Inspection on 24/07/07 for Abbey House

This inspection was carried out on 24th July 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 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

Abbey House 05/07/06

Abbey House 06/12/05

Abbey House 11/07/05

Abbey House 18/01/05

Abbey House 21/07/04

Similar services:

Applegarth

Trevayler Residential Care Home

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

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

CARE HOMES FOR OLDER PEOPLE Abbey House Stokes Drive Leicester Leicestershire LE3 9BR Lead Inspector Linda Clarke Key Unannounced Inspection 24th July 2007 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 Abbey House DS0000037630.V339991.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. Abbey House DS0000037630.V339991.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbey House Address Stokes Drive Leicester Leicestershire LE3 9BR 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) 0116 2312350 0116 2875186 socis215@leicester.gov.uk socis209@leicester.gov.uk Leicester City Council Mrs Jennifer Glover Care Home 33 Category(ies) of Dementia - over 65 years of age (20), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (20), Old age, not falling within any other category (33), Physical disability over 65 years of age (8), Sensory Impairment over 65 years of age (10) Abbey House DS0000037630.V339991.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service User Numbers DE(E) or MD(E) No one falling within category DE(E) or MD(E) may be admitted into Abbey House when 20 persons who fall within categories/combined categories DE(E) or MD(E) are already accommodated within the home Service User Numbers PD(E) No one falling within the category PD(E) may be admitted into Abbey House where there are 8 persons of category PD(E) already accommodated within the home Service User Numbers SI(E) No one falling within the category SI(E) may be admitted into Abbey House where there are 10 persons of category SI(E) already accommodated within the home 5th July 2006 2. 3. Date of last inspection Brief Description of the Service: Abbey House is a registered care home providing accommodation for up to thirty-three older persons and is owned by Leicester City Council. The home is situated along a main road in a residential area with car parking space to the front of the home. The home is located approximately a ten-minute bus journey from the city centre. There are shops, pubs, a post office and other local amenities approximately half a mile from the home. There is level entry access to the home with accommodation on the ground and first floor level, which can be accessed by a passenger lift or the stair lift. Bedrooms are all single rooms with wash hand basins with bath/shower and toilet facilities close by. Residents have a choice of lounges, located on the ground and first floor and dining room on the ground floor. There is seating available for residents to the front of the home and the garden to the rear is landscaped. The home’s brochure provides information about the service to prospective and current residents and includes the terms and conditions of the stay. People that live at the home are responsible for any additional charges such as private chiropodist, toiletries, hairdressing and newspapers. The CSCI published inspection reports are available at the home and referred to in the home’s brochure. The people who live there are informed of the CSCI inspection individually and through sharing information with relatives. Abbey House DS0000037630.V339991.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection process consisted of pre-planning the inspection, which included viewing the previous Inspection Report, reviewing of the Annual Quality Assurance Assessment (AQAA), and Comment Cards sent to service users and their relatives by the Commission for Social Care Inspection, twelve service user and eleven relative Comment Cards were returned. The unannounced site visit commenced on the 24th July 2007 and lasted 1 day. The focus of the inspection is based upon the outcomes for the service users. The method of inspection was ‘case tracking’. This involved identifying service users with varying levels of care needs and looking at how these are being met by the staff at Abbey House. Four service users were selected and discussions were held with two of them, additionally three service users and their relatives who were visiting were spoken with. The method of case tracking included the review of service users’ individual care records, discussions with staff of various delegated responsibilities within the home and reviewing the records, training records and the minutes of service user and team meetings. Of the Comment Cards returned by service users comments received were generally complimentary about the care, some recorded general comments: • • • • I’m very satisfied living at Abbey House I have no complaints. The staff are very good to me. I enjoyed the trips out. I am very happy living at Abbey House I have everything I need and the staff are great. What the service does well: Service users considering a move to Abbey House can be confident that their needs will be assessed, and that following the first four weeks of residency they will be invited to a review along with their relatives and representatives of staff at Abbey House, to discuss their views as to the care they are receiving. Service users views and aspirations and care needs are documented within detailed care plans, which are regularly reviewed, and signed either by the service user or their relative. Service users health is monitored and access to health care professionals is promoted with documentary evidence. Service users and relatives made comments as to the care received:• • “Since my mum has lived her physical health has improved.” “I wished to be kept informed when my mum is seen by a Doctor.” DS0000037630.V339991.R01.S.doc Version 5.2 Page 6 Abbey House • • “They always let me know if my mum is unwell.” “Happy with my care and the way it’s given.” Social activities are organised by the Activity Organiser and other members of staff, and include activities within Abbey House as well as trips out. The Activity Organiser enables service users to participate in art and craft activities and board games, whilst external trips are supported by care staff and relatives in some instances. Service users and relatives were very complimentary about the meals at Abbey House the following comments were made:• • “Meals are alright, you get a choice.” “Silver service, you couldn’t get better in a top hotel.” Abbey House is well maintained and decorated to a good standard throughout, service users and their relatives made the following comments about the Home environment when asked: • • • “I would like my bedroom decorated.” “The Home is always homely and friendly.” “The Home is clean and well cared for.” Service users have the benefit of having specialist equipment available to support them in bathing/showering and walking around the Home, and includes an accessible garden. Service users are encouraged to share their views and contribute to the dayto-day running of Abbey House by quarterly meetings held within the Home. The Commission for Social Care Inspection (CSCI) sent out surveys to a number of service users relatives when asked what the home does well the following comments were made: • • • • • • • • Provides a safe environment with 24 hour care. (service users name) is looked after very well, and is very happy at the Home. They have provided a comfortable, caring environment; they always try to understand the needs of both my relative and the other residents, which is not always easy. We think it does well, we realise it cannot give one to one care, given the number of residents. I think that they look after my mother very well, and have no concerns whatsoever about her welfare. The care by all staff at Abby House is excellent and couldn’t be improved. They have patience and good communication skills. Friendly atmosphere. Abbey House DS0000037630.V339991.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: The Service Users guide should be reviewed and a copy given to all service users. The document to include information about Abbey House, the staff employed, information on how to raise concerns, service users views of the home, and a copy of the most recent Inspection Report conducted by the Commission for Social Care Inspection. Service users access to activities and recreational pursuits either within groups or on a one to one basis is restricted in part by the hours worked by the Activity Organiser, this being two hours a week. Service users who would benefit from one to one activities, or individually tailored activities which reflects both their mental and physical health, can only be facilitated by a significant increase in the hours worked by an Activity Organiser. Service user continuity of care could be improved by the reduction of the number of Agency staff used, or where Agency staff are used that the same staff are requested to promote continuity of care. Service users who have a diagnosis of Dementia would benefit from receiving care from staff who are trained in Dementia Care. The views of service users, their relatives and visiting health and social care professionals should be actively sought as part of the Homes’ Quality Assurance Process, to effect change within Abbey House for the benefit of service user care. The Local Authority to set up a system where by Regulation Inspectors employed by the Commission for Social Care Inspection can confirm by the viewing of records that staff have had a Criminal Record Bureau disclosure. The Commission for Social Care Inspection (CSCI) sent out surveys to a number of service users relatives when asked what the home could do to improve the following comments were made: • I doubt they could improve much without better funding. DS0000037630.V339991.R01.S.doc Version 5.2 Page 8 Abbey House • • • • No, cannot see how the Home can be improved. I cannot see the need to make changes. Keep training going on the NVQ. More staff for trips out. 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. Abbey House DS0000037630.V339991.R01.S.doc Version 5.2 Page 9 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 Abbey House DS0000037630.V339991.R01.S.doc Version 5.2 Page 10 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): 1, 3 and 4. Standard 6 is not applicable at Abbey House does not offer intermediate care. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are provided with information about the service; and are involved in the assessment process that ensures their care needs are met. EVIDENCE: The Statement of Purpose and Service User Guide were not available on the day of the site visit, and therefore it could not be ascertained as to whether they are up to date and include the information as required. A subsequent conversation with the Assistant Manager confirmed that copies of the documents are in short supply, and that they need to be updated. The Statement of Purpose is a document that provides information about the Registered Manager and staff, including qualifications and experience. The range of needs that Abbey House aims to meet, and information as to social Abbey House DS0000037630.V339991.R01.S.doc Version 5.2 Page 11 activities, hobbies and leisure interests, and include information about specific policies and procedures of Abbey House. The Service User Guide is a document that is given to service users upon their admission to Abbey House, and should contain a description of the services provided, information about staff, a copy of the most recent Inspection Report undertaken by the Commission for Social Care Inspection (CSCI), the Complaints Procedures and existing service users’ views of the home. The records of four service users were viewed as part of the ‘case tracking’ process, this included looking at their initial assessment identifying their needs, which had been completed by a Social Worker and involved the service user and/or their relative. A service users residence at Abbey House is reviewed after the first four weeks to ensure that the needs of the individual are being met and that all interested parties have the opportunity to comment on the care being delivered. Unless a service user has change in circumstances or their needs change a review is then undertaken on an annual basis. Conversations were held with two service users, and the relatives of three service users who were visiting on the day of the site visit. Service users and relatives said that their needs were met, and that staff were kind and supportive. The Commission for Social Care Inspection (CSCI) sent out surveys to a number of service users when asked whether they received information about Abbey House and whether they received the care and support they need all indicated they yes. An additional comment made by a relative within their comment card: • It is my opinion Abbey House is a great home from home to live in, it is a very caring home and we are very happy with the care my sister in law gets from staff. Abbey House DS0000037630.V339991.R01.S.doc Version 5.2 Page 12 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): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are well cared for having their tailored health and daily care needs met through personalised care. EVIDENCE: The records of four service users were viewed as part of the ‘case tracking’ process, this included looking at their care plans. In the first instance a care plan is produced by the Social Worker, following the initial assessment of the service users needs. An additional care plan is written from the perspective of the service user, and includes information about a service users previous life and any significant events, this enables staff to have an understanding of a service users life prior to their residence at Abbey House, information is also detailed as to a service users views and wishes as to their expectations of care, information as to their views on dignity are included for example their preference as to the gender of Abbey House DS0000037630.V339991.R01.S.doc Version 5.2 Page 13 staff providing personal care. The care plan details those who are involved in the day to day lives of the service user and include personal relationships and health and social care professionals, including their contact details. Care plans provide information as to the support an individual requires with regards to their physical and mental health well being. Care plans focus on service users independence and abilities, and where assistance is required how this is to be delivered, with the views of the service user recorded. Service users who have specific health care needs for example Dementia can be confident that their care plan will provide information as to how their condition affects their daily lives, how staff need to be sensitive as to their daily care, and how this should be managed. The service user or their relative and keyworker had signed the care plans in three out of the four viewed. Relatives spoken with confirmed that they are aware of their relatives care plan, and are happy with its content. One relative spoken with said, his only criticism was that he was not always kept informed when health care professionals visited, or were visited by his relative, this was discussed with the Senior Carer on duty who acknowledged that information had not been passed on. Two other visiting relatives were spoken with who said that they were kept informed with regards to issues affecting their relatives’ health and welfare. Daily records of the four service users whose records were viewed detailed their access to a range of health care professionals, which included Specialist Consultants, Optometrists, Dentists, Chiropodists, General Practitioners and District and Specialist Nurses in Diabetes and Psychiatry. Service user records details their visit to health care professionals and any follow up action that needs to take place. Where potential risks to service users exist for example the moving and handling of individuals, service users health care needs such a Dementia/Diabetes or behaviour puts them at potential risk, a risk assessment is conducted which details how the potential risk is to be managed whilst maintaining and promoting the service users independence. The medication and medication records of the four service users who were ‘case tracked’ were viewed and were found to be in good order. Information as to service users prescribed medication is detailed on the individuals care plan. Service users have a dedicated member of staff who overseas the care of the service user referred to as their ‘keyworker’, part of this role is to review the care plan monthly with the involvement of the service user and/or relative, if any changes are noted the ‘keyworker’ advises a member of the Management Team who updates the care plan. Abbey House DS0000037630.V339991.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): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users make choices about daily living; and are offered a variety of meals; improvements to social activities could be improved. EVIDENCE: The care plans of the four service users viewed, and identified their hobbies and interests, their likes, dislikes and requirements with regards to food, their preferences for daily living i.e. the time they wish to go to bed, information as to personal relationships and their religious observance. Information supplied by the Registered Manager prior to the site visit states Church of England Church Services are held in the Home monthly, and include Holy Communion, additionally Catholic Priests visit for service users of the Roman Catholic Faith. The information supplied states that an Activity Organiser has been employed to provide activities for service users who wish to participate, the Activity Organiser on the day of the site visit spent time with four service users undertaking an Art & Craft activity. A conversation with the Activity Organiser and the reading of service user records confirmed that the Abbey House DS0000037630.V339991.R01.S.doc Version 5.2 Page 15 Activity Organiser also supports service users in games such as Bingo and Dominoes. The Activity Organiser works two hours a week, usually on a Tuesday afternoon, service users would benefit from the hours of the Activity Organiser being considerably extended, enabling service users to participate in a wider range of activities, and to also benefit from one to one time, especially beneficial to service users who do not like to mix in groups or may have specialist needs such as Dementia. Service users and their relatives need to have the opportunity to comment as to the activities provided, and as to whether the needs and expectations of all as opposed to some service users are being met. Daily records of service users recorded that some service users in July had been on a barge trip, and although it had rained all day everyone had an enjoyable time. Future planned activities include lunch at Mountsorrel, which is to take place in August. Regular activities such as Bingo also take place, organised and managed by a member of care staff, and there are weekly Coffee Mornings held locally ran by the Allotment Society, to which a number of service users attend. Abbey House provides a visitors room, which relatives and service users can use to meet if they do not wish to remain in the communal areas or in the bedroom of the service user. Abbey House encourages visitors, and there are no restrictions as to the time or frequency of visits. Care plans and records evidenced that for some service users a Solicitor handles their financial affairs, whilst other service users are supported by relatives, or manage themselves. Information supplied by the Registered Manager prior to the site visit acknowledge that information about Advocacy services needs to be used to greater effect, information leaflets about Advocacy services are located in the Office of Abbey House. Service users and their relatives were asked as to their views on the meals, all highly commended both the quality and choice available. There are choices available for the three set meals of the day, and specialist dietary needs are provided for. The Commission for Social Care Inspection (CSCI) sent out surveys to a number of service users when asked whether activities were arranged by the home, some indicated always, and some said usually whilst others recorded sometimes. Abbey House DS0000037630.V339991.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are protected by a robust and accessible complaints procedure and by staff trained in safe guarding adult processes. EVIDENCE: Documentation supplied by the Registered Manager prior to the site visit detailed that Abbey House has not received any complaints or concerns in the last twelve months. The Commission for Social Care Inspection (CSCI) in the last twelve months has not received any complaints or concerns with regards to Abbey House. The Service User Guide should include a copy of the Complaints Procedure, and should be given to all service users upon their admission, as the Service User Guide could not be located, a requirement has been made to ensure that the document is circulated to all service users. Service users and visiting relatives were asked if they new how to raise concerns, all indicated that they would speak to a member of the Management Team, whilst some service users said they would speak with their relative. Staff receive training in how to look out for signs of abuse and how they are to respond if they have any suspicions or concerns. Policies and procedures detail Abbey House DS0000037630.V339991.R01.S.doc Version 5.2 Page 17 the action that staff are to take should that have any concerns with regards to service user welfare. The Commission for Social Care Inspection (CSCI) sent out surveys to a number of service users when asked if they knew who to speak with if they were unhappy all but one indicated they did. To the question do you know how to make a complaint two indicated they did not. Abbey House DS0000037630.V339991.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): 19, 20, 22, 24 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are provided with a warm, safe, clean, comfortable and wellmaintained environment suitable for their needs. EVIDENCE: Abbey House has four communal lounges, three on the ground and one on the first floor, dining room and a visitors room are located on the ground floor, with bathing, shower and toilet facilities and bedrooms being on the ground and first floor. Access to the first floor is via a passenger lift or by one of two stairwells. All communal areas are decorated to a good standard and service users and visiting relatives were complimentary with regards to the standard of décor and cleanliness of the Home, the Registered Managers documentation detailed a plan to decorate the dining room. Abbey House DS0000037630.V339991.R01.S.doc Version 5.2 Page 19 There is a large side/rear garden, which is laid to lawn with mature trees, and a smaller garden, which is accessible via a ramp enabling service users with a physical disability to go into the garden. The garden has a lawn area, shrubs and plants with a patio area with furniture. Information supplied by the Registered Manager prior to the site visit identified that their plan is to purchase new patio furniture and provide awnings for the rear patio. Bathing, showering and toilet facilities within the home are accessible to service users with a physical disability, either through being level access in the case of showers or through the provision of specialist bathing equipment. Bedrooms are decorated to a good standard, a service user and their relative who were spoken with said that they would like the bedroom to be decorated, the Senior Carer on duty was advised of their request, and said that there is an ongoing maintenance programme for redecoration. Contracts are in place for the removal of clinical waste, and staff have undertaken training in infection control, policies and procedures are in place for the maintenance of infectious diseases including MRSA. Abbey House DS0000037630.V339991.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): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users needs are met by staff that are experienced and trained in the delivery of care, having their needs timely and safely met. EVIDENCE: Service users and their relatives spoke positively about the care staff saying that they are lovely, and that they always respond if you call them. During the morning and at lunchtime there are four members of care staff on duty; whilst in the afternoon and evening there are three members of care staff. Throughout the day the care staff are supported by a member of the Management Team or a Senior Carer. At night time there are two care staff on duty, supported by two Senior Carers who oversee the nine Older Persons Homes owned by Leicester City Council, by the way of an on-call service. Two staff did comment as to the use of Agency staff to cover for sickness and annual leave, one carer said that Agency staff were used several times a week, whilst one carer said that she had been on duty in the afternoon and had worked with two agency staff, which she found difficult as the agency staff are not familiar with the layout of the Home or the needs of service users, and therefore need constant direction. The Registered Manager in information Abbey House DS0000037630.V339991.R01.S.doc Version 5.2 Page 21 supplied prior to the site visit, recognises that the use of Agency staff is not ideal, but anticipates this will improve when current vacancies are filled. Abbey House employs eighteen members of care staff of which thirteen have attained a National Vocational Qualification (NVQ) in Care level 2, representing 72 of the staff team, with four members of staff working towards the qualification. The Assistant Manager has attained a National Vocational Qualification at level 4 and the Registered Managers Award. The Senior Carer on duty did not have access to staff recruitment files, however information supplied by the Registered Manager prior to the site visit identified that employment records and pre-employment checks such as the referenced and Criminal Record Bureau (CRB) disclosures, are held centrally by the Human Resource Team. Current policies and guidance issued by the Commission for Social Care Inspection identify that when a large corporation employs the staff, a system needs to be in place whereby the Inspector can verify that staff have had a CRB, it is recommended that the Local Authority establish such a system. The training records of the four members of staff who were ‘keyworker’ to the service users case tracked were viewed, staff receive training in a variety of topics related to health and safety, including moving and handling, hoist awareness, first aid and food hygiene. Additional training also takes place, which relates to service users health care, including stroke awareness, understanding Parkinson’s disease, and dealing with health care emergencies. Two members of staff are currently undertaking a twelve-week course in Understanding Dementia Care through North Warwickshire and Hinckley College. A significant number of service users have a diagnosis of Dementia and therefore all staff need to receive training in this area, to ensure the care service users receive is appropriate. The Commission for Social Care Inspection (CSCI) sent out surveys to a number of service users when asked whether staff listen and act upon what they say, and whether staff are available when you need them all recorded their satisfaction. Abbey House DS0000037630.V339991.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): 31, 33, 35, 37 and 38. 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 a well managed home with good leadership, having opportunity to shape and improve the service, whilst ensuring their health, safety and welfare are promoted. EVIDENCE: The Registered Manager Mrs Jennifer Glover has a National Vocational Qualification at level 4 and holds the Registered Managers Award. Service user meetings are held quarterly, a Senior Carer organises the meetings, which are held in small groups in the communal areas, alternatively meets with service users individually, these meetings enable service users to Abbey House DS0000037630.V339991.R01.S.doc Version 5.2 Page 23 comment as to activities they may have undertaken, the views as to their mealtimes and any issues which are of concern. The Senior Carer advised that questionnaires to service users, which incorporate a section for their relatives, have been circulated to some service users to ascertain their views as to the care they receive at Abbey House. This process needs to be formalised to establish a Quality Assurance system. The questionnaires that had been completed were photocopied and were in small print, consideration needs to be given to the format of these forms given the needs of the service users in the Home. The Quality Assurance system needs to include the views of all service users, their relatives and relevant health care professionals, the questionnaires will need to be tailored for each group of people. Information gathered from the questionnaires should be collated and a report produced of the findings, the report to include the plans of Abbey House to improve the care of service users, addressing any issues identified within the questionnaires. The report needs to be distributed to those that took part in the process. Information as to the management of service users financial affairs is detailed within the service users care plan, and often involves their family or legal representatives such as Solicitors. Staff spoken with confirmed that they receive regular supervisions from a member of the Management Team, and provide an opportunity to discuss service user care, training, issues of concern and general practical issues regarding the day to day care of service users and management of the Home. Information submitted prior to the site visit detailed the regular maintenance of health and safety systems within the home, including fire systems and equipment, environmental health visits, central heating systems and emergency call systems. Abbey House DS0000037630.V339991.R01.S.doc Version 5.2 Page 24 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 3 X 3 3 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X 3 X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X 3 X 3 3 Abbey House DS0000037630.V339991.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? N/A 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 OP30 Regulation 18 (1) Requirement Timescale for action 25/10/07 2 OP33 24 (1) The Registered Person to establish a programme of training that ensures all care staff receive training in Dementia Awareness. The existing Quality Assurance 25/10/07 process to be formalised, seeking the views of service users and relatives/carers as to the care provided by Abbey House. The Quality Assurance process should be open and transparent, with participants being given a report as to the outcome of the process, which details any actions the Home intends to introduce as a result of the audit. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Abbey House DS0000037630.V339991.R01.S.doc Version 5.2 Page 26 1 OP12 Service users and their relatives should be consulted as to the range and frequency of activities offered, and asked if there are any activities they would like to have the opportunity of taking part in. It is recommended that the hours of the Activity Organiser be extended to enable greater frequency of activities offered, and enable service users to receive one to one recreational and leisure pursuits where needed. It is recommended as good practice, consistent with CSCI policies and procedures that the Local Authority devises a system whereby Inspectors can ascertain and confirm that staff have had a Criminal Record Bureau disclosure. 2 OP29 Abbey House DS0000037630.V339991.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Abbey House DS0000037630.V339991.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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