Inspection on 19/12/07 for Abbeydale

This inspection was carried out on 19th December 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 14 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Abbeydale 23/10/08

Abbeydale 20/05/08

Similar services:

Agar Grove & St Augustine`s Alcohol Treatment & Rehab

Herbert Street

Haven (The)

Charis

Hartley House

Brook Drive, 124

Rugby House Project

City Roads Crisis Intervention

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

CARE HOME ADULTS 18-65 Abbeydale 98 Bisterne Avenue Walthamstow London E17 3QS Lead Inspector Sarah Buckle Unannounced Inspection 19th December 2007 10:30 Abbeydale DS0000069950.V354998.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Abbeydale DS0000069950.V354998.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Abbeydale DS0000069950.V354998.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbeydale Address 98 Bisterne Avenue Walthamstow London E17 3QS 020 8509 4100 020 8509 4101 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) Active Care Partnerships Limited Tracy Ann Collier Care Home 12 Category(ies) of Past or present alcohol dependence (12), Past or registration, with number present drug dependence (12), Mental disorder, of places excluding learning disability or dementia (12) Abbeydale DS0000069950.V354998.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following category of service only: Care home with Nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Mental Disorder, excluding learning disability or dementia - Code MD Past or present drug dependence - Code D 2. Past or present alcohol dependence - Code A The maximum number of service users who can be accommodated is: 12 First inspection since registration. Date of last inspection Brief Description of the Service: Abbeydale Care Centre is part of Abbeydale Independent Hospital. There are four units within the hospital and Abbeydale is the only one to be registered with the Commission for Social Care Inspection as a care home. The home is registered to accommodate twelve people with past or present mental disorder, drug and alcohol dependence. At the current time there are four residents living at the home. The home is situated in a purpose built building and is near to Walthamstow town centre with all of the amenities that this offers. There are bus routes near to the home. Abbeydale DS0000069950.V354998.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced key inspection. It was the first inspection to be carried out at the home since it was registered with the Commission. Both a Regulation Manager and a Regulation Inspector undertook the inspection on 19th December 2007. A number of surveys were sent out to residents and staff members, however none of these were completed and returned. The inspection of this service highlighted a number of areas of concern which need to be acted on with urgency, however, the service is aware of the improvements that need to be made and in some instances these are already being approached. What the service does well: What has improved since the last inspection? What they could do better: Initial assessments are not thorough and do not clearly outline the identified needs of the individual. Care plans do not cover all areas of the residents needs and information contained within them is often vague. Risk assessments are not comprehensive and risk management plans do not clearly outline preventative measures. People who live at Abbeydale do not have active involvement in the day-to-day running of the home and some of the routines were prescriptive. The overall environment within the home has an institutional feel to it that could be improved by making the home more comfortable and homely. Abbeydale DS0000069950.V354998.R01.S.doc Version 5.2 Page 6 Medication practice at the home does not operate with consistently best practice. Training of staff is due to be implemented, but is not currently satisfactory. There were some gaps and omissions in the staff recruitment process, which potentially can place residents at risk of harm. The complaints process at Abbeydale has not been implemented appropriately, however this issue is in the process of being addressed. The registered manager is currently not in post at the home, which means that the general manager for the entire hospital is also managing the care home. There is the potential for conflict within this as the culture difference between hospital wards and care homes is significant. 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. Abbeydale DS0000069950.V354998.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Abbeydale DS0000069950.V354998.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The initial assessment was vague and did not detail all of the information available regarding the person concerned. The assessments that were completed did not always translate into care plans. EVIDENCE: There are currently four people living at Abbeydale Care Centre, and they have all been recently admitted to the home. One pre admission assessment was examined in depth during the course of the inspection. The assessment contained personal details about the resident including their GP and next of kin. There was a brief medical history which outlined that the resident was diagnosed with paranoid schizophrenia, had previously had multiple admissions to hospital and that they presented with threatening behaviour and aggression. There was also a Nursing Admission proforma which was vague regarding the amount of information it contained, i.e. the family history section was not completed, plans for the future was not completed, the section on mood stated ‘blunt’, with no further information added, personal hygiene stated, ‘moderately’, with no further information added. Abbeydale DS0000069950.V354998.R01.S.doc Version 5.2 Page 9 Admission information was included in the file from a previous place of residence and this was detailed and contained information that the Abbeydale assessment did not include, for example, it stated that the person was at risk of promoting a ‘reactionary response from peers’ and that they require ‘level 3 or 4 observation at disturbed times’. There was also more detailed information regarding the person’s behaviour in this document. Further information contained within the care file detailed that the resident demonstrated some extreme behaviour, which resulted in (the resident) “often having to be controlled and restrained” and which meant they were seen to be “a risk to (themselves) and to others”, however there was no assessment information contained in the file regarding this or other behaviours and no risk management plan or care plan in place pertaining to it. Abbeydale DS0000069950.V354998.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Routines at the home are task based and not person led. Care plans that are in place at the home do not adequately reflect the needs of the person. EVIDENCE: A number of resident care plans were examined during the visit to this service. All of the support plans looked at were incomprehensive in terms of the detail they contained. For example, one resident had a care plan for ‘symptom control/medication’ which identified planned care as ‘ensure medication compliance’ and ‘identify relapse features and indicators’ and ‘admin depot injection two weekly’. The support plan did not outline how medication compliance would be ensured, or the steps that staff members should take in order to achieve this alongside the resident. The plan did not state who would be responsible for administering the depot injection and did not indicate what could be considered a relapse feature or what kind of indicators staff should be aware of. Similarly a support plan for aggression was completed, which stated Abbeydale DS0000069950.V354998.R01.S.doc Version 5.2 Page 11 ‘identify ways of channelling (the residents) aggression’ and ‘use PRN med when required’. Again, the information contained was non-specific and not completed in sufficient detail for care staff to be able to fully understand and meet the needs of the individual. Risk assessments were completed and hazards identified, however, the hazards for one resident were deemed to be ‘physical aggression, self neglect, fire risk and absconding’, and the measures in place were ‘nurse in safe and secure environment, supervise while smoking, maintain prescribed observation and use PRN meds’. Additional measures were recorded as ‘use of seclusion room’. During discussion, the manager at the home stated that they did not use restraint within the Abbeydale Care Centre, however, there were at least two instances where it is clearly referred to as a control measure within the documentation at the home. There was no evidence seen of resident or relative agreement to such restraint (where this applies). No clear risk management plan was in place to ensure the safety of this resident. There were no care plans seen in relation to many of the support needs of the residents. For example, one resident was smoking cigarettes on an hourly basis, and this was recorded in the daily notes, but there was no care/support plan in place detailing how this was to be managed. The resident was stated to be at risk of self-neglect; however, there was no care plan in place in relation to this. In the daily notes it stated that the resident ‘continues to carry out obsessional tasks’, this information was not highlighted within their assessment and there was no care plan in place detailing how they could best be supported with this. Within the care plan there was included a prescriptive ‘Daily Care Plan’, which outlined step by step what the resident would do throughout the course of the day and at what time. For example, “07:15: remain in bed; 08:00 get up and dressed for breakfast; 09:00 take meds under supervision; 09:30 have shower and shave; 10:00 go to Wood Street escorted by staff for tea or coffee/park/ feeding ducks/pub to watch football” etc until 22:00. This document presents an inflexible approach towards offering support, which does not take into account their changing needs and mood on a daily basis. It was positive to note that the staff team within the home were observed to be both friendly and approachable and their interaction with the residents was clearly supportive. Abbeydale DS0000069950.V354998.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15 and16 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Routines in the home are rigid. There are limited possibilities for residents to be involved in community activities. People who use this service are not able to achieve their full potential. EVIDENCE: There was no evidence seen at Abbeydale Care Centre of residents being involved in education, employment or training. However, there was evidence of staff members spending time with the residents outside of the home going to the shops, to visit Father Christmas, to Wood Street and to the swimming pool. The daily care notes for one resident were examined with regard to identifying their daily activities. On 07/12/07 the consultant stated whilst on their ‘ward’ round that the resident was “to be free to go out as much as (they) like”. On Abbeydale DS0000069950.V354998.R01.S.doc Version 5.2 Page 13 07/12/07 the resident played dominoes and draughts with staff at the nurses desk. On 08/12/07 they decided not to utilise their leave to the shops as it was raining. On 10/12/07 the resident went out to visit their GP and then spent a lot of time arranging and re-arranging their books. On 11/12/07 the resident went out for a walk with staff members and another resident. The daily care notes state that they ‘returned to the ward just before lunch’. On 12/12/07 the resident went out for a walk with staff and then played table tennis on a different ward. On 13/12/07 the resident played cards and on 14/12/07 they went to Wood Street. There was no evidence of resident involvement in daily routines within the home such as cooking or washing up, and there was no evidence of any support being offered regarding rehabilitation. Abbeydale Care Centre does employ a part time activities co-ordinator and a part time occupational therapist. Abbeydale DS0000069950.V354998.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who live in Abbeydale Care Centre have access to health care services. There is evidence in the care plan of health care treatment and intervention. Medication systems do not always follow good practice guidelines. EVIDENCE: During the inspection documents such as the ‘Daily Care Plan’ and the daily care notes were examined. These demonstrated that the routines within the home are not as flexible as they could be to ensure that the residents have a clear choice regarding how they live their lives. It was clear from documents seen, that residents do have access to healthcare practitioners and that their healthcare needs are met. Daily care notes recorded GP input and information concerning a new resident being registered at a local practice, and there were records of consultant visits. Abbeydale DS0000069950.V354998.R01.S.doc Version 5.2 Page 15 It was positive to note that all of the residents had keys to their bedrooms and were able to lock their doors as they wished. The medication procedure, storage and recording were examined. Medication is stored in a locked room, in a metal trolley and this is secured to the wall. There is a medication fridge, however, although this stated ‘keep locked’, it was open. The fridge temperature was 1 degree Celsius, this is below the required temperature range, which is between 2 and 8 degrees Celsius. There was a number of other dates when the fridge temperature had been recorded as being lower that it should have been, including being at 0 degrees Celsius on two occasions. This is of concern as there were insulin pens stored within the fridge, which require a specific temperature. There were no records of the room temperature in the medication cupboard being taken on a daily basis. There were no omissions of signature noted on the medication administration sheets. However, there were a number of good practice recommendations not complied with, for example, handwritten medication profiles were not double signed to reduce the risk of error, and where the MAR had been signed with a 5 (to indicate medication had not been given or taken) the reason for this was not identified. It was noted that Diazepam 10mg, which is to be administered rectally as required for the control of seizures, did not have a protocol in place outlining when and why this should be administered. It was also noted that an insulin pen in current use was not stored in the fridge between administrations. The controlled drug cupboard and register were examined. The register was not completed appropriately, and there were no witness signatures recorded at all. Mistakes had been made in the register, which were then crossed out and rectified. The CD cupboard is metal but is fixed to a stud wall as opposed to a solid wall, which is in contravention of regulation. Abbeydale DS0000069950.V354998.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The way in with complaints and concerns are being dealt with is being reviewed, to ensure residents feel that they are listened to in a way which makes them feel valued and respected. EVIDENCE: Abbeydale have a corporate complaints procedure, which is available within the home, and in information provided to residents, although it is considered good practice a more individualised policy is developed which is unique to this home. The Commission is aware of some concerns that have been raised though relatives and other agencies, and the registered manger not being proactive in investigating and reporting on the concerns or complaints raised. Improvement is still required in this area. Feedback from residents show that staff would be willing to listen and deal with their concerns, although it is not clear from the information currently available how residents, or their relatives are able to address any concerns with staff. No safeguarding training is available at present, however it was encouraging to note the comments of the service manager that staff are scheduled to attend adult protection training in the new year, which is being organised by the local authority. Abbeydale DS0000069950.V354998.R01.S.doc Version 5.2 Page 17 It is also important all staff are made aware of what action to take when someone wishes to raise a complaint or concern to ensure these issues are resolved to the satisfaction of the complainant. The complaints log was viewed, and it was noted that in the six weeks the home has had residents in occupation, none had been logged, despite residents saying they had made complaints to staff. It is recommended a senior member of the staff team is appointed to take the lead in safeguarding issues, and provides information and guidance to staff and reviews practices. Abbeydale DS0000069950.V354998.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides a physical environment that meets the specific needs of the people who live there, however, it is not personalised and homely. EVIDENCE: A tour of the premises was undertaken as part of the inspection process. It was positive to note that the homes statement of purpose, Certificate of Registration and complaints procedure were displayed on a notice board. The general environment within the home has an institutional feel. There were no curtains in the lounge and fire doors with bars were not curtained either. The TV was on and the reception quality was poor and fuzzy. There was curtain track, but no curtains hanging in the dining room. The kitchenette area within the dining room had a bin without a lid. A sign on the wall referred to ‘patients’. The telephone is housed in the dining area, which does not afford the residents privacy when making a call. Abbeydale DS0000069950.V354998.R01.S.doc Version 5.2 Page 19 The laundry room was unlocked and contained one domestic washing machine and one domestic tumble dryer. However the general manager explained that there is a laundry facility within the building. The cupboard in the laundry room was unlocked and contained cleansing solution, toilet cleaner and what looked like soap powder. There was also a bottle of cream cleaner. All of these items should be locked away in a COSSH cupboard for the purposes of safeguarding the residents. There were a number of water stains on the ceilings within the home. One bathroom was examined. The door to this room was open, however, it later transpired during conversation with a staff member that it should have been locked. The bathroom was not clean, and there was a strong odour. The wall fan was full of dust. It was positive to note that there are gym facilities available within the home for residents to use, and that this was seen in action during the course of the inspection. The overall environment at Abbeydale is not a comfortable and homely as it could be. Abbeydale DS0000069950.V354998.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The staff recruitment process at Abbeydale Care Centre is not robust. There is inconsistent and inadequate supervision in place. EVIDENCE: The staff team currently working in the care home are made up of staff that also work in the hospital. The service manager stated that the home is currently in the process of recruiting staff to work specifically in the residential care unit. Three staff files were requested for the purposes of examination in relation to recruitment practices within the home. Two of these were provided, however the third was not available for inspection, even though the member of staff had commenced their employment at the home. One of the staff recruitment files seen had a fully completed application form, evidence of induction over a two-day period, two references and proof of identity. There was no photograph of the employee on the file and the Criminal Abbeydale DS0000069950.V354998.R01.S.doc Version 5.2 Page 21 Records Bureau check for this staff member had been completed in 2002 and was from a different area of employment, but with the same provider. This CRB has therefore not been updated for five years, which is contrary to the specified three-year time frame. The second file examined contained a competed application form and two references. There was also a residence permit and a National Insurance card. There was no evidence of a Criminal Records Bureau check on this file and although the manager stated that a POVAFirst check had been undertaken prior to the person starting employment, no evidence was produced regarding this. Neither file contained evidence of an annual appraisal or supervision. However the manager did state that a schedule for supervision has been put together and will be implemented in the near future. The manager at Abbeydale Care Centre stated that the service is currently in the position of recruiting new staff members to work specifically in the care home unit as opposed to the other three hospital units within the building. On the day of the site visit to this service new staff were undergoing an induction process. Abbeydale DS0000069950.V354998.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. With a manager who has good leadership and organisational skills, and with the organisation ensuring that there are systems in place for monitoring and reviewing the quality of care to plan for continued improvement, it is considered the home has the capacity to improve. EVIDENCE: The service manager, who is a registered nurse, is temporarily managing the home. He has a great deal of experience in health, and residential care management. The service manager is providing a strong lead supporting other senior staff in the home to ensure the quality of care and management systems improve. Abbeydale DS0000069950.V354998.R01.S.doc Version 5.2 Page 23 Feedback from outside agencies show that there is an understanding that the quality of care, through strong management, needs to improve and an understanding of what constitutes good care is communicated to the staff group. The inspectors are of the view that the home has the capacity to improve, once the plans outlined to improve management and quality assurance systems are implemented and complaints are responded to appropriately. The current lack of quality assurance systems in place impacts on the quality of care provided. The service manger also plans to implement systems to address this. A quality assurance audit should also include a review of the Regulation 26 visits and Regulation 37 reports. This is clearly required as the inspection identified the lack of monitoring and reports being received by the Commission. The inspection also evidenced a lack of response from residents and staff surveys, and there is a clear need to focus on the quality of care experienced by residents to ensure improvements are made, as required by the Regulations. It is positive to note that staff meetings have commenced, however regular residents meetings should also be facilitated to share information, agree decisions and gain feedback into practices in the home. The health and safety of the home is generally acceptable, although potentially hazardous liquids and cleaning agents were stored in an unlocked cupboard in the residents laundry. The service manager was informed these must be removed and he should ensure the home complies with COSSH regulations. It is encouraging to note core training for staff is planned, and that induction training is being facilitated for new staff. Abbeydale DS0000069950.V354998.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 Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 1 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 1 23 1 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 1 33 X 34 1 35 1 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 1 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 2 16 1 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 X 1 X 1 X X 1 X Abbeydale DS0000069950.V354998.R01.S.doc Version 5.2 Page 25 N/A Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA2 Regulation 14 Requirement Timescale for action 31/03/08 2. YA6 15 3. YA7 12(2) 4. YA16 16(m) (n) The registered person must ensure that a full needs assessment is undertaken in relation to each resident prior to offering them a service and that this is carried out in consultation with the prospective resident of the representative and kept under review. The registered person must 31/03/08 ensure that a service user plan is developed in consultation with the resident or representative which details how their individual needs will be met, and this must be kept under review. The registered person must 31/03/08 ensure that residents are enabled to make decisions with respect to the care they receive. The registered person must 31/03/08 ensure that they consult with residents about their social interests and make arrangements for them to engage in local community activities; they must also ensure that residents are DS0000069950.V354998.R01.S.doc Version 5.2 Abbeydale Page 26 5. YA20 13(2) 6. YA22 22(2) 7. YA23 13(6) 8. YA32 18(1) 9. YA34 19(1)(b) 10. YA34 17(3)(a) consulted about a programme of activities and that recreational facilities are provided. The registered person must make arrangements for the safe recording, handling, safekeeping, administration and disposal of medicines received into the home. The Responsible Individual must ensure that complaints are responded to within given timeframes and that evidence of the complaint; the investigation and the outcome are retained. Staff must also be given instruction in how to deal with complaints and concerns to ensure people feel listened to. The Responsible Individual must ensure that by training staff or other measures residents are prevented from or are at risk from harm or abuse The registered person must ensure that there are suitably qualified and competent people working at the home and that any persons employed on a temporary basis will not prevent continuity of care for the residents; the registered person must also ensure that people working at the care home receive training appropriate to the work they are doing. The registered person must ensure that no one is employed to work at the care home unless the information specified in Schedule 2 of Care Homes Regulations 2001 has been obtained. The registered person must ensure that the records detailed in Schedule 2, 3 and 4 of the Care Homes Regulations 2001 DS0000069950.V354998.R01.S.doc 31/03/08 31/03/08 31/03/08 30/04/08 31/03/08 31/03/08 Abbeydale Version 5.2 Page 27 11. YA35 12. YA37 13. YA39 14. YA42 re available for inspection in the care by any person authorised by the Commission to enter and inspect the care home. 18(1)(c)(i) The registered person must ensure that all of the people working at the home receive training appropriate to the work they are doing. 12(1) The Responsible Individual must ensure that the registered manager promotes the health and welfare of residents. 24(1)(2)(3) The Responsible Individual must ensure that a system to review the quality of care is implemented, communicate this information to the Commission and consult with residents and relatives. 13(4) The Responsible Individual must ensure that measures to reduce hazards to resident’s safety are implemented and maintained. 30/04/08 31/03/08 30/04/08 31/03/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA35 Good Practice Recommendations A champion is appointed within the staff team to take the lead in safeguarding, and providing information and guidance to staff and review practices. Abbeydale DS0000069950.V354998.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU 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 Abbeydale DS0000069950.V354998.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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