Care Home: Abbey Hey Care Home Ltd

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What the care home does well The home is comfortable, homely and clean. Residents are happy, relaxed and enjoy an active lifestyle if they wish. Staff are well-trained and observed, and the manager makes sure that they available in sufficient numbers. Staff are friendly and approachable. The activities co-ordinator is very effective and enhances people`s lives through her personality and the variety of activities she offers, including: discussions, sing-alongs, quizzes, board and card games, arts and crafts and trips out. People spoken to liked the food provided by the home and the menus included a wide range of mainly classic English dishes that were appropriate for the group of residents living at the home. Visitors said that they were made welcome and that the residents they came to see generally presented as being well cared for and happy. Recruitment procedures ensured that people were vetted properly before working at the home; this meant that residents were protected from abuse. The manager is approachable and understands the actions she needs to continually improve the services provided at Abbey Hey. The manager is aware of the importance of asking for advice from relevant professionals about equipment needed for the home, to help staff and to assist residents to maintain their independence. The person who returned the survey commented: `They meet all the needs of my mother.` What has improved since the last inspection? The manager has started the process of updating assessment and care plans with information received about people. The care plans and files of recent admissions were detailed and complete. The procedure for the recording of controlled medicines is robust and an accurate record is kept of the numbers of medicines in the home.The manager now has records confirming that health and safety issues, such as fire drill records, are properly maintained and available. What the care home could do better: The registered person must continue to improve the information in care plans and care files to make sure that they contain all the information possible about the needs, events, and experiences of people living at Abbey Hey; this is so that everyone`s care can be effectively monitored. This will ensure that for every person, changes in needs are quickly recognised and appropriate interventions or changes in the care plan quickly made. The registered person must ensure that staff who manage medication always fully records the instructions about the dose, frequency and special instructions if they writing the Medication Record Chart. Two people must check-in medication so that the entries reduce the risk of mistakes. This will ensure that people always receive the correct medication, at the correct time and in the correct dose. All records and reports about people living at the home must be available in a way that is individual, so that they can be presented in individual files and not compromise the confidentiality of others. Residents would benefit further if all staff completed an accredited dementia care course. CARE HOMES FOR OLDER PEOPLE Abbey Hey Care Home Ltd 1 Delemere St Oldham Lancashire OL8 2BY Lead Inspector Michelle Haller Unannounced Inspection 3 September 2008 09:00 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 Hey Care Home Ltd DS0000005484.V367302.R02.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 Hey Care Home Ltd DS0000005484.V367302.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbey Hey Care Home Ltd Address 1 Delemere St Oldham Lancashire OL8 2BY 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 624 9518 0161 624 9518 Abbey Hey Care Home Limited Paula Finn Care Home 39 Category(ies) of Dementia (2), Dementia - over 65 years of age registration, with number (25), Old age, not falling within any other of places category (15), Physical disability over 65 years of age (15) Abbey Hey Care Home Ltd DS0000005484.V367302.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 39 service users to include: *up to 15 service users in the category of OP (Old age not falling within any other category); *up 15 service users in the category of PD(E) (Physical disability over 65 years of age); *up to 25 service users in the category of DE(E) (Dementia over 65 years of age); *up to 2 service users in the category of DE (Dementia under 65 years of age). No service user under the age of 55 to be admitted into the home. The service must at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 26th September 2007 2. 3. Date of last inspection Brief Description of the Service: Abbey Hey is a purpose built residential home for up to 39 service users, situated close to Oldham town centre, public transport and local amenities. The home is registered to provide care for service users in the following categories: Older People, service users with Dementia and those with a Physical Disability. Accommodation is provided in 34 single rooms, of which 33 have en-suites, and three shared rooms with en-suites. On the ground floor there are two large lounges and two smaller rooms, which can be used for dining or socialising, plus a large dining room. There is an additional lounge for service users on the first floor. Bathrooms and toilets are fitted with aids and adaptations in order to promote service users independence. Service users have access to a small enclosed patio area and a small seating area to the front of the property. Fees for accommodation and care at the home range from £343 to £380 per week. Additional charges are also made for hairdressing, newspapers and chiropody. Abbey Hey Care Home Ltd DS0000005484.V367302.R02.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 star. This means the people who use this service experience good quality outcomes. This was a key inspection that included an unannounced visit to the service. This means that the manager did not know in advance that we were coming to do an inspection. During the visit we looked around the building, talked to residents, relatives, staff and the registered provider. We observed the interactions between people living at Abbey Hey and examined care plans, files and other records concerned with the care and support provided to residents. We also looked at all the information that we have received or asked for since the last inspection. This included: The annual quality assurance assessment (AQAA) that was sent to us by the service. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. Information we have about how the manager has managed any complaints and adult protection issues that may have arisen. What the manager has told us about things that have happened in the home through ‘notifications.’ We also received one Commission for Social Care Inspection (CSCI) survey that was returned to us by a person with an interest in the service. At the time of this inspection, there was one protection of vulnerable adult investigation occurring. This investigation concerned an alleged incident between a resident and a member of staff. Abbey Hey Care Home Ltd DS0000005484.V367302.R02.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The manager has started the process of updating assessment and care plans with information received about people. The care plans and files of recent admissions were detailed and complete. The procedure for the recording of controlled medicines is robust and an accurate record is kept of the numbers of medicines in the home. Abbey Hey Care Home Ltd DS0000005484.V367302.R02.S.doc Version 5.2 Page 7 The manager now has records confirming that health and safety issues, such as fire drill records, are properly maintained and available. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Abbey Hey Care Home Ltd DS0000005484.V367302.R02.S.doc Version 5.2 Page 8 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 Hey Care Home Ltd DS0000005484.V367302.R02.S.doc Version 5.2 Page 9 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): 3 (standard 6 not applicable) Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. People moving into Abbey Hey benefit from well-planned care, because they have their care needs fully assessed before moving into the home. EVIDENCE: At this inspection we looked at the care files and admission records for five people living at Abbey Hey. These included long established residents and new admissions. The records were clearly written and contained information that confirmed that pre-admission assessments had been carried out by the social worker or referring agency and senior staff. This information was detailed and informed the manager of the level and type of support that would be needed to meet individual needs. The information included health needs, moving and handling needs, communication and nutritional and skin care assessments. Abbey Hey Care Home Ltd DS0000005484.V367302.R02.S.doc Version 5.2 Page 10 The assessment also showed that people were encouraged to have choice, as personal preferences such as preferred foods, bedtimes and personal care issues were highlighted. Signatures confirmed that assessments had been discussed with the person or their relative. This aspect of support could be improved if there was consistently more detail in relation to people’s social skills and previous interests. An individual keyworker is allocated to people when they move into the home. In the information returned, the manager stated that: ‘As a manager I personally visit to carry out care plans and risk assessments.’ This was verified through the evidence available on the day of inspection. Abbey Hey Care Home Ltd DS0000005484.V367302.R02.S.doc Version 5.2 Page 11 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 and 10. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. People at Abbey Hey benefit from having access to health and personal care, in keeping with assessed needs, and in a manner that promotes independence, a sense of wellbeing and maintains their dignity. EVIDENCE: Five residents were case tracked and the care files for several others were looked at regarding specific issues identified during the inspection. Care plans were generally person-centred and provided information that related to the assessments. Signatures of residents and their relatives confirmed that they had been involved in the development of these. Updated reports and changes to the care plans examined confirmed that care was reviewed and action taken to deal with changes identified. Abbey Hey Care Home Ltd DS0000005484.V367302.R02.S.doc Version 5.2 Page 12 Risk assessments relating to falls prevention, pressure area care, nutrition and diet and moving and handling were in place so that people received the best care in relation to reducing the risk of harm and maintaining maximum independence and comfort. Due to changes in the filing system and lack of detail in daily records, it was, at times, difficult to confirm that all people had received routine and specialist health care. However, when asked, the manager was able to provide evidence that people living in the home had recently been visited by the optician, dentist and podiatrist. It was also evident from records made in relation to updating medication that the general practitioner was involved in people’s care. Equipment was in place that confirmed that specialist health workers, such as community-based nurses, were involved in assessing needs and arranging the appropriate intervention. Turn charts were kept to ensure that staff completed pressure area care as required. The district nurse visiting the home was interviewed and she confirmed that the staff were capable of following instructions that were left. She confirmed that they were diligent and always requested guidance before situations became serious. The nurse confirmed that health care was always provided in privacy. The manager is in the process of reassessing all people at Abbey Hey; this process is important because she and the registered providers are relatively new to the home, and it is important to re-establish a base line of the current needs of people in the home and ensure that care plans are based on accurate and up-to-date information. Daily records are maintained. The information in these varied in respect of how much they related to the care plans or gave a description of what was happening for individuals from day to day. Some provided a clear picture in relation to a person’s mood, how staff had applied the information in care plans and how successful this had been, or there was detail about the visits from health professionals, such as the general practitioner, district nurses or friends. Other daily records gave little information and the same information for each day. The importance of staff always providing detailed ongoing information so that care and support can be accurately monitored was discussed with the manager. She acknowledged that she aware of this and was part way through the process of auditing care plans and daily records. This needs to continue until all staff are consistently working to the same high standard. Abbey Hey Care Home Ltd DS0000005484.V367302.R02.S.doc Version 5.2 Page 13 The weight for each person was seen on each file and where people lost weight, there was documentary evidence that the dietician or general practitioner had been informed, and appropriate intervention had taken place, such as investigating possible causes, fortifying the diet and prescribed food supplements. On the day of this inspection everyone living at the home was seen and each person looked well cared for. They were clean, hair was neatly combed and clothes were nicely laundered. People wore glasses that were clean. Oral care appeared effective, in that people had clean teeth. One person commented ‘We’re kept nice - our nails are cleaned.’ Staff related to the residents in a gentle kindly manner. They took time when completing moving and handling procedures, explaining all that they did. All personal care was dealt with discreetly and in private. Staff spent time talking to people and listened to their concerns before responding. One relative said: ‘Mum was ill recently and they were excellent! you‘ll find everything is fine.’ I’m sure Examination of several medication records showed that regular medicines had, in the main, been received, administered and recorded satisfactorily. However, there were two areas that the manager needed to deal with at the time of the inspection – one was that medication had not been entered on the medication administration record sheet correctly and the other was the need for her to ensure that the pharmacy provided MARS that allow her to ensure that the dates on the sheet correctly correspond to date that medication is given. There were no errors in relation to the controlled medication stored in the home. Abbey Hey Care Home Ltd DS0000005484.V367302.R02.S.doc Version 5.2 Page 14 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. People at Abbey Hey benefit from having a lifestyle that keeps them motivated, meets their individual interests and promotes contentment and a positive sense of wellbeing. EVIDENCE: An activities organiser has been appointed who works 25 hours per week. There was evidence through records kept and pictures and art work displayed throughout the home of the events that had taken place. These included an Easter bonnet parade, trip to Knowsley Park, working in the garden, cookery, games and quizzes and in-house entertainers. These pictures had been developed in large sizes to make sure that the residents could enjoy them. Abbey Hey Care Home Ltd DS0000005484.V367302.R02.S.doc Version 5.2 Page 15 The records demonstrated that the there was always an activity that most people could enjoy at some level. During the inspection the activities coordinator was observed as she and other members of staff entertained and related to the residents. People in the home were having a really good time. The care staff put on music that people enjoyed and spoke to people before the co-ordinator arrived. People sang and nodded to the music, they were encouraged to speak to each other and there was a lot of fun and laughter heard throughout the day. The service is flexible and staff treated people as individuals and in a manner that was reassuring, for example, if someone was petting a soft toy dog and asked staff to join in, the staff would talk to that person about a dog they might have owned and pet the toy dog as requested. The conduct of the staff encouraged good relationships between people living at Abbey Hey. Many of the people living at Abbey Hey have short-term memory loss. It was noted that the staff successfully dealt with these differing needs by adapting the way in which a game was played, making it possible for it to be appropriately challenging for each person. This was impressive because it was observed that the more independent residents copied the techniques and ways of communicating used by staff and so related well to residents with short-term memory loss. The record detailing the individual events and activities that people participated in was examined and confirmed that activities included reminiscence, board games, noughts and crosses, gardening, sing-along, quizzes and cards to dominoes, relaxation exercises, life stories, arts and crafts and bowling. The record showed that all the residents had been given the opportunity to participate in something and also identified their level of enjoyment. Care staff take responsibility for ensuring that people remain motivated when the activities co-ordinator is not available. A member of staff said ‘On Friday me and another girl did karaoke in the evening.’ The relative who returned a CSCI survey also stated ‘They are very good at providing activities, games, quizzes, etc., in the home and organising trips to the safari park, garden centre, etc.’ During the inspection people were seen using all parts of the home independently or with staff. There are quiet areas and a smoking lounge, which was used by one person at the time of the report. Visitors were noted at different times of the day and there did not appear to be any restrictions. Abbey Hey Care Home Ltd DS0000005484.V367302.R02.S.doc Version 5.2 Page 16 People commented ‘Oh there’s no problem, I come the same time each day.’ There is a four-week menu that is currently under review. The new menu will provide a varied diet. Residents will continue to have a choice of cereals, porridge, grapefruit and cooked options for breakfast. Typical food for the main meal of the day will continue to include roast dinners, casseroles, meat and potato pie, poached and baked fish, shepherd’s pie, and lamb, turkey and corned beef hash, and there will be a vegetarian option. Teatime meals will change to homemade soups and sandwiches, such as pea and ham and tomato; minced beef and onion pie; poached fish; salmon fish cakes; meat and potato pie and other hot choices. Meals for the day were displayed on a whiteboard outside the two dining rooms. Lunch on the day of the site visit was sausage and mash with carrots, swede, cabbage and onion gravy. The dessert was Angel Delight. The choice for tea was hot dogs and onions with chips followed by assorted cakes. Mealtime was a very pleasant occasion, the dining room and furniture were clean and people could choose where they had their meals. Both the meals served on the day of inspection were looked at; they were well presented and smelled very appetising. The staff placed jugs of fruit squash drink near each person and these were replenished throughout the day. Hot drinks were also offered frequently. Comments made by people about the food included: ‘The food’s ok and there’s lots of it.’ Staff commented that ‘Food is good - people have good meals and they do change - it’s not always the same.’ Abbey Hey Care Home Ltd DS0000005484.V367302.R02.S.doc Version 5.2 Page 17 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 arrangements in place ensure that people at Abbey Hey are listened to and protected from abuse while they live at the home. EVIDENCE: The complaints policy was available in the reception area of the home. Information in the care files confirmed that the complaints procedure was explained to new admissions. Relatives who were spoken to said they never had any complaints but would speak to the manager if they had any concerns and were certain that issues would be dealt with fairly. The person who returned the CSCI survey indicated that complaints were ‘usually’ dealt with appropriately, but this person did not give any examples of their experience. The record of complaints was looked through and those recorded had already been dealt with at a previous inspection. Abbey Hey Care Home Ltd DS0000005484.V367302.R02.S.doc Version 5.2 Page 18 There has been one adult protection safeguarding concern investigated by Oldham Metropolitan Borough Council’s Adult Protection team. The manager followed the expected procedure in informing all agencies, including ourselves. As yet, this investigation undertaken by the local authority has not been concluded. The manager ensures that a record of all incidents between service users is recorded and acted upon. The home’s policy states that residents who have been verbally or physically aggressive are closely monitored and a written report made about their whereabouts and mood is to be completed each hour or more frequently, depending on the risk assessment. This record book was examined and the information confirmed that steps were taken to keep people safe in this respect. It was also discussed with the manager however, that this information should be part of the care plan and be recorded directly into individual files or be easy to transfer once the issue has been fully dealt with. This same issue was identified at the previous inspection and should be remedied this time round. Staff who were interviewed were asked about the home’s adult protection procedure. One member of staff, who had worked at the home for just over four months, confirmed that she had received training at her previous employment, but that this had been updated when she began work at Abbey Hey. A recent recruit who was on her induction period was interviewed and she said that the senior staff and the manager had spoken to her about safeguarding adults. She also confirmed that she was aware of the training available and that she was due to start this within the next few weeks. This person was able to describe the type of incident that could be considered to be abuse and was confident in saying that if she reported something that was not dealt with to her satisfaction, she would inform Social Services. Staff have also received training in dealing with aggression and challenging behaviour. Abbey Hey Care Home Ltd DS0000005484.V367302.R02.S.doc Version 5.2 Page 19 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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The environment at Abbey Hey is clean, well furnished and specious and meets the needs of the people living there. EVIDENCE: Since the last inspection the ownership of Abbey Hey has changed and the new owners have begun a programme of redecoration and refurbishment. The communal areas of the property were readily accessible to the residents. The environment is light and airy. People were seen mobilising and using the facilities with assistance and independently. The home was clean and free from unpleasant odours. Furniture and fittings were also clean and free from any stains. The rooms were welcoming. Abbey Hey Care Home Ltd DS0000005484.V367302.R02.S.doc Version 5.2 Page 20 Toilet and bathroom doors have been labelled with the appropriate easy read symbol, which is in large print, light on a dark background. This helps people to recognise these areas. Most bedrooms that were looked at were homely and had been personalised with ornaments, pictures and family photographs. Some people had a television or radio in their rooms. Bedding was clean and looked new. All the bedrooms, except for one, provided en-suite facilities. Specialist equipment was in place, such as mobile commodes, hoists, feeding cups and adapted cutlery. The patio area was neat and tidy and planters had been put in place. It was clear from photographs and discussion with the residents that they spent time outside when the weather allowed. A small room was designated for residents wishing to smoke. The outcome in the area will improve further if the environmental needs of people with dementia are taken into account when redecorating the home and upgrading the fixtures, fittings and furniture. Abbey Hey Care Home Ltd DS0000005484.V367302.R02.S.doc Version 5.2 Page 21 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 and 30. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. People at Abbey Hey benefit from staff who are well-trained, employed using a robust recruitment process and available in sufficient numbers to meet their needs. EVIDENCE: On the day of this inspection there were 28 people living at Abbey Hey. The complement of staff for the day was: the manager plus five care staff and an agency worker, the cook, domestic and laundry assistant and the activities organiser. This staffing seemed ample for the number and needs of the residents. The manager and the registered provider stated that they were maintaining a good staff complement so that staff could be released for training. There are three staff on duty at night. The staff files for five people were examined, including the most recent recruits. These files were well-organised and contained evidence that confirmed that the manager uses a robust recruitment and selection process, which should assist in employing people who are suitable for working in a care home. Abbey Hey Care Home Ltd DS0000005484.V367302.R02.S.doc Version 5.2 Page 22 Each file contained a copy of the application form, confirmation of Criminal Record Bureau checks, two references and items confirming proof of identification. Notes made relating to phone calls that were made confirmed that the manager verified references if she was uncertain of their authenticity. The new recruit who was interviewed stated that she had commenced the induction programme using a workbook. She stated that the manager used videos and workbooks and questionnaires to provide training. She stated that this did help her to understand what she needed to do and how she should behave. The manager stated that she was in conversation with Oldham training partnership for some courses, such as medication training. The manager and registered provider stated that it was their intention to equip the manager with the skills to provide staff training through completion of the ‘train the trainers’ course. The manager said induction training was arranged through Oldham MBC and was in line with Skills for Care specifications. Of 22 care staff, 12 had successfully obtained NVQ level 2 and a further seven had enrolled for the training. This equates to 54 of care staff being trained at the present time. The training records confirmed that the majority of staff had attended various training courses since the previous inspection. This included first aid, nutritional support, dealing with challenging behaviour, protection of vulnerable training, food hygiene, moving and handling and fire training. The training calendar also included infection control and health and safety. Abbey Hey Care Home Ltd DS0000005484.V367302.R02.S.doc Version 5.2 Page 23 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 and 38. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. People benefit from a management team who understands the importance of providing a safe and efficiently run service that will ensure that people involved in the home are protected, well-informed and able to comment about what happens there. EVIDENCE: Since the last inspection the manager has completed the CSCI registered manager process. The ownership of the home has also changed. Abbey Hey Care Home Ltd DS0000005484.V367302.R02.S.doc Version 5.2 Page 24 The manager has achieved the registered manager’s award, NVQ level 4 and is an NVQ assessor and moving and handling facilitator. The manager has worked hard to deal with some of the issues identified at the previous inspections and she has worked hard to ensure that people living at Abbey Hey have a good quality of life from day to day. She clearly works to an ethos that places a high value on people been treated as individuals and with respect and dignity all times. Maintenance records demonstrated that the manager has ensured that health and safety checks have been completed in keeping with the manufacturer’s recommendations. The accidents and incidents record was examined. When these were completed properly, it was possible to track the accident and identify the support provided, the manager also assessed the accident and gave instructions about how to prevent a recurrence. It was also noted, however, that there were times when it was not possible to fully track the treatment and ultimate outcome of an accident through these and the daily records. This is because they were not updated when, what appeared to be, a minor injury turned out to be more serious. This means that there was a risk of staff not having the full picture of what had occurred for people and therefore the observations and interventions that may be needed. It also means that if there are concerns about an accident or care given by staff, the manager would find it difficult to prove that staff had carried out the correct observation and sought medical advice as soon as possible. The issues around comprehensive and clear record keeping is unfortunate because, in all other aspects, the manager has made great strides in improving the support and lifestyle of people living at Abbey Hey. People appeared genuinely happy to be there. The atmosphere is really homely. The manager was very approachable and confirmed that she was efficient, wanted to run a good home and would listen. The company undertook a quality assurance survey for residents and their representatives in January 2007 and was able to provide an action plan of how they were addressing points raised through this. The money held for four people was checked; the amounts balanced with the ledger that was seen and receipts were available showing that any expenditure was for the benefit of the resident. Records showed that weekly checks had been made of the building and equipment in respect of fire prevention and health and safety. Staff were seen to be using safe working practices. Abbey Hey Care Home Ltd DS0000005484.V367302.R02.S.doc Version 5.2 Page 25 Throughout the day staff wore aprons and used alcohol skin rub while providing personal care. Some people had returned from hospital with acquired infections; these people were being supported in their rooms and all precautions in relation to dealing with bedding, hand washing, wearing aprons and gloves were adhered to. People said that they liked living at Abbey Hey: ‘Yes, its all good really.’ Abbey Hey Care Home Ltd DS0000005484.V367302.R02.S.doc Version 5.2 Page 26 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 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 Abbey Hey Care Home Ltd DS0000005484.V367302.R02.S.doc Version 5.2 Page 27 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 OP9 Regulation 13 Requirement Staff must follow the correct procedures to ensure that an accurate record of the amount of medicines in the home is maintained which will allow the manager to be confident that all medication has been received and given as prescribed. Timescale for action 01/11/08 Abbey Hey Care Home Ltd DS0000005484.V367302.R02.S.doc Version 5.2 Page 28 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 OP7 Good Practice Recommendations The manager should make sure that, for every person, daily reports and information in care files, provide an accurate and detailed record of the care given to people and how they have progressed. The manager should make sure that any records relating to the care of residents are stored appropriately to maintain confidentiality. The registered person should provide all care staff with dementia care training so that they can improve further their understanding and communication skills in this area. 2 3 OP10 OP18 Abbey Hey Care Home Ltd DS0000005484.V367302.R02.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Manchester Area Office Unit 1, 3rd Floor Tustin Court Port Way Preston PR2 2YQ 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 Hey Care Home Ltd DS0000005484.V367302.R02.S.doc Version 5.2 Page 30 - 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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