01.S.doc Version 5.0 Page 6 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 Abbeys DS0000003069.V261347.R01.S.doc Version 5.0 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 Abbeys DS0000003069.V261347.R01.S.doc Version 5.0 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): 1, 3, 5 Information has been updated with the new company details, and service users and relatives felt well informed at the time of choosing a place to live. EVIDENCE: The statement of purpose and complaints information have been updated along with some other documentation since Southern Cross purchased the home, and this should assist service users with the correct contact details. Assessments were seen on service users files and contained all the required information to make an assessment of needs and whether the home could meet those needs. Service users and relatives stated that they had been able to visit the home prior to choosing a place to live, or had been offered the opportunity to visit, and this had helped them to make a decision. The Abbeys DS0000003069.V261347.R01.S.doc Version 5.0 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, 10 There is inconsistency in the quality of the care plans and their implementation, and the way that service users feel that they are treated by staff. There were many references to the staff being busy. EVIDENCE: A number of service user care plans were seen along with other related documentation, these were generally well kept and up to date for those on the Abbeydale unit, and variable for the other units including some requiring reviewing. One care plan stated ‘offer a weekly bath’, but when checked the last bath recorded was 14/9/05, showing either that they had not had a bath since then or that it had not been recorded. Another service user expressed a desire for more than one bath each week though this had not been happening recently. Generally service users did feel well cared for, but not always, as the carers were too busy. Responses to the questionnaires left by the inspector for service users and relatives indicated that several people felt that carers treat them well sometimes, and that their privacy was respected sometimes. During the inspection service users were generally more positive about the way they were treated by staff, though were concerned about how busy they were. The Abbeys DS0000003069.V261347.R01.S.doc Version 5.0 Page 10 A new system of medication disposal has been implemented for all homes providing nursing care, and the containers for disposal at the Abbeys were overflowing, resulting in insecure storage. It was also apparent that some empty cassettes had been put in the disposal containers taking up valuable space. The medication room was sometimes left unlocked and staff on duty advised to keep it locked for the security of the medicines and the safety of service users. Lockable facilities for money and keys have been provided and are no longer kept in the medication cupboards. The Abbeys DS0000003069.V261347.R01.S.doc Version 5.0 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, 13, 14 Generally most service users experiences of The Abbeys is positive and fulfilling, though there were some exceptions to this. EVIDENCE: Some service users and relatives were very pleased with life at The Abbeys, in terms of their personal needs being met and their own preferences. A range of activities is provided, and a game of bingo was being held that day. Sometimes there is visiting entertainment, or religious services, or shopping at the home. Outings have taken place, mainly shopping trips for one or two people at a time, due to staff shortages. There was concern from some relatives regarding a lack of activities and stimulation for service users who stay in their rooms. Care staff stated that due to staff shortages they spend less time with the people in their rooms, and agreed that these people have fewer activities. There are 2 people employed for activities, 1 works 20 hours a week in the Abbeyhill unit and the other works 12 hours a week in the Abbeydale unit. Both these people assist with other tasks, for example with mealtimes, that takes time away from activity time. As there is no activities budget, all monies for outings, including diesel to put in the minibus, and other activities has to be fund raised, again taking time and energy away from the main focus of the job. The Abbeys DS0000003069.V261347.R01.S.doc Version 5.0 Page 12 Relatives felt welcomed and generally well informed and consulted, and were able to maintain contact and in private at the wish of the service user. There were plenty of examples in care plans where people were expressing preferences about their daily lives, and these were usually met apart from some recent examples when carers had insufficient time, such as not bathing the desired twice a week. The Abbeys DS0000003069.V261347.R01.S.doc Version 5.0 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 the following standard(s): 16, 18 Systems are in place and were being used correctly to deal with complaints and adult protection referrals for the protection of service users. EVIDENCE: CSCI has received 3 complaints since the previous inspection, one regarding the standard of care, one regarding staffing and a member of staff, and one regarding a member of staff. These are currently being investigated. The home has a clear complaints policy and service users stated that they knew whom to contact if they were unhappy with their care. There have been 2 adult protection investigations since the previous inspection, one is ongoing and the other was not upheld. Documentation for these have been seen and the home have followed the correct procedures. The Abbeys DS0000003069.V261347.R01.S.doc Version 5.0 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 the following standard(s): 19, 26. The home is well presented and maintained, in an accessible location, and provides a comfortable environment for service users. EVIDENCE: The Abbeys is located just off the main road at Rawmarsh, which is not far from the centre of Rotherham. It is near to shops, transport, a church and a public house, providing good local facilities. The Abbeys comprises of two buildings, one on two floors and the other on three floors. The buildings are not linked together and access between the two is external. They were built as residential care homes about 15 years ago and have all the required facilities. All of the rooms are for single occupancy and some have an en-suite toilet. The home was clean, tidy, odour free and well maintained, providing a pleasant environment for the service users. The Abbeys DS0000003069.V261347.R01.S.doc Version 5.0 Page 15 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, 28, 29, 30. The home has had difficulty maintaining minimum staffing levels on some occasions recently, and was struggling to meet service users needs on those days. They are likely to meet the target of 50 trained in level 2 NVQ or above. EVIDENCE: Service users, relatives, and staff confirmed the evidence of the staff rotas that the home had sometimes failed to meet the agreed minimum staffing levels, putting service users at risk. On examination this appeared to have happened on occasion over the previous month due to a high level of staff sickness, as well as staff vacancies, and agency cover had been requested though not always met if it was short notice. Discussions with staff showed that they were tired and morale was low due to the heavy workload and covering for colleagues. Service users and their relatives raised concerns of low staffing regarding bathing, mealtimes and activities. Of about 25 carers at the home 10 have completed NVQ 2, 1 at NVQ 3, and a further 4 are in the process of doing NVQ 2. This means that they are on target for achieving 50 of carers trained to NVQ 2 or above. More staff expressed an interest in training, but they were unsure if funding would be available. There is a programme of other training in the home including moving and handling, fire, food hygiene, and health and safety that all staff must attend. A range of other training is available, though not well attended, and feedback The Abbeys DS0000003069.V261347.R01.S.doc Version 5.0 Page 16 about this indicated that staff are not paid for this training and have to attend on their precious days off, resulting in the poor attendance rates. Recruitment has been difficult recently with fewer suitable applicants for jobs, resulting in one post for a laundry assistant vacant since January 2005. There are also vacancies for senior carers at the home causing the existing seniors to cover many extra shifts. There is a recruitment policy that is being followed, and advertising was due in the local press the following week. The recruitment checks from the Criminal Records Bureau were stated to contribute to the delay in recruitment as they were taking a long time. Evidence in staff files demonstrated that a thorough recruitment procedure is used including all the checks to safeguard service users. The Abbeys DS0000003069.V261347.R01.S.doc Version 5.0 Page 17 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): 35, 38. The two standards assessed, service user financial arrangements and health and safety arrangements were being well managed. EVIDENCE: A random sample of service users monies held at the home was checked against the records held and found to be accurate. Some service users are able to manage their own finances and are provided with lockable facilities. A range of maintenance records were examined and found to be up to date promoting the safety of the service users. Health and safety meetings for all the heads of department have been implemented and found to be useful at identifying issues and planning action to be taken, therefore improving the safety for all at the home. The Abbeys DS0000003069.V261347.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X 3 The Abbeys DS0000003069.V261347.R01.S.doc Version 5.0 Page 19 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 OP7 Regulation 15 Requirement Care plans must be kept up to date and reviewed regularly, and the plan of care carried out according to service users wishes, and recorded accurately. Review the storage of medicines for disposal to ensure it is secure. Ensure that the home meets agreed minimum staffing levels at all times. Recruit to vacancies and set up robust systems for covering absences. Ensure that there are sufficient staff on duty at busy times to meet the needs of service users. Timescale for action 31/12/05 2. 3. 4. 5. OP9 OP27 OP27 OP27 13 18 18 18 31/12/05 01/12/05 31/01/06 01/12/05 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 OP10 Good Practice Recommendations Explore the reasons that service users only sometimes felt DS0000003069.V261347.R01.S.doc Version 5.0 Page 20 The Abbeys 2. 3. 4. 5. OP12 OP28 OP20 OP30 that they were treated well or that their privacy was respected. Consider how to meet the social needs of the service users that remain in their rooms, and how more outings can be provided. A minimum of 50 of care staff should be trained to NVQ level 2 or above by 31st December 2005. The installation of a covered walkway to connect the two buildings. Consider ways of improving attendance to training provided. The Abbeys DS0000003069.V261347.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Doncaster Area Office 1st Floor, Barclay Court Heavens Walk Doncaster Carr Doncaster DN4 5HZ 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 Abbeys DS0000003069.V261347.R01.S.doc Version 5.0 Page 22 - 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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