Care Home: Abbey Grove

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What the care home does well Abbey Grove indicated in the information provided to the Commission that they had received positive feedback from residents at meetings and relatives about the service they receive. The manager demonstrated a commitment to ensure care was delivered to a high standard and relatives, staff and people living there spoke highly of the manager and the work she had done since her appointment. Staff demonstrated a clear understanding of their role and responsibilities on care and protection issues. Residents said they knew who to contact if they had a concern about the care they received and were confident their concerns would be acted upon.Residents spoke positively about the care they received. Resident and relative questionnaires indicated that staff supported them and listened to them. One person stated, "service is very good and staff are very friendly, caring and helpful". During the visit the atmosphere in the home was welcoming and friendly. Staff and residents took an active part in the inspection visit. Relatives and residents said the home always has a nice atmosphere. What has improved since the last inspection? The manager has in the months since the last inspection been registered with the Commission for Social Care Inspection and is now the registered manager at Abbey Grove. This means that she has met the requirements of registration and is fit to manage the service. To ensure that residents` needs are always met, care plans have been developed for each individual resident, which address aspects of need, and staff support required to meet those needs. Care plans are reviewed and are updated when residents` needs change. The care plans continue to need some development to clearly identify the individualised needs of residents. A requirement was made on the last inspection to hold a record of the investigation and outcomes of all complaints so that people are assured that any concerns are fully investigated. We were told that a new complaints procedure has taken affect in the home. A requirement in relation to the recruitment and selection procedure was also made on the last inspection. The home was required to ensure that the recruitment and selection procedures promotes the protection of the residents by obtaining a full employment history, taking references and completing criminal record bureau disclosures checks before employment wherever possible. We were told by the manager in paperwork sent to us before this visit that the home had simplified the job application form by inserting sub headings of information and in relation to employment history and references the home now explain verbally when people come, a full history of employment is required. Manual handling equipment is now monitored weekly to ensure that it is in working order and charged. A lock has been installed on the fridge, which contains medication as recommended on our last visit. Observations on this visit found that the fridge was not locked and alternative arrangements need to be arranged to ensure refrigerated medication is maintained securely.The hairdresser has now been allocated a bathroom, for resident`s hairdressing. We were told that the bathroom is rarely used by residents during the day, and these alternative arrangements allow more privacy. The recommendation to undertake an audit in order to prioritise which bedroom furniture should be replaced first has been undertaken as the home continue to improve bedrooms. The bathrooms all now have privacy locks fitted and have been decorated so that they convey a more homely and personal atmosphere. The manager has created a record sheet, which consists of the staffs training history, which allows her to monitor, which staff still require specific training. What the care home could do better: The manager must ensure that written care plans within residents` care files identify their individual care needs and that these are kept under review and changed to meet residents` current needs and preferences. The details that are recorded in the progress reports of how assessed needs are met should be improved upon to make sure there is sufficient detail to evidence the care provided. Staff need to be provided with direction and guidance on how these need to be completed. Risk assessments need to be in place for all residents, which need to be up to date and reflect the needs and support of the resident. A registered provider in accordance with the Regulations should complete a report as a result of the formal unannounced visit to the home and the report made of the visit, sent to the home and made available to the Commission. Notifications of events that affect the health and well-being of residents needs to be made to the CSCI as required by the Regulations. The home is advised to do a summary report of the findings of the recent questionnaire survey to people living in the home and include the findings in the home`s statement of purpose to evidence this consultation process. CARE HOMES FOR OLDER PEOPLE Abbey Grove 2-4 Abbey Grove Eccles Gtr Manchester M30 9QN Lead Inspector Kath Oldham Unannounced Inspection 18th June 2008 08:15 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 Abbey Grove DS0000008331.V366135.R01.S.doc Version 5.2 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. Abbey Grove DS0000008331.V366135.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbey Grove Address 2-4 Abbey Grove Eccles Gtr Manchester M30 9QN 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) 0161 789 0425 gailmboys@aol.com Coveleaf Ltd Gail Boys Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Abbey Grove DS0000008331.V366135.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th July 2007 Brief Description of the Service: Abbey Grove is a care home providing accommodation for 19 older people who require personal care only. The registered provider is Coveleaf Ltd. The home is a detached property, situated in a residential area of Eccles. It has small, enclosed grounds, with parking facilities to the side, rear and front of the property, and a patio area leading to a formal lawn area to the side of the building. A ramp provides access to the patio area. Accommodation for residents is provided on the ground and first floor. A passenger lift provides access to all floors. The home offers accommodation in 13 single bedrooms and three double rooms. There is ample communal space comprising of two lounge areas, quiet sitting areas and a dining room. The fees charged are £364.19 per week, with additional charges for hairdressing, personal toiletries, newspapers and magazines. Abbey Grove DS0000008331.V366135.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This visit was unannounced, which means the managers and staff were not told we would be visiting, and took place on 18th June 2008, commencing at 8:15am until 4.30pm. The inspection of Abbey Grove included a look at all available information received by the Commission for Social Care Inspection (CSCI) about the service since the last inspection. We also sent the manager a form before the visit for her to complete and tell us what they thought they did well, and what they need to improve on. We considered the responses and information provided and have referred to this in the report. We call this form the Annual Quality Assurance Assessment (AQAA). CSCI is trying to improve the way we engage with people who use services, so we gain a real understanding of their views and experiences of social care services. We are currently testing a method of working where ‘experts by experience’ are an important part of the inspection team and help inspectors get a picture of what it is like to live in or use a social care service. At this inspection an Expert by Experience was used. Comments from the Expert by Experience’s report are used in this report. The expert by experience had lunch with the residents and explained that they were prepared to pay for myself but no charge was made. The expert by experience enjoyed lunch and there was sufficient for them to eat. The expert felt the dining room itself was very pleasant and light and airy. All the service users the expert by experience spoke to “seemed very happy living at the home and all through my inspection the service users could not praise the staff enough”. The expert by experience in their report to the Commission for Social Care Inspection said, “the home appeared a pleasant home and was well decorated and very comfortable. The residents I spoke to said that they were getting good care and that they were being well looked after. All the residents appeared well groomed and their clothes were clean and neat and were well fitted. There was a friendly atmosphere about the home and pleasant repartee between the residents themselves and between the residents and staff”. Abbey Grove DS0000008331.V366135.R01.S.doc Version 5.2 Page 6 Abbey Grove was inspected against key standards that cover the support provided, daily routines and lifestyle, choices, complaints, comfort, how staff are employed and trained, and how the service is managed. The requirements and recommendations from the last inspection were assessed. There was six requirement and eight recommendations arising from that inspection. The requirements had been complied with from that inspection. Comment cards were sent prior to the inspection for distribution to people staying at Abbey Grove their relatives and staff, the views expressed in returned comment cards and those given directly to the inspector are included in this report. We found our information at the visit by observing care practices, talking with people staying at Abbey Grove; talking with the manager, assistant manager and staff. A tour of Abbey Grove was also undertaken and a sample of care, employment and health and safety records seen. The main focus of the inspection was to understand how Abbey Grove was meeting the needs of residents and how well the staff were themselves supported to make sure that they had the skills, training and supervision needed to meet the needs of guests. The care service provided to two residents was looked at in detail to help form an opinion of the quality of the care provided. A brief explanation of the inspection process was provided to the deputy on arrival at the home and later to the manager. Time was spent at the end of the day to provide verbal feedback to the manager. What the service does well: Abbey Grove indicated in the information provided to the Commission that they had received positive feedback from residents at meetings and relatives about the service they receive. The manager demonstrated a commitment to ensure care was delivered to a high standard and relatives, staff and people living there spoke highly of the manager and the work she had done since her appointment. Staff demonstrated a clear understanding of their role and responsibilities on care and protection issues. Residents said they knew who to contact if they had a concern about the care they received and were confident their concerns would be acted upon. Abbey Grove DS0000008331.V366135.R01.S.doc Version 5.2 Page 7 Residents spoke positively about the care they received. Resident and relative questionnaires indicated that staff supported them and listened to them. One person stated, “service is very good and staff are very friendly, caring and helpful”. During the visit the atmosphere in the home was welcoming and friendly. Staff and residents took an active part in the inspection visit. Relatives and residents said the home always has a nice atmosphere. What has improved since the last inspection? The manager has in the months since the last inspection been registered with the Commission for Social Care Inspection and is now the registered manager at Abbey Grove. This means that she has met the requirements of registration and is fit to manage the service. To ensure that residents’ needs are always met, care plans have been developed for each individual resident, which address aspects of need, and staff support required to meet those needs. Care plans are reviewed and are updated when residents’ needs change. The care plans continue to need some development to clearly identify the individualised needs of residents. A requirement was made on the last inspection to hold a record of the investigation and outcomes of all complaints so that people are assured that any concerns are fully investigated. We were told that a new complaints procedure has taken affect in the home. A requirement in relation to the recruitment and selection procedure was also made on the last inspection. The home was required to ensure that the recruitment and selection procedures promotes the protection of the residents by obtaining a full employment history, taking references and completing criminal record bureau disclosures checks before employment wherever possible. We were told by the manager in paperwork sent to us before this visit that the home had simplified the job application form by inserting sub headings of information and in relation to employment history and references the home now explain verbally when people come, a full history of employment is required. Manual handling equipment is now monitored weekly to ensure that it is in working order and charged. A lock has been installed on the fridge, which contains medication as recommended on our last visit. Observations on this visit found that the fridge was not locked and alternative arrangements need to be arranged to ensure refrigerated medication is maintained securely. Abbey Grove DS0000008331.V366135.R01.S.doc Version 5.2 Page 8 The hairdresser has now been allocated a bathroom, for resident’s hairdressing. We were told that the bathroom is rarely used by residents during the day, and these alternative arrangements allow more privacy. The recommendation to undertake an audit in order to prioritise which bedroom furniture should be replaced first has been undertaken as the home continue to improve bedrooms. The bathrooms all now have privacy locks fitted and have been decorated so that they convey a more homely and personal atmosphere. The manager has created a record sheet, which consists of the staffs training history, which allows her to monitor, which staff still require specific training. What they could do better: The manager must ensure that written care plans within residents’ care files identify their individual care needs and that these are kept under review and changed to meet residents’ current needs and preferences. The details that are recorded in the progress reports of how assessed needs are met should be improved upon to make sure there is sufficient detail to evidence the care provided. Staff need to be provided with direction and guidance on how these need to be completed. Risk assessments need to be in place for all residents, which need to be up to date and reflect the needs and support of the resident. A registered provider in accordance with the Regulations should complete a report as a result of the formal unannounced visit to the home and the report made of the visit, sent to the home and made available to the Commission. Notifications of events that affect the health and well-being of residents needs to be made to the CSCI as required by the Regulations. The home is advised to do a summary report of the findings of the recent questionnaire survey to people living in the home and include the findings in the home’s statement of purpose to evidence this consultation process. Abbey Grove DS0000008331.V366135.R01.S.doc Version 5.2 Page 9 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 summary of this inspection report can be made available in other formats on request. Abbey Grove DS0000008331.V366135.R01.S.doc Version 5.2 Page 10 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 Abbey Grove DS0000008331.V366135.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 & 3. Standard 6 is not applicable to this service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users have their needs assessed prior to making any decisions about moving into the home. EVIDENCE: Assessments were obtained from social workers and through the home’s own assessment before residents came to stay at the home whenever practicable. The registered manager told us that where possible she visits service users in their own home or placement to complete the homes own pre assessment procedure. Where service users cannot be visited, the assessment procedure is completed when the service users is admitted. Abbey Grove DS0000008331.V366135.R01.S.doc Version 5.2 Page 12 As part of the assessment process, people were also able to visit the home prior to accepting any offer of a placement. The first six weeks were on a trial basis after which a review took place. The purpose of the review was to ensure that the resident was happy with the care being received and the home could meet their needs. Completed surveys from residents told us they received enough information about the home prior to moving in, which enabled them to make an informed decision about living at Abbey Grove. A service user guide was given to relatives and residents, which informed them about the home and what could be provided. A copy of the service user guide and statement of purpose was within the bedrooms that we looked at, so residents could refresh themselves by reading these documents at their leisure. The statement of purpose has not been reviewed since August 2006 and there was information within the document that was out of date. This needs to be updated and kept under review so the detail is up to date and reflective of the service provided at Abbey Grove. Abbey Grove DS0000008331.V366135.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 &10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The detail contained in the care plans evidences that service users’ needs, including physical, personal, medical and social needs, are planned for and that staff will know how these should be met. EVIDENCE: Of the two care plans looked at both contained the correct information. However, more detail about service users personal preferences and preferred way they wish to receive support would ensure that the individuals’ needs were recognised and made known to care staff. In order to ensure that service users and staff can monitor personal belongings and identify when items are missing and or lost, each service users should have their own personal possessions list in place. These lists should details all Abbey Grove DS0000008331.V366135.R01.S.doc Version 5.2 Page 14 their belongings including clothing and bedroom fixtures and fittings, together with items such as jewellery and ornaments. There was a record to say care plans had been reviewed in the care files looked at. Residents require differing degrees of support in aspects of daily living. This was clearly evident from observations of direct intervention and support provided by staff. Independence and increased life skills should be promoted within a risk management framework. One of the care files looked at on this visit did not include up to date risk assessments. There should be documentary evidence that risk assessments had been updated to ensure that the staff team manage newly identified risks appropriately. There is a form within service users’ care files to record service users’ weights. One of the care files looked at recorded that the service users had lost a lot of weight from one month to the next. We were told that it was disputed that the previous months weights had not been done properly. This wasn’t recorded or the resident re weighed to double check. For the second service user there was only one weight recorded when they had been at the home for some time. The manager said she was confident that the service user had been weighed regularly due to their health problems. This record was not within the file examined. Service users should be weighed monthly, or more regularly if the care plan identified this as needed. Service users said the food was good and they ate well. Two service users said they were weighed each month and it was noted what they weighed so that they knew if they were gaining or loosing too much weight. One service user said they had never bothered about their weight when they were at home but understood that this was needed as the home could tell if everything was all right with them. We were told that service users’ preferences are addressed and, where this is not practicable due to mental health, then the relatives are able to contribute to their cared for service user’s preferred needs from their knowledge of that person. When talking with service users, they gave us positive feedback about the home. They confirmed that staff listened to what they said and attended to their needs appropriately. It was observed that the care and attention to detail was paid to service users. Service users looked clean and tidy and attention was paid to ensure hair, nails Abbey Grove DS0000008331.V366135.R01.S.doc Version 5.2 Page 15 and the appearance of service users was promoted. Service users said they were, “were being well looked after”. Staff were aware of the need to support all service users in the same manner, which ensures their dignity and respect, regardless of the service users ability to understand and or communicate. Abbey Grove works closely with health professionals to ensure that all service users’ health care needs are met. Domiciliary visits from opticians and podiatrists are arranged as required. The home feels they have a sound professional relationship with outside agencies such as district nurses, social workers and GPs. Examination of the records detailed visits to or from health care professionals. Health professionals spoken with on the visit indicated that staff carry out support to service users as indicated by district nursing staff. Service users had their health care needs met, by visiting health care professionals. When asked about the support they received they told us “we are well cared for” and “the staff are very good.” Examination of the daily reports, which are used by staff to record the support and intervention and the development of service users contained limited information. It was not recorded for example if service users took part in activity. One service user care plan identified that they liked to go to church. We were told that the service users went to church each week. This detail was not recorded in the daily reports. This limited information would not help the manager if an investigation into a service user’s care was needed. In order to gain consistency, the manager should review the daily recordings periodically and discuss any problems that some of the staff may be having with recording, during their supervision. The information provided to the Commission for Social Care Inspection by Abbey Grove has a medication policy that is adhered to. Examination of the medication administration records identified that the records had been completed recording medication administration. The medication administration records included a record of the staffs’ signatures in some cases as opposed to a record of their initials. The manager said she would remedy this. Abbey Grove DS0000008331.V366135.R01.S.doc Version 5.2 Page 16 Observations of the lunchtime medication administration process identified that staff were following guidelines and administering medication in a safe manner. We were told that staff with responsibility for administering medication had received appropriate and up to date training. The home does not have a system in place to evaluate staff practice when administering medication to ensure they are confirmed as continuing to be competent to administer medication. A photograph of each resident to aid identification, as is best practice was on the majority of medication records examined. This practice is good as if a service user was to go missing then a photograph would be available to aid their identification. It can also be used to identify any changes in residents’ appearance. We were told that two recently admitted service users would have a photograph on file as soon as possible. We discussed with the manager perhaps including this in the admission process then this oversight did not get forgotten. The medication administration records are printed by the pharmacist detailing the prescribed medication and when and how the medication should be given. The pharmacist provides these monthly. Handwritten medication was detailed on the medication administration records. This was usually when a new service user was admitted or when the doctor had visited and prescribed additional medication after the printed medication records have been received. Handwritten medication needs to be verified by a second member of staff to confirm that the detail is recorded accurately, so service users receive the correct medication at the right time. Some medication has limited shelf life and the date the medication is opened needs to be written on it to make sure it is safe. Two such medications did not have the date they were opened, so it could not be confirmed if the medicine was still in date. Medication that needs refrigeration is kept in the fridge in the kitchen. It was identified on the last inspection that this medication needs to be kept securely in a locked refrigerator. A devise has been fitted to the fridge. Due to the fridge being in the kitchen and staff needing access to provisions within the fridge, the fridge wasn’t locked. To safeguard service users alternative refrigeration storage or a different locking mechanism needs to be obtained. Abbey Grove said they strive to respect service users privacy and dignity at all times. The NVQ training, which some of the staff team have completed and others are working through, reiterates this important area. Abbey Grove DS0000008331.V366135.R01.S.doc Version 5.2 Page 17 Service users were seen to be spoken with discreetly when discussing personal care support and staff were observed knocking on doors before entering. Abbey Grove DS0000008331.V366135.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The provision of additional daily activities would add to service users’ stimulation and lead to greater physical, emotional and social health. This contributes to the benefits already received from visits from family and friends. EVIDENCE: Service users were complimentary about the meals and they said a choice was available to them. One service user said they themselves (the residents) had devised the menus and they include all meals that they like. We were told that the menus were to be reviewed again taking into account any changes in preferences and to make sure that new service users likes and preferences were included. It was of some surprise that the lunch time meal served on the visit was all shop bought with no home made cooking. We feel that service users enjoyment of meals will be further enhanced if food was home cooked. The cook works between the hours of 7.30am and 2.00pm. There is currently a Abbey Grove DS0000008331.V366135.R01.S.doc Version 5.2 Page 19 cook for 5 days each week. A vacancy has occurred for a cook the remaining days. We were told that staff do additional hours to cover cooking in the absence of the cook. These hours need to be recorded on the duty roster clearly indicating staff role whilst on duty. Lunch was taken with service users, staff were heard to ask individuals preferences and choices. One service user said she loved salads and liked to have salad each day. The salad was attractively presented and the service users said they thoroughly enjoyed it. One service user was heard to comment that they weren’t very hungry and only ate a small amount of their meal. An alternative was not provided of say a lighter meal. At feedback we were told that staff couldn’t have heard this service users comment, as an alternative would have been provided. Service users can have a hot drink with their meal. Some service users who live at Abbey Grove are independent and are able to do a lot of things for themselves. Staff were observed with a large teapot serving everyone drinks irrespective of their abilities. To further promote service users independence and to ensure they can just help themselves to drinks thought needs to be given to providing those service users who are able with smaller tea or coffee pots on the table so they can help themselves. It is understood that some service users would be at a great risk and these arrangements should be considered and each service users needs assessed to see that any risks are minimised. Serviettes were not on the table, which would further promote service users dignity. We were told that service users are not able to have a hot drink when they get up early in the morning as staff are busy getting other residents up and they wait until breakfast is served at 8.00am until they have a hot drink. Two service users spoken to said they got up early one around 6.30am and the other at about 6.40am. Staff need to arrange for service users to have a drink before breakfast is served at 8.00am. One service user commented that although they had never asked, they felt that a cup of tea would not be available during the night if they required it. At feedback the manager told us that any resident wanting a drink out of normal meals times, day or night would be attended to and this was always the case. Currently a hot breakfast option is not available with service users having cereals or cereal and toast. We were told that cooked breakfast had been offered in times past and service users did not want it. Service users should be provided with an opportunity of having a hot breakfast option and this needs to be explored by the home. Abbey Grove DS0000008331.V366135.R01.S.doc Version 5.2 Page 20 Service users’ meetings are arranged to enable service users to exercise their right to choice. Food and meal times are regular agenda items discussed at these meetings. Abbey Grove feels they encourage service users’ comments on improving the standards and service they deliver. Examination of the records didn’t detail what activities or stimulation was provided to service users or what impact this had on their day. The manager was surprised that this detail was not included in the records looked at. One service user said she helped with the washing up on occasions to keep herself busy. We were told that entertainers do come to the home periodically and residents said they enjoyed this. Birthday celebrations are arranged and events like St Georges day celebrations are organised with staff and residents dressing the dining room on the particular theme. Service users said that from time to time they had entertainment provided by some singers and that a quiz similar to “Name that Tune” took place. They said that they never had trips out from the home. The expert by experience said, “On talking to the residents I felt that more activities should be available as there did not seem to be a lot going on to break up the daily routine. I felt chair based exercises would have been a good activity for them as constantly sitting about does not do them a lot of good”. We were told that gentle exercises had in the past been arranged however these had not been organised in recent months. We were told that trips out had in the past been arranged but service users haven’t wanted to go when the day came. There was no information about what activities were planned for each day. In order to ensure that activities can be tailored to suit the needs of individuals, social assessments should be in place that identifies past, hobbies and interests, preferences then and now, remaining abilities and skills. Abbey Grove DS0000008331.V366135.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had relevant policies, procedures and systems in place to enable concerns to be raised and to protect residents from neglect and/or abuse. EVIDENCE: Information about how to make a complaint is included in the Service User Guide and residents have a copy of this in their room. We spoke to a number of residents who told us that if they had a concern or complaint they would “Go to Gail (manager)”, “I would speak with one of the girls” and “I would tell Wendy or Sarah (deputy manager)”. We examined the complaints records kept by the manager and these showed one complaint had been recorded since our last visit and that this had been appropriately dealt with. A policy was in place for the protection of vulnerable adults and staff were aware of how to put the policy into practice. Adult Protection training had been provided to staff and a date was booked for a staff member who had not yet done this training. Staff spoken to were aware of the whistle blowing policy. A strategy meeting had been held with the local authority regarding one resident and the home attended to the recommendations of that meeting to safeguard residents and further improve practice. Abbey Grove DS0000008331.V366135.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 &26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was clean, tidy and comfortable with systems in place to protect the health and safety of the residents. EVIDENCE: A visitor’s book is placed in the hall and visitors to Abbey Grove are encouraged to sign in and out. This is to ensure that in an emergency situation, everyone in the building is accounted for. A number of rooms are looking tired and would benefit from redecoration. Since the last inspection visit conducted in July 2007 improvements had been made to the environment. The manager had also carried out an updated audit of the standard of furnishings and decoration of all bedrooms and communal Abbey Grove DS0000008331.V366135.R01.S.doc Version 5.2 Page 23 areas of the home. Following this a number of bedrooms had been redecorated. A rolling programme of redecoration is in place to cover all areas of the home. There are a selection of chairs placed around the perimeter of the lounges, a large screen television is available in the larger of the two lounges. Within the lounge the arms on one of the chairs were loose and may not be safe for service users if they are using the arms to get themselves up. The expert by experience sat on a “chair in the lounge the armrest came away from the vertical support”. This information was given at feedback to the manager. Some of the bedrooms had an odour within them. We were told that carpets are shampooed periodically. The home is without domestic staff and we feel this is having an effect on the odour within the home. Domestic staff would have a routine of shampooing carpets to make sure there were no residual odours. Bedrooms were personalised, with items brought from residents’ homes. Some had a television and chose to spend time in the privacy of their rooms when they wished. A passenger lift is available to support residents getting upstairs to their bedroom. All communal areas, bedrooms and toilets were fitted with a call system. This enables residents to call for staff assistance or support. A service user said that the buzzer to call for assistance in their bedroom did not work and another service user said that they had difficulty using the key to get into their bedroom and they always had to call for assistance. We were told by the manager that she would enquire about the problems regarding service users having difficulty getting into their room and that she was aware of the buzzer not working in one of the bedrooms and that was being attended to. Maintenance contracts are in place and the manager stated Abbey Grove meets the requirements of Health and Safety, Fire and Environmental Health regulations Abbey Grove DS0000008331.V366135.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 &30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The recruitment and selection policies and procedures that are in place were not being fully adhered to leading to the potential for residents to be put at risk. The lack of dedicated domestic staff could compromise the cleanliness and freshness the home strives to achieve. EVIDENCE: We looked at staffing rotas and they demonstrated that enough care staff appeared to be on duty to meet the needs of those residents living in the home and the manager confirmed this. Staffing was discussed with two residents who said “Staff are very good – I’m glad I came to live here” and “(There is) always enough staff around – they are all good and help you when you need it”. We also spoke with a member of the staff team who said, “There is usually enough staff on duty, we are a good team of staff and we all work well together”. Abbey Grove are currently without any cleaning staff. On the inspection the home was clean however thorough cleaning tasks are not being undertaken as is necessary to ensure the house is thoroughly cleansed. Carpet shampooing Abbey Grove DS0000008331.V366135.R01.S.doc Version 5.2 Page 25 within bedrooms is taking place but not at the regularity that promotes an odour free environment. Comment cards indicated the home was always fresh and clean. The manager understood the comments made on the visit and was mindful that if cleansing routines are not maintained to the highest level it is harder to eradicate any malodours. We were told that a domestic had been appointed and was awaiting the necessary checks to be undertaken before staring work. It was hoped that these would be concluded soon. We suggested to the manager that the hours of the domestic are reviewed to ensure there are cleaning hours available at weekends, as if these were covered by care staff either additional care staff would need to be working at weekend or residents care needs would be compromised by care staff carrying out cleaning duties. Currently care staff that want additional hours covers these duties. Abbey Grove employs a cook for five days a week and the other two days care staff who want additional hours will do the cooking. The staff duty roster included the name of the staff and their hours of work and their usual role. We were told that staff do carry out cooking when the cook is off duty and in addition some cleaning duties are covered by care staff in the absence of a domestic. These additional hours worked in the differing roles need to be clearly defined on the duty roster. So it is clear what hours are allocated to which role. The home manages to retain staff and continues to have a low turn over of staff. We were told that two staff are currently signed up to undertake NVQ training so the majority of staff now have this qualification. The home completed its own induction, which appeared to be of a good standard, staff also attend induction training issued by Skills for Care, which supports continuing professional development, including helping prepare workers for entry onto the appropriate Health and Social Care National Vocational Qualification (NVQ). Where prospective employees state they have qualifications, they should produce certificates, and where the home relies on them to confirm staff are trained, copies should be retained on file. This was the practice within the files looked at. The manager told us that she keeps an individual record of all the training staff undertakes and we saw evidence of this. We saw that individual records Abbey Grove DS0000008331.V366135.R01.S.doc Version 5.2 Page 26 contained the date training took place, the type of training attended, whether the training had been successful and the date of review. The manager also told us that most of the care staff team had successfully completed National Vocational Qualification training Level 2. Examination of a newly appointed staff file identified that one reference was obtained after the staff had commenced employment. A thorough recruitment and selection procedure goes some way to protect service users and staff and should be adhered to. Before staff commence work at Abbey Grove criminal record disclosure and POVA first checks are sent for. In the staff file examined the disclosure had not been returned. The manager stated that their continues to be difficulties in obtaining full CRB check in a timely manner from the statutory bodies. Staff who commence employment on a POVA first should shadow a member of staff and should not support service users alone. This safeguard is in place to ensure the safety of service users and staff. Abbey Grove DS0000008331.V366135.R01.S.doc Version 5.2 Page 27 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35, 36 &38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems and procedures were in place, which safeguard and protect residents. Tightening up of the recording systems to evidence fire training will further safeguard service users and staff. EVIDENCE: Since the last inspection the manager has been successful in obtaining registration with the Commission for Social Care Inspection. This means that she has attended a fit person interview with the registration team at CSCI and has satisfied them that she has the skills and qualifications to be registered. Abbey Grove DS0000008331.V366135.R01.S.doc Version 5.2 Page 28 The registered manager has completed the registered managers award level 4. The deputy is currently studying to obtain NVQ 3 qualifications. The registered person should, in line with Regulations, visit the home once a month and undertake specific tasks to check that Abbey Grove is being managed appropriately. We were told that the registered person does visit the home very regularly and speaks to residents individually. A report of these visits had not been completed. The home was informed that these need to be done and a copy kept at Abbey Grove available for examination by the Commission. A quality assurance system is in place that seeks and acts upon the opinions of residents in terms of their day-to-day experiences and improvements that could be made. The home is advised to do a summary report of the findings of the recent questionnaire survey to residents and include the findings in the home’s statement of purpose to evidence this consultation process. The management team supports staff and there was evidence of an ongoing supervision programme for staff. This ensures that senior staff monitor the performance of staff and any training needs are identified. The sample of staff files looked at provided evidence that some staff had received supervision and appraisals. All staff need to receive these sessions with their line manager up to six times each year. The supervision sessions need to examine staff performance in delivering care and identify any training needs. Fire equipment had been regularly maintained. Not all staff had recorded that they had taken part in fire drills. It is essential that staff are aware of what to do in the event of an emergency. We informed the manager that staff must on their next duty take part in a fire drill practice and sign to say they have undertaken this. We were informed after the inspection that all staff on duty have now received this essential training and as staff return from holiday or sickness they will also have this training. The checks to the fire alarm system had been recorded as having been undertaken at the regularity indicated by the fire authority. This ensures that equipment is working properly so in the event of an emergency staff would be alerted to this fact quickly. There is a keypad on the back door for which a code is needed to leave the house. To safeguard residents and staff, Abbey Grove needs to consult with the fire authority to check that this is appropriate as, in an emergency situation, the code to the door will need to be known to enable people to leave from this exit. Staff meetings are arranged which provides staff with an opportunity to influence how Abbey Grove is run and contribute to its effectiveness. Abbey Grove DS0000008331.V366135.R01.S.doc Version 5.2 Page 29 Accident records were available and monitoring of accidents had been undertaken. To protect the privacy of residents the collation of these records needs to be changed. All incidents affecting the health and wellbeing of residents should be routinely reported to the Commission. This is not routinely being undertaken as required by the regulations. To ensure the Commission is aware of these events the manager needs to arrange for this information to be sent to us routinely. We were told that staff did not help manage residents’ personal finances. There were small amounts of money held on behalf of some residents for purchases of toiletries and such like. Those records looked at were in order with receipts in place and balances indicated. We were told that the manager and deputy have access to these finances and residents can requests amounts from their monies at any time. Abbey Grove DS0000008331.V366135.R01.S.doc Version 5.2 Page 30 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 2 Abbey Grove DS0000008331.V366135.R01.S.doc Version 5.2 Page 31 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement Timescale for action 31/07/08 2 OP38 37 Ensure that risk assessments are in place for all residents that are up to date and reflect the needs and support of the individual. The manager must ensure that 04/07/08 she keeps us informed of any event within the home which effects the well-being of a resident. 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 Refer to Standard OP33 OP7 OP7 Good Practice Recommendations A summary report of the outcomes of the recent survey should be included in the homes statement of purpose to evidence this consultation process. Further develop the care plans detailing the actual care and support needed to ensure service users get the care they need when they need it. Daily records should reflect their daily life within the home, service user achievements and individuality as well as DS0000008331.V366135.R01.S.doc Version 5.2 Page 32 Abbey Grove 4 5 OP7 OP9 cares staffs’ individual support. Each service user should have an accurate and up to date personal possessions list, which includes clothing and fixtures, fittings and personal items. To safeguard service users and to make sure refrigerated medication is kept securely and at the right temperature obtain a fridge that locks or fit to the fridge a lock which is kept locked. To further promote service users with additional opportunities to be independent provide those who are able with tea/coffee pots on the table at mealtimes of a design and size, which they can help themselves. Review and amend the menus to provide service users with a hot meal option at breakfast. Provide service users as a matter of routine with the opportunity to have a hot drink when they get up in the morning. The homes staffing rota should clearly detail the names and staffing positions of all staff. Those staff undertaking cooking duties should be clearly identified and the time spent on such duties. The staffing rota should record the individual hours worked including those worked by staff covering ancillary duties. Ensure that there are sufficient numbers of cook and domestic staff employed at the home to maintain and enhance the cleanliness of the house and to ensure care staff are not undertaking these duties when they should be providing care or support to service users. To safeguard and protect service users and staff, ensure the recruitment and selection procedures are followed correctly and two references are received before staff commence employment and staff that have started in an emergency on POVA first checks do not work alone. Provide all staff with one to one supervision with their line manager at a minimum of six times a year to assist staff in their development and identify any training needs. The sessions should include discussion of care practice, training needs, the philosophy of the home and the progress of residents. To protect the privacy of residents the accident book must be used correctly in accordance with the Data Protection legislation. To ensure that the safety of residents, staff and visitors is not compromised in an emergency situation by the placement of a keypad on the back door, Abbey Grove needs to consult with the fire authority to check that this DS0000008331.V366135.R01.S.doc Version 5.2 Page 33 6 OP15 7 8 9 OP15 OP15 OP27 10 OP27 11 OP29 12 OP36 13 14 OP38 OP38 Abbey Grove 15 OP31 practice satisfies fire regulations. A formal unannounced visit by a registered provider should be undertaken in accordance with the Regulations and a report made of the visit, which is kept at the home and made available to the Commission on request. Abbey Grove DS0000008331.V366135.R01.S.doc Version 5.2 Page 34 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Abbey Grove DS0000008331.V366135.R01.S.doc Version 5.2 Page 35 - 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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