Inspection on 07/11/05 for Abberleigh House

This inspection was carried out on 7th November 2005.

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 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

Abberleigh House 10/02/09

Abberleigh House 20/02/07

Abberleigh House 02/03/06

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 Patricia Hellier Announced Inspection 7th November 2005 13:00 Abberleigh House DS0000008079.V250029.R01.S.doc Version 5.0 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.V250029.R01.S.doc Version 5.0 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.V250029.R01.S.doc Version 5.0 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.V250029.R01.S.doc Version 5.0 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 14th December 2004 Date of last inspection Brief Description of the Service: Abberleigh House is a large Victorian house providing residential care for young men and women with learning disabilities. The home is set in a quiet residential area with a large garden. An on site craft workshop is provided for residents to encourage expression of creativity and practical tasks. Its sister home, Abberleigh Grove, is in the next road and residents from the two homes share many social events together and facilities. 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. They also enable links with local health services. A range of other professional input is sought on each resident’s behalf and the team involves relatives appropriately to ensure that residents receive the services they need to enable them to enjoy the best possible quality of life. Respite care is offered, one client at a time. Abberleigh House DS0000008079.V250029.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over four hours on 7 November 2005. The Provider, Registered Manager and three members of staff were present during the inspection. All residents and members of staff present also took part in the inspection. Before the inspection the information about the home was received from the pre inspection questionnaire. The inspector looked around the whole of the building and inspected a number of records. The residents have all lived at the home for some years, and the people who regularly come for respite care are well-known to the resident group. Residents were very positive about what it is like to live at the home, and about the good relationships they enjoy with the other people there. Residents who found communication with the inspector showed their contentment with the home through their behaviour and non-verbal communication. What the service does well: The home is well decorated providing a comfortable family environment for the residents. On the day of the inspection there was a lively atmosphere with staff and residents purposefully involved in the days activities. Staff were observed interacting with residents in a caring and enabling manner. The staff group work well as a team, are resident focused and provide continuity for residents. They ensure the well-being and comfort of the residents’ and treat them with great respect and kindness. The home has good links with the local GP, district nurses and other professionals that they involve appropriately to ensure all care needs are well met. All residents’ spoken with praised the care they received from the staff. The home continues to provide high quality care with competent staff in a welldecorated, pleasant and homely environment. Consultation is embedded in the home’s culture, going on as a regular part of daily life rather than by more formalized methods. Some of the residents were able to tell the inspector about the various ways in which they contribute to the homes running. Residents are supported to take informed risks, and written risk assessments are drawn up in respect of these. Abberleigh House DS0000008079.V250029.R01.S.doc Version 5.0 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. Abberleigh House DS0000008079.V250029.R01.S.doc Version 5.0 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.V250029.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 The Residents’ guide is comprehensive and provided prospective residents with information to make an informed choice. The home’s assessment process is thorough and ensures that it is able to meet residents’ needs. EVIDENCE: Residents are provided with a comprehensive Residents’ booklet containing the Statement of Purpose and all the information required to ensure they or their relatives have access to the relevant information at all times. Care needs and aspirations are well met through a full assessment process and the completion of a care plan from this information. The assessment includes all the elements listed in the standard. A comprehensive assessment was seen for a recent short-term resident. The resident when spoken to said ‘I like it here – it’s great’. Abberleigh House DS0000008079.V250029.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 Service users benefit from care plans that are well formulated and give clear information to enable staff to meet residents’ health and social care needs. Residents are consulted on aspects of life in the home, however there is little documentary evidence to support this. Personal and environmental risks are well managed EVIDENCE: Individual records are kept for each of the residents and inspection of the records for three residents contained well-formulated personal and environmental risk assessments to ensure the safety of the resident while promoting independence as able. The care plans clearly identified health and social care needs and actions to meet these needs. Personal goals and assistance for residents with the decision making about their lives are clearly stated. The interactions of the care staff observed demonstrated respect for individuals and their right to privacy. Residents spoken to said ‘the staff are very nice and kind and treat you very well’. Staff were observed consulting residents on their wishes regarding household activities and the meals, however this is not formally documented to reflect the good practice observed. Abberleigh House DS0000008079.V250029.R01.S.doc Version 5.0 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,15,17 Social activities, personal development and meals are all well managed, providing creative, daily variation and interest for people living in the home. Residents right to choice and control over their lives are well respected and encouraged. EVIDENCE: All the residents have a regular timetable of varied activities where they can meet with their peers and utilise opportunities for personal development. They and are assisted to make use of community facilities such as pubs, bowling, cinema and local events. Where able they are encouraged to help with some basic household chores. Friends and relatives are welcomed in the home. The atmosphere in the home was lively, with laughter and activity filling the house. When one resident was upset and this was responded to by staff quickly and with sensitivity. All the residents said that the ‘food is good’ and that they liked the daily choices offered. Evidence of personal preferences was seen in care records. Menus showed a varied, balanced and nutritious diet. Abberleigh House DS0000008079.V250029.R01.S.doc Version 5.0 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Residents right to choice and control over their lives is well respected, and encouraged. Autonomy and personal choice is promoted via advocacy services helping residents to maintain independence. Physical and emotional health needs are well recognised and met. The systems in place for the management of medicines are good. EVIDENCE: During the inspection the relationship between residents and staff appeared to be one based on mutual respect. Support was observed being given in the residents preferred way, as stated in care plans. One resident stated that the member of staff on duty was her friend. Care records inspected showed that residents healthcare and well-being is reviewed monthly. Physical and emotional health needs were well recorded with actions and outcomes noted. Records of consultation and interventions from other professionals are well maintained. Staff observed and interviewed demonstrated good understanding and competence in meeting these needs for different residents. The medication administration system is good and reflects knowledge and understanding. Hand transcribed prescriptions were seen and these had not been signed by two members of staff when written thus not providing the recommended safeguard for residents. Homely remedies are stocked and administered but there are no policy guidelines developed with the local GP’s to ensure the safety of residents. Abberleigh House DS0000008079.V250029.R01.S.doc Version 5.0 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Residents are confident that they are listened to and their requests acted upon. Staff have a good knowledge and understanding of the forms of abuse and of the procedures to follow to ensure adult protection. EVIDENCE: The home has a detailed complaints procedure, both written and in Widget form, that is well displayed and all residents have a copy. There have been no complaints and residents indicated that if they were not happy about anything they would speak to a member of staff. Staff and residents spoken to, say the manager is very approachable and understanding. Residents interacted with staff in a relaxed way and were evidently comfortable approaching them. A procedure for responding to allegations of abuse is available and staff demonstrated good awareness and understanding of this process. Staff said they had not seen any signs of abuse in the home. Staff could identify forms of adult abuse and all said that they would challenge and report any poor practice. Resident’s monies are well managed with each resident having their own bank account into which their personal allowance is paid. They can access this in the normal way and staff assist as needed. All other monies are paid into the homes account and transport and other expenses for residents paid from this account. Holidays are organised annually. Clear records and bank statements enable a full audit trail. Abberleigh House DS0000008079.V250029.R01.S.doc Version 5.0 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Residents are provided with safe, comfortable surroundings. Outdoor space is attractive and accessible for residents to enjoy. Control of infection practices and facilities in the home to prevent cross infection are sufficient and suitable. EVIDENCE: The property is well maintained, with homely and comfortable communal spaces. Residents were observed to be very relaxed and at home. The living accommodation is well decorated and homely. Residents’ rooms are personalised and comfortable with some having been decorated to resident’s choice. Communal lounges are well equipped with TV and video, and a variety of board games. The large garden is home to chickens and a goat. There is also a large decking area used for outdoor activities, parties and barbecues. The home was clean and free from offensive odours throughout. The laundry facilities were well organised. Staff interviewed and observed demonstrated good understanding of Infection control procedures and practices and maintained a clean and hygienic environment. Abberleigh House DS0000008079.V250029.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34 The numbers and skill mix of competent staff are sufficient to meet residents’ needs. Staff access external training to ensure training is matched to the residents needs. EVIDENCE: A number of staff have an NVQ 2 qualification and others are working towards obtaining it. The owner encourages staff to access training and achieve the qualifications to meet residents’ needs. Staff spoken with confirmed there are regular opportunities for training. A number of certificates were seen displayed around the home. Staff told the inspector the owner provides in house training in specialist areas, however these sessions are not well documented to evidence the good practice. This documentation is recommended. There is a low turn over of staff which provides continuity and stability for residents. Staffing rota’s inspected showed adequate numbers on duty to meet resident’s needs. Staffing levels are managed in conjunction with the sister house (Abberleigh Grove) nearby with all sickness and holidays being covered from within the staff team across the two houses. Recruitment procedures are robust. Files inspected did not contain proof of identity, however the regulations are unclear about this and clarification is being sought. All staff interviewed stated they had contracts of employment and job descriptions. Newly appointed staff confirmed they had completed an induction programme and evidence of this was seen in personnel files. Abberleigh House DS0000008079.V250029.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,42 The manager provides clear leadership and guidance to staff to ensure residents receive consistent care in a safe environment. Residents’ views are sought and acted on, but a formalised system is not in place. EVIDENCE: The manager gives clear leadership, guidance and direction to staff to ensure residents receive consistent care. The manager has a number of academic qualifications pertinent to her role and several years experience in the post. The home has a quality assurance statement that lists the ways in which it consults residents, their relatives and other carers. A formal quality assurance tool was not available however residents were observed being consulted and two told the inspectors that their views were sought and acted upon. Records confirmed this. A formalised quality assurance process is recommended. Records inspected indicated regular safety and fire checks are carried out. Staff spoken to confirmed that regular fire instruction and drills had taken place. Abberleigh House DS0000008079.V250029.R01.S.doc Version 5.0 Page 16 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X 3 LIFESTYLES Standard No Score 11 3 12 3 13 X 14 X 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 3 3 X X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Abberleigh House Score 3 3 2 X Standard No 37 38 39 40 41 42 43 Score 3 3 3 X X X 3 DS0000008079.V250029.R01.S.doc Version 5.0 Page 17 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 Refer to Standard YA20 YA20 YA34 YA35 YA39 Good Practice Recommendations Hand written entries on the medicine administration records should be signed and dated by 2 members of staff To develop a homely remedies policy in conjunction with the local doctors. To maintain proff of identity for all employees. The record of training to include the numerous one-to-one training sessions that the owner-manager provides. A formalised system of Quality Assurance that analyses the results of a resident survey, produces an action plan and feedback to residents and staff, should be developed Abberleigh House DS0000008079.V250029.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL National Enquiry Line: 0845 015 0120 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 Abberleigh House DS0000008079.V250029.R01.S.doc Version 5.0 Page 19 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!