Inspection on 23/01/07 for Abbey Lodge Residential Care Home

This inspection was carried out on 23rd January 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Abbey Lodge Residential Care Home 11/09/07

Abbey Lodge Residential Care Home 25/10/06

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Abbey Lodge Residential Care Home Cranmore Avenue Tettenhall Wolverhampton WV6 8PW Lead Inspector Bhag Jassal Key Unannounced Inspection 23rd January 2007 09:00 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 Lodge Residential Care Home DS0000066038.V326183.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 Lodge Residential Care Home DS0000066038.V326183.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbey Lodge Residential Care Home Address Cranmore Avenue Tettenhall Wolverhampton WV6 8PW 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) 01902 745181 F/P01902 745181 Mr Vijay Odedra Mr Arjan Bhoja Odedra, Mrs Shanta Arjan Odedra, Jasvinder Takhar, Daljit Takhar *** Post Vacant *** Care Home 25 Category(ies) of Dementia (7), Old age, not falling within any registration, with number other category (25) of places Abbey Lodge Residential Care Home DS0000066038.V326183.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The home should only accommodate up to 7 (seven) service users with mild dementia. The home must provide safe and secure gardens. Females 60 years and above and males 65 years and above Date of last inspection 25th October 2006 Brief Description of the Service: Abbey Lodge is a large detached house that has been extended to provide accommodation for 25 older people. It is situated in a private residential area on the outskirts of Wolverhampton approximately 1.5 miles from Tettenhall village where the amenities include a post office, shops and a public house. The accommodation consist of one double bedrooms and 23 single bedrooms, 13 of which have en-suite facilities, two lounges, conservatory a dining room, laundry, kitchen, staff room and Registered Managers office. There is a car park at the front of the building and gardens and to the front and rear. The current fees range from £336 to £400 per week Abbey Lodge Residential Care Home DS0000066038.V326183.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced key inspection and took place on 23 January 2007 and started at 9.00 am and lasted 7 hours and 25 minutes. The Home had 21 places occupied and 4 beds remain vacant. The inspection included discussions with the new Acting Care Manager – Mrs Susan Parry and some of the time with the Registered Provider Mr Jasvinder Takhar, the service users and their relatives and the staff. The daily routines were observed and service users’ and staff records, and the home’s policies and procedures were examined. The previous reports of the Fire Safety Officer and the Environmental Health Officer were also considered. The inspection of premises both inside and outside and facilities were also undertaken. Four members of staff, six service users and two relatives were spoken to. Comments cards were distributed to all service users and their relatives prior to the date of inspection. 13 questionnaires were completed by the service users and two questionnaires were completed and returned by the relatives were received by the Commission for Social Care Inspection (CSCI). Issues raised through a formal complaint against the home received by the CSCI in early January 2007 and Regulation 37 Notifications received from the home were also considered and discussed with the Registered Provider and the new Acting Care Manager. What the service does well: Abbey Lodge care home is registered for 25 older people, of which 7 old people can have Dementia. The home makes every effort to provide individuals with a good standard of care to meet the assessed needs following a care plan. The home has a good key worker and staff supervision system in place. The home communicates well with the families/friends and representatives of the service users. The visitors’ book indicated a lot of activity. The service users spoken with said that they are happy and content with living in a homely and caring place. Service users were in the lounges engaging in their daily routines and activities and they further commented that they were comfortable Abbey Lodge Residential Care Home DS0000066038.V326183.R01.S.doc Version 5.2 Page 6 and satisfied with the care provided. Two service users’ relatives also stated that they are more than happy with the care being offered by the home. The atmosphere within the home was observed to be relaxed, comfortable and friendly. Friendly rapport was also observed between service users and staff. Meals are varied, balanced and well - presented to meet each individual’s choices, preferences and requirements. Most of the service users spoken to who could express themselves in a meaningful way expressed their satisfaction with the care they received and they commented “the food is very good here and tasty”, ”I am very happy in this place” and “The staff are very good and kind”. “The new manager is very good and she sort things out for us”. The home has introduced a good training programme for staff, which all staff are actually involved in. Thus this will ensure that they are improving their knowledge and skills to meet the changing needs of the service users. The home provides a good standard of accommodation, which is being safely maintained to good standard and secure. What has improved since the last inspection? There was clear evidence to show that the home has made very little progress in implementing the requirements arising from the last inspection report dated 25 October 2006 However, the Registered Provider – Mr Takhar stated that all of the outstanding issues will be addressed as a matter of priority. The new Acting Care Manager provided documentary evidence, which showed that now all staff have been POVA and CRB checked and two written references are also been obtained on all new staff. The home has continued to redecorate bedrooms and communal areas. New floor covering has been provided in the main lounge, dining room and corridors on the ground floor. New en-suites to bedrooms have been fitted with a mirror, cabinet for toiletries and safety rails around the toilets. Now all members of staff receive formal supervision from the new Acting Care Manager. Abbey Lodge Residential Care Home DS0000066038.V326183.R01.S.doc Version 5.2 Page 7 It was noted that the new Acting Care Manager is making progress, which will assist the Registered Provider to implement his action plan to address all of the issues contained in this report. What they could do better: The home must continue to update the service users’ needs assessments, risk assessments and care plans. The home must also continue to improve further the quality of daily care recordings. Those members of staff who as yet have not received training in safe working practice topics, NVQ Level 2 and safe handling of medication must do so as a matter of priority. This training would enable staff to improve further their care practices and professionalism. The introduction of a programme of social and leisure activities provided after consultation with the service users would really improve the quality of life and help maintain links with the community. There were a number of negative comments made by the service users and their relatives through questionnaires received by the CSCI regarding the lack of staff on duty, and they also expressed their concern about the lack of variety of food and social and leisure activities. The Registered Provider and the new Acting Care Manager must take appropriate action to address these issues and concerns as matter of priority. There are three requirements and one recommendation relating to the environment, which must be addressed as a matter of priority. The Registered Provider must take swift action to ensure that the home has a registered manager in post, so that the service users are protected and appropriately cared for, and staff are supported and supervised. The Inspector wishes to thank the Acting Care Manager, the Registered Provider, the service users, their relatives and staff for their assistance and cooperation on the day of inspection. Abbey Lodge Residential Care Home DS0000066038.V326183.R01.S.doc Version 5.2 Page 8 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 Lodge Residential Care Home DS0000066038.V326183.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 Lodge Residential Care Home DS0000066038.V326183.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): Quality in these outcome areas is good, This judgement has been made using available evidence including a visit to this service. Standards 3 and 6 were inspected Perspective residents have their needs assessed and are issued with a contract which clearly tells them about the service they will receive. The home does not provide intermediate care. However, the home does offer short stay and introductory stays when the home has a vacancy. EVIDENCE: Admissions are not made to the home until a full needs assessment has been undertaken. The home is then able to confirm that they can meet the needs of the individual through the service they deliver as detailed in the Statement of Abbey Lodge Residential Care Home DS0000066038.V326183.R01.S.doc Version 5.2 Page 11 Purpose. For people who are self-funding and without a care management assessment, they always receive assessments by the care manager. The six residents’ files and care plans were inspected which contained preadmission assessments of the service users’ needs, both from assessments by the home’s staff and other relevant professionals. Observations and discussions with the service users, the Acting Care Manager and staff on duty indicated that the home continues to meet the individual needs of all the service users accommodated at the home in a satisfactory and sensitive manner. A service user spoken with stated that she was satisfied with the information she and her family had received prior to admission and since living at the home. The home does not offer intermediate care. Abbey Lodge Residential Care Home DS0000066038.V326183.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): Quality in these outcome areas is Good This judgement has been made using available evidence including a visit to this service. Standards 7,8,9 and 10 were inspected The staff within the home are aware of and sensitive to the needs of each and all service users, meeting their needs in a professional manner. There are care plans in place, which provides the information the staff require to meet the service users’ health and care needs. The home has good policies and procedures on medication. The senior members of staff who are responsible for safe handling of administration of medication have received accredited training in this field. EVIDENCE: It was evidenced that all service users undergo an assessment of their needs prior to admission to the care home. A Care Plan is produced, which is based on the assessment of needs. The home operates a key worker system, which Abbey Lodge Residential Care Home DS0000066038.V326183.R01.S.doc Version 5.2 Page 13 helps to ensure that the recommendations arising from the care plans and monthly reviews are implemented. Six service users’ care plans were examined in detail and it was noted that the short-term and long-term goals, aims and objectives needs to be clearly identified and appropriate interventions required to put them into action to meet the individual service users’ needs. It was noted that the care plans are being reviewed on a monthly basis. The daily care (day and night) formats were also examined and it was noted that the quality and detail of recording needs improvement. The Acting Care Manager stated that the revised and updated formats of care plans and daily recordings will be implemented immediately. The Acting Care Manager stated that the staff will be closely supervised and supported to make further improvements in daily care recordings as a matter of priority. The home maintains records of all health checks carried out by doctors, opticians, dentists, district nurses and chiropodists. It was also evidenced that the home ensures that the detailed nutritional screening is undertaken, including a weight gain and loss record are maintained and appropriate action is taken if required. The home also maintains records of all health checks. The case tracking demonstrated an effective review process together with the home’s ability to meet the changing needs as they occur. The service users’ health is closely monitored and appropriate medical care services are sought as and when required. It was observed on the day of inspection that no personal care interventions were undertaken in communal areas. In addition, consultations with health and social care professionals are carried out within the service users’ bedrooms. Visitors are able to meet service users in their bedrooms or conservatory on the ground floor, which offers privacy when not being used. It was observed that service users were being treated with respect and staff are working both professionally and sensitively in meeting individual needs. The Inspector spoke at some length with ten service users and all of them commented positively about their care and they felt that they have everything that they need. Several service users stated that “the carers are very good and kind and they look after us very well”. Three service users said that the carers are always there to help. Generally the service users appeared to be content, comfortable and happy. The service users were complimentary regarding the quality of their lives and the care they are receiving at the home. It was evidenced from the staff records and from discussion with the Acting Care Manager that several carers and three senior carers have completed their Abbey Lodge Residential Care Home DS0000066038.V326183.R01.S.doc Version 5.2 Page 14 training in safe handling of medication. However, it is the home’s policy that only the senior members of staff would be responsible for the safe handling and administration of medication. Records evidenced medication received, administrated and leaving the home. The photographs of service users have been provided on the medication sheets to avoid any risks of maladministration of medication. Abbey Lodge Residential Care Home DS0000066038.V326183.R01.S.doc Version 5.2 Page 15 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): Quality in these outcome areas is Adequate This judgement has been made using available evidence including a visit to this service. Standards 12,13,14 and 15 were inspected. The home does not provide a good programme of social and leisure activities and outings, which are designed to meet the service users, preferences and capabilities. The Acting Care Manager and staff encourage family and friends to maintain good contact with their relatives at the home. The service users are positively helped to exercise choice and control over their lives as far as practicable and safe to do so. Meals at Abbey Lodge are a good homely type, offering choice, variety and catering for special dietary needs and requirements. EVIDENCE: Abbey Lodge Residential Care Home DS0000066038.V326183.R01.S.doc Version 5.2 Page 16 It was evidenced that the home does not provide a good programme of social and leisure activities inside and outside the home in accordance with the service users’ choices, preferences and capabilities. There is no proper system of maintaining records of activities in place in the home. The home does not have a staff member designated to organise social and leisure activities and who identified interests that the service users wish to pursue. It was also noted that there is very little in the way of entertainment and activities provided within the home and no outings or trips have been arranged throughout last summer months. The Registered Provider and the Acting Care Manager stated that a carer has been identified to act as an activities co-ordinator and she will have the responsibility to plan and implement in the home in liaison with other carers a programme of social and leisure activities for all the service users. The external entertainers would also be invited/requested to deliver entertainment in the home in accordance with the service users’ choice and preferences. The Acting Care Manager stated that the activities for the service users with dementia care needs would be carefully planned, which would actually meet their particular needs and well being. The Acting Care Manager must ensure that the daily programme of social and leisure activities is displayed on the Notice Board in the main lounge for the service users’ information. The Acting Care Manager must also ensure that the activities enjoyed by the service users must be incorporated into their individual care plan All the service users spoken to stated that they are in touch regularly with their friends and family members and spoke about their visitors’ interest in their daily care matters. The visitors’ book showed considerable activity. The Inspector spoke to two relatives and they expressed their satisfaction with the care and services provided to their relatives in residence at the care home. The Acting Care Manager stated that the service users are positively assisted and helped to exercise choice and control over their lives as far as possible and practicable. A close liaison is maintained with the relatives and representatives, where the service users are not able to make certain decisions. The service users and their relatives are informed of the availability of the Advocacy Service based at the local Age Concern. The information about the Advocacy Service is included in the Home’s Statement of Purpose and the Service Users’ Guide. Several service users told the Inspector “the food was very nice and tasty”. The consensus of service users was the range, quality and choice of food provided was very good and the home caters for those service users who have individual preferences and medical needs. The Acting Care Manager stated Abbey Lodge Residential Care Home DS0000066038.V326183.R01.S.doc Version 5.2 Page 17 that the menu is changed on a regular basis in consultation with the service users. The kitchen is well equipped and kept clean and tidy. The catering staff are well trained in food safety and hygiene matters. There was adequate an stock of food in the home. Abbey Lodge Residential Care Home DS0000066038.V326183.R01.S.doc Version 5.2 Page 18 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 these outcome areas is Adequate. This judgement has been made using available evidence including a visit to this service. Standards 16 and 18 were inspected. Concerns and complaints are dealt with promptly and professionally. The service users are protected from abuse by the home’s policies and procedures. The arrangements for the protection of service users from abuse are satisfactory. EVIDENCE: The home has a good complaints procedure, which is referred to for information in the Service Users’ Guide. There are satisfactory systems of recording complaints and concerns. It was noted there were two minor and informal complaints recorded recently in the Complaints Book and they were immediately responded to and resolved satisfactorily to the satisfaction of the complainants. It was also noted that there has been one anonymous complaint made against the home at the beginning of January 2007 and was directed to the Commission for Social Care Inspection (CSCI). The Registered Provider and the new Acting Care Manager have investigated the issues raised by the Abbey Lodge Residential Care Home DS0000066038.V326183.R01.S.doc Version 5.2 Page 19 Complainant and a formal response is being sent to the CSCI by 26 January 2007. Service users, when asked, were certain of how to formally make a complaint but they said they would quite happily talk to one of the staff in charge. The home has not had to report any vulnerable adult issues. The home has good policies and procedures regarding restraint, dealing with aggressive behaviour and prevention of abuse, which, includes whistle-blowing policy. The Acting Care Manager stated that adult protection issues are discussed during induction training and supervision meetings. Training in protection of vulnerable adults have been received by all members of staff. Service users stated that they are satisfied with the service provision, feel safe and well supported by staff that have their protection and safety as a priority. Abbey Lodge Residential Care Home DS0000066038.V326183.R01.S.doc Version 5.2 Page 20 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): Quality in these outcome areas is Adequate This judgement has been made using available evidence including a visit to this service. Standards 19 and 26 were inspected. General standard of the environment is good providing a homely and secure place to live, but needs some improvements. The home was found to be clean, tidy and free from of unpleasant odour. EVIDENCE: The home is accessible, safe, secure and generally well maintained. The home has adequate space for dining and lounge areas. All the bedrooms are of good size and 13 have en-suite facilities. It was noted that a considerable amount of work has taken place within the home since the change of ownership. Three new bedrooms with en-suite have been provided in order to reduce double Abbey Lodge Residential Care Home DS0000066038.V326183.R01.S.doc Version 5.2 Page 21 bedrooms. Several bedrooms have been redecorated, refurbished and fitted with new floor covering. New floor covering has been fitted to the hall, and ground floor corridors. The Manager’s office has been extended, redecorated and new floor covering fitted. The general appearance of the internal environment is good but the rooms on the first floor are in need of redecoration and refurbishment and a rolling programme of redecoration and refurbishment must be introduced to modernise and improve the environment. The floor covering in the first floor corridor and in the conservatory must be replaced. The gardens and patio areas were tidy and accessible for use by the service users. The Acting Care Manager stated that the premises continue to be in compliance with the requirements of the West Midlands Fire Authority and Wolverhampton City Council’s Environmental Health Department. It is recommended that the unused bathroom on the first floor be converted into a walk-in shower for less able service users. The home was found to be clean, tidy and free from odour. The home has good policies and procedures regarding infection control and staff have received training in food hygiene and infection control. From observations and discussions with staff they appeared to be conscious of the dangers of crossinfection. Abbey Lodge Residential Care Home DS0000066038.V326183.R01.S.doc Version 5.2 Page 22 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): Quality in these outcome areas is Adequate. This judgement has been made using available evidence including a visit to this service. Standards 27, 28, 29 and 30 were inspected. The home is not adequately staffed at all times, which could impact on the quality of care provided and the ability of the home to meet the needs of the service users. The home continues to support staff to complete training. The home has satisfactory staff recruitment policy and procedure. EVIDENCE: On the basis of information provided by the home and the available staff rotas on the day of inspection indicated that the home does not meet the National Minimum Standard OP27 and Regulation 18 of the Care Homes Regulations 2001. During the Inspector’s meetings with the staff on duty, they also stated that they are “pushed” and “rushed” off their feet at peak times, and in particular in the morning and evenings. The carers are also expected by the Registered Providers to cover domestic and laundry duties more particularly during the weekends. The carers are also expected to cover duties in the Abbey Lodge Residential Care Home DS0000066038.V326183.R01.S.doc Version 5.2 Page 23 kitchen in the evenings. The staffing deficiencies have been identified at the previous inspection and in the recent complaint against the home received by the Commission for Social Care Inspection. It was also noted that as the numbers of service users increase and the dependency levels rise and additionally five residents with dementia, the staff are struggling to provide a good standard of care. Also it was noted at the last inspection and at this inspection that the staff have little time to provide social and leisure activities. In order to provide a good standard of care and upkeep the cleanliness of the home, the Registered Providers must take appropriate action to provide adequate numbers of care and ancillary staff on duty at all times. The Acting Care Manager’s hours are in addition to the above staff hours and considered to be supernumerary to allow Mrs Susan Parry to manage the care home effectively and efficiently. It was evidenced from the staff training records and discussions with staff and the Acting Care Manager that the home have over 50 qualified care staff in NVQ Level 2 and a number of carers and senior carers are undertaking their NVQ Level 3. The Acting Care Manager stated that the staff have also have completed their safe working practice topics training and a new member of staff is undertaking her induction training in accordance with the Skills for Care Council’s requirements. The home now operates an acceptable recruitment procedure since the new ownership and management has taken over. On inspecting six staff files, it was evidenced that now all staff are POVA and CRB checked, and two written references have been obtained on all staff. The Acting Care Manager stated that there are three CRB still awaited on other staff. All staff at the home are committed to developing their knowledge and skills through training and have regular opportunities to do so external and internal training courses and activities. The home has a programme of NVQ training that has now exceeded the minimum standard. The care staff have attended courses on Safe Handling of Medication, Dementia Care, Fire Prevention and Health and Safety at Work. The Acting Care Manager stated that she will be preparing a training matrix on staff and devise an efficient training recording system. Abbey Lodge Residential Care Home DS0000066038.V326183.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in these outcome areas is Adequate. This judgement has been made using available evidence including a visit to this service. Standards 31, 33, 35, 36 and 38 were inspected. The Registered Providers have appointed a new Acting Care Manager and attention needs to be given to formalising the position of Mrs. Susan Parry. An application for registration with the CSCI must be pursued as a matter of priority. There are satisfactory systems of communication in place to seek views and feedback from the service users and their families/friends. The home is operating a good system to assist service users with safe handling and keeping of their personal finances and good records are being kept of all transactions made. The staff are now regularly supervised and enabled to carryout their work professionally. Health, safety and welfare of the service users and staff are promoted by the safe working systems put in place by the Registered Providers. Abbey Lodge Residential Care Home DS0000066038.V326183.R01.S.doc Version 5.2 Page 25 EVIDENCE: The home is without a Registered Manager. However, the Registered Providers appointed a new Acting Care Manager in mid-January 2007. Mrs Susan Parry appears to be managing the home well. The Registered Provider stated that a formal application to register Mrs Parry will be submitted shortly to the CSCI. There are clear lines of accountability within the home and the Acting Care Manager is very well supported by the Registered Providers. The home has a formal staff supervision system in place and the new Acting Care Manager have already implemented supervision of staff and meetings with staff and service users. Observations made and discussions with service users and staff indicated that the New Acting Care Manager is very approachable and operates an open door policy. The staff and service users, who could express themselves stated that they are happy to approach the Acting Care Manager and staff with any problems they might have and were confident that they would respond to them. It was also noted the home has a Quality Assurance monitoring system in place, which includes questionnaires to service users, visitors and relatives to obtain feedback on the quality of service. The feedback from the last monitoring report was generally very positive regarding the home and care received. However, there were comments regarding the quality of some areas of internal decoration, lack of social activities and the teatime menus. Thirteen questionnaires completed and returned by the service users prior to this inspection also indicated similar issues as above. The Acting Care Manager and the Registered Provider stated that an Action Plan will be implemented immediately to address all of the issues raised by the service users, including a formal programme of daily activities, revision of menus and review of staffing levels/arrangements. It was noted that the Registered Provider has undertaken Regulation 26 visits to the home during the autumn, 2006, but did not follow through the issues affecting the management of the home, and also requirements contained in the previous inspection report dated 25 October 2006. The Registered Providers must ensure that during the Regulation 26 visits to the care home, Abbey Lodge Residential Care Home DS0000066038.V326183.R01.S.doc Version 5.2 Page 26 all aspects of management, care and protection of service users and health and safety areas should be inspected and recorded and appropriate action taken to rectify any outstanding issues. The copies of the monthly Regulation 26 visits reports must be sent to the CSCI. All financial records and administrative procedures within the home that were inspected were found to be well ordered and maintained. The home has a good health and safety policy and all staff are aware of their responsibilities regarding these issues and a number of staff have received training on these issues. Matters pertaining to fire safety and environmental health were found to be satisfactory and all the issues identified in the recent inspection reports of the Fire Safety Officer and the Environmental Health Officer have been appropriately implemented. All safety systems and equipments are regularly checked and well maintained and records of all checks are kept up to date. Abbey Lodge Residential Care Home DS0000066038.V326183.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 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 X 17 X 18 3 1 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 3 X 3 Abbey Lodge Residential Care Home DS0000066038.V326183.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? YES 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 OP12 Regulation 12 7& 17 Requirement The Registered Provider must ensure that staff are pro-active in positively encouraging the service users to take part in a range of social and leisure activities both indoor and outdoor of the Home. The activities must be varied in range and appropriate, and in accordance with the service users’ choice, preference and capacities, and displayed in the main lounge for service users’ information. The Home must maintain records of all activities enjoyed by the service users and must also be incorporated into the individual service users’ care plans. The Registered Provider must ensure that the levels of care and ancillary staff are reviewed and increased in order to meet the assessed care needs of all current service users. The Registered Provider must ensure that POVA and CRB DS0000066038.V326183.R01.S.doc Timescale for action 28/02/07 2. OP27 18 28/02/07 3. OP29 19 28/02/07 Page 29 Abbey Lodge Residential Care Home Version 5.2 checks must also be carried out on all current and new members of staff; and that all staff files must have their current photographs and/or copies of their birth certificates. 4. OP31 8 The Registered Provider must ensure that a registered manager is provided for the care home. The Registered Provider must ensure that all the service users’ care plans are reviewed and more detail aims and objectives recorded; and the detail and quality of daily care recording must be improved. The Registered Provider must take appropriate action to refurbish and refurnish all the bedrooms on the first floor. The Registered Provider must ensure that a suitable lockable facility is provided in the new bedrooms on the ground floor. The Registered Provider must ensure that new floor covering is fitted in the conservatory and first floor corridor. The Registered Providers must ensure that the Commission for Social Care Inspection receives a copy of the monthly reports of Regulation 26 visits to the care home. 28/02/07 5. OP7 15 28/02/07 6 OP19 23 31/03/07 7. OP19 23 28/02/07 8. OP19 23 31/03/07 9 OP33 24 28/02/07 Abbey Lodge Residential Care Home DS0000066038.V326183.R01.S.doc Version 5.2 Page 30 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP19 Good Practice Recommendations The Registered Provider considers the provision of a walking shower room on the first floor. Abbey Lodge Residential Care Home DS0000066038.V326183.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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 Lodge Residential Care Home DS0000066038.V326183.R01.S.doc Version 5.2 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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