Inspection on 13/10/05 for Abbeymead Lodge

This inspection was carried out on 13th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Abbeymead Lodge 23/05/06

Abbeymead Lodge 19/04/05

Abbeymead Lodge 17/12/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Abbeymead Lodge Abbeymead Avenue Abbeymead Gloucester GL4 5GR Lead Inspector Mr Richard Leech Unannounced Inspection 13th October 2005 11:50 Abbeymead Lodge DS0000062092.V258611.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Abbeymead Lodge DS0000062092.V258611.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Abbeymead Lodge DS0000062092.V258611.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Abbeymead Lodge Address Abbeymead Avenue Abbeymead Gloucester GL4 5GR 01452 617566 01452 763890 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) Aspirations Care Limited Mr Colin Anthony Beard Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Abbeymead Lodge DS0000062092.V258611.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th April 2005 Brief Description of the Service: Abbeymead Lodge first opened in September 2004. The home is registered to provide care for up to eight people with a learning disability. The Statement of Purpose indicates that service users may have complex needs. The property is a detached building in a residential area of Gloucester. The home was a care setting in the past (run by a different organisation). It has been completely refurbished to meet with the National Minimum Standards. Bedrooms are situated on both the ground and first floors. All have en-suite bathrooms. The home also has three lounges, a dining room, a conservatory, a staff sleeping-in room, office, kitchen and laundry. There is a large garden. Abbeymead Lodge DS0000062092.V258611.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection began at midday and lasted about five hours. The manager was present throughout. Several service users were met with, and comment cards were left for people to complete if they wished to. Certain records were checked including medication records and some risk assessments. There was discussion with some staff members and a shift handover was observed. The building was not checked in full although two service users showed the inspector their rooms and some of the communal areas were seen. The summary sections below relate to the limited number of areas considered during this inspection. For a fuller picture of the home this report should be read in conjunction with the previous report from April 2005. What the service does well: What has improved since the last inspection? What they could do better: There need to be further improvements in the way that medication is handled in the home in order to make the systems safer and more watertight. Please contact the provider for advice of actions taken in response to this Abbeymead Lodge DS0000062092.V258611.R01.S.doc Version 5.0 Page 6 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Abbeymead Lodge DS0000062092.V258611.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Abbeymead Lodge DS0000062092.V258611.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of the standards in this section were inspected on this occasion. EVIDENCE: There have been two new admissions since the last inspection. Abbeymead Lodge DS0000062092.V258611.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 The home has appropriate systems for assessing and managing risk, promoting service users’ independence whilst identifying any necessary support or intervention. EVIDENCE: Risk assessments for two service users were checked in more detail. Staff spoken with demonstrated awareness of these. Discussion with the manager provided evidence that they had been written in consultation with service users. Where appropriate risk assessments and related documents had been put into a more accessible format. One risk assessment about going to a local shop independently had last been reviewed on 07/02/05. It was agreed that this should be reviewed to ensure that it remained up to date. Abbeymead Lodge DS0000062092.V258611.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 Staff support each person to take part in meaningful activities of their choice, including leisure and vocational opportunities and skills development. EVIDENCE: At the time of the inspection most service users were out on activities. A timetable in the office provided evidence of very individualised programmes based on each person’s needs and interests. Service users spoken with expressed satisfaction with how they spent their time, including at evenings and weekends. Staff and service users mentioned recent holidays from the home, describing these enthusiastically and positively. They have led to some projects such as annotating photographs using a computer. Abbeymead Lodge DS0000062092.V258611.R01.S.doc Version 5.0 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 Ongoing shortfalls in systems for handling medication in the home could place service users at risk. EVIDENCE: In May 2005 the pharmacist inspector carried out a specialist inspection of the handling of medication in the home. Their requirements and recommendations were checked during this visit. Many of the issues identified had been addressed. However, the following requires attention: • Some eye drops with a shelf-life of one month following opening had not been dated at the time they were opened. It was therefore not possible to tell when the product should no longer be used. The home’s pharmacy has provided a list of products’ shelf-lives and recommended writing the date after which a product should not be used rather than writing the date of opening. Which ever dating system is used it needs to be implemented clearly and consistently. For example, one cream had been marked with a date but it was not evident whether this was the date of opening or the date after which the product should not be used. A product with a variable dose had been administered but there was no indication on the MAR chart whether one or two tablets had been given. Whilst the manager was confident that recording on the MAR chart had improved there were still some instances of gaps in the record (two DS0000062092.V258611.R01.S.doc Version 5.0 Page 12 • • Abbeymead Lodge • • • entries for one person on October 1st 2005). Such instances need to be investigated in order to identify if the medication was administered and to establish the reason for the record not being completed. Some handwritten entries on the MAR chart were not double signed as required by the pharmacist inspector. The manager said that some service users had now provided their consent to medication. He is devising a symbol format for use with some people though this is not yet completed. The manager said that the medicine policy has not yet been reviewed, as per a requirement from the pharmacist inspector (in the subsequent action plan it was reported that some of the issues had been addressed in separate policies but that the general medication policy would now be reviewed and amended to ensure compliance). As recommended in the pharmacist’s report, the manager is devising a file of patient information leaflets. The manager said that service users’ GPs had been asked to check over-thecounter remedies used in the home for compatibility with prescribed medication. He has chased this up and expects a response in the near future. Examples of individual protocols for the use of ‘as-required’ medication and over-the-counter remedies were viewed. The manager said that he had raised the issues identified by the pharmacist inspector in a staff meeting. He also intends to designate a second senior staff member with a lead responsibility around the handling of medication in the home. In addition he is arranging to staff to have further training through the supplying pharmacy. A policy and risk assessment on self-administration of medication has been devised. The inspector has checked with the pharmacist inspector about recording receipt of medication. His view is that it does not matter whether receipt is recorded on the MAR chart or a separate form provided there is a clear procedure and staff consistently work to this. The pharmacist has also checked the policy for taking medicines on home leave and made the following comments: • • The policy should state that the medicines must be sent in the container as dispensed and labeled by the pharmacy. Regarding sending a photocopy of the MAR chart on leave it was felt that the first two paragraphs were slightly unclear. There needs to be a distinction for going on leave when no carer from the home accompanies the service user but they go to family, for example, who will administer the medicines. In this case there is no requirement for the family to sign the MAR chart photocopy although they may like to have it as a Abbeymead Lodge DS0000062092.V258611.R01.S.doc Version 5.0 Page 13 • • • reference. The original MAR must stay in the home and is marked D for social leave in the appropriate boxes. If a carer accompanies the service user and is then responsible for the administration then a record must be made on the original MAR. The record of medicines taken out and returned in a book kept for each person is fine but this must contain full details for an audit trail such as date, name and dose form of medicine, strength, quantity, signatures etc. The policy seen was not signed and dated. It was suggested that the manager could contact the pharmacist inspector directly if there were any issues requiring clarification or further advice. Some material sent by the pharmacist inspector will be forwarded to the home for reference. Abbeymead Lodge DS0000062092.V258611.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 Arrangements are in place to protect service users from harm and abuse, promoting their safety and wellbeing and contributing to a sense of empowerment. EVIDENCE: All staff receive training in a system of managing challenging behaviour called ‘CALM’. This training provider is accredited by BILD. Staff spoken with demonstrated a mature understanding of the principles of this system, including the emphasis on de-escalation. Discussion with the manager along with records provided evidence of considerable multi-disciplinary work towards establishing the reasons for one person’s more unsettled behaviour. This now appears to have stabilised. The manager had produced a protocol/agreement made into an accessible format for the person. Staff spoken with confirmed that they would report any concerns which they had about care or practice. Some service users who were asked also indicated that they would feel confident raising any issue with staff, the manager or providers and that they would be listened to. The home has procedures about the protection of vulnerable adults and prevention of abuse. Staff spoken with described the importance of respecting people’s privacy and dignity and gave examples of this. They also offered examples of how people’s conditions may manifest and result in different perceptions, experiences and behaviours. Abbeymead Lodge DS0000062092.V258611.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 Abbeymead Lodge is homely and comfortable. Bedrooms are personalised and the communal areas are being used imaginatively and flexibly. EVIDENCE: Although the building was not checked systematically during this inspection, all areas viewed (including two service users’ bedrooms) were well decorated, homely and comfortable. Service users asked indicated that they were very happy with their rooms. All bedrooms have en-suite facilities. The home has three lounges and a conservatory, as well as other communal space. The use of some shared areas has changed in accordance with service users’ ideas for the best use of each room. There is a large back garden. The manager said that since the previous inspection individual controls have been fitted on radiators as recommended in the last report. Areas of some ensuites which had been prone to peeling paint have been re-tiled. The manager indicated that staff are working with some service users to encourage them to consider additional storage for their rooms to avoid having items on the floor. Abbeymead Lodge DS0000062092.V258611.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 & 35 Staff receive a good induction and have opportunities for professional development, thereby developing skills and promoting good practice. EVIDENCE: Discussion with the manager and team members provided evidence of a commitment to staff obtaining NVQ qualifications in care. Staff described their inductions and were very positive about these. This includes an in-house and a LDAF accredited induction. The organisation is investigating options for other LDAF accredited training. The manager described further courses available to staff including a foundation certificate in care. Some staff are attending specialised training on a condition experienced by a service user. In the last report a requirement was made to ensure that, as far as possible, staff are up to date with mandatory training. Selected staff records provided evidence that this was being achieved. The organisation now has a company coordinator who coordinates this process. It was agreed that it would be useful to update the at-a-glance training matrix in the office. Part of a handover was observed. Staff conveyed relevant information in a respectful manner, elaborating on the notes on the handover sheet. Service users spoken with praised the staff team. Selected staff records provided evidence that a requirement about having records on file of a satisfactory CRB/PoVA check had been implemented. Abbeymead Lodge DS0000062092.V258611.R01.S.doc Version 5.0 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 The home is well run, promoting positive outcomes for service users. EVIDENCE: The manager is undertaking NVQ level 4 in care and the Registered Manager’s Award. He expects these to both be completed by around May 2006. Staff spoken with felt that the home was well run and described the manager as approachable. They also commented positively on the providers’ role, indicating that they were committed to providing an excellent service and were very client-centred. Service users also praised the manager. Reports made under Regulation 26 are being forwarded to CSCI. These are exceptionally thorough and high quality. They are informative for CSCI, but also form an important part of the home’s own quality assurance systems. Although health and safety issues were not looked at in detail, a report from the Fire Officer from April 2005 was checked through. Abbeymead Lodge DS0000062092.V258611.R01.S.doc Version 5.0 Page 18 • • • • • • The home keeps a record of drills, including who was present and how they went. It was agreed that there should be a more systematic approach to ensuring that all day staff take part in a drill and/or instruction at least twice a year and that night staff receive this input quarterly. A requirement about non-slip treads on the external fire escape is not repeated on the basis that this has been revisited and current provision found to be acceptable. The manager stated that night staff remove all wedges in use during the day and close all fire doors, as per instruction from the fire officer. Records of tests of emergency lighting were found to be acceptable. The manager said that this includes checking them at night to establish if outside areas are sufficiently lit. The manager said that portable heaters are no longer in use in rooms, the fire officer having noted these when they visited. Abbeymead Lodge DS0000062092.V258611.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 Score x 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score x x x 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x x LIFESTYLES Standard No Score 11 x 12 3 13 x 14 x 15 x 16 x 17 Standard No 31 32 33 34 35 36 Score x 3 x x 3 x CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Abbeymead Lodge Score x x 2 x Standard No 37 38 39 40 41 42 43 Score 3 x x x x x x DS0000062092.V258611.R01.S.doc Version 5.0 Page 20 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 YA20 Regulation 13 (2) Requirement Eye drop containers and any medicine with a limited shelf life when used to be dated on opening and used within the manufacturer’s stipulated period (Timescale of 16/05/05 not met). Where a medication has a variable dose ensure that the actual dose given is documented (Timescale of 15/06/05 not met). Implement a system for checking whether the MAR charts are being consistently and correctly completed. Where errors and omissions are identified these must be investigated. Handwritten entries on MAR charts to be signed and dated by the authorised staff member with a signed second check for correct transcription (Timescale of 15/06/05 not met). The medicine policy to be reviewed to include the issues from the pharmacist’s inspection (Timescale of 31/07/05 not met). Timescale for action 10/11/05 2 YA20 13 (2) 10/11/05 3 YA20 13 (2) 10/11/05 4 YA20 13 (2) 10/11/05 5 YA20 13 (2) 15/12/05 Abbeymead Lodge DS0000062092.V258611.R01.S.doc Version 5.0 Page 21 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA9 YA20 Good Practice Recommendations Review risk assessments regularly (at least every six months) to ensure that they remain as up to date and accurate as possible, such as the example cited in the text. Residents’ consent to medication should be obtained and recorded in the individual plan. Record receipt of medication according to a clear procedure which is consistently followed, whether this be on the MAR chart or a separate form. Address the bullet points made by the pharmacist inspector in the text about the policy for taking medicines on home leave. Update the at-a-glance training matrix in the office. Adopt a more systematic approach to ensuring that all day staff take part in a drill and/or fire safety instruction at least twice a year and that night staff receive this input quarterly. 3 4 YA35 YA42 Abbeymead Lodge DS0000062092.V258611.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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