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Care Home: Abbey Lodge Residential Care Home

  • Cranmore Avenue Tettenhall Wolverhampton West Midlands WV6 8PW
  • Tel: 01902745181
  • Fax: 01902745181

Abbey Lodge is a large detached house that has been extended to provide accommodation and personal care for 25 older people. It is situated in a private residential area on the outskirts of Wolverhampton approximately 1.5 miles from Tettenhall village where the amenities include a post office, shops and a public house. The accommodation consist of one double bedroom and 23 single bedrooms, of which some benefit from en-suite facilities, two lounges, conservatory a dining room, laundry, kitchen, staff room and Registered Manager`s office. There is a car park at the front of the building and gardens and to the front and rear. The current fees range from £358.00 to £420.00 per week Information of the home and the provision of the service are available in the statement of purpose and service user guide, both documents have recently been revised and are readily available. Commission for Social Care Inspection reports for this service are available from the provider or can be obtained from www.csci.org.uk

  • Latitude: 52.591999053955
    Longitude: -2.1679999828339
  • Manager: Mrs Susan Wyn Shelley
  • Price p/w: £389
  • UK
  • Total Capacity: 25
  • Type: Care home only
  • Provider: Mrs Shanta Arjan Odedra,Mr Arjan Bhoja Odedra,Mr Vijay,Daljit Takhar,Jasvinder Takhar
  • Ownership: Private
  • Care Home ID: 1211
Residents Needs:
Dementia, Old age, not falling within any other category

Previous Inspections

This may not be the latest inspection for this service as we are having techinical problems updating from CQC - please check directly on the regulators website for the most recent report; bestcarehome hopes to be back to regular updates shortly.

For extracts, read the latest CQC inspection for Abbey Lodge Residential Care Home.

CARE HOMES FOR OLDER PEOPLE Abbey Lodge Residential Care Home Cranmore Avenue Tettenhall Wolverhampton WV6 8PW Lead Inspector Bhag Jassal Unannounced Inspection 1st 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 Lodge Residential Care Home DS0000066038.V370615.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 Lodge Residential Care Home DS0000066038.V370615.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbey Lodge Residential Care Home Address Cranmore Avenue Tettenhall Wolverhampton WV6 8PW 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) 01902 745181 01902 745181 Mr Vijay Odedra Mr Arjan Bhoja Odedra, Mrs Shanta Arjan Odedra, Jasvinder Takhar, Daljit Takhar Care Home 25 Category(ies) of Dementia (7), Old age, not falling within any registration, with number other category (25) of places Abbey Lodge Residential Care Home DS0000066038.V370615.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The home should only accommodate up to 7 (seven) service users with mild dementia. The home must provide safe and secure gardens. Females 60 years and above and males 65 years and above Date of last inspection Brief Description of the Service: Abbey Lodge is a large detached house that has been extended to provide accommodation and personal care for 25 older people. It is situated in a private residential area on the outskirts of Wolverhampton approximately 1.5 miles from Tettenhall village where the amenities include a post office, shops and a public house. The accommodation consist of one double bedroom and 23 single bedrooms, of which some benefit from en-suite facilities, two lounges, conservatory a dining room, laundry, kitchen, staff room and Registered Managers office. There is a car park at the front of the building and gardens and to the front and rear. The current fees range from £358.00 to £420.00 per week Information of the home and the provision of the service are available in the statement of purpose and service user guide, both documents have recently been revised and are readily available. Commission for Social Care Inspection reports for this service are available from the provider or can be obtained from www.csci.org.uk Abbey Lodge Residential Care Home DS0000066038.V370615.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 Star. This means the people who use the service experience good quality outcomes. This report is on a Key Inspection, part of which included an unannounced visit undertaken on 1st September 2008. This unannounced visit started at 09:00 and lasted 8 hours and 10 minutes. The home had 23 places occupied and 1 remains vacant. The judgements made within this report are based upon information supplied by the home, from interviews with staff, people who use the service and their relatives. During the course of inspection the assessment information and care plans were inspected for 4 people who use the service. Medication administration was checked. Staff records were seen to check staff rotas, recruitment procedures and training. Various documents were seen in order to check compliance with health and safety legislation. A tour of premises was also undertaken, and care practices and interaction between staff and people who use the service were observed. Discussions took place with several members of staff on duty, and several people using the service and two visiting relatives were spoken to throughout the day of inspection. The Acting Care Manager was present throughout the Inspection. Mr Jaswinder Takhar – Responsible Individual was present briefly in the morning and the Deputy Manager was also present for most part of the inspection. On this occasion all the key Standards of the National Minimum Standards were inspected. Regulation 37 Notifications, concerns and complaints against the home, and Regulation 26 reports received from the care home and an Annual Quality Assurance Assessment (AQAA), which had been completed by the Acting Care Manager and submitted to the Commission for Social Care Inspection (CSCI) prior to this inspection, offering a full overview of the home were considered and discussed with the Acting Care Manager. We wish to thank the Acting Care Manager, the Responsible Individual, the staff, people using the service and their relatives for their assistance and cooperation on the day of inspection. Abbey Lodge Residential Care Home DS0000066038.V370615.R01.S.doc Version 5.2 Page 6 What the service does well: The home provides a relaxed, comfortable and friendly atmosphere where people are treated with respect and in a dignified way. The home makes every effort to provide people with good care to meet their assessed needs following a care plan. The home has a good key worker system and staff supervision system in place. The home communicates well with the families, friends and representatives of people who use the service and welcomes visitors. People who use the service say they are happy and content with living in a homely and caring place. The feedback the home received in April 2008 via quality assurance questionnaires from people included: • “ The staff and the Manager always appear to be helpful and friendly and try and create a good atmosphere. Overall we are pleased with the care my mother receives and she seems to be very content. Well done”. “ Thank you for helping my mother to settle in her new home. She has found the transition difficult. It is great comfort to know that she is in a safe, secure and caring environment”. “ We do appreciate the fund raising activities and film evenings, fish & chips nights. Great atmosphere at party times”. • • People who use the service are often vulnerable both physically and emotionally and the Registered Provider and the Acting Care Manager ensure that staff recruited have the ability to carry out personal care services for people sensitively and tactfully. The recruitment of good caring staff is critical to the running of care homes and the Registered Provider and the Acting Care Manager at Abbey Lodge undertake this carefully. The home has a good staff training and development programme in place. A majority of staff have received mandatory training in safe working practice topics, safe handling of medication, Adult Protection and safeguarding issues and NVQ Level 2. Thus this training will ensure that the staff have improved their knowledge and skills to meet the changing needs of people who use the service. The home provides good standard of accommodation and facilities for people using the service. What has improved since the last inspection? Abbey Lodge Residential Care Home DS0000066038.V370615.R01.S.doc Version 5.2 Page 7 The home has implemented all 3 requirements and two recommendations from the previous key inspection report. People commented that: • • “Lots of recent improvements to décor and fittings etc. I am pleased that at long last a new correctly sized boiler for central heating has been installed”. “The facilities and the care provided by management and staff is far superior than previous years”. The home has an experienced Acting Care Manager in post and she is managing the care home well. Conversations with staff, people using the service and their visiting relatives, indicated that the Acting Care Manager is service user focused, leads and supports an enhanced staff team providing them with improved training and supervision. This style and approach to management aims to pursue future improvements in all aspects of service. One person who lives at the home stated that “This place is a lot more peaceful and better organised now”. The home has made some good improvements in their record keeping and care planning. Care Plans seen for people who use the service were informative and gave good indication of how care is to be delivered for each of them. Medication practices have improved and more senior staff have received training in safe handling of medication. The home has organised staff training on Dementia care. A majority of staff have received training in safe working practice topics, abuse awareness/adult protection and that will enable them to expand their knowledge and skills and enhance the care they give to people using the service. What they could do better: The home should continue to improve further the detail and quality of daily care recordings. Activities enjoyed by the people who use the service should be consistently recorded, evaluated and incorporated into their individual care plans. Those members of staff who as yet have not received training in safe working practice topics, including Infection Control/COSHH, safe handling of medication, Dementia care, NVQ Level 2, Adult Protection/safeguarding issues must do so as a matter of priority. This training would enable staff to improve further their care practices, knowledge and skills. Abbey Lodge Residential Care Home DS0000066038.V370615.R01.S.doc Version 5.2 Page 8 The AQAA submitted prior to this visit by the Acting Care Manager stated that “ We will continue to monitor all aspect of care and service we provide to ensure the best result is achieved to ensure that the service users have an excellent quality of care”. 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 Lodge Residential Care Home DS0000066038.V370615.R01.S.doc Version 5.2 Page 9 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 Lodge Residential Care Home DS0000066038.V370615.R01.S.doc Version 5.2 Page 10 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 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Everyone receives a full assessment prior to admission to the home to make sure that their needs can be met. EVIDENCE: Abbey Lodge care home provides detailed and clear information, in the form of a Service Users’ Guide, to people who will be using the service and their families to enable them to make decisions about whether or not to live at the home. Admissions are not made to the care home until a full assessment has been undertaken. The home is then able to confirm that they can meet the needs of the individual through the service they deliver as detailed in the Statement of Purpose. For people who are self-funding and without a care management assessment, they always receive assessment by the Acting Care Abbey Lodge Residential Care Home DS0000066038.V370615.R01.S.doc Version 5.2 Page 11 Manager. 4 files/care plans of people who use the service were inspected, which contained pre-admission assessments of their needs, both from assessments by the home’s senior staff and other relevant professionals. Observations and discussions with people using the service, their visiting relatives, the Acting Care Manager, and staff on duty indicated that the home continues to meet the needs of older people in a satisfactory and sensitive manner. It was noted from the staff training records that a majority of staff have undertaken their training in Dementia care and adult protection and safeguarding issues. The home does not provide a service for those assessed and referred solely for intermediate care, who require help to maximise their independence and return home. Abbey Lodge Residential Care Home DS0000066038.V370615.R01.S.doc Version 5.2 Page 12 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 who use the service have individual plans of care, which ensures that their personal, healthcare and social needs can be met. Medication is administered and stored in a manner that safeguards everyone using the service. People who use the service are treated with respect and dignity and their right to privacy is understood and upheld. EVIDENCE: People who use the service undergo an assessment of their needs prior to admission to the care home. A Care Plan is produced, which is based on the assessment of needs. The home operates a good key worker system, which helps to ensure that the recommendations arising from the care plan reviews are implemented. Four Care Plans of people using the service were inspected and examined in detail. There was evidence to show that the short-term goals and long-term goals, aims and objectives were clearly identified and appropriate interventions required to meet the individual needs of people who Abbey Lodge Residential Care Home DS0000066038.V370615.R01.S.doc Version 5.2 Page 13 use the service were also identified. The detail and quality of daily care recording has improved since the last inspection. Discussion with people who use the service showed that the home has a good ethos of involving them in all aspects of their life. The care plans that were read were clearly written and included an element of risk assessment. Information from the initial assessments had been written into plans of care. The care plans are reviewed on a monthly basis by senior staff. Care Plans demonstrated that the staff actively promoted the rights of people who use the service of access to the health services both within the home and the community. Appointments are planned or arrangements are made for professionals to visit frail people using the service. Whenever possible continuity of care for the service users’ declining state of health is assured. District Nurses are called upon to assist with clinical help, equipment and advice where necessary. The Acting Care Manager promotes the key worker system so that relationships between staff and individuals are enhanced. Visitors are able to meet people using the service in their bedrooms, in the lounge or in the visitors’ room on the ground floor. It was observed that people who use the service were being treated with respect and staff were working both professionally and sensitively in meeting individual needs. We spoke at length with several people using the service and all of them commented positively about their care and felt they have everything that they need. Four people who use the service stated that “The carers are very good and kind and they look after us very well”. Two other people who use the service said “The carers are always there to help us”. Generally people who use the service appeared to be content and comfortable. They were complimentary regarding the quality of their lives and care they were receiving at Abbey Lodge care home. There are appropriate policies and procedures in place for the administration of medication. It was noted that the care plans contained a list of current medication. The Acting Care Manager stated that reviews are carried out on a regular basis of all the care plans to ensure that medication details are up to date. Appropriate records are kept of all medicines received, administered and leaving the home. Random sample of medication and administration sheets were seen at the inspection and there were no discrepancies. All the medicines are stored in the medication room kept under lock and key. Daily checks are taken of the temperature of the medicines in the refrigerator and the medication room. There are controlled drugs used by one service user at the care home, which are stored securely and safely in a lockable metal cupboard in the medication room. Abbey Lodge Residential Care Home DS0000066038.V370615.R01.S.doc Version 5.2 Page 14 Medication rounds were observed during the inspection. Senior staff were seen to administer and record when medicines had been given. The Acting Care Manager stated that all senior staff responsible for administering medication were appropriately trained in safe handling of medication. Abbey Lodge Residential Care Home DS0000066038.V370615.R01.S.doc Version 5.2 Page 15 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 who use the service are able to exercise choice with regard to social and leisure activities at the home. Activities provided meet the needs of the people using the service. Relatives and friends are encouraged and assisted to maintain contact with the people using the service. The food at the home is of good quality and choices are always available. EVIDENCE: The home provides an activities programme in accordance with everyone using the service, their choices, preferences and capacities in relation to – social, leisure and cultural interests. People using the service, who were able to give opinion, were very complimentary about the activities provided, and particularly the external entertainers. People who use the service are enabled to enjoy a full and stimulating life style with a variety of options to choose from. A record of activities participated in is kept and photographs of major events displayed in the home. However, the activities enjoyed by the people who use the service need to be evaluated, consistently recorded and incorporated into their individual care plans. Abbey Lodge Residential Care Home DS0000066038.V370615.R01.S.doc Version 5.2 Page 16 People using the service were seen sitting in the lounges chatting to staff and visiting relatives and in other communal areas within the home. Three people who use the service stated that they preferred to sometimes sit quietly in their bedrooms and the staff respected this. After lunch time a number of people who use the service were engaged in playing different games or watching television. Several people using the service spoken to stated that they were in regular contact with their family members and friends, and spoke about their visitors’ involvement and interest in their care matters. The visitors’ book kept in the home showed a considerable activity. People who use the service also keep contacts with the local community – for example, church services, pubs, shops and park. Five people who use the service told us that they are happy with the care and social activities offered by the care home. They further added “the home provides a good service and the staff are very caring and they are pleasant”. The home also provides a variety of indoor activities, including festive and birthday parties. The Acting Care Manager stated that the people who use the service were positively encouraged and helped to exercise their choices, and control over their lives and daily living, subject to risk assessments in terms of safety, security and capacity to make certain decisions. The Acting Care Manager also stated that a close liaison is maintained with the relatives and representatives, where the people using the service are not able to make certain decisions. The relatives of people using the service and their representatives are informed of the availability of Advocacy Service based at the local Age Concern. The information about the Advocacy Service is included in the home’s Statement of Purpose and Service Users’ Guide. Several people who use the service told us “The home is very good and its peace and quiet here”. “The food was very nice well cooked and tasty”. The consensus of people using the service was the range, quality and choice of food provided was very good and the home catered for those people using the service, who have individual preferences and medical needs. The Acting Care Manager stated that the menu is changed regularly in consultation with the people who use the service. This is usually done in accordance with seasonal changes as well. The kitchen is well equipped and kept clean and tidy. The catering staff are trained in food safety and hygiene matters. Abbey Lodge Residential Care Home DS0000066038.V370615.R01.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. There is clear Complaints Procedure in place, a copy of which is made available to people who use the service and their relatives. This should ensure that any complaints made are listened to and acted upon. The home has an Adult Protection policy and procedure in place to protect people who use the service from all forms of abuse. EVIDENCE: The home has a good Complaints Procedure in place, which is referred to in the home’s Service Users’ Guide and in the Statement of purpose. There is a system of recording concerns and complaints. The AQAA completed by the Acting Care Manager states “ We have open door policy so that relatives and service users or any other persons can discuss any complaints/concerns as soon as they arise. Policies and procedures revised annually, complaints procedure is in place and visible” The Commission for Social Care Inspection (CSCI) has received two complaints about the care home, which were dealt with promptly by the home. There was no adult protection referral made during the last 12 months. Abbey Lodge Residential Care Home DS0000066038.V370615.R01.S.doc Version 5.2 Page 18 People, who use the service, when asked, were certain of how to formally make a complaint but they said they would quite happily talk to one of the staff or the Manager. The home has good policies and procedures in place regarding restraint, dealing with aggressive behaviour and prevention of abuse, which includes whistle-blowing policy. The Acting Care Manager stated that adult protection issues are discussed during induction training and supervision meetings. The Acting Care Manager stated that a majority of staff have received formal training in protection of vulnerable adults and those who as yet have not received this mode of training will do so as a matter of priority. She also stated that trainers are being approached to set up this training. Several people who use the service stated they are satisfied with the service provision, feel safe and well supported by staff that have their protection and safety as a priority. Abbey Lodge Residential Care Home DS0000066038.V370615.R01.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 standard of the environment is good providing a homely, clean and secure place to live. EVIDENCE: The home offers a comfortable and well-maintained environment to all people who use the service. The home has ample communal space – two lounges, a dining room and a conservatory on the ground floor. The home has a rolling programme of redecoration to maintain good standards. The small garden and patio areas are well - maintained. The home has provided suitable aids and adaptations in the home to meet the general and specific needs of all the people using the service. There are adequate numbers of bathrooms/showers and WCs in the home. It was noted that the bedrooms are “personalised” by most of the people using the service. Abbey Lodge Residential Care Home DS0000066038.V370615.R01.S.doc Version 5.2 Page 20 During the day of inspection, the home was found to be clean, tidy and free from any unpleasant odour. However, there were several bedroom carpets in need of thorough steam cleaning. The Acting Care Manager stated that these carpets will be cleaned immediately, but they are due to be replaced shortly by new floor covering as part of the ongoing refurbishment programme. It was also noted that bedrooms and a bathroom on the first floor were being refurbished. The Acting Care Manager stated that on completion of all the outstanding refurbishment work, all indoor and outside areas will be tidied up by the end of September 2008. The home has good policies and procedures in place regarding infection control/COSHH. An infection prevention and control audit was carried out of the home on 14th March 2008 by the Wolverhampton PCT – Infection Prevention and Control Team. The overall result of the audit was 83.3 (Green). However, it was noted from the staff training records that a majority of staff have undertaken training in infection control and those members of staff who as yet have not received this mode of training will do so shortly and as a matter of priority. It was noted that all new members of staff received induction training and they are made aware of the dangers of cross-infection. Abbey Lodge Residential Care Home DS0000066038.V370615.R01.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. Abbey Lodge care home is staffed by well-trained and experienced staff to meet the needs of people who use the service. There are robust recruitment procedures in place to protect people who use the service. There is a good training programme in place that ensures staff are competent to do their jobs. New members of receive structured induction training. EVIDENCE: Information provided by the home and available staff rotas for the months of August and September 2008 indicated that the home has sufficient care staff to meet the needs of the 23 people using the service at present. There is one senior carer or deputy manager and three carers on duty in the morning and one senior carer or deputy manager and three carers in the afternoon shift. Two carers are on wakeful night duty and a senior member of staff on-call. The Acting Care Manager’s hours are supernumerary. There are adequate number of ancillary staff employed in the home to cover catering, cleaning and maintenance duties throughout the week. The staff training records showed that a majority of staff have completed their NVQ Level 2 qualification and three members of staff have also completed their Abbey Lodge Residential Care Home DS0000066038.V370615.R01.S.doc Version 5.2 Page 22 NVQ Level 3 training. The remaining members of staff who as yet have not received this mode of training will also be nominated to undertake this mode of training shortly. The home does not employ Agency staff. The staff team is a well-balanced group in terms of age, experience, gender and ethnicity. Four staff files were examined in detail in order to check compliance with the recruitment requirements. All four files contained copies of two written references, and a full employment history. There was evidence on staff files that all four had been subject to satisfactory Criminal Records Bureau (CRB) and POVA checks prior to being appointed. There was evidence on files that staff have received the statements of their terms and conditions of employment. There is a staff training and development programme in place. In addition to the mandatory training (see NMS OP38) staff also would benefit from training in adult protection/safeguarding issues, Mental Capacity Act 2005, equality and diversity, and physical aggression/challenging behaviours. Staff confirmed that training is provided and there are many opportunities to improve themselves for the benefit of the care of people using the service. All new staff received their induction training in accordance with the Skills for Care standards and specifications. People who use the service commented that they feel safe with staff caring for them and they felt that the home employs people that are capable of carrying out their care duties. Abbey Lodge Residential Care Home DS0000066038.V370615.R01.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 who use the service can be assured that the home is run in their interests. Financial interests of people using the service are safeguarded. The home promotes the health, safety and welfare of people who use the service. EVIDENCE: The Acting Care Manager – Ms Susan Shelley has made an application to be registered with the CSCI earlier this year and she has been through the “Fit Person Interview” process and awaiting the decision of the CSCI. Ms Shelley is currently undertaking her Registered Managers’ award and then is to complete her NVQ Level 4 in care qualification. She appears to be managing the home Abbey Lodge Residential Care Home DS0000066038.V370615.R01.S.doc Version 5.2 Page 24 well. There are clear lines of accountability within the home and the Acting Care Manager is well supported by the Registered Provider. The home has a formal staff supervision system in place, and Ms Shelley is implementing the system of supervision of staff and meetings both with staff and people using the service. Observations made and discussions with people who use the service and their relatives and staff have indicated that the Acting Care Manager is very approachable and she operates an ‘open door’ policy. People who use the service, who could express themselves stated that they are happy to approach the manager and staff with any problems they might have and were confident that they would respond to them appropriately. Equality and diversity for people who use the service were seen to be promoted throughout the home within the assessments, care plans and activities. Equality for staff is promoted through the opportunities for training at all levels. The home has a Quality Assurance monitoring system in place. Quality Assurance takes place throughout the service in both a formal and informal manner. Meetings and day-to-day contacts all provide records to show that satisfaction is at the heart of the service for people who use the service. Surveys were carried out for the years 2007 and 2008. A report on the result of the feedback from people who use the service and their relatives had been prepared. The comments received were generally very positive. In addition, stakeholders’ survey was also carried out and the feedback was also positive. Financial records and administrative procedures relating to the handling of the monies of people who use the service were looked at and were found to be well ordered and maintained. The home actively encourages people using the service, where able, to manage their own money. The home keeps records to show that health and safety of people who use the service is promoted and protected. It was noted that the hot water supply in all the hot water outlets was not available in afternoon due to the refurbishment work being carried out in the bathroom on the first floor. This matter was raised with the Acting Care Manager and she undertook to ensure the hot water supply is restored immediately in the same evening to the recommended temperature level of close to 43 Degrees C. Several self-closure devices fitted on the bedroom doors were in need of checking and appropriately adjusting to ensure they close properly to their rebate to protect people using the service from the risks of fire. The Acting Care Manager stated that this matter will be addressed immediately. The staff training records showed that a majority of staff have received their mandatory training in safe working practice topics, e.g. moving and handling, food hygiene, first aid, health and safety and fire safety. The Acting Care Abbey Lodge Residential Care Home DS0000066038.V370615.R01.S.doc Version 5.2 Page 25 Manager stated that all those members of staff who as yet have not received this mode of training will do so shortly. They will also receive training in Adult Protection/safeguarding issues, safe handling of medication, Infection Control, NVQ Level 2, Mental Capacity Act 2005 and Dementia care. People who use the service spoken with were very complimentary about the Registered Manager and staff in the home. Many of them knew who they were by name and looked at ease in their presence. Abbey Lodge Residential Care Home DS0000066038.V370615.R01.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 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 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 Lodge Residential Care Home DS0000066038.V370615.R01.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. Standard Regulation Requirement Timescale for action 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 OP12 Good Practice Recommendations Records of all activities enjoyed by the people who use the service should be consistently maintained and also incorporated into the individual service user care plans. The home should also consult with people using about what they would like the home to provide in terms of a range of indoor and outdoor social and leisure activities. The Registered Providers should provide staff with training in Safeguarding Adults to ensure they are familiar with the process of recognising potential abuse and formal referral process. Appropriate action should be taken to ensure that essential maintenance and repairs, such as those identified in this report are dealt with promptly. This is to ensure that people live in a comfortable and safe home. 2. OP18 3. OP19 Abbey Lodge Residential Care Home DS0000066038.V370615.R01.S.doc Version 5.2 Page 28 4. OP30 The Registered Providers should consider providing staff training in Dementia care, Mental Capacity Act 2005, equality and diversity and aggressive/challenging behaviours in order to safeguard, and fully meet the needs of people using the service. The Registered Providers should make sure that all those members of staff who as yet have not received mandatory training in safe working practice topics do so as soon as practicable in order to ensure safety of people who use the service. Action should be taken to ensure that a consistent supply of hot water at all times at a high enough temperature for the comfort of people who use the service but with the safeguards in place against the risk of scalding. 5. OP38 Abbey Lodge Residential Care Home DS0000066038.V370615.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 Lodge Residential Care Home DS0000066038.V370615.R01.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. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!

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