Inspection on 17/10/05 for Wyton Abbey

This inspection was carried out on 17th October 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Wyton Abbey 27/11/08

Wyton Abbey 20/11/07

Wyton Abbey 11/06/07

Wyton Abbey 06/05/06

Wyton Abbey 11/04/05

Wyton Abbey 18/11/04

Wyton Abbey 10/06/04

Wyton Abbey 08/03/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

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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 Wyton Abbey Wyton Bilton Hull East Yorkshire HU11 4DJ Lead Inspector Sarah Sadler Unannounced Inspection 17 October 2005 09:30 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 Wyton Abbey DS0000019777.V250953.R02.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. Wyton Abbey DS0000019777.V250953.R02.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Wyton Abbey Address Wyton Bilton Hull East Yorkshire HU11 4DJ 01482 817610 01482 815604 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) Prime Life Limited Undergoing Registration Process Care Home 33 Category(ies) of Dementia (6), Dementia - over 65 years of age registration, with number (33), Old age, not falling within any other of places category (33) Wyton Abbey DS0000019777.V250953.R02.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. That able service users will be accommodated in the `Garden Cottage`. That service users and their family are made fully aware that the staff, after 10.00 pm are accessed from the main building. That Contracting Services (Social Services Department) are fully aware of the night staffing arrangements in the home. That the service users are fully aware of what procedures to follow in case of a fire or break-in to the `Garden Cottage`. The category Dementia (DE) is for service users over 50 years only. Date of last inspection 11th April 2005 Brief Description of the Service: Wyton Abbey is a large house set back from the main road, in its own grounds, adjacent to the village of Wyton, in the East Riding of Yorkshire. The house is a listed buiding, has extensive grounds with a small walled garden area for service users to sit in and a large car park for approximately 10 cars. Access to public transport is from the adjacent main road which is a short walk along the homes driveway. Prime Life Ltd owns the home, which is registered for 33 service users of either sex, the majority of whom are over 65 years of age; Six service users may be under the age of 65 years and some service users may have dementia. The majority of the bedrooms are single with five bedrooms being shared. The adjacent Garden Cottage has three service users’ rooms for service users who are more independent. Services provided include personal care, meals, laundry and health care, with additional health services being accessed as necessary, for example, the district nursing services. Wyton Abbey DS0000019777.V250953.R02.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was completed as part of the programme of inspections for the year. It was an unannounced inspection undertaken by two inspectors, Sarah Sadler and Tom Tomlinson. The inspection day lasted from 9.30 am until 1.45 pm with a previous two hours preparation also undertaken. During the inspection a tour of the premises was completed, a number of services users were spoken with, both in their own rooms and in the communal areas of the home. Further time was spent reading service users’ care plans and files. Discussions were held with the new manager and staff throughout the day. Feedback was also given to the manager and their line manager at the end of the inspection. What the service does well: What has improved since the last inspection? There is a new manager in post who has worked hard to address the requirements of the previous inspection report. Although there are a number of outstanding requirements a good number of the previous requirements and recommendations have been met. The ambience of the home has improved greatly and service users appeared much calmer. Service users’ appearances were greatly improved and people looked clean and tidy. The cleanliness of the home has improved and service users now have access to more bathrooms and toilets. The home is now well lit. Visits as per the requirements of regulation 26 are now being undertaken and the new manager is receiving management support. A staff member confirmed that the new manager has made positive improvements to the home they stated, “ It is much better now.” Wyton Abbey DS0000019777.V250953.R02.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. Wyton Abbey DS0000019777.V250953.R02.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 Wyton Abbey DS0000019777.V250953.R02.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): 3,6 Service users cannot be assured that the home can meet their needs, as insufficient assessment is undertaken before they are admitted. EVIDENCE: Two of the three service user files assessed included an assessment of the service users needs. This included a general assessment of the service users personal care and health needs, an assessment of their mobility, communication and mental health needs. However the third pre admission assessment inspected contained only limited details of the service users needs. As the pre admission assessment is used as the basis of the care plan for each individual service user it therefore must contain detailed information about a service users needs and how these are to be met by the registered provider. The manager confirmed that intermediate care is not provided within the home. Wyton Abbey DS0000019777.V250953.R02.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): 7,8,9,10,11 Service users’ health and personal needs are not fully met. EVIDENCE: Two of the service user files examined contained an individual assessment and plan of care. These service user files included the details of the service users’ health needs, their GP, chiropodist, dentist and optician. Visits to or from these professionals, were recorded with the reasons for the contact. A visiting district nurse stated that she thought the home has improved greatly. However in one case a service user had an incomplete care plan, these service users had been resident in the home since August 2005. Also some of the assessments highlighted that risk assessments were required for a particular area of need, for example a behavioural or a mental health risk assessment. However often these risk assessments had not been completed. Also where risk assessments were available, these have not all been regularly reviewed. Assessments did not always include the name of the service user or the date the assessment was carried out. Wyton Abbey DS0000019777.V250953.R02.S.doc Version 5.0 Page 10 Assessments, care plans and risk assessments need to be kept up to date and fully completed to ensure service users care needs are communicated throughout the staff team and all staff are aware of how service users needs are to be met in a safe and consistent way. This remains an outstanding issue from the previous inspection Service users are assessed regarding their nutritional needs and a number had identified needs with taking a normal diet, however no records of the monitoring of service users’ weight were found. Only one file contained a copy of the service user review held with Social services. No other evidence was seen of regular care plan reviews within the home. One service user had two full days with no recorded entries in the daily notes. There are daily living profiles held within service user files that are provided to record events in their lives. For example, when they have a bath or are visited by the hairdresser. Again these are not always completed regularly. Staff were observed to speak respectfully to service users, asking if they could be of help to them. Service users’ appearances have improved greatly since the last inspection. Service users and their clothing were clean, people have had their hair combed and gentlemen had received a shave. The manager confirmed that this is an area she has worked hard on with the staff team. The work included the appointing of a new hairdresser. The manager detailed that after discussion with the pharmacist, all medicines requiring to be kept cool are stored in a separate lockable container in a fridge. She confirmed that some staff are undertaking accredited medication training, and that some staff have completed this training. There are no certificates yet in place for this training. However not all staff who administer medication have completed the training, this could pose a risk to service users and remains an outstanding requirement from the previous inspection. Records are now kept of all medicines administered in the home, this includes ointments and creams. Service users wishes regarding death and dying were well recorded. Wyton Abbey DS0000019777.V250953.R02.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): 12,13,15 Service users are supported to maintain relationships, but are not well provided for with social opportunities/activities. Not all support at mealtimes is provided in a dignified way. EVIDENCE: Service user files reflected some of the choices of service users, for example, ‘likes to watch TV’. However, service user records reflect few activities being undertaken. No activities were observed during the inspection. The manager stated that an activities session is completed every afternoon with staff and service users; again no formal records were available for this. There is a document in the service users’ file where key workers record the individual 1:1 time spent with the service user. The records in this are inconsistent and one file had no entries since April of this year. Relatives were observed to visit during the inspection and service user files included notes when people had visited, for example, “son visited today”. Service users were observed to be supported with their lunch, and service users spoken with were aware of the food choices for the day. One service user commented that the planned menu is not always the same as the actual food provided. Service users were observed to be able to choose what to eat for lunch and to change their choice at lunchtime if they wished to. Wyton Abbey DS0000019777.V250953.R02.S.doc Version 5.0 Page 12 Service users were supported by staff with the eating of their meal, with staff seated with service users. However one staff member was supporting two service users at once which is inappropriate and undignified. Also some service users appeared to have some specific needs in relation to the eating of their meals, however no specialist equipment was observed to be available, and the necessity for this was discussed with the manager. However in contrast to the last inspection this mealtime was unrushed and much calmer. Wyton Abbey DS0000019777.V250953.R02.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): 18 Service users are protected from abuse by the policies and procedures in the home. EVIDENCE: There is a policy held within the home that deals with the issues of abuse. There is also a copy of the Local Authority’s policy ‘ The Protection of Vulnerable Adults’. The manager confirmed that there have been no allegations of abuse since the last inspection. There are polices for the dealing with aggression and for if a service user is unexplainably absent from the home. Wyton Abbey DS0000019777.V250953.R02.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): 19,20,21,22,24,25,26 Service users reside in a home that overall is clean and comfortable, but which continues to require some improvements in relation to odour control. EVIDENCE: Service users now have access to more bathrooms and toilets. The home is now well lit. However some service users’ rooms continue to have an unpleasant smell and the staff members and manager confirmed that a new carpet is on order for one of these rooms, with cleaning being undertaken in the other room. One service user commented that the smell in the home prevents them from mixing with other service users. Service user rooms had staff call bells in place, however some of these, due to positioning, would not be easy for service users to reach and in double rooms there are not always two staff call bells available. When tested the call bell worked, and staff responded, however, as staff were unsure as to the room numbers it was some time before staff reached the appropriate room which could delay service users receiving necessary treatment as quickly as possible. Wyton Abbey DS0000019777.V250953.R02.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 Service users are on the whole supported by an adequate number of appropriately recruited staff, although all the staff are not well trained. EVIDENCE: The manager confirmed that all staffing vacancies have now been filled and that some of the staff hours have been redeployed in order to meet the needs of service users more effectively, for example there are now 3 cleaners available, who through adequate deployment ensure that the home does not go for long periods of time without being cleaned. Care staff supported more than one service user at a time with the eating of their meal, compromising the effectiveness of this support therefore more staff support must be made available to service users at mealtimes. Staff files included two written references and confirmation that a Criminal Records Bureau (CRB) and where necessary a Protection of Vulnerable Adults (POVA) check had been completed. Details were also available that staff identities had been checked as had employment matters, which may include their eligibility to work. Staff files included details of the training that staff had undertaken, this included; Food hygiene, COSHH, Fire and Moving and Handling. There is an induction process in place and recent employees have utilised an induction pack that relates to the Skills for Care (previously TOPSS) requirements. Wyton Abbey DS0000019777.V250953.R02.S.doc Version 5.0 Page 16 The manager confirmed that staff are undertaking accredited medication training and that some staff have now completed this. However certificates for this training is not yet in place and all staff who give out the medication have not had the training. The manager also confirmed that training specific to dementia care has not yet taken place due to difficulties in accessing this. This training is now planned for in the near future. One staff file included details of courses previously undertaken, this included; NVQ training, First Aid and Non abusive intervention. Approximately 25 of care staff have achieved the NVQ level 2 in care, 6 more have enrolled and it is recommended that at least 50 of all care staff deployed have achieved at least NVQ level 2 in care. One staff member confirmed that there had been an improvement in staffing since the commencement of the new manager. Wyton Abbey DS0000019777.V250953.R02.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): 31,33,38 A manager who has made some positive changes to the home supports Service users. However, not all of the Health and Safety needs of service users are met. EVIDENCE: There is a new manager in the home, who is working proactively to meet the requirements of the previous inspection report. One service user commented that she“….. Is very good”. Copies of the notes of management visits required under regulation 26 were available within the home. These reflect that these visits take place regularly and that they include; attending a service users’ meeting and speaking to relatives. Wyton Abbey DS0000019777.V250953.R02.S.doc Version 5.0 Page 18 There is a quality assurance system, which seeks the views of service users, and others involved with the home and from which an annual report is published with targets for change. Cleaning products were observed to be stored correctly. The lift has had the doors replaced. Fire extinguishers were in place, however the annual service was one month out of date. Some fire extinguishers were not stored on the wall as per their fixings and were placed on the floor. A five year electrical safety wiring certificate is not in place for the home, the registered provider has informed the Commission For Social Care Inspection that a member of Prime Life staff is undertaking training to carry out this check in all Prime life Care Homes, this is not yet complete. With regard to the homes call bell system please refer environment section of this report. Wyton Abbey DS0000019777.V250953.R02.S.doc Version 5.0 Page 19 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 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 X 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 3 3 3 1 X 3 3 1 STAFFING Standard No Score 27 1 28 2 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X X 1 Wyton Abbey DS0000019777.V250953.R02.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? Yes 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 OP3 Regulation 14 Requirement The registered person must ensure that an assessment is undertaken of all service users prior to them entering the home. This must include consultation with the service user and/or their representative. The registered person must ensure that • There is an individual up to date plan of care for each service user . • All documents are properly named and dated. • Contain up to risk assessments to address the identified needs of service users. This is an ongoing requirment with a previous compliance date of 11/5/05. The registered person must ensure that service users’ • weight is monitored and any changes acted upon. • receive appropriate support with their dietary intake, including specialist Version 5.0 Page 21 Timescale for action 15/11/05 2 OP7 13(4) 15,17 Sch 3 15/11/05 3 OP15OP8 17 Sch 3 15/11/05 Wyton Abbey DS0000019777.V250953.R02.S.doc equipment as professionally assessed as necessary. Staff support only one service user at a time with the eating of their meal. The registered person must ensure that only staff that have received appropriate training and have been assessed as competent may administer medication. This is an ongoing requirement with a previous compliance date of 6/5/05. The registered person must ensure that service users are provided with appropriate activities and key-worker time that reflects their interests and wishes with accurate records of this being kept. This is an ongoing requirement with a previous compliance date of 11/7/05. All call points in communal areas and individual service users’ rooms must be accessible to service users. Staff should be aware of the layout of the home, in order to be able to respond appropriately to the call bell The registered person must ensure that the home is free from offensive odours. The registered person must ensure that additional staff are available at peak times of activity. The registered person must ensure that staff are appropriately trained specifically in dementia care The registered person must ensure that the wiring in the home meets the requirements. This is an ongoing requirement with a previous timescale from DS0000019777.V250953.R02.S.doc • 4 OP9 13,18 15/11/05 5 OP12 16 11/07/05 6 OP22 23 17/11/05 7 8 OP26 OP27 13,16 18 15/11/05 30/04/05 9 OP30 18 11/07/05 10 OP38 13,23 30/04/05 Wyton Abbey Version 5.0 Page 22 11 OP38 23 the report of November 2004 and 30/4/05. The registered person must 15/11/05 ensure that the fire extinguishers are regularly maintained and correctly stored. 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 Refer to Standard OP8 OP28 Good Practice Recommendations The registered person should ensure that there are no gaps in the service user daily records. The registered person should ensure that 50 of the staff team are qualified to a minimum of level 2 in a National Vocational Qualification in care. Wyton Abbey DS0000019777.V250953.R02.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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. 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