Inspection on 23/05/06 for Abbeymead Lodge

This inspection was carried out on 23rd May 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Abbeymead Lodge 13/10/05

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 Key Unannounced Inspection 23rd & 24th May 2006 09:30 Abbeymead Lodge DS0000062092.V296547.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 Abbeymead Lodge DS0000062092.V296547.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. Abbeymead Lodge DS0000062092.V296547.R01.S.doc Version 5.2 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.V296547.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th October 2005 Brief Description of the Service: Abbeymead Lodge 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. The manager reported that fees for the service ranged from a minimum of £1400 per week upwards, depending on individual needs. Abbeymead Lodge DS0000062092.V296547.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection began on a Tuesday morning, lasting until early evening, and continued the next morning for a couple of hours. The manager was present on the first day and the responsible individual on the second day. All of the service users were met and some showed their rooms and provided a tour of parts of the home or grounds. Several members of the staff team were met and some spoken with in depth. A range of records was checked including care plans and risk assessments, daily records, medication charts, policies and procedures and healthcare notes. Two service users’ care was looked at in more detail through ‘case tracking’. Before the inspection the manager distributed comment cards to service users, health and social care professionals and relatives/visitors. A good response was received and feedback is incorporated into this report. What the service does well: What has improved since the last inspection? Requirements were made in the last report about how medication is handled in the home. There was evidence in the inspection that all of these issues had been sorted. Throughout the inspection there were examples of how the manager and staff team have focussed on improving different areas of the way the home runs in a very creative way. Good systems have been developed for identifying how Abbeymead Lodge DS0000062092.V296547.R01.S.doc Version 5.2 Page 6 the home could be better, including asking service users and other people involved with their care what they think. What they could do better: 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. Abbeymead Lodge DS0000062092.V296547.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 Abbeymead Lodge DS0000062092.V296547.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. A thorough admissions procedure and strong underpinning philosophy help to ensure that only appropriate referrals are accepted. EVIDENCE: There had been no new admissions since the last inspection. The organisation has a thorough admissions policy which meets the expectations of the National Minimum Standards. Service users described visiting the home before moving in and having plenty of information about the service. Examples of assessments conducted by the service were seen on file (‘proposals for the provision of residential care’). These were very thorough and were accompanied by appropriate background material. Staff spoken with commented on how the providers and manager had thought very carefully about the resident mix, resulting in a slower pace of admissions rather than simply filling vacancies. One of the providers confirmed that their approach was to consider admissions thoroughly rather than to accept inappropriate or emergency referrals. Care plans were seen to relate to original assessments, and there was evidence throughout the inspection that the team was able to meet the needs of people admitted to the home, as described in other sections of the report. Abbeymead Lodge DS0000062092.V296547.R01.S.doc Version 5.2 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): 6, 7 & 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. A thorough and clear care planning system operates in the home which is person centred and which reflects service users’ needs, interests and goals. Service users are offered meaningful choices, helping them to take control of their lives. A strong value base and a sound assessment framework promote the taking of measured risk, benefiting service users’ confidence and independence and allowing them to take up diverse and rewarding opportunities. EVIDENCE: Care plans checked were detailed and covered appropriate areas. Most were signed by the service user. There was evidence of regular review. The manager, staff and service users described keyworker meetings where the care plans and general care needs were reviewed. There were also full internal and external reviews on file. The manager described how he monitors the care plan and review system, whilst delegating day-to-day responsibility to others team members to review and amend care plans as necessary. Abbeymead Lodge DS0000062092.V296547.R01.S.doc Version 5.2 Page 10 Some person centred care planning formats had been started, in some cases written directly by the service user. The manager described how this work would be taken forward. One person has their care plans on audiotape. Daily notes were very structured and provided relevant information. Care plans referred to offering choice, and documented decisions such as not to have a room key or certain items of furniture in the bedroom. There was a record of significant limitations, although during the course of the inspection other areas were identified such as: • • Issues around service users having front door keys. Staff access to service users’ bedrooms for cleaning (or for other reasons) when the service user is out. Service users’ consent to this should be documented, along with a description of the circumstances in which staff may access the room. Access to food/the pantry. Some service users commented on limited access, although the service provider and staff said that this would now be reviewed and was likely to be relaxed due to a change in circumstances in the home, though some limitations may continue. • There should be clear documentation of these issues (and any other significant limitations in place) if not already undertaken. Service users spoken with described being offered choice, both in day-to-day matters and about longer-term issues. Staff talked about how they offered choice as much as possible, and how different people communicated their decisions and preferences. The home has a risk taking policy which refers to the right to an ordinary life and to people reaching their potential. There were examples throughout the inspection of this philosophy being put into practice, with service users being supported to take measured risks as part of developing confidence and independence and taking up opportunities reflecting their needs and interests. These included vocational projects, going out alone, keeping livestock, using public transport and taking driving lessons. Risk assessments also covered issues such as safety and wellbeing within the home. There was evidence of these assessments being reviewed regularly. Revised risk assessments and care plans were submitted to CSCI following some significant incidents in the home and community. These provided evidence of a thorough review system and a thoughtful, balanced approach to providing care and managing risk in the context of challenging behaviour. Abbeymead Lodge DS0000062092.V296547.R01.S.doc Version 5.2 Page 11 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, 13, 15, 16 & 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users take part in a range of activities appropriate to their needs and interests, both in the home and community, helping them to develop new skills and to lead full lives. Sound policy and practice underpinned by a strong value base help to ensure that people’s rights are respected and that there is support for people to meet their responsibilities. A healthy, varied diet is provided which responds to people’s individual needs and preferences. EVIDENCE: Service users’ activity care plans and schedules provided evidence of a varied and individual programme. Discussion with staff along with records provided evidence that one person whose care was looked at in more detail had made significant progress in terms of going out more and becoming involved in new Abbeymead Lodge DS0000062092.V296547.R01.S.doc Version 5.2 Page 12 activities. Another person whose care was tracked was supported to keep their own livestock and to regularly visit places and people of interest to them, as evidenced by observation, care records and discussion with the staff and service user. Activities were seen to be reviewed through routine care plan reviews and broader periodic reviews. Other service users spoken with described their activities in the home and community, and were observed to be going out and about following individual programmes either independently or with support. People were enthusiastic about how they spent their time and also confirmed that there were activities offered during evenings and weekends. Staff spoken with felt that service users led full lives which corresponded to their needs and interests. Forthcoming activities for the day and evening were discussed during a handover which was observed. Activities in the community included helping to arrange a regular disco, going to shops, church, banks and local places of interest, meeting friends, going for walks, doing voluntary work and helping with recycling. Care plans referred to contact with family and friends. Discussion with staff and service users provided evidence of support to maintain and increase this contact (including offering transport over long distances) and of people being supported to develop new relationships. A policy about social and personal relationships sets out a strong value base, including reference to people’s rights. Comment cards provided evidence of specialist workers being involved around personal issues and relationships where appropriate. Other policies also referred to people’s rights as well as to legislation such as the Human Right’s Act, and there is a service users’ charter which also sets out the home’s value base. Care plans noted people’s preferred form of address. There was evidence on file of people being on the electoral register. Routines were observed to be flexible and individual throughout the inspection, for example, with people eating at different times and pursuing very diverse activity programmes. Service users spoken with were clear about their rights, and also about responsibilities such as developing independent living skills in areas such as cooking and taking part in vocational opportunities. Some people commented on issues that they saw as impacting on their rights (see Standard 7). Service users were generally positive about the food and confirmed that they could have alternatives to what was on the menu. Staff described how service users were involved in writing the shopping lists and menus, and how they provided alternatives if requested. People were seen to eat different foods and Abbeymead Lodge DS0000062092.V296547.R01.S.doc Version 5.2 Page 13 times which suited them. Fruit and healthier food was seen to be available and menus/meal records provided evidence of a healthy diet being offered. Care plans addressed issues around food where relevant and staff commented on the progress that one person in particular had made in varying their diet more. As noted, arrangements around access to food are likely to be reviewed following a change of circumstances in the home, and any remaining restrictions will need to be documented along with the rationale. Abbeymead Lodge DS0000062092.V296547.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Appropriate support is provided with personal and healthcare needs, promoting service users’ dignity and wellbeing. Good systems are in place for handling medication and for ensuring that staff are confident and competent in this area, promoting service users’ safety and wellbeing. EVIDENCE: Care plans described people’s personal care needs and also referred to respecting people’s privacy and dignity. Many of the service users are largely independent with personal care and their privacy and dignity is enhanced by each room having en-suite facilities. Staff spoken with described how they offered personal care or prompted service users in a sensitive manner when necessary. Service users spoken with about this indicated that they were happy with how the staff supported them. Records and discussion with the manager/staff provided evidence of service users being supported to access routine and specialist healthcare as required. Notifications made under Regulation 37 have also offered evidence of working Abbeymead Lodge DS0000062092.V296547.R01.S.doc Version 5.2 Page 15 in partnership with health and social care professionals. One person whose care was tracked is supported with routine healthcare appointments by a family member. It was agreed that it would be useful to include a summary of appointments and significant outcomes in the home’s healthcare records as part of general monitoring under duty of care. The manager provided evidence that requirements and recommendations from the previous report about medication handling had been met. This included creating new audit and monitoring systems (examples of which were viewed) and awareness-raising in a staff meeting. Staff receive training from the supplying pharmacy and also have access to a distance learning course through a local college to supplement in-house training about medication. Storage arrangements were satisfactory. Medication administration records and accompanying information and protocols appeared to be fully in order, although it was suggested that the allergy box could be completed both where an allergy or intolerance have been identified and where there are none known. In addition it was suggested that the homely remedies sheets could also note where a preparation contains ingredients to which some people are intolerant. Staff spoken with were very aware of issues around allergy/intolerance, indicating that arrangements for informing staff of this important area were effective. A policy and risk assessment format are available around self-administration. Abbeymead Lodge DS0000062092.V296547.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good arrangements are in place for handling concerns and complaints and some developmental work should further promote this, giving service users confidence to voice their opinions and raise issues. Measures are in place which help to protect service users from harm and abuse. Additional work planned in this area will help to further protect people living in the home. EVIDENCE: The manager and service provider reported that there had been no formal complaints since the last inspection, although they regularly dealt with informal issues on a day-to-day basis. Service users were observed approaching staff and management throughout the inspection and openly raising concerns which were handled in a positive and supportive manner. Those asked said that they felt able to approach the manager and staff with any concerns and that they generally felt listened to. Staff described how people indicated dissatisfaction and how they responded. The home has a complaints procedure with text and symbol versions. The manager confirmed that all service users have been given copies. However, a recent survey highlighted that some service users and staff were unsure about the procedure. As a result the manager had added the complaints procedure to a forthcoming staff meeting agenda and was also planning to revisit the procedure with service users individually. This is an example of a very proactive approach. Abbeymead Lodge DS0000062092.V296547.R01.S.doc Version 5.2 Page 17 The manager had also identified that relatives were unsure about the complaints procedure (a point also reflected in the CSCI comment cards). He planned to send copies of the procedure to family and to conduct a general awareness-raising exercise. The home has policies covering whistle blowing, adult protection and abuse. A copy of the ‘No Secrets’ paper was also on file. Staff spoken with indicated that they would have no hesitation in reporting concerns and that they would be confident that any such issues would be handled appropriately. Although there is some coverage of adult protection and abuse issues in induction and through NVQ work, it was agreed that it would be helpful for staff to have some dedicated input on this. The manager and service provider said that the organisation’s training coordinator had just completed a ‘train the trainer’ course in this area and would be cascading this through the team. The manager understood that there was no copy of the local adult protection team’s procedures/handbook in the home. If not, this should be obtained. A policy on physical intervention was seen to be detailed and up to date. There was also a copy of the government’s guidance on the subject. Care plans were in place around challenging behaviour and placed a clear emphasis on deescalation. Discussion with staff provided evidence that they had received appropriate training in the management of challenging behaviour and were aware of principles and good practice in this area. They indicated that the incidence of challenging behaviour was low. Information supplied to the Commission under Regulation 37 provided evidence of an appropriate and measured response to extreme and high-risk behaviour when it arises. Records of service users’ finances were checked. These appeared to be in order. However, one person had purchased some flowers/tubs and these had not been added to their inventory. Whilst the Care Homes Regulations talk only of furniture being listed, staff should ensure that all significant purchases are recorded so that it is clear who owns which items. Abbeymead Lodge DS0000062092.V296547.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. A homely, clean and spacious environment is provided, promoting service users’ independence and quality of life. EVIDENCE: All communal areas were viewed and appeared comfortable and homely. Three lounges are available to service users and visitors, as well as the dining room and a conservatory. In addition there is a large, well-maintained garden. Service users expressed satisfaction with their rooms, all of which have ensuite facilities. Those viewed were homely and personalised. Service users confirmed that they had chosen their décor and furnishings. Some people said that they would like more space. The team has supported some people to put certain possessions in other parts of the home with their consent, in order to free up space in their rooms. One person said that they would rather not have window restrictors. It was agreed that, whilst the default is that they should be in place, there is scope for services to individually risk assess if it is proposed to deviate from this (including considering the risk posed to other service users who may access an unrestricted window in another part of the home). Abbeymead Lodge DS0000062092.V296547.R01.S.doc Version 5.2 Page 19 All areas of the home seen were clean and appeared to be hygienic. A colour coding system for cleaning equipment operates. Cleaning rotas were viewed. The manager described findings from a visit by an Environmental Health Officer and what had been done to action their recommendations. Evidence of this was seen on records in the kitchen. A recent quality assurance exercise highlighted some concerns from staff about the arrangements for cleaning the home. It was planned to take this forward as an agenda item for a staff meeting. Abbeymead Lodge DS0000062092.V296547.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care is provided by a competent and committed staff team, promoting high quality, individualised care. Arrangements are in place to staff to receive training appropriate to their roles, further promoting the quality of care as well as service users’ safety. Good recruitment and selection procedures help to reduce the risk of unsuitable carers being employed. EVIDENCE: Staff spoken with demonstrated a good understanding of people’s needs, their roles and responsibilities and of care plans. They also expressed a clear value base such as the promotion of independence and choice and respecting people’s rights, as well as commenting on the team’s cohesion and people’s commitment. Service users were positive about the staff team. Comments included that ‘the staff are very good’. Some service users have moved on to more independent living, providing evidence that staff are developing people’s independent living skills rather than promoting dependence. Abbeymead Lodge DS0000062092.V296547.R01.S.doc Version 5.2 Page 21 Care records, comment cards and information supplied under notification provided evidence of a good working relationship with health and social care professionals and of the staff team being held in high regard. Comment cards from relatives and visitors were very positive. Comments included that staff were always helpful, care was exemplary and that the home was excellent. The manager described progress towards staff achieving NVQs in care. The home was well on the way to 50 of the team having the level 2 qualification. It was planned for senior staff to undertake the level 3 qualification, although the home has encountered some difficulties in sourcing this training. It was agreed that this should be pursued so that senior staff have this qualification. The manager described the recruitment process. He conducts interviews with the providers according to a set formula to promote objectivity. The manager discussed the home’s commitment to equal opportunities in recruitment. There are clear job descriptions and employee specifications. Examples were viewed. The home has a clear and thorough induction programme. Staff spoken with were very satisfied with their inductions to the home and service. Staff files contained information required under the Care Homes Regulations. However, it was suggested that the application form could be modified to ask people to supply the months of previous employment as well as the year, in order that a more complete picture of employment history is recorded. There was also a discussion about the source of references since the application form only asked for one professional referee. However, the responsible individual subsequently clarified this, stating that the application form had recently been modified to ask for two professional references (as well as a supplementary personal reference). The management team is aware of the need for references to be sought from previous social care employers in some circumstances as described under Schedule 2 of the Care Homes Regulations. The organisation has a training coordinator. The manager and responsible individual described some training that the coordinator has undertaken as part of their own professional development and also to cascade to staff through indication and other training sessions. Training records provided evidence that mandatory training was largely up to date and that where gaps were identified training was booked or planned. Some specialist training has been provided in the past, for example about particular conditions experienced by service users. The manager said that specialist training/input would be sourced/provided if identified as a training need. Some literature is available in the home about specialist conditions. As noted senior staff do not yet have NVQ 3, although they have had access to some other relevant training such as in-house workshops and a course on supervisory management. Abbeymead Lodge DS0000062092.V296547.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is very well run, promoting positive outcomes for service users. Systems are in place or being developed for monitoring and improving the quality of the service, helping to encourage reflective practice and to ensure that everybody feels listened to. Health and safety is effectively managed, making the home a safe place to live and work. EVIDENCE: The manager has completed the Registered Manager’s Award and the NVQ level 4 in care. The responsible individual, staff and service users praised the manager. For example, there were comments about his commitment and professionalism, and also about increasing the delegation of responsibilities whilst maintaining an overall awareness of issues and monitoring the systems in place. Staff described the manager as approachable but also assertive when Abbeymead Lodge DS0000062092.V296547.R01.S.doc Version 5.2 Page 23 necessary. Staff also commented positively on the overall management structure, which includes senior carers. There was evidence throughout the inspection of the home being well run, as summarised in this report. Comment cards provided further evidence of this. Quality assurance was discussed. Regulation 26 reports are being forwarded to the Commission. These are very detailed. The manager confirmed that they are unannounced visits. Records were seen of monthly health and safety audits/checklists. The manager said that he saw supervision as part of the quality assurance process, inviting ideas and honest feedback. Staff spoken with indicated that they found supervision meetings helpful and open. The manager had just completed a survey of staff and service users and was compiling a feedback summary. Whilst there was much positive comment, some issues were raised as noted in this report (such as about the complaints procedure). The manager plans to take forward some practical suggestions such as having a suggestion box, and other issues were to be discussed at a forthcoming staff meeting. He was seeing the survey as a pilot, with a view to revising the tool and periodically repeating the exercise. The manager described how service users who needed help with the survey were supported. The home has an excellent track record of implementing requirements and recommendations from previous reports. Minutes from a residents’ meeting in May 2006 were seen. Issues discussed included menus and activities. The manager said that the service may aim for the Investors in People Award. Staff spoken with felt that the home was a safe place to live and work. The home has a detailed health and safety policy. The fire logbook was checked and appeared to be in order, with evidence of issues having been picked up and appropriate action taken. There was evidence of staff receiving instruction about fire safety at regular intervals. Records were seen of monthly water temperature checks. As noted, there is a monthly health and safety audit. Portable appliance testing was seen to be up to date. Various checks are undertaken in the kitchen such as fridge and freezer temperatures and using food probes. The manager described the input that he and the rest of the team had received about recent changes to food safety legislation. Training in infection control was taking place around the time of the inspection. The manager and staff described the course as more in-depth than most courses in this area, with an assignment to complete and a qualification if successful which can contribute towards NVQs. As described, a good risk assessment and management system is in place. Abbeymead Lodge DS0000062092.V296547.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 4 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 4 23 3 ENVIRONMENT Standard No Score 24 4 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 x 4 x LIFESTYLES Standard No Score 11 x 12 4 13 4 14 x 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 4 x 4 x x 4 x Abbeymead Lodge DS0000062092.V296547.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO 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. Standard Regulation Requirement Timescale for action 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 YA7 YA19 Good Practice Recommendations Ensure that all significant restrictions and limitations are clearly documented and, ideally, agreed with service users such as the examples cited in the text. Where service users are supported by relatives to access routine healthcare a summary of appointments and significant outcomes should still be maintained in the home’s healthcare records. • The allergy box on medication administration records should be completed (including ‘none known’ where appropriate). • Homely remedies sheets could also note where a preparation contains ingredients to which some people are intolerant. Ensure that all significant purchases are recorded on people’s inventories so that it is clear who owns which items (see example in text). Ensure that there is a copy of the local adult protection team’s procedures/handbook in the home. DS0000062092.V296547.R01.S.doc Version 5.2 Page 26 3 YA20 4 5 YA23 YA23 Abbeymead Lodge 6 YA34 The application form could be modified to ask people to supply the months of previous employment as well as the year, in order that a more complete picture of employment history is recorded. Abbeymead Lodge DS0000062092.V296547.R01.S.doc Version 5.2 Page 27 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. Extracts may not be used or reproduced without the express permission of CSCI Abbeymead Lodge DS0000062092.V296547.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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