Inspection on 13/11/07 for Abbeydale Residential Home

This inspection was carried out on 13th November 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

Abbeydale Residential Home 08/02/10

Abbeydale Residential Home 05/11/09

Abbeydale Residential Home 04/11/08

Abbeydale Residential Home 05/12/06

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Abbeydale Residential Home 281 Gloucester Road Cheltenham Glos GL51 7AD Lead Inspector Mr Peter Still Key Unannounced Inspection 12:30p 13th November 2007 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 Abbeydale Residential Home DS0000067444.V348274.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. Abbeydale Residential Home DS0000067444.V348274.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbeydale Residential Home Address 281 Gloucester Road Cheltenham Glos GL51 7AD 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) 01242 525107 01242 522671 Charlton Care Ltd Brian Darlison Care Home 11 Category(ies) of Old age, not falling within any other category registration, with number (11) of places Abbeydale Residential Home DS0000067444.V348274.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 5th December 2006 Brief Description of the Service: Abbeydale is an adapted older property situated in the residential area of St Marks, within easy reach of local shops and the railway station. The Home is also on a bus route to Cheltenham town centre. Ownership of this home changed in July 2006 when Charlton Care Ltd purchased the business. The Commission for Social Care Inspection is currently processing an application for Registered Manager. Single accommodation for eleven elderly service users, who require personal care, is provided on two floors, accessed by a stair lift. All the bedrooms are pleasantly decorated comfortably furnished and have en-suite facilities. Communal facilities are provided on the ground floor and consist of a comfortable lounge and a large conservatory, which is used as a dining room. The attractive well maintained garden has easy access and may be enjoyed by the service users during the summer months. A copy of the most recent CSCI report is contained in an information folder located in the main hall of the home. Current fees range from £357 to £650. Prices for hairdressing, chiropody and any personal items are available on request. Abbeydale Residential Home DS0000067444.V348274.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the Home and takes into account the views and experiences of people using the service. One inspector undertook the inspection of Abbeydale over two days in November 2007. As part of this unannounced inspection people who use the service were spoken with. A check was made against the requirements that were issued following the last inspection, in order to establish whether the Home had ensured compliance in the relevant areas. Care records were inspected and the care of three residents were particularly examined to ‘Case track’ their care. The management of residents’ medications was also inspected. Six residents and three staff were spoken with to hear about their views and experiences of the services and care provided. A visiting District Nurse was seen and had no points to discuss. Prior to the inspection, survey forms had been sent out to residents and staff, one was returned by a resident and four by staff. Prior to the inspection, the manager had completed an annual quality assurance assessment for the Home, which was helpful and provided some key information. The catering arrangements were considered and the quality and choice of meals was inspected as well as the opportunities for residents to exercise choice. The arrangements for the recruitment, training and supervision of staff were inspected, as was the overall management of the Home. Both the manager and his deputy were spoken with and were open and cooperative in providing information requested. A tour of the premises took place. What the service does well: Abbeydale Residential Home DS0000067444.V348274.R01.S.doc Version 5.2 Page 6 Residents who spoke with the inspector were very clear that staff provide an environment, which is homely and where staff work with commitment to meet their needs. The inspector found a happy and relaxed atmosphere at the home, where residents talked positively about their experiences. For example one resident told the inspector he should go away with the idea that this is a very happy home – it is another family and I would miss the smiley faces of the staff, if I were not here. Residents spoke warmly and were appreciative of the way staff provide individual care. The provider wishes to consider improvements at the home and took the decision to install a lift. The arrangements for the work to be undertaken had started and this will be a valuable facility. The premises were well decorated and the accommodation was comfortable. The manager has completed his NVQ level 4 qualification and the deputy manager has started the training for this award. Staff training is progressing well. The residents said the staff work well together and staff in their survey responses were very positive. This was also observed and heard in discussions with staff. One member of staff said in their survey response that there was emphasis on improvement of the standard of the Home, also of checking whether the residents are happy and well cared for. What has improved since the last inspection? What they could do better: Abbeydale Residential Home DS0000067444.V348274.R01.S.doc Version 5.2 Page 7 More detail and information must be recorded to support the pre admission process. Care Plans and Risk Assessments must be reviewed to ensure they all provide adequate detail so that the resident and staff are fully aware of residents needs and how staff will meet them. The record of daily observations should show greater detail on things, which are important to residents and provide information helpful for the review of care plans. Risk assessments must be put in place, where a resident partially self medicates and there must be records of medication that has not been used. This concerned medication a resident had dropped on the floor. Staff should have a minimum of six formal and recorded supervisions each year. An effective quality assurance system must be put in place with an annual development plan for the Home. The registered provider should work with the manager to identify ways of supporting the manager with the action plan following this inspection. 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 Residential Home DS0000067444.V348274.R01.S.doc Version 5.2 Page 8 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 Abbeydale Residential Home DS0000067444.V348274.R01.S.doc Version 5.2 Page 9 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): 2, 3, 5. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who consider the Home receive information and have visits and a trial stay to help them make their decision. Pre-admission documentation must be in sufficient depth to ensure the manager has all necessary information to make a fully informed decision about whether the Home can meet a persons needs. EVIDENCE: The files of three residents were inspected to check that contracts were satisfactory and also the process of admission. Current contracts were on file Abbeydale Residential Home DS0000067444.V348274.R01.S.doc Version 5.2 Page 10 for two residents and another was a social services contract dated 2003. The detail of extra charges was seen, such as hairdressing. One Care file showed that no information had been gained prior to admission however the person had been at the Home for a long time and before the current owners took over the Home. The records for two other people included full social services assessments, however the Home’s care plan did not reflect these in sufficient detail to describe the needs of residents and how staff would meet those needs. No medical or life history was seen for one resident. A more robust process must be undertaken to ensure the necessary information is obtained to enable a good decision about the admission of residents. An incident arose with a resident who was on a respite stay. There was a concern raised about the Home’s process for considering people who wish to move to the Home. The outcome was that there had been no previous information to highlight any concern and the person returned to their own home. However the points raised by this matter, reinforces the need for a robust admission process and for the manager to ensure he has full and recorded information when considering a prospective resident. Prospective residents have a trial stay and visits to the Home. Residents spoken with praised the Home and said that they had chosen it because of the good care provided. One resident had wanted to leave but chose to stay. This person was very positive about their decision to remain at the Home and of their happiness now and said, “You wouldn’t believe how good it is since the deputy manager came”. The inspector spoke with another resident who said that they had also chosen the Home and said, “I am very happy and have made the decision to stay at the Home”. Another said, “ This is the next best place to home, that is saying something. Very homely.” Intermediate care is not provided at this Home. Abbeydale Residential Home DS0000067444.V348274.R01.S.doc Version 5.2 Page 11 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): 7,8,9,10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There must be a review of the process and recording of care plans and risk assessments to ensure a more comprehensive and robust approach to safeguard residents. Residents enjoy good care from staff, which meets their needs. Further refresher training for the assistant manager will assist with the responsibility for the handling and management of medication to protect residents. EVIDENCE: The care of three residents was case tracked. The care plans for two people were basic and limited in detail, one care plan said “Must be given full support” and this fails to provide staff with sufficient information to meet individual care Abbeydale Residential Home DS0000067444.V348274.R01.S.doc Version 5.2 Page 12 needs. The care plan for one resident was in greater depth, though the risk assessment did not have sufficient detail. There was no evidence that residents and or their advocates had been involved in their care plans. One resident spoke very positively about the way staff know their needs and gave an example about moving a chair at particular times during the day, to enable the person to watch television. There was also no delay in staff responding, which meant a great deal to the resident. Four staff returned care workers surveys for this inspection and key points, which emerged, included: a view that a member of staff may not be aware of what to do if a residents’ needs change; there may sometimes, not be clear instructions from the manager about the expectations required when working with a new resident. One member of staff considered that they were sometimes told how to understand the work to do and record in the care plan. A key worker system was not operational at the Home. The daily record of staff observations, reviewed, were mainly poor and lacked sufficient detail, for example most reported: “bed made & self wash”. Both the manager and deputy manager said that they had raised the issue of staff being more comprehensive in their daily observation records but agreed it remained unsatisfactory. It should be noted that there were some good and relevant records made by staff so recording was not entirely unsatisfactory. Prior to this inspection, the inspector contacted a District Nurse who visits the Home on a regular basis and was told there were no current concerns about the Home. She also said that The District Nursing service can sometimes provide Care homes with training to support their practice and the inspector discussed this with the manager who agreed to talk with the District Nurse. The handling of medication was found to be mainly satisfactory, except that there was no risk assessment or detail, in the care plan for a resident who wishes to partially self medicate. There was also no record of medication, which had been dropped on the floor by the resident. A recent visit by the pharmacist took place to conduct an audit at the Home but there was no record of this and it was recommended to the manager that visits are noted so that any points are recorded as well as the date of the audit visit. The deputy manager is the key person responsible for medication and reinforcement training in the handling and management of medication would be helpful to ensure knowledge is kept up to date. The Commission have guidance on handling medication on the website, which would also be helpful for the home to use. Abbeydale Residential Home DS0000067444.V348274.R01.S.doc Version 5.2 Page 13 Staff were observed to show residents respect and to ensure their rights and privacy is upheld. One resident said, “I like my own space at the Home and freedom to do what I want.” Abbeydale Residential Home DS0000067444.V348274.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): 12,13,14,15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are well supported so that they can feel content with their lives and enjoy activities and interests. A record of meetings and discussion with residents about their activities and of any points they wish to raise, may help staff to reflect and continue to meet the individual and group needs of residents. Residents feel largely positive about the food they have and the choice available. EVIDENCE: Residents were observed to be open and relaxed with staff. Activities have increased and residents were seen to be involved. An entertainer who visits twice a week was doing a quiz and singing with residents. In the hallway there was a board with a significant number of photos of recent activities, Abbeydale Residential Home DS0000067444.V348274.R01.S.doc Version 5.2 Page 15 one was of a boat trip. Another member of staff also has specific responsibility for activity on two other days during the week. A Christmas party has been arranged. There is a computer in the residents lounge with photos for residents to look at and this approach may be developed, possibly with photos sent in by relatives. Symbols are used in conjunction with photos to help people with a short-term memory. One resident said they read a lot and do written puzzles – “There is enough activity for me. I like my own space at the Home and freedom to do what I want.” One member of staff spoken with said they work along with residents to ensure they have choice and care in the way they wish and gave an example of the way they give time for a resident to get up in the morning so the person is not rushed and can know that they are in control. The manager said he talks with residents individually about the menu and any other issues but there was no record and no resident meetings were currently being held, however the manager said he would consider trying to have a meeting again. He said staff find the best approach was to talk directly with residents on a day-to-day basis. The manager said residents are fully involved in the running of the Home and with decisions about trips out. Residents say they like to go out in small groups. Recently residents had been included in discussions about the planning permission for a lift to be installed at the home. Two residents talked about the importance of contact with their family. In speaking with residents, there was much praise for the food, which “were always hot and included fresh vegetables.” One said they have a lot of choice and another person who has complex needs said there was enough choice in the menu to meet their needs. Another said they were always asked about what they wanted due to dietary difficulties. However one resident said the food can be rushed occasionally and that the manager needed some help “she has a lot to do”. One member of staff responding to the survey said there could probably be an improvement to the Home if there was a cook to be responsible for cooking only. Abbeydale Residential Home DS0000067444.V348274.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): 16, 17, 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected by the Homes policies and procedures for responding to complaints and residents feel they are listened to. Staff induction must ensure that staff are supported to read and understand the homes policy and procedures and in relation to adult protection to safeguard residents. EVIDENCE: The one survey response from a resident showed they had no complaints and knew how and who to complain to if they did have a concern. The complaints procedure for residents was posted up at the home for ease of access. One resident said they were most easy talking with the deputy manager if they had things on their mind. Other residents said staff listen to them and address any issues. Since the last inspection, staff have received training concerning adult protection and one person is booked to undertake the training on the 4th December; a local college is used to provide the training. Abbeydale Residential Home DS0000067444.V348274.R01.S.doc Version 5.2 Page 17 The Home has policies and procedures in place for staff, however one member of staff said they had not had time at work to study them in depth and said they had not read the policy about ‘whistle blowing’, which enables staff to know what to do if they have a concern about other staff or people important to the resident. Also one member of staff said they didn’t know what would happen if a colleague accused them of anything. A pack of key information for staff may be helpful or other ways should be found to ensure staff have a clear understanding of the Homes policies and procedures. Abbeydale Residential Home DS0000067444.V348274.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, 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a safe, clean and well-maintained environment, which provides homely and comfortable accommodation. The provider should establish the date of the last electrical installation check of the home so that it can be undertaken if necessary. EVIDENCE: A tour of the building was made and the environment was homely, clean, hygienic and well decorated, there were no offensive odours. Residents were observed to be happy and content and bedrooms were personalised, the Abbeydale Residential Home DS0000067444.V348274.R01.S.doc Version 5.2 Page 19 shared accommodation was comfortable and bright. The second lounge off the main one provided an alternative space for people. Points raised at the last inspection had been addressed and the Home was in good order. A plumbing job in the bathroom was being completed. The laundry room was reasonably tidy and organised. The kitchen was very clean and in good order and also well located in the Home. The provider had a meeting at the Home during the inspection to discuss the installation of a lift, which will be important for residents. Residents said they were happy with their own accommodation and with the Home in general. One resident spoken with, talked about their lovely room, which was very sunny and the next best place to Home. A review of records seen at the home and set out in the managers annual quality assurance assessment showed that tests and checks to equipment and facilities at the Home have been completed and are carried out according to a programme of checks. For example the temperature monitoring for water was last reviewed on 19/10/07 and is carried out monthly. The Fire risk assessment was dated 04/10/06 and there was a visit by the Fire Officer on 20/03/07, when no points were raised. There was no record provided for the last electrical installation check for the Home and this should be reviewed to see if a check is needed. Abbeydale Residential Home DS0000067444.V348274.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): 27,28,29,30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive care from staff who are committed to their work. The lack of a robust staff induction process may result in staff not having all the information and support they need to ensure residents have their needs fully met. EVIDENCE: Staff spoken with showed a strong commitment to the individual care needs of residents, ensuring their happiness; this was echoed by residents. Staff made a number of positive comments about the home, which include: I have worked in many establishments and feel I have got complete job satisfaction here at Abbeydale. We work well as a staff team and our priority is the happiness of the residents. I have 100 support and backup from the manager. “I went to a number of Care Homes and I chose this Home – it was the best, homely, a good atmosphere and friendly”. Abbeydale Residential Home DS0000067444.V348274.R01.S.doc Version 5.2 Page 21 One member of staff said the owner and manager have discussed how they can help provide individual support for training needs. A review of staff files showed the home to have good recruitment practice. Staff Induction needs a review to ensure it meets the ‘Skills for Care’ training standards. One recently employed member of staff said that induction had been comprehensive and had given confidence in the job but that they had not had sufficient time to really read all the policies and procedures; a way must be found to support staff with their understanding of these. The Annual Quality Assurance Assessment completed by the manager stated that staff have induction on their first day and then have updates. The inspector considers that this statement does not give justice to the good induction work, which he promotes, however it is an indication that a review is needed to ensure a more robust process. The induction package was seen and the written detail in relation to induction needs to be more comprehensive. A member of staff had a meeting with the manager, at the end of their induction period, when he checked that the member of staff was happy with the procedures and the way the work was going. A record of the meeting was seen, it was basic and simply said the staff member had completed induction satisfactorily. It was signed. Good progress has been made with NVQ training for staff. Three staff were on duty on the first day of inspection, with the addition of an activities organiser and residents needs were well met on both days. An extra member of staff is employed in the mornings, to ensure sufficient staff cover for the deputy manager who undertakes the role of cook for the Home. The Home has staff meetings and the most recent minutes of 09/10/07 were seen with a poster for the meeting. The minutes had no recorded comments from staff and it appeared to look like an agenda. The manager said he had tried to engage with staff more at the meetings but had not been successful. It was felt that because the Home is small, most points are raised and responded to on a daily basis. A member of staff spoken with about staff meetings felt that staff did not say much but that she would do so in the future. The manager was encouraged to try to help the meetings to be more of a two-way dialogue. Abbeydale Residential Home DS0000067444.V348274.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, 32, 33, 36, 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Relationships between staff and residents are good and staff teamwork ensures residents are happy in the way their needs are met. Staff should receive a minimum of six formal recorded supervisions a year. The manager must ensure records are comprehensive and in sufficient detail so that they can inform staff and protect residents well being. An effective system of quality assurance must be put in place with an annual development plan to ensure the home meets its aims, objectives and statement of purpose. EVIDENCE: Abbeydale Residential Home DS0000067444.V348274.R01.S.doc Version 5.2 Page 23 There is much that is positive about the way Abbydale is run and there is good evidence that the current residents are having their needs well met. The general happiness and wellbeing of residents indicates that the manager is ensuring good practice. He is well supported by his deputy, who was highly praised by residents for the way she ensures care needs are met. However there is a need to improve record keeping. In discussion with the manager, he was open and honest and clearly wanting to make the necessary improvements. Once the issues of detailed recording are responded to, with systems to ensure a comprehensive approach is taken, the Home should be able to demonstrate that Abbeydale is Good or Excellent in a number of standards. The registered provider should consider an action plan with the manager and what support is needed. This may take the form of a mentor or coach. The manager said he was aware he needed guidance and had tried to gain support. The Commission website is one valuable place to obtain much information, which will help him. Staff supervision does not meet the standard and staff may not achieve a minimum of 6 formal and recorded supervisions a year, whilst noting that there may be good day-to-day discussion. A timetable plan of staff supervision may help to ensure a proper programme. The supervision record is not satisfactory and the process should be reviewed to ensure a good record of supervision is made. The manager should seek guidance on what constitutes good staff supervision and may wish to establish a template format so that there is an agenda of key points to include in the meeting. The records of two staff reviewed showed that one recently employed member of staff had not received formal supervision within four weeks of starting employment. The record for another member of staff contained some basic detail. One member of staff said they had received supervision from the deputy manager, which was recorded and many with the manager but was not sure that they were recorded. At the inspection, the manager was asked to provide evidence of staff supervision, but this was very limited and he is aware of the need to improve supervision practice. The deputy manager who is undertaking NVQ Level 4 was aware of failings in the record keeping and documentation and said that the manager gives 100 back up and support in the job and that this support will be returned to help the manager overcome the issues needing action. The registered provider was spoken with briefly at the inspection and he said that he leaves the management of the Home to the manager and ensures that any issues are responded to. The manager and other staff said they have good support from the provider who makes monthly visits to the Home and reports of these visits were seen. Abbeydale Residential Home DS0000067444.V348274.R01.S.doc Version 5.2 Page 24 The manager is aware he needs to gain feedback from residents and people important to them so that he can analyse the responses, which will help him to produce a development plan for the Home. The Home needs to establish an effective quality assurance and quality monitoring systems so that the annual development plan for the Home is based on a cycle of planning – action review, reflecting the aims and outcomes for residents. Records are in place to show that mandatory checks have taken place to ensure the home is safe and that maintenance is kept up to date. Abbeydale Residential Home DS0000067444.V348274.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 2 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X X 2 X 3 Abbeydale Residential Home DS0000067444.V348274.R01.S.doc Version 5.2 Page 26 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 OP3 Regulation 14 (1) Requirement The care needs of each resident must be fully assessed and a record made of the processes. (Requirement not met from 31/01/07) Care plans must be provided to address residents’ care needs, particularly in relation to pressure relief, maintaining a safe environment and emotional needs. (Requirement not fully met from 31/12/06) Timescale for action 01/02/08 2. OP7 15 28/03/08 3. OP7 13 (4)(c) There must be a review of residents’ care plans to ensure they are comprehensive, robust and provide detail so that staff understand how to meet residents needs. 28/03/08 Any identified risks to residents, particularly in relation to mobility and pressure area care, must be clearly recorded. (Requirement not fully met from 31/12/06) There must be a review of all risk assessments, including those for medication to ensure all risks are identified, and clearly recorded. Abbeydale Residential Home DS0000067444.V348274.R01.S.doc Version 5.2 Page 27 4. OP18 13 (6) 5. 6 . OP36 OP33 18 (2) 24 Staff must be supported to ensure they have a good understanding of Adult Protection policies and procedures for the home, including The up-to-date ‘Whistle blowing’ policy. Staff must receive appropriate supervision, which is recorded. The registered person must establish and maintain a system for reviewing and improving the quality of care provided at the home 25/01/08 29/02/08 30/04/08 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 OP29 Good Practice Recommendations It is recommended that a written record should be maintained of the interview processes for the recruitment of new staff. Staff should be supported to improve their recording of daily observations for residents so that matters of importance and changes can be monitored and addressed and used to provide information for the monthly care plan review. The registered provider should review his records to see if the Home needs to have a check of the electrical system. 2. OP7 3. OP38 Abbeydale Residential Home DS0000067444.V348274.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Residential Home DS0000067444.V348274.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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