Inspection on 12/05/05 for The Abbeys

This inspection was carried out on 12th May 2005.

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

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

Other inspections for this house

The Abbeys 01/05/07

The Abbeys 09/05/06

The Abbeys 11/11/05

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 S62 6LT Lead Inspector Stephanie Kenning Unannounced 12 May 2005 9:00. 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 ABBEYS CS0000003069.V175447.R01.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Abbeys Address High Street Rawmarsh Rotherham South Yorkshire S62 6LT 01709 719717 01709 710149 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) Southern Cross Operations Limited Mrs Alison Tripp CRH (N) Care Home with Nursing 80 Category(ies) of OP Old Age 80 registration, with number of places THE ABBEYS CS0000003069.V175447.R01.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Nursing clients are admitted to the Abbeyhill Unit only. Date of last inspection 28 October 2004 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 CS0000003069.V175447.R01.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over 13 hours on two dates and involved a second inspector for part of the first day. Each inspector focussed on one building during the first date and the lead inspector met with the manager on the second date to bring the two together. A tour of each building was carried out including visiting some service users rooms. Records were inspected including care plans, policies, supervision notes, staffing rotas, medication, incidents, accidents, death notifications, and meeting minutes. Meals were observed in the two buildings and service users, visitors and staff were spoken to for their views about the home. An immediate requirement was issued on the first date to repair the sluicing washing machine that had been broken for several weeks. This was repaired within the timescale set and confirmed at the second visit. What the service does well: What has improved since the last inspection? Progress has been made towards meeting all the requirements of the previous inspection, with only minor amendments needed. Additional information regarding the communal rooms has been inserted into the statement of purpose. A copy of the recent inspection report was available with plans to insert a summary of this report. The complaints procedure along with other documentation will need to be amended again to reflect the new owner. Care plans were sampled and were up to date with new assessments and care plans following changes. Medication administration records were generally up to date with photographs for identification and changes had two signatures to confirm that the change was correct. The bedroom with an offensive odour has had a new carpet that has addressed the problem. Staffing levels are being maintained most of the time, with some reorganising to cover busy times, however there are still some issues regarding staffing. Staff supervision has been implemented and records are kept. THE ABBEYS CS0000003069.V175447.R01.doc Version 1.30 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 CS0000003069.V175447.R01.doc Version 1.30 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 ABBEYS CS0000003069.V175447.R01.doc Version 1.30 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) 1 and 3. The information provided still requires some additions and now some amendments due to the new owners. Improvements had been made following the previous inspection. EVIDENCE: The new owners are reviewing all the documentation and information provided to potential and existing service users in line with their own policies. At present the information provided by the previous owners is still being used and is not expected to change significantly. The Statement of Purpose was seen, contains relevant information, including, expanded information regarding communal facilities, and it states that it is also available on an audiocassette. A copy of the service user guide is given to each service user and is also available in the empty rooms so that new service users have access to it straight away. It does not contain a summary of recent inspection reports or have service users views of the home, both useful sources of information that could assist potential service users to choose a suitable home. The complaint policy requires updating so that people have up to date contact details, including CSCI and Southern Cross. THE ABBEYS CS0000003069.V175447.R01.doc Version 1.30 Page 9 Assessments carried out by a member of staff were seen in service user files and these covered all the required areas and linked to care plans where needed. Those seen were completed on the day of admission and reviewed about every six months to ensure they were up to date. Some reassessments were also seen after changes such as illnesses rather than waiting for the planned review. THE ABBEYS CS0000003069.V175447.R01.doc Version 1.30 Page 10 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 and 9. The health and personal care of service users is well documented and planned, involves service users and their relatives when appropriate, and is carried out respectfully. EVIDENCE: Several care plans were looked at in depth to find out if they were appropriate. The plans of care could be linked to assessments of need, and they detailed action to be taken by care staff to ensure that the needs are met. The information included likes and dislikes, and the service user’s preferred regime so that their wishes could be carried out. Service users and relatives have signed some of the care plans indicating that they were either involved in its creation or that they agree to it. A record is kept of care given and other areas of daily life that helps to inform the reviews held every six months. There is evidence in the records of relatives attending the reviews to represent the service user, and relatives stated that they felt well informed and involved with the care. Files were organised into separate sections, had regular entries, and were up to date. The previous requirements of reassessment following readmission from hospital, and formulating a care plan for areas identified appear to have been met. Named nurses review each section of the care plans THE ABBEYS CS0000003069.V175447.R01.doc Version 1.30 Page 11 each month to ensure accuracy. The manager identifies gaps or issues when auditing, and has then raised these with individuals to rectify. Health issues are identified and appropriate intervention taken, such as prevention or treatment of pressure sores. A number of pressure relief mattresses and cushions were seen in use and these linked to care plans. There were a number of people requiring wound care and the tissue viability nurse was involved to provide advice and support. Referrals to other specialists were noted on file, such as to a speech therapist, indicating that appropriate access to health care services is obtained. Medications were mainly administered by staff members and due to the large number of medications at the home only a sample were inspected. Money and a key were stored in the controlled drug cabinet, which is unhygienic and inappropriate. Two recent drug errors were looked at and it was decided to ask the pharmacist to make the instructions clearer to prevent further mistakes. Medication sheets are up to date and have photographs (except one) and two signatures, where hand written, to ensure accuracy. Some improvements to the organisation of medications and policy information available to staff members were noted between the two inspection visits, indicating that they were responding to advice given. THE ABBEYS CS0000003069.V175447.R01.doc Version 1.30 Page 12 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) 12,13,14 and 15. Service users were able to follow choices in their lifestyles within the residential setting and to maintain contacts with their family, friends and the local community. Service users made many positive comments regarding the quality, choice and flexibility of meals. EVIDENCE: Routines and choices preferred by individuals were noted in the care plans and service users confirmed that they had choices in their daily lives including social activities. Two part-time activity staff members are employed, each based in one of the two buildings of the home. They organise a range of activities for groups of people, including entertainment in and out of the home. The notice boards gave information about forthcoming events including religious services, bingo, board games and quizzes. Some people choose not to participate, preferring to pursue their own activities or none. There was an outing on the day of inspection to the Meadowhall shopping centre that was enjoyed. Some service users would like more outings to be arranged, especially in summer months, though activity staff felt unable to facilitate this on their current hours. THE ABBEYS CS0000003069.V175447.R01.doc Version 1.30 Page 13 Several visitors attended the home during the inspection and stated that they were welcomed and involved in the home. Service users received them in their own rooms or in the communal areas, and there were sufficient quiet areas available for people to converse comfortably. Menus show that a choice is available for all meals and alternatives can be ordered if the choices are not liked. Special diets are catered for such as diabetic and liquidised foods. The menu was not on display in all areas of the home, though staff asked service users what they wanted for lunch and tea. Most people had eaten a light breakfast, and when asked thought that a cooked breakfast was not available. One service user stated that they had a bacon sandwich every other morning indicating that a cooked breakfast is available. All service users spoken to after lunch stated that they had enjoyed the meal. Mealtimes were busy with many people requiring assistance, especially on the nursing unit. The staff were in demand at this time which was evident due to the number of times the nurse call system was activated from individuals in their own rooms. The activities staff assisted with the lunch so that service users were not kept waiting too long. One service user did become agitated, shouting and banging at the table, which took staff away from what they were doing to attend to the situation. Assistance was given in a sensitive and discreet manner, helping to promote independence whenever possible. THE ABBEYS CS0000003069.V175447.R01.doc Version 1.30 Page 14 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 Service users have access to clear information about how to make a complaint except that the contact details require amending. EVIDENCE: The complaints policy does require some amendment to the contact details for CSCI and now the new owner, though the remainder of the content is clear and easy to follow. Complaints information is included in the service user guide and is displayed on the notice board giving everyone an opportunity to read it and therefore know how to make a complaint. Most people did know what to do and all of them said that they would go to the Manager as she was approachable. THE ABBEYS CS0000003069.V175447.R01.doc Version 1.30 Page 15 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) 19,20, 23 and 26. The home is clean, tidy, well decorated and maintained. Facilities are suitable for their intended purpose. EVIDENCE: There are two separate buildings forming the Abbeys home and they continue to be suitable for the purposes of caring for older people. It is located just off a main road with shops, church and public houses nearby. The buildings are well maintained, decorated and furnished providing a safe and comfortable environment. There are a number of communal areas and garden areas that provide suitable accessible space for a variety of activities or sitting. All the bedrooms meet the required space standards and the home has no shared rooms. The home was clean, tidy and free of offensive odours, providing a pleasant environment for service users. On the first visit an immediate requirement was issued to repair the sluicing washing machine on the Abbey Dale unit, which had been broken for several weeks and meant that foul linen was being dealt with manually, increasing the risk of cross infection. This was rectified before the second visit as required. A recommendation of a covered THE ABBEYS CS0000003069.V175447.R01.doc Version 1.30 Page 16 walkway between the two buildings remains outstanding, causing people going between the buildings to suffer the effects of the weather, and be more vulnerable at night. It was stated to be under consideration. THE ABBEYS CS0000003069.V175447.R01.doc Version 1.30 Page 17 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, and 28. Staffing levels are just adequate for the dependency of the current service users. Staff were very busy at some parts of the day. There are less staff around at weekends. In addition to registered nurses on duty at all times, 5 staff have NVQ level 2 or above. EVIDENCE: The staffing rota was seen and discussed with different staff in relation to service user dependency levels. This was found to be generally adequate though there are times when certain areas require a lot of staff time, for example, at meal times where many people require assistance. The manager was aware of this and has tried to increase staff at these times without increasing the overall staff hours. This will need to be monitored to ensure it is adequate. Within the staff rota it was also noticed that some people were working 7 days a week, or had very long shifts such as 2pm to 8 am the next day, therefore staff would be very tired and this may impact on the care to service users. Care staff in Abbeydale were covering some laundry and domestic duties at the weekends, as no other cover was provided. There are registered nurses on duty at all times. 1 care staff is qualified to NVQ level 3 and 4 are qualified at level 2. A further 12 people are currently undertaking NVQ training, which when completed is only just under 50 (17) of the 36 care staff employed. The staff were able to describe the care of service users and were observed to be respectful and friendly, showing good relationships. Service users and THE ABBEYS CS0000003069.V175447.R01.doc Version 1.30 Page 18 relatives praised the staff, saying things like they were helpful and kind. Relatives felt that they were kept informed, knew how to complain if necessary and were involved in life at the home. THE ABBEYS CS0000003069.V175447.R01.doc Version 1.30 Page 19 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, 33, 36 and 37. The home is managed well with service users able to have a say through meetings, open surgeries with the manager, or through their review process. EVIDENCE: The manager is Alison Tripp who is a qualified nurse and has completed the CSCI registration process as a fit manager. She has recently finished a Certificate in Health and Social Care at Leeds University. People stated that she was approachable and flexible and had been implementing a number of changes to improve care since being appointed. She stated that she receives regular and ongoing support from her manager who visits the home at least monthly, to monitor the home. Copies of these monthly reports are sent to CSCI as evidence of the monitoring visits. Service user reviews are used as a way of gathering information about their views of the home, though the manager was keen to introduce some surveys to contribute to an audit. A monthly newsletter is circulated to keep people informed about events at the THE ABBEYS CS0000003069.V175447.R01.doc Version 1.30 Page 20 home. The manager also advertises a monthly open surgery for service users, visitors or staff to bring forward any issues or ideas. Auditing of key areas such as care planning is part of the managers role to ensure that staff are carrying out the policies and procedures of the home correctly. Previous inspection reports are available to people visiting the home or those living at the home to inform about the homes meeting of national standards. A system of staff supervision has been implemented to ensure staff carry out their jobs as required, and records were seen. The storage of these was discussed regarding the need to keep them secure and confidential and some changes were made immediately to improve this. All records seen were well maintained and up to date to assist in the protection of service users. THE ABBEYS CS0000003069.V175447.R01.doc Version 1.30 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 x x 3 x x 3 STAFFING Standard No Score 27 3 28 3 29 x 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 3 3 3 x x 3 3 x THE ABBEYS CS0000003069.V175447.R01.doc Version 1.30 Page 22 no 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 1 Regulation 4 Requirement Update the statement of purpose, complaints information and other documentation with the new owners details and the CSCI contact details. Provide suitable storage for monies and keys and remove these items from the medication storage. Monitor and review staffing levels according to dependency/need. Timescale for action 30 th September 2005 1st August 2005 ongoing 2. 9 13 3. 27 18 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard 1 2 28 20 Good Practice Recommendations Include a summary of the inspection report in the service user guide. Include service user views in the service user guide. 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. THE ABBEYS CS0000003069.V175447.R01.doc Version 1.30 Page 23 Commission for Social Care Inspection First Floor, Barclay Court Heavens Walk Doncaster South Yorkshire 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 CS0000003069.V175447.R01.doc Version 1.30 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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