Inspection on 06/08/05 for Tickford Abbey

This inspection was carried out on 6th August 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

Tickford Abbey 19/09/06

Tickford Abbey 31/01/06

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 Caroline Roberts Unannounced 6th August 2005 9:30am 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. Tickford Abbey Version 1.10 Page 3 SERVICE INFORMATION Name of service Tickford Abbey Address Priory Street, Newport Pagnell, Bucks, MK16 9AJ 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) 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 Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th October 2004 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 Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the summary of the un-announced inspection carried out at Tickford Abbey on the 6th and 8th August 2005. The lead inspector was Mrs Caroline Roberts. The 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 toured the building, gaining permission from a number of residents to enter their bedrooms and viewing a further number from the doorway. The inspector met and discussed the inspection findings with the manager before leaving on the second day. This inspection has resulted in three requirements being served. 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 would like to thank Arlin Joyce (senior carer) for her help during the first day of the inspection. The inspector would especially like to thank the residents for their time and for allowing the inspector into their home. What the service does well: Tickford Abbey is homely and comfortable, providing adaptations and equipment necessary to support the residents in a safe and inviting environment. The Manager is approachable; operating an open door policy to ensure issues of concern can be raised appropriately. All residents have an individual plan of care, which supports staff to implement appropriate care in a manner preferred by the resident. Personal care is implemented in a manner that ensures the privacy and dignity of residents is maintained. Staff have a clear understanding of individual residents needs, receiving additional training and support as needed to fulfil their roles. The Staff team are dedicated and committed to providing a professional service. Visitors are welcomed at the Home with no restrictions in place. Tickford Abbey Version 1.10 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 full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Tickford Abbey Version 1.10 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Tickford Abbey Version 1.10 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3 Current and prospective residents have adequate information provided in the homes Statement of Purpose and Service User Guide, to enable informed choice about where they live. Written contracts are in place to ensure that residents have agreed the terms and conditions for living in the home. Though all residents at the home have needs assessments, those examined did not provide enough detail to allow the home to make an informed choice as to if they can fully meet the needs of the individual. EVIDENCE: The homes statement of Purpose and Service User Guide are accessible to residents and families and clearly state the services and accommodation, which are to be provided. Detailed contracts are in place for each resident, which fully explain contractual terms and conditions, and copies are provided to privately funded residents, and to residents funded by the local authority. Two residents assessments were examined these did not clearly indicate the needs of the potential resident. It was evident that potential residents are Tickford Abbey Version 1.10 Page 9 being visited prior to admission in order to establish if the home can meet the needs identified however, more detail is required to be documented on the pre-admission assessment tool used. The senior on duty (Arlin) was clearly able to demonstrate a good knowledge of the care needs of both of the residents whose records were examined. Tickford Abbey Version 1.10 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) 7,9,10, The home has a clear care planning system in place, however, those care plans viewed were inconsistent in the level of information recorded; therefore residents identified needs are not clear or up to date and do not enable staff to provide the most appropriate care. Medication is appropriately stored, and administered, the practices relating to handwriting mar sheets and use of tippex are not in line with the homes policies and therefore have potential for putting residents at risk. Staff practice in giving and assisting with such elements as personal care and arrangements for medical examination ensure the privacy and dignity of residents. EVIDENCE: Greensleeves Trust introduced a new care plan format last year; this has now been fully adopted in the home. Three care plans were examined and all contained a personal profile, and specific health needs. Moving and Handling assessments were also evident. Tickford Abbey Version 1.10 Page 11 It was disappointing to note that the care plan for one resident who was being cared for in bed did not reflect the present situation, and had not been updated, the care plan stated that this individual could walk unaided and would come downstairs for meals, at the time of the inspection this individual was receiving palliative care. The resident appeared to be being cared for very well, a pressure relieving mattress was in use on the bed, as a preventative measure and this resident did not have any pressure sores. Regular checks were being undertaken on this resident and recorded on the monitoring chart in the bedroom, drinks were also being offered and recorded. The manager needs to audit the daily reports and health and medical intervention to ensure that all health issues are followed through: for example one resident had requested a G.P visit on the 2.8.2005 due to not feeling well no record of a visit or outcome could be found within the care plan, or by asking the senior on duty. Another care plan for a recently admitted resident had not been completed fully and therefore did not clearly describe the care needs to be met by the home. The inspector and the manager discussed care planning on the second day of the inspection as the manager felt disappointed that in the last report the home had received a 4 (commendable) for care planning, and that at this inspection care planning was being discussed as an area that needed improvement. Further work is needed to fully develop the care planning process in this home, more attention to specific detail is required, comments such as all care required, and just a little prompting are not clear instructions for staff. A requirement will be made that the manager audit the care plans to ensure that individual needs are identified fully and described within the care plan, this will then be reviewed during the next inspection. Practices relating to the handling, storage and administration of medications within the home were inspected. Medication is stored securely within the treatment room. No unexplained gaps were noted on the mar sheets. Photographs are provided on all mar sheets. All staff have received training in medication administration. Staff are hand writing instructions on medication administration records, without evidence of the original prescription, (this was discusses with the manager) • The use of tippex on the mar sheets, (this was also discussed with the manager) The practice of using tippex on the medication administration sheets must cease immediately. Staff spoken with at the time of inspection were knowledgeable of the individual needs of residents and the need for a holistic approach to care provision. Staff conveyed a sense of pride in their work and dedication, Tickford Abbey Version 1.10 Page 12 • • • • • ensuring the needs of residents is central to the day-to-day operation of the Home. Residents were addressed using their preferred name and interactions were relaxed and sensitive to the individual personalities and needs of the residents. Staff were observed knocking on doors prior to entering any room. Tickford Abbey Version 1.10 Page 13 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) EVIDENCE: Not assessed during this inspection. Tickford Abbey Version 1.10 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) EVIDENCE: Not assessed during this inspection. Tickford Abbey Version 1.10 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) 19,22,26 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 Version 1.10 Page 16 Tickford Abbey Version 1.10 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) 27,29 Residents are supported by sufficient numbers of suitably trained and skilled staff ensuring the needs of residents are met at all times. The home has a full recruitment procedure in place, unfortunately this has not been fully complied with, therefore there is a potential for putting residents at risk. EVIDENCE: The rotas were viewed this confirmed that during the morning period the home has 5 care staff, reducing to 4 during the afternoon period, staff and residents spoken with confirmed that this was adequate. Based on 23 residents in the home at the time of the inspection this appeared adequate. The manager confirmed that she could increase the staffing if needed. The personal files for three staff were viewed, this confirmed that all staff complete an application form and have 2 references in place prior to the commencement of employment. One file indicated that a member of staff commenced employment 5 weeks prior to her CRB disclosure, no POVA first check was evident and upon discussion with the manager she was unaware of changes in legislation regarding POVA first checks. The manager was advised to update her knowledge regarding this, and the organisation are advised to ensure that this subject is discussed with the manager during Regulation 26 visits to the home. Tickford Abbey Version 1.10 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 The Health and Safety procedures and record keeping of the home ensures residents, staff and visitors to the home are protected as far as is reasonably practicable. EVIDENCE: The homes fire safety records indicate regular testing of the alarms. All staff receive fire safety training as part of the mandatory training arranged by the home. During the tour of the building two doors were noted to be wedged open, the senior on duty removed these wedges immediately. Two doors rooms 13 and 18 did not close full onto their stops. By the second day of the inspection the manager had arranged for the above doors to be adjusted. Tickford Abbey Version 1.10 Page 19 The lino at the entrance to the laundry room had torn and come away from the floor, this now presents a trip hazard, and again by the second day of the inspection the manger had arranged for this to be repaired. The home has service agreements in place for: Boilers Lifts Hoists Electrical equipment Contractual arrangements are also in place for clinical waste. The Health and Safety policies and procedures were not fully assessed during this inspection Tickford Abbey Version 1.10 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 2 x x x 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 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION 3 x x 3 x x x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x x x x x x 3 Tickford Abbey Version 1.10 Page 21 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 2 Regulation 14(1) Requirement Needs assessments must be in sufficient detail to allow the home to make an informed choice as to if they can meet a residents needs. 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. The organisation must ensure that staff are employed in line with Regulation 19 and Schedule 2 of the Care Homes Regulations 2001, and as per the homes policies and procedures. Timescale for action 1.12.2005 2 7 15(1) 1.2.2006 3 29 19 and Schedule 2 1.12.2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Tickford Abbey Version 1.10 Page 22 Commission for Social Care Inspection Cambridge House, Smeaton Close 8 Bell Business Park, Aylesbury Buckinghamshire 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 Version 1.10 Page 23 - 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. 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