Inspection on 16/02/07 for 33 Abbotswood

This inspection was carried out on 16th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

33 Abbotswood 30/08/07

33 Abbotswood 12/12/05

33 Abbotswood 25/08/05

33 Abbotswood 21/12/04

33 Abbotswood 01/07/04

33 Abbotswood 12/02/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Abbotswood (33) 33 Abbotswood Guildford Surrey GU1 1UZ Lead Inspector Christine Bowman Unannounced Inspection 16th February 2007 11:00 Abbotswood (33) DS0000040846.V327568.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 Abbotswood (33) DS0000040846.V327568.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. Abbotswood (33) DS0000040846.V327568.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbotswood (33) Address 33 Abbotswood Guildford Surrey GU1 1UZ 01483 440352 01483 566056 fourseasonstrust@yahoo.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) The Four Seasons Trust Limited Mr Paul Joseph Fitzroy Bennett Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Abbotswood (33) DS0000040846.V327568.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th December 2005 Brief Description of the Service: 33 Abbotswood, The Four Seasons Trust, is a large detached house developed to provide a good standard of accommodation for 4 adults with learning disabilities and epilepsy. It is set in a pleasant residential area of similar homes and situated close to Guilford town centre. All the service users bedrooms are on the 1st floor are single occupancy and have en-suite facilities. A sleeping-in room is provided for the staff also on the first floor. The ground floor has a dining room, sitting room, utility room, kitchen and toilet. Redevelopment has provided an office leading from the sitting room to accommodate a computer, safe storage for documents and a place for administration tasks to be completed. There is a garden to the rear and side of the property and some off road parking. There is a multi-person vehicle to ensure residents have easy access to local community. Fees for the service are £945 per week. Abbotswood (33) DS0000040846.V327568.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit was conducted as part of a Key inspection process. The visit took place over seven hours commencing at 11.00 am and ending at 18.00 pm and was undertaken by Ms Christine Bowman, regulation inspector. The manager was not available so the staff on duty kindly assisted in the inspection process. The deputy manager arrived to commence duty in the afternoon and provided continuing assistance. Two clients were at home one was assisting a staff member in the kitchen and the other was playing on their computer when the inspector arrived. The remaining two clients had left to spend the weekend with relatives. A client offered to give a tour of the premises and showed the inspector the shared accommodation and their bedroom. All the key inspection standards for Younger Adults were assessed and the care of two clients was sampled, including their care records. The staff were interviewed and observed engaging with the residents. Medication records, menus and health and safety checks were sampled. The personnel files of two staff were inspected and recruitment, induction and training records were viewed. All the clients completed comment cards and feedback was received from a sample of care managers. Two relatives of clients completed comment cards. The inspector would like to thank the clients and staff of Abbotswood for their assistance throughout the site visit and to all those who completed comment cards. What the service does well: The clients of 33 Abbotswood continue to lead busy and interesting lives, attending college courses at two local colleges and taking part in voluntary work at Hatchlands, a National Trust property, and at Hollycombe, where a leisure steam train service is housed. They tend the gardens, tracks, stables and paddocks and enjoy watching the trains. Another two-week holiday to Tenerife had been undertaken in the summer of 2006, and earlier in the year, ten days had been spent in the company’s caravan at Pagham by the sea. The home benefits from its own vehicle for transporting the clients to access leisure activities in the community. They visit nightclubs and enjoy discos, visits to the theatre and cinema and swim at the local leisure centre. Relatives and friends are welcomed at the home, a member of staff stated, and some of the clients spend weekends with their families. Abbotswood (33) DS0000040846.V327568.R01.S.doc Version 5.2 Page 6 The home was spacious, airy, well furnished and clean. 100 of the clients confirmed in their comment cards that the home was always fresh and clean. The clients had access to shared accommodation including a large sitting room equipped with television, DVD player and comfortable seating, a large dining room and a large well-equipped kitchen. What has improved since the last inspection? What they could do better: The Service User Guide was in need of a review to include the information required in recent legislation to inform the clients and their representatives about the arrangements for fees. It could also be improved by being made available in a format more accessible to the clients. The home needs to develop an assessment policy and process to ensure that the needs of potential new clients can be met. The client’s care plans had not been reviewed in a timely manner and their current goals and aspirations had not been recorded to inform the staff of their changing needs. The risk assessments, which had been completed originally, were simplistic and did not take into account the continuous development of the client to attain their potential balancing the positive outcomes of taking the risk with potential harm to the client. They merely stated there were certain things the Abbotswood (33) DS0000040846.V327568.R01.S.doc Version 5.2 Page 7 client could not engage in without support. Risk assessments should be undertaken to support the clients to live as independently as they are able. A local adult protection policy and procedure based on the Surrey Multi-Agency Adult Protection Procedures was not available to guide the staff to make a referral should a safeguarding situation arise, and the telephone number on the inside cover of the file was out of date. This is an area that remains outstanding from the last inspection. The recruitment procedure had a number of shortfalls, which potentially compromised the safety of the clients. There was no recruitment and employment policy or staff grievance and disciplinary action policy to inform the staff. The application form did not require sufficient information for a decision to be made with respect to the suitability of the applicant. Criminal Record Bureau Checks from another agency had been accepted on behalf of a newly recruited staff member and a CRB check and Protection of Vulnerable Adults First check had been received many months after the staff member had commenced employment. Interview notes had not been recorded and there was no evidence of a formal induction in line with national guidance and requirements to prepare the staff for the caring role. The staff did not have individual development plans with respect to training and it was not possible to confirm that mandatory training had been accessed. Staff meetings were infrequent and supervision did not comply with good practise recommendations to support the staff in their role. Policies and procedures were in need of review to ensure the staff had access to the correct information they need to carry out their role, and that they include updated information with respect to changes in legislation. Quality assurance monitoring, which consults and feeds back to clients and their relatives, needs to be in place to ensure that continued improvements are in the best interests of those using the service. There are concerns regarding subsidence to the building and a requirement was made at the last inspection by the commission for the home to advise if the buildinnng was structurally sound and safe. This matter has not received attention and remains outstanding since the last inspection. 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. Abbotswood (33) DS0000040846.V327568.R01.S.doc Version 5.2 Page 8 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 Abbotswood (33) DS0000040846.V327568.R01.S.doc Version 5.2 Page 9 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 1,2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Shortfalls in the information about the home available to current and prospective clients meant making an informed choice about the suitability of the home would be difficult. The needs of current clients had been assessed prior to the offer of a placement at the home to ensure their needs would be met but there were shortfalls in terms of a written policy and procedure for assessment and admission to the home for prospective clients. EVIDENCE: Copies of the Service User’s Guide had been placed on individual client’s files so it was not clear if they had access to this information. 100 of the clients stated in their comment cards they, ‘had chosen to live in the home and had received sufficient information about the home to decide if it was right for them’. There was no date on this document to confirm that it had been regularly reviewed and it was not available in a format accessible to the clients. In the light of new legislation the Service User Guide must include a description of the standard services offered by the care home to the clients and the fee payable for this. Also included must be the arrangements for charging and paying for any services additional to the standard service. A statement must be included to explain how these arrangements would be affected if all or part of the fee was provided by a person other than the client. Abbotswood (33) DS0000040846.V327568.R01.S.doc Version 5.2 Page 10 Detailed assessments completed by care management were held on the client’s files inspected. These forms included details with respect to equality and diversity issues of the clients including ethnic origin and religion to inform the home of any special requirements they might need to provide for. The clients had all lived at the home from the time of its registration and there had been no new admissions. No written policy and procedure for the assessment and admission to the home for prospective clients was available to be viewed on the site visit. Abbotswood (33) DS0000040846.V327568.R01.S.doc Version 5.2 Page 11 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 6,7,8,9 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Clients were able to make some decisions about their lives and the running of the home, but there was a lack of clarity regarding their changing needs and goals, and the level of support they required. The potential for the development of the skills associated with an independent lifestyle had not been routinely risk assessed to ensure the clients were enabled to achieve in this area. EVIDENCE: The client’s needs had been originally assessed prior to living in the home and transitional arrangement had been thorough. The initial care plans were appropriate, covering all areas of need at the time, but they were not in a format, which was accessible to the clients. There was some evidence in the files inspected that a review of one client’s needs had taken place within the last year and this was confirmed by a care manager. This had explored some areas of the client’s life in detail with respect to work experience, college courses and interests to social life including friendships, and parental Abbotswood (33) DS0000040846.V327568.R01.S.doc Version 5.2 Page 12 involvement, medical needs and holidays. There was no updated care plan containing the personal goals and aspirations of the client or risk assessments to support the attainment of the skills associated with independent living. In another client’s file there was no evidence of a review of their needs having taken place. The client’s key worker had recently completed a report in conjunction with other staff in the home with respect to their changing needs, but there was no evidence of a meeting in which the client, their relatives and representatives attended to give their views and to be consulted. The client’s key worker explained that the client would be consulted with when the report was complete and it would be shared with relatives and representative in agreement with the client. A client spoken with at the time of the site visit did not know what a review meeting was or what his care plan referred to. The manager stated that he had attempted to arrange review meetings with care management, but so far had been unsuccessful. Staff confirmed that clients were able to make decisions about their lives in terms of college courses, meals, activities and their own finances. No documentation was seen with respect to supporting clients and giving the tuition needed to manage their own day-to-day finances. All the clients agreed they could make decisions about what to do each day. Minutes of client’s meetings confirmed they had taken place and recorded the client’s involvement. Records show that these meetings did not take place on a regular basis. There was no evidence that the client’s could significantly affect the way the service was run. The quality assurance feedback had not been developed. There was little indication of the development of skills with respect to maximising the client’s ability to live independently or of the recording of the future aspirations of the clients. The risk assessments, which had been completed originally were simplistic and did not take into account the continuous development of the client to attain their potential balancing the positive outcomes of taking the risk with potential harm to the client. They merely stated there were certain things the client could not engage in without support. Abbotswood (33) DS0000040846.V327568.R01.S.doc Version 5.2 Page 13 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 12,13,14,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Many opportunities are provided for the clients to engage in peer and culturally appropriate activities in the community. Relationships are promoted, rights and responsibilities recognised and the clients enjoy a wholesome balanced diet. EVIDENCE: The clients of 33 Abbotswood continued to lead busy and interesting lives, which included attending the College at Merrist Wood to take part in a twoyear Horticulture course, having successfully gained certificates last year for completing the preliminary course. Another day was taken up with attendance at the Guildford College, the deputy manager stated and individual timetables showed that the courses attended supported independence skills and community living. Some of the courses included assertiveness, rights and responsibilities, positive alternatives to paid work, an introduction to practical citizenship, investigating community facilities, personal safety, health and safety and literacy and numeracy skills. The clients continued to do voluntary work at Hatchlands, a National Trust property, and at Hollycombe, where a Abbotswood (33) DS0000040846.V327568.R01.S.doc Version 5.2 Page 14 leisure steam train service is housed and they tend the gardens, tracks, stables and paddocks and enjoy watching the trains. Another two-week holiday to Tenerife had been undertaken in the summer of 2006, a member of staff stated and, earlier in the year ten days had been spent in the company’s caravan at Pagham by the sea. On the table in the dining room were some photographs of these and other happy events enjoyed by the clients, which were in the process of being sorted out. Daily records confirmed that the clients attended social clubs and the local day centre, and enjoyed discos, sports, art and crafts, and shopping trips. Also recorded were individual’s interests in computer games, completing jigsaw puzzles, taking meals out and assisting with tasks in the home such as helping to prepare tea and clearing the table afterwards. ‘Relatives and visitors are welcomed at the home’, a member of staff stated, and one client had a female friend from school days who visited him occasionally, another client had received a number of Valentine Cards earlier in the week and all the clients had attended a St Valentine’s Disco at a Woking nightclub. The dining room had been completely refurbished since the previous inspection and was comfortably furnished and attractively decorated. Models of cars and motorcycles were displayed in cabinets, huge plants in large pots were located around the room, there were framed photographs of clients, a compact disc player and the lighting was in the style of candelabra. The record of meals taken was viewed and the result was well balanced and appropriate. The clients had been encouraged to include more fruit in their diet by adding fruit smoothies and yoghourt to the breakfast menu. On the day of the site visit the two clients enjoyed a light lunch of home-made soup and bread and a choice of desserts. Abbotswood (33) DS0000040846.V327568.R01.S.doc Version 5.2 Page 15 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 18,19,20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Clients receive the support they need and access specialist services when they are required. Shortfalls in the provision of a Medication Policy and Procedure leaves the staff without the guidance they need to ensure the clients medication is safely handled to protect them. EVIDENCE: The Statement of Purpose stated that all staff had specialist training to support the clients whose special needs were learning disability and epilepsy, but no routine training was offered for the staff to access the Learning Disability Framework Award. The clients required only prompts to remind them to complete personal care tasks, a member of staff stated. There were no health action plans for monitoring the health needs of the clients and recording appropriate action required and interventions taken. Appointments with dentists, opticians and other specialists had been recorded in the home’s diary and follow up information for the attention of staff was recorded in the personal daily logs of the individual clients. Specialist services were accessed through client’s General Practitioner and records confirmed they had all been registered. Abbotswood (33) DS0000040846.V327568.R01.S.doc Version 5.2 Page 16 The initial risk assessment of a client stated that they could not take responsibility for their own medication and there had been no subsequent risk assessments to ascertain if the situation had changed or to build the confidence of the client. The medication was stored securely and appropriately and medication records sampled had been completed properly. A list of the names of the staff, which had received medication training, was held with their specimen signatures. A staff member confirmed they had received accredited medication training but no certificates were held on staff personnel files to confirm this. A staff member explained that the clients often spent weekends at home, and checks were made on quantities of medication sent out and returned. A record was kept of medication returned to the pharmacy, but this had not been signed for as received. This should be recorded to ensure the medication is correctly disposed of and to complete the audit trail. No medication policy and procedure was available to inform the staff of action to take with regard to medication errors or emergencies. There was no protocol available for the administration of rectal diazepam to ensure the dignity and privacy of the clients was protected and to guide the staff in their own protection when performing this intimate procedure, but a staff member confirmed they had received training from the epilepsy nurse. Abbotswood (33) DS0000040846.V327568.R01.S.doc Version 5.2 Page 17 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 22,23 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Some improvements had been made to the complaints procedure and clients confirmed they knew how to complain and that they were listened to. The home did not have it’s own safeguarding poicy which reflected the local authority multi-agency procedure to instruct the staff and protect the clients. EVIDENCE: Comment cards completed by clients with support from the staff were 100 positive with respect to the staff listening to them and acting on what they say. A key worker system was in place to support the clients and there was evidence of some irregular client meetings having taken place in which their views had been recorded. The complaints procedure had been updated to include the timescale in which a response should be received by the complainant to inform them of any action to be taken. Correct information for contacting the Commission for Social Care Inspection had also been included. The procedure could be improved to welcome complaints as a positive element in the improvement of the service and also to welcome compliments. A more accessible version of the complaints procedure was included in the Service User Guides held on the client’s files, but it was not clear if they had access to this information. All the clients indicated in the comment cards, they had completed with support from the staff, that they knew who to speak to if they were not happy and always know how to make a complaint. Abbotswood (33) DS0000040846.V327568.R01.S.doc Version 5.2 Page 18 The folder for the recording of complaints could not be found on the day of the site visit, but a recent provider visit reported that the complaints record had been viewed and there had been a recent complaint from a relative of one of the clients, which was being dealt with. A member of staff stated that discussions had been held between the relative and the home. They could not confirm if the wishes and feelings of the client had been considered of paramount importance with regard to the issue. The copy of The Surrey Multi-Agency Adult Protection Procedures sampled was out of date and the home did not have it’s own local procedure in respect of safeguarding to provide the staff with clear instructions on how to respond to allegations of abuse in order to protect the clients. A local telephone number recorded inside the folder for contacting the local care management team was not current. A requirement for the home to produce a local policy for safeguarding is outstanding from the last inspection. Abbotswood (33) DS0000040846.V327568.R01.S.doc Version 5.2 Page 19 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 24,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements in the interior redecoration of the home created a pleasant and homely environment in which to live. However, evidence of recent subsidence and lack of written confirmation with respect to the state of soundness of construction and the completion of the structural reinforcement of the building leads to uncertainty with regard to the fundamental safety of the home. The home was clean, hygienic free from odours and suited the client’s lifestyles. EVIDENCE: The redecoration of the home had been completed resulting in a bright, cheerful and pleasant environment for the clients to live in. A client showed their bedroom to the inspector and stated they had chosen the colour and the soft furnishings. The area outside the kitchen had been improved by the laying of paving stones to be used in the summer as an outdoor room. An office had been added on the ground floor improving the practicalities of the administration processes and the proximity of secure storage for confidential documents. The home was spacious, airy, well furnished and clean. 100 of Abbotswood (33) DS0000040846.V327568.R01.S.doc Version 5.2 Page 20 the clients confirmed in their comment cards that the home was always fresh and clean. The clients had access to shared accommodation including a large sitting room equipped with television, DVD player and comfortable seating, a large dining room and a large well-equipped kitchen. The utility room had a door leading outside to facilitate the safe movement of soiled linen. A broken hand towel dispenser in this area was in need of repair to ensure good hygiene practises. An infection control policy was not available in the policy folder for staff information. A requirement had been made and is outstanding from the previous inspection with respect to written confirmation of the soundness of the construction of the building and the completion of the structural reinforcements. This confirmation had not been received and there were signs that subsidence was continuing as a recent crack had appeared on the ceiling along the stairwell and the door latch was stuck in an open position. Abbotswood (33) DS0000040846.V327568.R01.S.doc Version 5.2 Page 21 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 32,34,35 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Shortfalls in the recruitment, induction and training of the staff result in unsafe practices, which potentially place clients at risk. EVIDENCE: The staff personnel files had not been inspected in the previous inspection year because they had been stored in the provider’s main office located at an address across the road. The office had been locked and the registered manager did not have a key. Since the previous visit improvements had been made with respect to the provision of an office in the home and lockable storage facilities for confidential files had been moved from the staff sleepingin room to the new location. No recruitment policy and procedure was available for inspection, but a staff member described the process. They had seen the advertisement in a local newspaper and been invited for an interview, after which, they were asked if they wished to continue and given an application form to complete and return. Confirmation of acceptance of the applicant for the position had not been received until responses had been received from the two referees. Application forms viewed on the personnel files of the most recently recruited staff did not Abbotswood (33) DS0000040846.V327568.R01.S.doc Version 5.2 Page 22 contain sufficient information to make a decision about the suitability of the applicant for consideration for employment in a caring role with vulnerable people. For example, a full employment history was not required or an explanation for any gaps in employment. Reasons for leaving posts which involved the care of vulnerable adults or children were not required and there was no statement of ‘No criminal convictions’ to be signed. Interview notes had not been retained on the file and there was no job description, person specification, signed statement of conditions of employment or evidence that equal opportunities legislation had been complied with. One member of staff had been employed with a Criminal Record Bureau (CRB) check from a previous employer and neither the Protection of Vulnerable Adults First (POVA) or the CRB check for this organisation had been received until fifteen months after taking up employment. It is recommended that the manager accesses the CRB website for current guidance including the storage and retention of CRB checks. The staff had not been given copies of the General Social Care Council Code of Practise to inform them of their rights and responsibilities as employees and the expectations and responsibilities of the employer. There was no policy covering staff grievance and disciplinary action to inform the staff should these situations arise. There was no evidence that a formal induction in line with national guidance (‘The Skills to Care’) had been offered to the most recently recruited staff. One member of staff described their first week of induction as shadowing a more senior staff member, who gave them support. The staff did not have individual training programmes, but a staff member stated that the manager conducted annual appraisals in which future training was discussed. No record of these meetings was available for inspection. Supervision had also been infrequent and the staff had not been given signed copies of these meetings when they had occurred to confirm their agreement with the contents. The two staff files inspected did not contain evidence of mandatory training, but certificates of a more senior staff member included The Protection of Vulnerable Adults, The Administration of Rectal Diazepam, Food Hygiene, First Aid, Health and Safety and Manual Handling. The member of staff stated they had also received training in the administration of medication, but the certificate was not on file. The minutes of staff meetings were recorded in a logbook and dated. This information confirmed that staff meetings were infrequent. Abbotswood (33) DS0000040846.V327568.R01.S.doc Version 5.2 Page 23 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 37,39,42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home benefited from the stability of having a qualified manager but shortfalls in management practise left the clients potentially at risk. Quality assurance monitoring needed to be improved to include feedback from clients and relatives. Routine health and safety checks were satisfactorily carried out promoting a generally safe environment. EVIDENCE: The manager had completed the Registered Managers Award since the previous inspection, but had not kept himself up-to-date with current legislation and guidance in some important areas practise such as employment and adult protection. An improvement since the previous inspection was that the staff had signed to confirm they had read the home’s policies. However, a Abbotswood (33) DS0000040846.V327568.R01.S.doc Version 5.2 Page 24 number of important policies were absent from the folder and those included, required expansion and review. A staff member interviewed, stated they felt valued as part of team. They felt confident about taking responsibility and the manager’s style of management made them feel empowered. Client meeting minutes confirmed some participation in decision-making about how the home was run, but the minutes were not available in a format, which was accessible to the clients, limiting that participation. There was no evidence of the development of a quality assurance system or of a development plan for the home setting out priorities for action and improvement. Provider visits had been completed on a monthly basis, containing feedback with respect to improvements. These were held on file to be inspected. Pre-inspection data confirmed health and safety checks had taken place in a timely manner and a sample of records confirmed that they were in place to protect the clients. Abbotswood (33) DS0000040846.V327568.R01.S.doc Version 5.2 Page 25 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 2 2 2 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 1 23 1 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 2 33 X 34 1 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 1 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 X 2 X X 3 X Abbotswood (33) DS0000040846.V327568.R01.S.doc Version 5.2 Page 26 Yes 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 YA1 Regulation Requirement Timescale for action 30/03/07 2. YA6 3. YA9 4. YA20 5(1)(a)(2)5(B) The Service User Guide must be reviewed and updated to include terms and conditions with respect to the provision of accommodation and personal care to the clients. The details of the total fee payable for standard care and additional services must also be included to inform the clients, prospective clients and their representatives. 14(2)(a)(b) All the clients must have their 15(1)(2)(a) care needs reviewed on a (b)(c)(d) regular (for example sixmonthly) basis and a current care plan which sets out their goals and aspirations must be compiled to inform the staff of their changing needs. 13(4)(b)14(2) The client’s skills in achieving an independent lifestyle should be risk assessed to promote continuous development and kept under review. 13(2) A medication policy and procedure must be developed to instruct the staff on the safe receipt, recording, DS0000040846.V327568.R01.S.doc 30/03/07 30/03/07 30/03/07 Abbotswood (33) Version 5.2 Page 27 5. YA23 13(6) 6. YA24 23(2)(b) 7. YA34 19 Schedule 2 8. YA35 19 storage, handling administration and disposal of medication. A local policy and procedure, which reflects the local authority multi-agency adult protection procedures, must be developed to inform the staff and protect the clients. This requirement had not been met and an extended timescale has been set. Written confirmation must be sent to the CSCI local office regarding the action required to address the problem with subsidence at the home and verify that the structure of the home and that the premises are of sound construction and safe for the clients to live in. This is the second time this requirement has been carried forward and an extended timescale set. A recruitment and employment policy and procedure must be in place and all necessary checks and documentation completed in respect of staff and as detailed in Schedule 2. The staff must have individual training plans and records to confirm that mandatory and specialist training has been accessed to ensure the clients are supported by appropriately trained staff. 30/03/07 30/03/07 30/03/07 30/03/07 Abbotswood (33) DS0000040846.V327568.R01.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 YA1 YA6 2. 3. 4. 5. YA39 YA19 YA34 YA35 YA39 Good Practice Recommendations All the documentation produced for the clients including The Service User Guide, the care plan and the minutes of client meetings should be produced in a format, which is more accessible to the clients to facilitate their participation. It is recommended that health action plans be introduced to identify, record and respond to client’s health needs in line with current good practise. It is recommended that the Criminal Record Bureau website is accessed to obtain current information with respect to CRB checks and their storage and retention. It is recommended that the staff induction cover the common induction standards as a sound introduction to care practise. It is recommended that the home conduct quality assurance monitoring to identify areas of improvement. Abbotswood (33) DS0000040846.V327568.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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. 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