Care Home: Abbeyfield Grange

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CARE HOME ADULTS 18-65 Abbeyfield Grange 148 Burngreave Road Sheffield South Yorkshire S3 9DL Lead Inspector Ivan Barker Key Unannounced Inspection 13th January 2009 12:05 Abbeyfield Grange DS0000002931.V373808.R01.S.doc Version 5.2 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 Abbeyfield Grange DS0000002931.V373808.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 Adults 18-65. 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. Abbeyfield Grange DS0000002931.V373808.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbeyfield Grange Address 148 Burngreave Road Sheffield South Yorkshire S3 9DL 0114 275 9482 0114 275 9996 abbeyfieldgrange@aol.com 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) Mr Kenneth Trevor Brack Ms Zofia Sabina Janina Britain Ms Zofia Sabina Janina Britain Mrs Rachel Kirsty Coates Care Home 26 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (26) of places Abbeyfield Grange DS0000002931.V373808.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd January 2007 Brief Description of the Service: Abbeyfield Grange Care Home comprises two houses. Numbers 143 and 148 Burngreave Road. Number 148 is the main care home with extensions and has room for twenty beds and the second building Number 143 which is across the road, has room for six beds. The home caters for people with mental health problems. It is registered to provide personal care and support to men and women between the ages of 18 - 65 years. However, the clients are all male. The home is in a residential area of Burngreave and near a GP surgery, a hospital, day centres and other amenities. There is regular public transport to the city centre and other areas from Burngreave. The fees range between min £329 and max £360 Abbeyfield Grange DS0000002931.V373808.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 that the people who use this service experience good quality outcomes. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations – but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. Only a limited number of the National Minimum Standards were examined at this inspection (with emphasis on the ‘key standards’), and the previous requirements. The person present at the inspection was: Shaun Jordon, deputy manager. Within this site visit, which occurred over a four hour and fifteen minutes period, the inspector toured the building, examined requirements relating to the previous inspection, case tracked 3 people (Case tracked means looking at the care and service provided to specific people living at the home; checking records relating to their health and welfare, care plans and other records; by talking to the people who use the service; viewing their personal accommodation as well as communal living areas), and spoke with other people, and 3 staff and examined assessments, care plans, risk assessments, menus, complaint files, staff files and quality monitoring documents. The history of the service was examined prior to the site visit. This included the Annual Quality Assurance Assessment document, telephone contacts, letters, notifications etc. People who use the service will be referred to within this report as people. What the service does well: Through monitoring during visits and comprehensive documentation being drawn up, the service and each member of staff will be aware of the people’s needs prior to admission. People will benefit from up to date comprehensive documentation as the staff will be aware of the persons needs. The peoples quality of life will be enhanced because of the availability of activities and outings and the participation within their selection of their meals. Abbeyfield Grange DS0000002931.V373808.R01.S.doc Version 5.2 Page 6 People were able to exercise their right of choice and they were able to express their concerns and these were acted upon. The people commented that they went out to places as they wished and confirmed that there was a choice of a second meal and expressed that they were satisfied with the food. The environment, monitored at this inspection, was clean, homely and generally maintained to a good standard. The atmosphere within the service was warm, friendly and relaxed. The staff recruitment process regarding the checking of staff will contribute toward the protection of the people who use the service. Two experienced registered managers were in post. This will contribute to the effective organisation and operation of the service. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The 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. Abbeyfield Grange DS0000002931.V373808.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Abbeyfield Grange DS0000002931.V373808.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Through monitoring during visits and comprehensive documentation being drawn up, the service and each member of staff will be aware of the people’s needs prior to admission. EVIDENCE: The deputy manager advised that the potential people who were looking to live at the service were assessed over several visits. The visits were first for a few hours, then for dinner, dinner and tea, and an overnight or a weekend stay. Following these visits a case review with the case manager or placing Local Authority / Health Authority would be held to discuss if the persons needs could be met at this service. The assessments were comprehensive and detailed all the social and health needs of the person so that it informed the service and staff of their needs so that further accurate documentation could be produced. Abbeyfield Grange DS0000002931.V373808.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6,7 and 9 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People will benefit from up to date comprehensive documentation as the staff will be aware of the persons needs. EVIDENCE: On examination of the documentation, it was found that these were extensive and details all aspects of the care needs of the individual. These included the required social, mental and physical interventions. However there was not a care plan to identify the needs of the individual and the care to be delivered on a daily basis. It was discussed that this document would be an easy reference rather than reading all the other documents on a daily basis. The deputy manager advised that he could see the practicalities of such a document. There was a daily record, known to the staff in the service as the individuals hand over sheet. This had been completed on a daily basis. When asking to see records more than a month old, the deputy manager advised that the daily hand over records and other documentation was filed at Abbeyfield Grange DS0000002931.V373808.R01.S.doc Version 5.2 Page 10 the end of each month. He went to collect the records relating to the people who were being case tracked, from the storage area and he was away for some time. On producing the records he identified that all the peoples records were archived each month and kept in one file, so he had difficulty locating specific peoples files. It was discussed that he may wish to discuss with the manager that it may be easier, should other professionals beside us want to access some documentation, that each person had their own archived file. He agreed to discuss this matter with the manager. Abbeyfield Grange DS0000002931.V373808.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,15 and 17 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The peoples quality of life will be enhanced because of the availability of activities and outings and the participation within their selection of their meals. EVIDENCE: There was evidence that people participated in various activities. These ranged from attending computer courses at the day centres, attending the green fingers group and included trips out to the pub for drinks or meals. One individual was interested in bird watching, he had purchased several books and the staff supported this individual should he wish to watch in the garden or in parks etc. Another individual held a season ticket to watch Sheffield United FC. The activities within the service included pool, darts, bingo and karaoke. Abbeyfield Grange DS0000002931.V373808.R01.S.doc Version 5.2 Page 12 The people commented that they went out to places as they wished and reiterated some of the places stated above. Regarding the meals, the deputy manager advised that there was a monthly meeting and the people expressed their choice of meals during this meeting. These views were then passed to the cook, who produced a four weekly menu. The menus were displayed on a notice board. However there was only one meal indicted for each day, rather than a choice. The deputy manager advised that if a person did not like the meal on offer then they would raise it with a carer or the cook and a different meal would be provided. The people confirmed that there was a choice of a second meal and expressed that they were satisfied with the food. Abbeyfield Grange DS0000002931.V373808.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18,19 and 20 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People were able to exercise their right of choice. People receive their medication in a safe manner. EVIDENCE: People were allowed to wash and dress themselves as they were able. Verbal encouragement and support was given by the staff were necessary. People were allowed and encouraged to be as independent as they wished. People were able to leave the service as they wished, and return at a reasonable time, which had been agreed with the person. People had the opportunity to access the primary care facilities, which included GP and dental services etc. The medications were stored within a cupboard within an office. The medication administration records were pre printed and all the administration boxes were signed. Abbeyfield Grange DS0000002931.V373808.R01.S.doc Version 5.2 Page 14 On discussing the staff training on the administration of medications, the deputy manager identified that two staff administered the medication at each time the medication was due to be given. The staff had received medication training. The doctors surgery was across the road from the service. This surgery had a dispensing pharmacy which provided medication to the service. The deputy manager explained the ordering and disposal system. The explanation give was satisfactory. Abbeyfield Grange DS0000002931.V373808.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People were able to express their concerns and these were acted upon. EVIDENCE: The complaints procedure was printed within the service user guide and the policy file. A copy of the guide was available to the people and visitors. On discussing complaints with the deputy manager, he identified that the service had not received any complaints. However a person may express a concern and this was recorded within the daily hand over sheet. For example, a shirt was shrunk in the wash, and was recorded in the daily hand over sheet and this item had been replaced. There had been no complaints received by us regarding the service prior to, or during the visit. The service had policies and procedures regarding Safeguarding Adults. The training records of the staff were held in each member of staffs files. Some staff files were selected and the certificates were in the files. Abbeyfield Grange DS0000002931.V373808.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 and 30 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The environment, monitored at this inspection, was clean, homely and generally maintained to a good standard. However some areas needed attention. EVIDENCE: On touring the building it was observed that the rooms had been personalised by pictures, posters and included items, which would be in a younger persons room i.e. stereos etc. There was a smoking room which was also the pool, darts and activity room. The deputy manager advised that the council had visited and accepted the room as all except 2 of the people smoked. He also advised that should there be a planned activity for example, a pool evening then the 2 people would be able to participate as another area would be designated a smoking area for that period of time. Abbeyfield Grange DS0000002931.V373808.R01.S.doc Version 5.2 Page 17 In addition to the smoking room, there was a conservatory which was used as a lounge, and a separate dining room. The other conservatory had been converted into an office and small meeting area. Room 16 was occupied by 2 people and had 2 beds, a sofa and a television. This room opened out onto a courtyard at the rear of the property. The manager advised that should the people wish to gain access to the dining room or lounge then they could either walk through the office as it had an exit door or walk round the building to the entrance. There was also a small office for the staff. The home was clean, generally well maintained and well decorated and odour free. The atmosphere within the service was warm, friendly and relaxed. It was observed that Room 8 had a step near the entrance, inside the room. The top step and the floor to the room were at different levels. This presented a tripping hazard to the person living in this room. Also the corridor carpet outside rooms 12 and 13 had become worn to threads in one area, and a tripping hazard. The deputy manager explained that the carpet was being replaced by wooden floor covering. He showed us the wood covering which was being stored on site, and advised that they were waiting for the fitters to give them a fitting date. He also identified that the hazard in Room 8 would receive attention as soon as possible. Since the inspection, the deputy manager has contacted us and informed us that the hazard within Room 8 has received attention and that it is now safe. A CCTV camera was installed at the entrance to the service. On questioning this with the deputy manager he identified that it was security for the entrance and the main office, and not to monitor any people. Other CCTV cameras were positioned outside the building. Within House 143 there was very much a homely atmosphere, and environment and evidence of a more independent lifestyle. There was a lounge, dining / kitchen and the individual bedrooms. Within Room 6 there was damage to the plasterboard on the wall. This consisted of a hole approximately 15cm x 20cm. On examination of the maintenance file the repair had not been recorded. The deputy manager advised that the repair would be made as soon as possible. Abbeyfield Grange DS0000002931.V373808.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 34 and 35 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The staff recruitment process regarding the checking of staff will contribute toward the protection of the people who use the service. EVIDENCE: On examination of the staff on duty and the rota it was established that the staffing was as follows: A.M. P.M. N. 2 care staff 2 care staff 2 care staff The manager or deputy manager was supernumerary to these figures. The manager role was operating as a Job share. Abbeyfield Grange DS0000002931.V373808.R01.S.doc Version 5.2 Page 19 There also domestic staff and a cook. The deputy manager identified that there was a stable workforce with a minimal turnover of staff. The deputy manager advised that a member of staff visited House 143, five times a day. He provided evidence that these visits did occurred by showing us the visit book that each member completed at each visit. There was also a call system which if operated in House 143 rang an alarm in the main building of House 148. On examination of the staff training records, the staff had received training in fire, moving and handling and other training specific to the needs of the people who lived at the service. Again these records had to be checked by examination of individual staff files. It was discussed that the introduction of a matrix may assist in the planning, recording and reviewing of the staff training. The deputy manager agreed to explore this issue. On examination of 3 staff files, it was established that the files contained all the information required within Schedule 2. Abbeyfield Grange DS0000002931.V373808.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39, and 42 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Two experienced registered managers were in post. This will contribute to the effective organisation and operation of the service. EVIDENCE: On arrival at the service, on this unannounced inspection, it was established that the managers were both unavailable due to personal circumstances. This situation had been discussed with us, the previous week and we were satisfied with the arrangement that the deputy manager was in temporary charge of the service. Therefore the inspection was undertaken with the assistance of the deputy manager. Abbeyfield Grange DS0000002931.V373808.R01.S.doc Version 5.2 Page 21 We observed that both managers had obtained the National Vocational Qualification Level 4, as their certificates were displayed on the wall of the office. Regarding Quality Assurance, the deputy manager provided evidence that some quality monitoring did occur and identified that this was an area that they intended to build on. Regulation 26 documentations, which are a record of the registered person’s monthly visits, were not applicable as one of the managers is also a provider. Regulation 37 notices, which are documents that are sent to the Commission regarding untoward occurrences, including falls, accidents etc; have been received by CSCI (Commission for Social Care Inspection). Abbeyfield Grange DS0000002931.V373808.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Abbeyfield Grange DS0000002931.V373808.R01.S.doc Version 5.2 Page 23 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA24 Regulation 23 Requirement The service should be in a good state of repair. The floor covering, the uneven floor and the hole in the wall require attention. Timescale for action 13/02/09 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 YA6 Good Practice Recommendations The manager needs to review the documentation relating to the delivery of care and look at introducing care plans which would inform the staff the expected care to be given on a daily basis. Abbeyfield Grange DS0000002931.V373808.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Abbeyfield Grange DS0000002931.V373808.R01.S.doc Version 5.2 Page 25 - 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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