Inspection on 20/02/07 for Abberleigh House

This inspection was carried out on 20th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Abberleigh House 10/02/09

Abberleigh House 02/03/06

Abberleigh House 07/11/05

Abberleigh House 14/12/04

Abberleigh House 17/05/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Abberleigh House 17 Grove Park Road Weston Super Mare North Somerset BS23 2LW Lead Inspector Catherine Hill Unannounced Inspection 20th February 2007 09:30 Abberleigh House DS0000008079.V326753.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 Abberleigh House DS0000008079.V326753.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. Abberleigh House DS0000008079.V326753.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abberleigh House Address 17 Grove Park Road Weston Super Mare North Somerset BS23 2LW 01934 621397 01934 623162 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) Dr Joseph Conlon Mrs Jacquetta Miner Dr Joseph Conlon Care Home 9 Category(ies) of Learning disability (9), Learning disability over registration, with number 65 years of age (9) of places Abberleigh House DS0000008079.V326753.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 9 persons aged 18 years and over with learning disabilities. May include persons aged 65 years and over Date of last inspection Brief Description of the Service: Abberleigh House is a large Victorian house providing residential care for younger adults with learning disabilities. The home is set in a quiet residential area with a large rear garden, which has goats and hens. Its sister home, Abberleigh Grove, is in the next road and residents from the two homes share many social events together. Most staff work in both homes as well as in the supported living service run by the homes’ owner. The home aims to support its residents to develop their independent living skills in a family environment with a view to moving on to more independent living if appropriate. Staff support residents to access community facilities and pursue their social, vocational and leisure interests. There is an independence flat on the top floor of the house which is used by one person at a time as a springboard to moving on to more independent living. High levels of one-to-one staffing are offered to the person in this flat. Respite care is offered, one client at a time. Abberleigh House DS0000008079.V326753.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over one day, starting in the late morning and ending in the late afternoon. The inspector spoke with four of the residents, a visitor, and two of the staff on duty, as well as with the manager. The inspector also spent time sitting in the communal rooms with the residents. The inspector looked at all the communal areas, and one person showed her his bedroom. The inspector spent most of the first visit with the residents and some of the staff, but also looked at a number of records, including: • the Statement of Purpose • residents care records • records relating to residents activities and social support • meals records • medications records • the complaints log • staff recruitment and training records • some of the home’s policies and procedures • records of fire precautions checks • records of health and safety checks. What the service does well: Residents get good support to move into more independent accommodation, if this is what they want. One person had recently moved into supported living, and evidently had a real sense of achievement. The environment is particularly welcoming. All communal areas are decorated and furnished to a very high standard. There is plenty of clear written guidance to staff, and this consistently emphasizes residents rights and interests. The home’s atmosphere is very relaxed and staff treat residents as valued individuals. The manager of the sister home has a health and safety qualification, and particularly thorough health and safety checks are done on people, the premises and processes. Abberleigh House DS0000008079.V326753.R01.S.doc Version 5.2 Page 6 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. Abberleigh House DS0000008079.V326753.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 Abberleigh House DS0000008079.V326753.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): 1, 2, 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their representatives get useful and up-to-date information about the home before they move in. A thorough assessment is done on their needs before they move in for a trial period. Arrangements for trial periods are flexible. EVIDENCE: The Statement of Purpose was last updated in 2005 and was in the process of being updated again at the time of this inspection. More detail is being added about the range of needs that the home is able to meet. The Statement of Purpose includes a list of all staff, their qualifications, the position they hold in the home, and how long they have worked there. The file of the most recently admitted resident was checked and this showed that a good level of information had been gathered about the person before they were offered the placement. In practice, new residents are usually people who already know the home from having respite care. However, these people still have a trial period before deciding to stay long-term. Abberleigh House DS0000008079.V326753.R01.S.doc Version 5.2 Page 9 Residents contracts were not checked at this inspection. Abberleigh House DS0000008079.V326753.R01.S.doc Version 5.2 Page 10 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): 6, 7, 8, 9, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents personal care needs are well documented, kept under regular review, and well met. People are supported to take informed and wellmanaged risks. EVIDENCE: The newly admitted resident’s placement had been reviewed with his social worker at the end of his trial period. The home had reviewed his care plan again two months later. Residents files contained easy to access information. Files begin with a photograph and essential details about the person, including their likes and dislikes. Names and contact details of family members are kept on file, along with a list of people to whom the person would like to send birthday cards. Abberleigh House DS0000008079.V326753.R01.S.doc Version 5.2 Page 11 Staff do a monthly review on each persons care and progress, and a more indepth six monthly review is also carried out. These reviews look at issues such as medications, dental appointments, and care plan goals and the actions taken to meet these. A detailed and informative profile has been drawn up on each resident, and these had been updated last year. Each profile begins with a nice photograph of the person and basic essential information about them. Profiles describe personalities, significant needs, the strategies in use to manage behaviour, and risk assessments on issues that particularly affect each person. Profiles also give information on employment, responsibilities, personal hygiene, and food dislikes. These profiles were written positively. They did not gloss over unacceptable or difficult behaviour, but made factual statements and gave clear guidance to staff on how to respond to this. Profiles also emphasized the persons strengths and the things that make them particularly interesting. Profiles have also been drawn up on the people who regularly come for respite care. The level of detail in care plans has been increasing over the past couple of years. Care plans are being reviewed more regularly than before, and are being amended on any significant change. Day-to-day records on the individual residents are also much more informative and regular than previously. Abberleigh House DS0000008079.V326753.R01.S.doc Version 5.2 Page 12 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): 11, 12, 13, 14, 15, 16, 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents generally get good support to enjoy full and varied lives, but there is insufficient evidence that each person is getting a good level of activities and one-to-one support. The homes culture recognizes residents rights and responsibilities. Residents are offered balanced and interesting meals that suit their tastes. EVIDENCE: A resident had just moved into supported living at the time of the last inspection. Another resident has recently moved into supported living. He Abberleigh House DS0000008079.V326753.R01.S.doc Version 5.2 Page 13 visited during this inspection. Conversation with this person and staff showed the value of carefully planning this transition. The staff who work in the homes also provide support to people living in the community, and this means that service users moving between services benefit from continuity of staff. This persons room was kept vacant for the first couple of months after they moved out so that he would be able to move back into the home if he felt that supported living was not working for him. A file is kept of residents current timetables at their day placements. Each person has a section in this file with information about their individual activities programmes. Some residents go to evening activities in the community. Group activities are organized between the two homes. Some of the more able residents occasionally arrange their own activities. Holidays tend to be arranged in small groups for those people who want them. Plenty of trips out are offered to people who do not enjoy staying away overnight. A daily log is kept in the hallway so that staff can record who is coming on duty, any visitors to the home, the name of the person staying for respite care, meals provided to each resident, and group- or one-to-one activities offered. The inspector looked at these records for the month before this inspection. Several days showed a really good range of one-to-one activities, some of which were routine household chores, and some of which were more interesting activities, such as walking to the local pub, going to the bank and doing some shopping, being taken to visit a relative, being visited by family, going to clubs in the community, and going out for shopping and a drink. But by far the majority of days had no entries about either one-to-one or group activities. As many of the residents were not able to tell the inspector about their lifestyles, this record is the main evidence of what staff are doing to ensure that each person has a full range of social opportunities. Comparing this record with the rota showed that it tends to be the same staff on duty on the days when a full schedule of activities is recorded. This could indicate that some staff are better at recording what they do with the residents, but it could also be an indication that some staff are not fulfilling their duties. The manager of the home intends to address this issue with staff. However, there is often only two staff on duty when residents are home, rather than the three staff that the home previously provided. The group activities plan for last year showed a wide range of interesting weekly activities, but this stopped abruptly in October. Staff told the inspector that this had been because of staffing problems, which meant that there were insufficient staff on the night when group activities between both homes usually took place. The two staff on duty are also responsible for activities such as cooking the evening meal, supporting residents to take baths, and making packed lunches for the following day. The care manager said that a new rota is about to start, and Abberleigh House DS0000008079.V326753.R01.S.doc Version 5.2 Page 14 this allocates three staff to work on Monday, Tuesday and Friday evenings each week. It is recommended that this is kept under review to ensure that sufficient staff hours are being provided for activities at the times residents are at home. Several of the residents the inspector spoke with said that they see the people they share the home with as friends, and that the staff are all nice as well. Residents are actively encouraged to maintain links with the other people who are significant to them. At present, people are being supported to buy cards and gifts for Mothers Day. The policy on participation, choice, social life, privacy and dignity, independence and control looks at some of the ways in which residents will be enabled to participate in decision-making. It gives a number of concrete examples of how residents can be helped to do things for themselves in areas of their lives such as meals, socializing, leisure, risk-taking, and care needs. Supplementary guidance points out that part of people’s enjoyment of life is derived from taking risks and that staff need to balance this with their duty to take reasonable care. A list of shift duties is kept on the office noticeboard, and this includes tasks such as making packed lunches with the residents. It would be useful to record this kind of activity on the daily log, as it not only demonstrates one-toone input but also how people are being helped to achieve greater independence. Guidance on challenging behaviour emphasizes that staff need to change the situation rather than confronting behaviour head-on. Menu planning is done on a monthly basis with input from the residents. Residents said that they like the meals. The meals seen at this inspection looked appetizing, and the menus sampled showed a reasonably balanced diet with dishes that are likely to suit residents tastes. Food stores included a good variety of healthy snacks and treats, as well as good quality meal ingredients. Abberleigh House DS0000008079.V326753.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): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents generally get good support that takes account of their individual preferences and emphasizes their rights. However, Health Action Plans need to be drawn up with or for each person. EVIDENCE: Care records reflected residents individuality. The records and residents comments showed that residents wishes are at the centre of the care planning process. Some residents were able to give examples of the way routines are adapted to suit their individual preferences. Residents files contained records of some health matters. These mostly related to dental appointments, but one file sampled included records of cervical smear tests, and a note by a staff member who had contacted the GP to check when the next one was due. Although it appears that residents health care needs are being met, this needs to be part of a formal, recorded plan. Abberleigh House DS0000008079.V326753.R01.S.doc Version 5.2 Page 16 The inspector advised the home at the last inspection that Health Action Plans need to be developed, in line with the guidance of Valuing People. These need to show not only how each persons particular health needs are being met but also how they will be supported to access routine health check services. This had not been done by the time of the latest inspection. The Action for Health Coordinator of the Community Team for People with a Learning Disability will be able to give advice on drawing up Health Action Plans. The medications policy begins by saying that residents should be enabled to retain control of their own medicines where possible. It gives clear guidance on safe handling of medications. Supplementary guidance tells staff the exact procedure to follow when administering medications. The inspector suggested at the last inspection that it might be useful to include a copy of the homely remedies policy in the medications file. This suggestion has been taken up, and there is now a very straightforward policy on file. Medications administration records sampled were in good order. They clearly show when any short-term courses of medicine have been finished. Medication administration records are highlighted to draw staff attention to where they need to sign. The inspector suggested it might be more useful to use different coloured highlighters for the different times a day at which medicines are given. It was recommended at the past two inspections that handwritten entries on the medication administration records should be signed and dated by two members of staff. No handwritten entries were seen on the medications records sampled at todays inspection. Abberleigh House DS0000008079.V326753.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): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents rights and wellbeing are well protected. EVIDENCE: The complaints procedure is very welcoming, and is updated every year. It includes clear instructions on how to contact CSCI. The resident who recently moved in has his own Makaton version of the complaints procedure on the noticeboard in his bedroom. A copy of this is also included in the homes complaints log. No complaints have been received by CSCI or the home since the last inspection. Those residents who were able to tell the inspector said they felt comfortable raising any worries or grumbles with the staff. Residents said that staff listen and try to put things right for them. Staff will also raise any concerns on residents behalf, and felt that the manager encourages this. The home has very clear and informative policies on malpractice, abuse and inappropriate behaviour, which link to North Somerset Social Services No Secrets guidance. These emphasises staff duty to report any concerns, and give guidance on the procedure to follow. They also give brief guidance on individuals capacity to consent. The training records did not show that staff have had abuse awareness training within the past couple of years, but discussion with staff and observation of Abberleigh House DS0000008079.V326753.R01.S.doc Version 5.2 Page 18 practice revealed that staff are alert to the possibilities of abuse and how to avoid it. Abberleigh House DS0000008079.V326753.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): 24, 26, 27, 28, 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The environment is well suited to residents needs. EVIDENCE: There is a very high standard of décor throughout the home, and furniture and fittings are of a good quality. The environment is particularly comfortable and pleasant. There is a large lounge at the front of the building, and a dining room adjacent to the kitchen. There is also a small computer room that residents can use. One of the downstairs bedrooms has an ensuite bathroom, and communal toilets and bathrooms are provided within easy access of each bedroom. All bedrooms are single and two bedrooms are on the ground floor. All bedrooms are at least 10 m squared. Abberleigh House DS0000008079.V326753.R01.S.doc Version 5.2 Page 20 The home’s written policy says that residents should hold keys to the front door and to their own bedroom door, if they should wish. Locks are not automatically provided on bedroom doors, but will be provided if anybody wants one. There is a very large back garden, mainly laid to lawn. A goat and some hens have their houses out here. There is a raised decking area at the back of the house, which is reached by a French window. All areas of the home seen were clean and well maintained. Abberleigh House DS0000008079.V326753.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): 32, 34, 35, 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from safe staffing practices. Keeping the rotas under review and improving staff training records will help to ensure this is consistent. EVIDENCE: Three staff files were sampled, one relating to the newest member of staff, and two relating to people who recently left the service’s employment. The application form asks for a job history of the past 10 years, and the names of three referees, one of whom must be the most recent employer. Reference requests ask for in-depth information and invite additional comments. References, identity checks and PoVA First/CRB checks are sought prior to the person starting work in the home. A copy of the staff member’s contract was on file, with a copy of their basic rota. Staff who use their cars to transport residents also had a copy of their car insurance on file. These files contained induction training records, which went into detail about each aspect of their role, and which were initialled and dated. In some cases, Abberleigh House DS0000008079.V326753.R01.S.doc Version 5.2 Page 22 the senior staff delegated with responsibility for giving this training had added further explanatory notes. Staff training records showed that people had sufficient training in 2005 but the records became very patchy after this. One persons file showed six training sessions in 2005, but then no training until December of the following year. A second staff member’s file listed had three types of training in 2005 but no further training recorded until January 2007. A third staff member’s file showed that the person had a training session in August 2005, two training sessions in December 2006, and a further one in March 2007. However, a fourth staff member’s file showed a good range of regular training, and the staff the inspector met during these visits described frequent training on a broad range of subjects, much of this from Dr Conlon. One staff member told the inspector that she had had more training last year than she had recorded in her own training record. Staff have been delegated with responsibility for keeping their own training records up to date, and it appears that not all staff are doing this. The manager keeps the master list of staff training, and this shows that staff have regular statutory training, with the exception of abuse awareness. However, it does not include all the additional training sessions laid on by the provider. Ten staff between the two homes hold NVQ 2. Two staff are starting NVQ 3. The care manager in each home will be doing the Registered Managers Award. The care managers in each home have recently taken on delegated responsibility for staff supervision. The registered managers in each home give formal supervision to each care manager. Abberleigh House DS0000008079.V326753.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): 37, 38, 39, 40, 41, 42, 43 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a well-run service that puts their interests at the heart of its decision-making. EVIDENCE: Joe Conlon holds a number of higher qualifications in psychology and education, and has been registered manager of Abberleigh House since it opened in 1989. Staff described a relaxed working atmosphere, in which they are encouraged to question practice and contribute their own ideas. Senior staff and managers are seen as a supportive and approachable. Staff feedback indicated that oneAbberleigh House DS0000008079.V326753.R01.S.doc Version 5.2 Page 24 to-one supervision with care managers is working well. Senior staff regularly spend time discussing principles of care with the staff group. Policies and procedures are kept under review. Following a recent incident with a resident who went missing, the homes missing person procedure was reviewed. The quality assurance policy covers a range of methods by which residents and staff will be given opportunities to think about what might improve the service and to contribute their ideas. This policy also looks at the links established between the home and various other significant people. The policy on money management begins with the premise that all residents have the right to manage their own money with any support necessary. This emphasises that being kept without money or having to ask someone else for your own money is a form of abuse. One persons financial records were sampled in more depth, and showed that actual practice matches the homes stated aims. Cash is held in the office on behalf of one person, but all other residents have a lockable cash box in their own rooms. Risk assessments are carried out for people, activities, and the premises, and these were reviewed last month. Regular health and safety checks are carried out on the premises, and staff have regular health and safety refresher training. The fire precautions log shows that fire safety training was given to staff four times last year. Staff covering night-time duties are now due for further refresher training, as they have not had it for just over three months. Fire drills are held every month or so, and these are also used as a training opportunity. The logbook shows that fire precautions equipment is being tested with the frequency recommended by the Fire Officer. Records of small electrical appliance testing showed that PAT testing had been carried out every six months until October 2005. Electrical wiring was last tested in 2004. Gas safety is checked yearly. The maintenance log shows that staff are reporting any minor problems, and that these have generally been addressed. A few issues had not been ticked as completed but a tour of the premises showed that this was probably simply an oversight, as some of the issues had evidently been put right. Abberleigh House DS0000008079.V326753.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 3 2 3 3 X 4 3 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 4 25 X 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 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 3 x 3 3 3 3 3 3 3 Abberleigh House DS0000008079.V326753.R01.S.doc Version 5.2 Page 26 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 YA19 Regulation 12 Requirement Health Action Plans need to be developed, in line with the guidance of Valuing People. These need to show not only how each persons particular health needs are being met but also how they will be supported to access routine health check services. Timescale for action 20/04/07 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 YA33 YA35 Good Practice Recommendations Staffing levels at times when residents are at home should be kept under review to ensure that sufficient staff hours are being provided for activities and one-to-one support. The record of training should include the numerous one-toone training sessions that the owner-manager provides. This recommendation was first made at the inspection of 02/03/06. Abberleigh House DS0000008079.V326753.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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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