Inspection on 31/01/06 for Tickford Abbey

This inspection was carried out on 31st January 2006.

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

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

Other inspections for this house

Tickford Abbey 19/09/06

Tickford Abbey 06/08/05

Tickford Abbey 06/10/04

Tickford Abbey 10/06/04

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 Tickford Abbey Priory Street Newport Pagnell Bucks MK16 9AJ Lead Inspector Mrs Caroline Roberts Unannounced Inspection 10:00 31 January 2006 st 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 Tickford Abbey DS0000015073.V282057.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Tickford Abbey DS0000015073.V282057.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Tickford Abbey Address Priory Street Newport Pagnell Bucks MK16 9AJ 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) 01908 611121 Greensleeves Homes Trust Ms Heather Joy Lee Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32) of places Tickford Abbey DS0000015073.V282057.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for 32 older people. Date of last inspection 6th August 2005 Brief Description of the Service: Tickford Abbey is a care home providing residential and personal care for 32 older people. It is owned and managed by The Greensleeves Trust and is situated in a rural area close to the town centre of Newport Pagnell. The home is a large detached property with a modern extension. Part of the house is listed and was once an abbey set on the riverside of the River Ouse. There are extensive grounds, which are well maintained. Accommodation is individual and comfortably appointed. There are 28 single rooms; nineteen have en suite facilities. There are two double bedrooms with en suite facilities, which are currently being used singly. There are three spacious lounge areas and a separate dining room. Tickford Abbey DS0000015073.V282057.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Each care home that is registered with the Commission for Social Care Inspection, receives one announced and one unannounced inspection each year and further additional visits as necessary. All inspections, both announced and unannounced are followed by a written report, which eventually become public documents. It is a requirement that inspection reports are made available within the home. This inspection was announced and took place on the 31st of January 2006. The inspector present was Mrs Caroline Roberts (Lead Inspector). This inspection consisted of meeting with Residents and staff, viewing records and documents pertaining to the provision of care and the running of the home. The Inspector found staff polite, helpful and welcoming, and would like to thank them for their co-operation and assistance throughout the course of the inspection. The inspector met and discussed the inspection findings with the manager before leaving. What the service does well: What has improved since the last inspection? Tickford Abbey DS0000015073.V282057.R01.S.doc Version 5.1 Page 6 Recruitment procedures have improved ensuring that residents are safe from the recruitment procedures operated within the home. It was evident that the home has worked hard to develop the care plans. 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. Tickford Abbey DS0000015073.V282057.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Tickford Abbey DS0000015073.V282057.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 Standards not assessed during this inspection. EVIDENCE: Intermediate care is not provided in this home. Tickford Abbey DS0000015073.V282057.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,10 Every resident has a care plan, which is regularly reviewed to reflect the changing care needs. The visiting healthcare team, and homes staff meet Resident’s health needs. All the staff understand the issues around privacy and dignity, and the residents are treated with respect. EVIDENCE: A random selection of residents care plans were sampled, they contained a satisfactory level of information about the care needs of residents. Risk assessments for aspects such as moving and handling, falls and risk of pressure sores, were not clearly documented within the care plans. The need for specific tissue viability risk assessments was discussed with the manager who agreed to implement them fully. Any visit by a healthcare professional is documented within the health intervention section of the care plan. Daily reports were found to be well completed. Tickford Abbey DS0000015073.V282057.R01.S.doc Version 5.1 Page 10 Leisure and social interests are detailed within the care plan. At the last inspection a requirement was served that Careplans must be in sufficient detail to provide clear guidance to staff on the actions to be taken to meet residents health and welfare needs. Residents care plans must be kept under regular review. It is pleasing to note that this requirement has been met, and that the home have worked extremly hard to ensure that care plans are relevent to the individuals needs. Dentist, chiropody, and opticians are all readily accessible to the residents. The inspector observed the staff communicating with the residents in an appropriate and respectful manner, always using their preferred form of address, and always knocking on doors before entering. Tickford Abbey DS0000015073.V282057.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 The routines of daily living and general activities in the home provided for a relaxed atmosphere that met with the preferences expressed by residents. Residents receive a wholesome nutritious diet, and every effort is made to ensure that meal times are a pleasurable experience. EVIDENCE: Activities in the home are provided on a regular basis in accordance with a written programme. This is largely based on the preferences and choices expressed by residents. One resident told the inspector how she enjoyed the art class. Discussions with residents indicated that they were supported to maintain contact with family / friends and representatives. Information about advocacy services is displayed within the home. Residents are supported in bringing personal possessions with them into the home. Lunch was observed being served and the food was of a good quality. One resident stated “Meals are discussed with me and I am able to make a choice from the menu”. Tickford Abbey DS0000015073.V282057.R01.S.doc Version 5.1 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Residents and relatives feel confident that their complaints will be listened to and acted upon. Residents are not fully protected by the current policies and procedures adopted by the home, with regards to adult protection. EVIDENCE: Adult Protection training has not been provided to all staff, the home did not have a copy of the Milton Keynes Adult Protection Policies. The manager agreed to contact the local authority to obtain a copy of the policies. A requirement is served that all staff receive adult protection training. The manager is aware of issues that would need reporting under local adult protection policies. The home has a complaints policy, which is accessible to residents and relatives; no complaints have been received in the period under review. Tickford Abbey DS0000015073.V282057.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Residents live in a safe well-maintained environment, which includes specialist equipment to maximise independence. The home is clean pleasant and hygienic throughout. EVIDENCE: The location of the home and its stated size and layout are well suited to the homes stated purpose and resident needs. It is an old adapted building, still with many of the original features, it is easily accessible from the town of Newport Pagnell and has ample car parking facilities. The bedrooms are large clean rooms some with en-suite facilities adapted bathrooms are also available. Residents have access to all communal areas and to their bedrooms at all times of the day and night. Grab-rails and a range of aids such as wheelchairs and walking frames are in use specific to assessed needs. The home has a well-maintained lift between floors. All rooms are fitted with a nurse call bell. The home has good facilities in place for cleaning, laundering and disposal of clinical waste. The home was very clean and free from any offensive odours. Tickford Abbey DS0000015073.V282057.R01.S.doc Version 5.1 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29,30 The home has a full recruitment procedure in place. Staff are well trained and competent to undertake their duties fully. EVIDENCE: Two staff files were examined; these indicated that a POVA First check and completed CRB check had been returned for both members of staff. Improvements have been made regarding the homes recruitment practices following a requirement being made at the last inspection. Current records seen evidences that all mandatory training is up to date with update training planned as needed. Individual certificates are held within the staff personal records. All staff receive 3 days per year paid training. Tickford Abbey DS0000015073.V282057.R01.S.doc Version 5.1 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 The home has an experienced and supportive registered manager. The home is run in the best interests of residents. Residents are safeguarded by the systems in place to look after their personal money. EVIDENCE: The registered manager is a qualified nurse who has worked at the home for a number of years. She has recently completed her registered managers award. Quality assurance questionnaires are sent out to residents and relatives 6 monthly, the information from this exercise is then collated and feedback is given to residents and relatives. Tickford Abbey DS0000015073.V282057.R01.S.doc Version 5.1 Page 16 No evidence was available to show that the Organisation undertake a continuous self-monitoring quality assurance system, internal audit. A requirement is served that the home undertake an annual internal audit. Regulation 26 visits are conducted monthly by one of the senior management team. The records of resident’s personal money held by the home were examined. The records were well kept and the money was securely stored in the home. The records included two signatures for all transactions and receipts maintained. Tickford Abbey DS0000015073.V282057.R01.S.doc Version 5.1 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 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 X 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X x Tickford Abbey DS0000015073.V282057.R01.S.doc Version 5.1 Page 18 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP33 Regulation 24(1)(2) Requirement The manager must ensure that an internal audit is undertaken at least annually. Records of this to be maintained for inspection. The manager must arrange for all staff to attend training in adult protection. Timescale for action 01/07/06 2 OP18 13(6) 01/07/06 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 Tickford Abbey DS0000015073.V282057.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury HP19 8JR 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 Tickford Abbey DS0000015073.V282057.R01.S.doc Version 5.1 Page 20 - 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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