Inspection on 17/06/08 for Abbegale Lodge

This inspection was carried out on 17th June 2008.

CSCI found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Abbegale Lodge 02/06/10

Abbegale Lodge 18/03/10

Abbegale Lodge 06/10/09

Abbegale Lodge 15/05/07

Abbegale Lodge 07/02/07

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Abbegale Lodge 9-11 Merton Road Bootle Liverpool Merseyside L20 3BG Lead Inspector Mrs Margaret Van Schaick Key Unannounced Inspection 17th June 2008 09:30 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 Abbegale Lodge DS0000067128.V362203.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. Abbegale Lodge DS0000067128.V362203.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbegale Lodge Address 9-11 Merton Road Bootle Liverpool Merseyside L20 3BG 0151 9223124 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) brenda.bailey@blueyonder.co.uk Mr Ramesh Chander Parkash Sabberwal Miss Brenda Bailey Care Home 41 Category(ies) of Old age, not falling within any other category registration, with number (41) of places Abbegale Lodge DS0000067128.V362203.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. One named out of category service user in the category of Learning Disabilities. This variation applies to the named service user only. Should they leave the home, the variation will cease to apply. Ramp access to be provided to the home within six months of registration. One named service user under pension able age Date of last inspection 15th May 2007 Brief Description of the Service: Abbegale Lodge is an established privately owned care home that is registered to provide residential care for 41 older persons. Mr Ramesh Chander Parkash Sabberwal is the registered provider. The registered manager is Miss Brenda Bailey. The service is situated on a busy road close to bus services and a train station. It is within easy distance of local amenities. The service is set out as two converted Victorian villas with a two storey modern extension. There is lift access to the main building with a stair lift in place to the other villa and extension. A ramp access is provided to number 11. The service has a call bell facility in residents’ rooms and public areas. The service provides upper and ground floor accommodation with lounges and dining rooms in each ground floor area. A large rear garden and off street parking is available to the front of the premises. Weekly fees are £374 Abbegale Lodge DS0000067128.V362203.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. A site visit took place as part of the unannounced key inspection. It was conducted over a two-day period for the duration of 13 hours. Thirty-seven residents were accommodated at this time. As part of the inspection process all areas of the home were viewed including resident’s bedrooms. Care records and other associated records were viewed. Discussion took place with residents, staff and visiting relatives. The inspection was conducted with Ms Brenda Bailey, registered manager. Discussion also took place with the registered provider Mr Ramesh Sabberwel and his business partner. During the inspection three residents were case tracked (their care files were examined and their views of the service were obtained). All of the key standards were inspected and also previous requirements and recommendations from the last inspection in May 2007 were discussed. Satisfaction forms “Have your say about….”were distributed to a number of residents, relatives, visiting health professionals and staff prior to the site visit. A number of comments included in this report are taken from surveys and from interviews. An AQAA (annual quality assurance assessment) was completed by the manager prior to the site visit. The AQAA comprises of two self-assessment questionnaires that focus on the outcomes for people. The self-assessment provides information as to how the manager and staff are meeting the needs of the current residents and a data set that gives basic facts and figures about the service including staff numbers and training. What the service does well: Sufficient information is collated to ensure residents’ needs are identified prior to admission. Residents who were interviewed are happy to live in the service. One relative interviewed stated, “a friend had recommended mum coming Abbegale Lodge DS0000067128.V362203.R01.S.doc Version 5.2 Page 6 here. Mum was admitted for two weeks emergency respite. When she returned home she did not settle and wanted to go back to Abbegale and now she hopes to be here to stay”. Support from staff and their families enables residents to live their lives as they wish within their abilities. Residents are encouraged to spend time with their families. Families interviewed stated, “we can visit at any time, I just pop in” and “staff make us welcome, this is the only place he has ever been to that offer a cup of tea or coffee when you come in”. Residents confirmed they were able to do as they wish within their ability and with support from staff where needed. Residents interviewed stated, “I love it, I like everything. The staff are lovely, they can’t do enough for you”. The complaints procedure ensures all residents’ concerns/complaints are listened to and investigated with outcomes recorded What has improved since the last inspection? What they could do better: Some of the care plans did not highlight all of the residents care needs although following discussion with residents, relatives and staff it is clear their individual needs are being met. Care plans need to be improved so that each Abbegale Lodge DS0000067128.V362203.R01.S.doc Version 5.2 Page 7 evidences all of the residents care needs to ensure the needs and problems are addressed, reviewed and managed. It would benefit the service if care staff has some training with regard to care plans and person centred care, as this will improve their understanding of how they work to ensure residents’ needs are managed well. Filing cabinets are placed in the sitting rooms of each building and store residents care files. These are not locked and need to be at all times to maintain residents confidentiality or placed in a lockable separate room Residents would benefit if they were encouraged to be involved in the decisionmaking with regard to activities to be provided. This may encourage more residents to participate and provide choices for themselves. Equality and diversity training needs to be provided to ensure residents individual needs are fully met. Urgent action needs to be taken to ensure the fire escape at no11 is clear and easily accessed in the event of a fire. One or two of the windows in the ‘flats’ need to have replacement/repair of window security chains to promote safety of the resident. For residents who wish to have a key to their door, a risk assessment has to be in place and keys provided for the residents who it is agreed are safe to use theirs. The induction training needs to be improved to ensure all new staff has a thorough induction that meets with the government training targets. The service has improved some of the staff training but further mandatory training needs to be provided for care staff to ensure residents and staff are protected. 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. Abbegale Lodge DS0000067128.V362203.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Abbegale Lodge DS0000067128.V362203.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP3 was assessed. OP6 is not applicable. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient information is collated to ensure residents’ needs are identified prior to admission. EVIDENCE: There is evidence in care file notes that pre admission assessments are carried out on prospective residents. One of the residents care files evidences this with dates of assessment recorded and place of assessment carried out. This particular resident’s family visited the service prior to admission and chose the service on behalf on their relative. The relative interviewed stated, “it was an emergency admission, the social worker assessed him in hospital and gave us a list of homes. We were given information about the home and chose this one as it was nearer his home and he knew this area. We went round a number of rooms and chose one but he was given a choice when he came also and he chose the one he is in”. Abbegale Lodge DS0000067128.V362203.R01.S.doc Version 5.2 Page 10 The other two care assessments are not dated. One resident was admitted for respite through an emergency admission process with information collated and recorded on assessment documentation. Another relative interviewed stated, “a friend had recommended mum coming here. Mum was admitted for two weeks emergency respite by the health professional. When she returned home she did not settle and wanted to go back to Abbegale therefore her respite was extended and now she hopes to be here to stay”. One resident interviewed about the admission process had previous knowledge of the service and had visited their relative regularly. They then made a decision to join their relative and are very settled in the service. The documentation viewed evidences sufficient information is collated to ensure residents needs are identified. Following admission to the service the staff continue to assess residents so that further information is gathered to help to set up care plans. Copies of social work assessments are in place in care files. Abbegale Lodge DS0000067128.V362203.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP7,8,9,10 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans need to be improved so that each evidences all of the residents care needs to ensure the needs and problems are addressed, reviewed and managed well. EVIDENCE: Three of the residents were case tracked and two other residents care plans were viewed. There is quite a lot of information collated about residents’ medical and social needs prior to and on admission to the service. Each of the residents case tracked had a care plan in place. Care plans evidence how some of the residents’ care and social needs are being met. The manager audits care plans at random usually on a monthly basis. The audits were viewed during the visit and evidence which residents care plans were checked by the manager. Where the manager thinks improvements are needed notes are recorded for action by care staff. The record shows a detailed audit. Care staff review care plans 3 monthly as evidenced by a separate written record. Abbegale Lodge DS0000067128.V362203.R01.S.doc Version 5.2 Page 12 Residents were interviewed about what they knew about their care plans. Statements include “I have not seen a care plan, no one discussed care”, “once or twice we have discussed our care plan” and “yes, I have a care plan, now and again they come and discuss it with me, I sign it sometimes”. Relatives interviewed stated, “ Brenda explained the care plan” and “we do know that the social worker will review it”. Care plans did not fully reflect some of the residents’ care therefore this needs to be addressed to ensure all care needs are managed. Through further discussion with the residents, relatives and staff it is clear that residents are getting the support and help they need. Staff who were interviewed were knowledgeable about the residents under their care and their changing conditions. There is a need for care staff to have further training with regard to care plan input to ensure all care needs that are identified are reflected in the plan. Residents were interviewed about the care provided by the service. Residents were positive in their response and each was happy with the care and support provided at the service. Residents interviewed stated, “I’ve seen the Dr three or four times and the physiotherapist”, “I get a little dizzy so I get help with my shower”, “ the district nurse comes to do my legs” and “I get my medication on time”. Relatives interviewed stated, “I would say that he has all the help he needs, he wasn’t taking his tablets when he was at home” and “Mum is happy and well cared for”. Medication has greatly improved since the last inspection with records evidencing this. The medication records viewed are mostly computerised and were clear and easy to follow with allergies identified. One of the residents on respite has no record of the amount of medication brought in on admission to the service. The manager has changed pharmacies and is happier with the support now received. The service holds medication records for each resident and signatures of care staff are evidenced after each medication is administered. The service also lists each resident’s medication with reasons for him or her being prescribed it. The service is split up into three separate buildings and each building has it’s own medication trolley. These are secure to the wall. Medication trolleys viewed were tidy and well organised. A lockable storage room is available for new medication arrivals and unused stock awaiting return to pharmacy. There is recorded evidence of audits being carried out by the manager with regard to medication administration and record keeping. Where needed staff have been provided with further training. Medication policies were updated in January 2008 as evidenced in new policies and procedures. A new medication returns book evidences unused medication is returned to pharmacy with dates and pharmacist signature. The inspector met with many of the residents during the visit and observed all to be suitably dressed and groomed. Staff was noted to be respectful in their Abbegale Lodge DS0000067128.V362203.R01.S.doc Version 5.2 Page 13 approach to residents. Residents interviewed confirmed staff were kind and respectful at all times. Filing cabinets are placed in the sitting rooms of each building and store residents care files. These are not locked and need to be at all times to maintain residents confidentiality or placed in a lockable separate room. Locks are fitted to most of the residents’ bedrooms so the remaining ones need to be completed to give residents privacy. Abbegale Lodge DS0000067128.V362203.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP12,13,14,15 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Support from staff and their families enables residents to live their lives as they wish within their abilities. EVIDENCE: Interests and hobbies are recorded in residents care files, which gives staff some information on how the individual resident likes to spend their time. Resident activities are listed with a record kept to show which residents attend. Activities recorded include sing-a–long, listen to music, chat and reminisce, exercise dancing, pamper and relax, bingo and board games. One or two of the residents who are able like to carry out chores such as table laying and ‘wiping’ dining tables. Residents were interviewed about how they spend their time and some are happy and content with others not so. Residents interviewed stated, “I go for a walk every day and my sister comes and visits me”, “I don’t’ get involved with activities”, we don’t have many activities, they show a film now and again”, “I would like more bingo”,“ we play ludo, we don’t sing but have a music person who comes in, I do the crossword every day” and “we go to the strand in a taxi for shopping”. It would benefit the residents if they were encouraged to be involved in the decision-making with regard to activities to be provided. This may encourage more residents to participate Abbegale Lodge DS0000067128.V362203.R01.S.doc Version 5.2 Page 15 and provide choices for themselves that others are not aware of. Where residents are out shopping independently, risk assessments are in place to ensure safety is followed. Residents are encouraged to spend time with their families and the service encourages visiting throughout the day. There are no restrictions. Families interviewed stated, “we can visit at any time, I just pop in” and “staff make us welcome, this is the only place he has ever been to that offer a cup of tea or coffee when you come in”. Residents in the service confirmed they were able to do as they wish within their ability and with support from staff where needed. Residents interviewed stated, “I love it, I like everything. The staff are lovely, they can’t do enough for you”, my dog stays with me in my ‘flat’, they are awfully good to let me have her”, “I can go to bed when I want to usually at 10pm”. Residents interviewed gave positive views about the meals served. Residents interviewed stated, “the food isn’t bad”, the food is excellent”, not much choice”, “we have lots of tea and coffee, no trouble, plenty of that”, “the food is lovely” and “the food seems to have improved lately, you get another choice if you don’t like what is on”. A relative interviewed stated, “Mum said its good old fashioned food and plenty of it”. Holy communion is arranged at Abbegale Lodge for the residents who wish to participate. The manager advised that no other residents practice any other religion at present. Abbegale Lodge DS0000067128.V362203.R01.S.doc Version 5.2 Page 16 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): OP16,18 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints procedure ensures all residents’ concerns/complaints are listened to and investigated with outcomes recorded. EVIDENCE: A complaints procedure is in place and following discussion with residents some were aware of the process of how to complain. The service provides a brief outline of the complaints procedure in a printed format. This includes information on what to do if they are not happy with the outcome of their complaint. One of the residents interviewed confirmed they had a copy and stated, “yes I am aware of the complaints procedure, I have a leaflet in my drawer and I could go to Brenda”. A new complaints book is now in place and was viewed during the visit. The complaints process has improved. The log evidences concerns/complaints raised by residents and their relatives. Each complaint shows it is investigated with outcomes recorded. Where the complainant is not happy with the outcome there is evidence of further input by the manager and provider until the complainant is satisfied with the outcome. Residents interviewed were confident that any concerns they had would be dealt with. The manager stated, “I try to deal with any issues at the time and I follow it up to ensure the resident is satisfied”. Abbegale Lodge DS0000067128.V362203.R01.S.doc Version 5.2 Page 17 The service has a copy of the Sefton Adult Protection Procedure and staff is booked to attend training with regard to this in July this year. The inspector viewed information regarding the postal voting system for local and national elections. All residents at present use the postal system of voting. Abbegale Lodge DS0000067128.V362203.R01.S.doc Version 5.2 Page 18 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): Op19,26 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. An effort has been made with the new owners to improve the facilities at the service and residents are benefiting from this. EVIDENCE: The service holds maintenance books for each building. Each log evidences jobs that need carrying out. Staff records these. When the job is completed it is signed off. The service does not have a full time maintenance person. Most work is carried out by the owners or contracted out where necessary. There is evidence since the new owners have taken over that money has been spent and work carried out. Many of the bedrooms have been redecorated and re carpeted. The new ramp access to number 11 has been resurfaced to prevent residents and visitors slipping. There are new blinds fitted to the lounges and most of the public areas have been decorated. New beds are in place in one of the bedrooms. New dining room tables and chairs with matching crockery are in place, which residents confirm makes for comfortable dining. The service Abbegale Lodge DS0000067128.V362203.R01.S.doc Version 5.2 Page 19 has also a nursing bed on loan for one of the residents, as their needs require it. An emergency call system is in working order as checked at random by the inspector. The service now employ a gardener to help with the maintenance of the grounds although the grass is mown some areas of the garden grounds needs some attention. These were discussed with the manager and owner. The rear fire escape is partially blocked at no 11 by the overhanging branches of a tree. The manager and owner have been advised that this needs to be cleared as a matter of urgency to ensure clear passage. The basement area of this building that includes a washing machine area has lots of junk that needs clearing. Some pillows and soft toys are stored in a drying room therefore where they could be a fire risk so the manager was advised that they should be stored elsewhere. Care staff transport dirty laundry in large buckets then transfer clean linen in the same ones therefore the manager was advised to use a separate container to transfer the clean linen to prevent cross contamination. During the tour one or two of the windows in the ‘flats’ were noted to have faulty safety closures therefore these need to be addressed. The main kitchen and two smaller kitchen areas were clean and tidy. The cook keeps clear records of hot foods and fridge/freezer temperatures. The main kitchen was well organised and storage areas clean and tidy. One of the care staff was in the kitchen without a change of uniform or apron. The manager needs to ensure that staff changes their uniform before entering the kitchen. Menus are on a four weekly rota with a choice on offer. Residents interviewed about their bedrooms and the cleanliness of the service were complimentary. Residents interviewed stated, “my bedroom is fine, it’s very handy on the ground floor and next to the toilets, “my bedroom is gorgeous and comfy, everything is nice” and “I like my room, it’s bigger than the other one”. Relatives interviewed were also complimentary about the accommodation. One relative interviewed stated, “Mum’s bedroom is lovely”. Abbegale Lodge DS0000067128.V362203.R01.S.doc Version 5.2 Page 20 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): OP27,28,29,30 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are happy with the support and care that is provided by staff. EVIDENCE: The staffing rota was viewed and evidences sufficient staff is on duty to meet the residents’ needs. The manager is supernumerary therefore allowing her to supervise the service. There is no laundry assistant and no 11 has only part time domestic hours therefore the manager needs to monitor this to ensure residents needs are not compromised. Students from a local college are on work placement in the service and the inspector met with some of the staff and students. The student and care staff was complimentary about the service and enjoyed their work/placement. Staff interviewed stated, “I think the care is good” and “staff are lovely, you couldn’t ask for more loyal staff”. Residents were pleased with the staff that cares for them. Residents interviewed stated, “staff are alright”, staff are nice, they have a tough job, they are very good with all of us”, “they can’t do enough for you”, “night staff don’t rush you, they give you time”, “some staff are nicer than others” and “staff are great”. Families interviewed about how staff cares for their relatives were complimentary. Relatives interviewed stated, “they have absolutely fantastic staff, “they certainly seem to look after the other residents”, “staff Abbegale Lodge DS0000067128.V362203.R01.S.doc Version 5.2 Page 21 are good and other residents are happy here too”. Relatives commented favourably in the surveys distributed by the commission with comments such as, “the staff are excellent, very supportive towards my mum and myself”, “Brenda and the staff are always there for us”. Six staff has commenced NVQ level 2 and two at level 3. Three staff already has NVQ 2, 8 have level 3 and two staff have the registered managers award. The inspector viewed three staff files including training records. Personal details are recorded for each staff member. Staff files are stored in secure accommodation in the manager’s office. Staff files evidence application forms, police checks, reference checks and copies of certificates for attending training including NVQ. Training attended includes staff induction, fire and fire warden, coshh (control of substances hazardous to health), adult protection, first aid, health and safety, manual handling, oral health, basic food hygiene, infection control and medication. Training records and certificates confirm this. The induction training record is brief and needs to be improved to ensure all new staff has a thorough induction that meets with the government training targets. The student on placement was enjoying her stay and stated, “the staff are lovely, they all go out of their way to speak to you”. She was aware that she has not to carry out any personal care. Following further discussion it became clear that she had no induction therefore this needs addressing for any student on placement. They need to have a short induction to ensure they are familiar with the service and their role with records kept. Equality and diversity training has not been addressed therefore this needs addressing to ensure residents individual needs are fully met. Two written references were on file for one staff but undated therefore this needs addressing. Some of the police checks were undated therefore the manager has been advised that following disposal of Criminal Record Bureau checks that the date is kept on file. Abbegale Lodge DS0000067128.V362203.R01.S.doc Version 5.2 Page 22 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service has improved some of the staff training but further mandatory training needs to be provided for care staff to ensure residents and staff are fully protected. EVIDENCE: The registered manager has been in post for approximately four years. The manager gained the registered managers award in 2006. The manager has attended fire warden training in 2007 and is booked to attend adult protection training in July 2008. The manager has not attended any further training since the last inspection and this needs to be rectified in particular for the remaining mandatory training. It is important for the registered manager to demonstrate that she has undertaken periodic training to update her skills, knowledge and competency whilst managing the service. The manager has taken on board Abbegale Lodge DS0000067128.V362203.R01.S.doc Version 5.2 Page 23 recommendations made by the commission and therefore improved the service overall. Residents were complimentary about the manager and of how she managed the service. One resident interviewed stated, “Brenda is very good”. Staff were also complimentary about the manager and owners of the service and stated, “if I have any worries, I would speak to Brenda she has quite an open ear and does listen to what you say”, “I think the owners have put a lot into the home, they do actually listen and are open to fresh ideas, they are also pleasant with the relatives”. One of the relatives interviewed stated, “Brenda is so reassuring and supportive”. Discussion took place with the owner and manger with regard to provider visit records. The owner does visit the service regularly but does not evidence this though a written report. Residents, staff and relatives did confirm however that they had met the owners on many occasions. The manager and owner were advised that a monthly written report needs to be kept on file so that they can be viewed during inspection visits. A business and improvement plan for 2007-2008 and 2009-2013 is in place and was viewed during the visit. The registered provider and his business partner also discussed the planning application that has been proposed to improve facilities for the residents. An outline of the improvements was viewed. The provider is awaiting a response from the local council. Resident questionnaires were last issued in January 2008 by the service. The responses from these were viewed and were found that the majority of residents were satisfied with the service. The manager advised that a residents meeting was held in March this year but the minutes were not available. The manager and provider had also set up a relatives meeting a few months ago with no one turning up. The provider and manager do meet up with the relatives on a daily basis when on the premises and are able to have chats with them individually with families confirming this. The most recent care staff and senior care meeting was held earlier this year and the minutes were viewed. Staff interviewed also confirmed that meetings are held. The service has received an external quality assurance award. A full audit of the building was carried out in August 2007. The inspector viewed this. Certificates for the servicing and safety of equipment in the premises including emergency lighting are in place and random certificates were viewed during the inspection. All are in date. The fire brigade have also visited the service and given advice. Following this new smoke alarms have been fitted to the premises and an annual risk assessment recommended. The risk assessment was viewed and had been carried out in January 2008. The fire alarm system is tested throughout the Abbegale Lodge DS0000067128.V362203.R01.S.doc Version 5.2 Page 24 year with records kept for all three areas. These were faxed to the commission. There is also recorded evidence of staff fire training including the drill and evacuation procedure. The service does hold some money on behalf of a few residents. The record keeping for this has improved. The records were viewed during the visit and evidence individual records for each resident. Clear records evidence amounts of money held with receipts kept for financial transactions. The manager checks these amounts with written evidence to verify this. The manager was advised to have another senior member of staff to audit these accounts with her on a regular basis with signatures kept. The manager was also advised where possible to have the residents sign for each financial transaction or their family where needed. One of the residents had a serious fall in the service recently and this has been recorded in the accident book. The accident has not been reported to RIDDOR (REPORTING OF DISEASE AND DANGEROUS OCCURENCES REGISTER). Therefore this needs addressing. The requirements and recommendations have been addressed since the last inspection visit. An area that needs to be looked at is the induction programme for new staff although there has been no new staff since the last visit. Some of the staff are still not up to date with mandatory training therefore the manager needs to identify who is or is not up to date with all mandatory training, in particular for manual handling and ensure their individual training needs are implemented. Risk assessments also need to be in place for residents who hold their key to their bedroom Abbegale Lodge DS0000067128.V362203.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 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 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Abbegale Lodge DS0000067128.V362203.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP19 Regulation 23 4 (b) Requirement The registered provider must ensure that the fire escape at no 11 is cleared of the tree branches so that a free passageway is available. The registered provider must ensure that clean and dirty bed linen is transferred in separate containers to prevent cross contamination. Timescale for action 07/07/08 2. OP26 13 (3) 18/08/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP3 OP7 Good Practice Recommendations It is recommended that the dates of assessments carried out for prospective residents should be recorded. It is strongly recommended that training should be provided for care staff to improve their skills in producing care/person centred plans that reflect the needs of the residents. It is recommended that all residents sign and agree their care plan. DS0000067128.V362203.R01.S.doc Version 5.2 Page 27 3. OP7 Abbegale Lodge 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. OP9 OP14 OP19 OP22 OP26 OP27 OP29 OP29 OP33 OP35 OP38 OP38 It is recommended that all medication amounts should be entered on the medication administration records. It is recommended that residents should be encouraged to be involved in the decision-making around which activities are arranged. It is recommended that the window catches should be repaired. It is recommended that consideration should be given to installing a handrail along the hallways in the ‘flats’ building to assist residents with their mobility. It is recommended that care staff in the kitchen should be dressed in the uniform provided to prevent contamination. It is strongly recommended that the manager monitor staffing levels to ensure residents’ needs are not compromised. It is recommended that all written references should be dated to confirm authenticity. It is recommended that police checks carried out prior to new staff employment should have the date of referral recorded. It is strongly recommended that the registered provider should produce a written report on a monthly basis and keeps a record of this in the service. It is recommended that two senior staff on a regular basis should audit all financial records/monies with residents signatures evidenced for each financial transaction. It is recommended that risk assessments should be in place for all residents who hold a key to their rooms. It is recommended that RIDDOR (REPORTING OF DISEASE AND DANGEROUS OCCURENCES REGISTER) should be informed where needed. Abbegale Lodge DS0000067128.V362203.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Merseyside Area Office 2nd Floor South Wing Burlington House Crosby Road North Waterloo, Liverpool L22 OLG 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 Abbegale Lodge DS0000067128.V362203.R01.S.doc Version 5.2 Page 29 - 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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