Inspection on 27/09/07 for Abbeywood House

This inspection was carried out on 27th September 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

Abbeywood House 11/11/08

Abbeywood House 26/09/06

Abbeywood House 13/12/05

Abbeywood House 11/08/05

Abbeywood House 08/12/04

Abbeywood House 08/06/04

Abbeywood House 10/02/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE Abbeywood House Abbeywood House Cary Park Babbacombe Torquay Devon TQ1 3NH Lead Inspector Peter Wood Unannounced Inspection 10:00 27 September 2007 th 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 Abbeywood House DS0000018311.V342814.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. Abbeywood House DS0000018311.V342814.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbeywood House Address Abbeywood House Cary Park Babbacombe Torquay Devon TQ1 3NH 01803 313909 01803 313925 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) TorbayResidentialHomes.com Mr Clifford Derek Strange Mrs Phillipa Wanda Strange Mrs Anne Long Care Home 30 Category(ies) of Dementia - over 65 years of age (30), Old age, registration, with number not falling within any other category (30), of places Physical disability over 65 years of age (30) Abbeywood House DS0000018311.V342814.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Key Inspection: 26th September 2006 and 07 November 2006 Random Inspection 26 March 2007 Brief Description of the Service: Abbeywood House is now registered to provide accommodation and care for a maximum of thirty people who are elderly and who may have physical disabilities and/or dementia following the completion of a ten-bed extension. The home is situated in a quiet residential area and overlooks Cary Park. Shops, churches and other local amenities are within walking distance. The home is very well presented and all rooms seen were well decorated, comfortably furnished and clean. The home has sufficient adaptations and equipment to assist those with physical difficulties. Fees range between £350 and £500 depending on the care needs of the resident and the quality of the room. Inspection reports are available from the manager. Abbeywood House DS0000018311.V342814.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and undertaken over one weekday in September 2007. The focus of this inspection was to inspect all key standards and to seek the views of people who live at the home, staff, relatives and professional visitors to the home, the latter mainly using and survey forms. At the time of writing this report no survey forms have been returned, possibly owing to the postal strike. They will be incorporated into the next draft, if appropriate. Considerable time was spent with the Registered Manager examining documentation, particularly that relating to client assessment and care planning, staffing and health and safety. We selected and closely examined a selection of files of staff and people who live at the home. We also consulted people who live at the home, including taking lunch with them. We also consulted staff who were on duty, including attending a staff handover meeting. A full tour of the building was undertaken. The Annual Quality Assurance Assessment was taken into account during the inspection of this home. Fees range between £350 and £500 depending on the combination of the individual resident’s care requirement and quality of the room. What the service does well: The Annual Quality Assurance Assessment received from the home states that: “We provide a high level of quality care whilst promoting independence and choice. We provide a safe comfortable environment in which our people who live at the home can maximise their potential physically, intellectually, socially and emotionally. We retain staff.” The home has been operating since 1983 to enable older people to live in a residential care setting while encouraging them to remain as independent as possible. The home caters particularly for people with a degree of dementia, in an attractive setting. The recently enlarged building is very pleasant offering mainly single bedrooms, many with en suite facilities. The whole house is very well decorated and furnished. Assessments undertaken prior to admission allow prospective people, those who live at the home and their relatives to be confident that their needs can be met. People who may come to live at the home and their relatives are encouraged to visit prior to admission. Abbeywood House DS0000018311.V342814.R01.S.doc Version 5.2 Page 6 Their physical health and care needs are now more comprehensively set out in their care plan, and properly met. People who live at the home are treated respectfully. The home’s improved practices relating to medication administration now protect the service users from risk. Social activities are provided which gives interest for those who live at the home. People who live at the home maintain contact with their friends and families and are encouraged to exercise as much choice and control over their lives as possible. Complaints and suggestions from people who live at the home, relatives or other visitors to the home, are treated seriously. They are listened to and issues resolved promptly. People who live at the home enjoy a very pleasant, well-maintained home that is comfortable and warm and which provides sufficient facilities to meet their needs. They are cared for by competent staff in sufficient numbers to meet their needs. They live at the home live in a home which is run in their best interests. The owner, manager and staff team provide a comfortable home where their health, safety and welfare are promoted and protected. What has improved since the last inspection? The Registered Manager is now well on the way undertaking the huge task of modernising the home’s documentation, policies, procedures and practices. Client assessments are now more comprehensively recorded, which in turn ensures that care plans generated from them are more detailed. In turn this ensures that staff have a clearer understanding of the needs of their clients and how to meet them. The Annual Quality Assurance Assessment states that: “Staff are now currently doing NVQ at levels 2, 3, 4. Staff have completed distance learning training in “Safe Handling of Medicines”, Infection Control, Health and Safety and Food Hygiene.” The registered person has now ensured that all hot water pipes and radiators pose no hazard of scalding to people who live at the home. The home has implemented the key worker system so that specific members of staff can get to know individual people who live at the home better to give them a better service. The home has implemented a “zone area” whereby the house is divided into three areas, staff allocated to people who live at the home in each zone. This ensures continuity of care and accountability. Abbeywood House DS0000018311.V342814.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Abbeywood House DS0000018311.V342814.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 Abbeywood House DS0000018311.V342814.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): 3, 5, 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Assessments undertaken prior to admission allow people who may come to live at the home and their relatives to be confident that their needs can be met. These assessments are now properly recorded. People who may come to live at the home and their relatives are encouraged to visit prior to admission. EVIDENCE: The manager writes in the Annual Quality Assurance Assessment that: “Prospective residents and their representatives are invited to visit the home prior to making a decision to stay. This would follow an assessment visit by the manager having been completed which satisfies each party that the prospective resident’s assessed needs can be fully met. We liaise with care managers for people who live at the home to be admitted through Care Management arrangements.” Abbeywood House DS0000018311.V342814.R01.S.doc Version 5.2 Page 10 Examination of the newly implemented Standex Care Planning System evidences that a Resident Pre-Assessment Form is completed when the manager visits the prospective resident in his / her home prior to admission. Nobody is admitted to the home unless either the qualified owner or his qualified manager has undertaken an assessment visit to the prospective resident prior to admission. Either the owner or manager satisfies himself or herself that the needs of the prospective resident can be met by the home. The home also receives assessment documentation from Social Services. The manager now uses a new and comprehensive documentation system to complete a more detailed assessment, to enable her to generate the client’s care plan, but only new people who have come to live at the home and a proportion of existing people who live at the home have benefited from this new system. Client assessment documentation for the majority still consists of a brief sheet with biographical details and a tick list of abilities and disabilities. People who may come to live at the home and their relatives are encouraged to visit before making a decision to move in on a trial basis. The home does not offer intermediate care. Abbeywood House DS0000018311.V342814.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 good. This judgement has been made using available evidence including a visit to this service. The health and care needs of people who live at the home are set out in their care plan, and properly met. They are treated respectfully. The home’s medication administration policies and procedures protect them. EVIDENCE: The manager writes in the Annual Quality Assurance Assessment that: “Residents’ health, personal and social care needs are set out in an individual care plan (after an initial assessment) to identify the level of support that each resident requires. We promote and maintain our resident’s care needs and ensure they have access to Health Care Services. Residents are protected by the home’s policies and procedures for dealing with medicines. Medication is administered by designated and appropriately trained staff. Controlled drugs – their receipt, storage and administration complies with the Misuse of Drugs Abbeywood House DS0000018311.V342814.R01.S.doc Version 5.2 Page 12 (Safe Custody) Reg. 1973. We ensure that residents are treated at all times with respect and dignity and their right to privacy is upheld.” Examination of the care files of four people who live at the home evidenced the improvement brought about by the newly implemented Care Planning System. Newly admitted people who live at the home now benefit from this new system. Some incumbent people who live at the home have also benefited. However, it remains an Hercluean task to convert the care planning documentation of all people who live at the home. The care plans of those with the new system are much more detailed, based upon much more detailed assessments. This improved documentation now allows care staff to be much clearer of the needs of those who live at the home and how best to meet those needs. This ensures that people who live at the home receive appropriate care. The documentation in respect of most people who live at the home, however, remains the old system. Their basic physical health and care needs are set out in their concise care plan, itself generated from the brief assessment documentation. The care plan consists of a short list of care tasks to be undertaken on a daily (or otherwise) basis by each resident’s keyworker, whose initials verify that each task has been undertaken. However, despite the paucity of written information within the old system, it is nevertheless clear from consultations with the owner, manager, staff, people who live at the home and relatives that their health, social and personal care needs are properly assessed, monitored and met. It was evident from observing the shift handover meeting that the care staff have a far greater understanding of the holistic needs of the people who live at the home, what is needed to meet those needs, and their action to ensure that such needs are met, than the old documentation gives them credit for. The home’s system of medication administration was completely overhauled in the light of pharmacist inspector’s visit two years ago. The new system of receipt, checking, storage, administration and recording of medication can now be commended. The senior on duty is the only person to hold the key to the hospital – style medication trolley. The MAR (Medication Administration Record) sheets examined were correctly signed. We observed that people who live at the home and staff treated each other with mutual respect. The dignity of people who live at the home is maintained by, for example, being presented well, and being addressed as each prefers. Abbeywood House DS0000018311.V342814.R01.S.doc Version 5.2 Page 13 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. Social activities are provided which gives interest for people who live at the home. They maintain contact with their friends and families and are encouraged to exercise as much choice and control over their lives as possible. EVIDENCE: The manager writes in the Annual Quality Assurance Assessment that: “ We strive to ensure the routines of daily living experienced are flexible and varied to residents’ expectations, preferences and capacities. Residents are encouraged to maintain contact with family / friends / representatives and the local community as they wish. Residents are helped and encouraged to exercise choice and control over their lives. Residents receive an appealing, wholesome, well balanced diet prepared by a knowledgeable experienced person, in pleasant surroundings, and at times convenient to them. Social, recreational and occupational activities are arrange to suit our residents’ capacities and preferences.” Abbeywood House DS0000018311.V342814.R01.S.doc Version 5.2 Page 14 We had discussions with the manager, staff and people who live at the home. These discussions evidence that social, recreational and occupational activities are arranged, some by the care staff themselves but mostly by external professional entertainers. Some of these were advertised on the notice board. An activities person visits the home several times a week, as on the day of inspection, when people who live at the home were enjoying arm chair aerobics. Those with relatives who lived locally enjoyed being visited and taken out by them, while some others said they would like to be taken out by staff more often than they were. Several relatives, friends and professionals visited over the time of the inspection. Many of these commented very positively about the home. People who live at the home are encouraged to do as much for themselves as possible, rather than becoming dependent on staff. Some assist, for example, with setting the tables for meals. Both the cook and manager have attended the Safer Food Better Business event, and partake in this safe and healthy food programme promoted by the local council. The cook and seniors have undertaken training in food hygiene. Meals are taken in the pleasant dining room. Some people who live at the home sometimes require discrete assistance, others are allowed to take their time to eat their meal. Abbeywood House DS0000018311.V342814.R01.S.doc Version 5.2 Page 15 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, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints and suggestions from people who live at the home, relatives or other visitors to the home, are treated seriously. People who live at the home are listened to and issues resolved promptly. EVIDENCE: The manager writes in the Annual Quality Assurance Assessment that: “We strive to ensure that our residents and their relatives and friends are confident that their complaints will be listened to and taken seriously and acted upon. We also strive to be aware that residents who may be unable to voice a complaint due to poor capacity may show this in a non-verbal communicating way. We welcome constructive comments and suggestions about how things might be improved as this may help to create cooperative relationships within our home and help prevent situations where complaints need to be made from developing. Our residents are protected from all forms of abuse and staff are aware of how to report any suspicions of abuse without fear of reprisal.” The home has a complaints procedure prominently displayed and a book for recording complaints, but this has not been used in about twenty years. This lack of documentation is in line with the owner’s philosophy that the important thing is to respond appropriately rather than to waste time writing about the Abbeywood House DS0000018311.V342814.R01.S.doc Version 5.2 Page 16 issue. Staff report any signs of dissatisfaction from people who live at the home in the daily report book. The home also has a comments / suggestion process in which people who live at the home and their advocates and outside agencies are invited to participate. The home has a policy on abuse and whistle blowing. The home has a copy of the Alerter’s Guide, which is the local guidance produced by Social Services, Health and Police as to how to respond to an allegation of adult abuse. The video “No Secrets” which is the Government’s guidance to local authorities in setting up their safeguarding procedures is used as part of staff training. The home has produced an “incident form” and a “behaviour form” that ensures physical and /or verbal aggression by people who live at the home is recorded. The manager and staff are aware that such behaviour may be the only form of communication open to some people who have dementia. They are aware that the person acting in this way may be trying to express pain or other distress or dissatisfaction that requires an appropriate response from staff. We talked to several people who live at the home. Those who were able to voice an opinion told us that any suggestions or complaints they may have are resolved satisfactorily without recourse to a formal complaints system. Abbeywood House DS0000018311.V342814.R01.S.doc Version 5.2 Page 17 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, 20, 21, 23, 24, 25, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live at the home benefit from a very pleasant, well-maintained home that is comfortable and warm and which provides sufficient facilities to meet their needs. The risk of burns from the previously unprotected radiators has now been eliminated. EVIDENCE: The manager writes in the Annual Quality Assurance Assessment that:” Abbeywood provides a safe, well-maintained environment that meets our resident’s’ individual and collective needs in a homely and comfortable way. Routine maintenance is implemented. The grounds are safe, attractive and accessible. We have complied with standard 25.5. CCTV cameras do not intrude on the daily life of our residents. The building complies with the local Abbeywood House DS0000018311.V342814.R01.S.doc Version 5.2 Page 18 fire service and Environmental Health Department. The home is clean, pleasant and hygienic and systems are in place to control the spread of infection in accordance with relevant legislation and published professional guidance.” Abbeywood is a large detached property close to all local facilities opposite a public park in the Babbacombe area of Torquay. The home benefits from a newish ten-bed extension which matches the existing property very well. The home has attractive grounds which includes a very pleasant patio area with a fountain. This garden is well used during the summer and has been made safe as the gate can only be opened by means of a keypad from inside the gate or remotely from inside the house. Visitors have to announce themselves from outside the gate by an intercom system. The home is well presented, comfortably furnished and clean. All but two of the people who live at the home’ bed-sitting rooms are single rooms and all but two of these have en-suite toilet facilities. Resident’s rooms reflected their personality, containing items of their own furniture as well as smaller personal items. The heating, lighting and ventilation are satisfactory. Until very recently, hot water radiators posed a risk of scalding to people who live at the home. These have now been made safe by the fitting of locking radiator valves which can be set so that a maximum temperature of 22oC is achieved. This will be sufficient for a warm ambient temperature but not so as to cause burns / scalds. Abbeywood House DS0000018311.V342814.R01.S.doc Version 5.2 Page 19 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. People who live at the home are cared for by competent staff in sufficient numbers to meet the needs of those currently living there. The home now has a robust recruitment system. Staff training, induction and supervision have improved since the last inspection though still needs improvement. EVIDENCE: The manager writes in the Annual Quality Assurance Assessment that: “Staffing levels are of sufficient numbers to meet the residents’ safety and needs. Abbeywood adheres to a proper recruitment policy. Staff are encouraged to undergo NVQ training and any other relevant training to equip them to meet the residents’ needs. New staff receive induction training. Staff are employed in accordance with the Code of Conduct and Practice set by the GSCC. Staff are competent, experienced and respectful to the diverse nature of our residents. Supervision meetings – formal and informal to ensure good communication and continuity of care. Dedicated, quality team of staff who continually strive to meet the resident’s personal, physical, social and emotional needs. Our housekeeping and catering staff are adequate.” Abbeywood House DS0000018311.V342814.R01.S.doc Version 5.2 Page 20 Consultations with the owner, manager, staff, people who live at the home and relatives evidence that the staffing levels are satisfactory to meet the needs of the people who live at the home. We observed and consulted staff in their care of people who live at the home. They appeared experienced in the provision of care to elderly people, were patient and treated the people who live at the home with respect. People who live at the home confirmed this observation: “the girls are so good”, “they will do anything for you” “they never get cross”. Observation of the shift handover meeting evidenced that the care staff have a more detailed knowledge of the people who live at the home and their conditions than the (old) documentation (which was quite sparse)would suggest. (Documentation in respect of people who have recently come to live in the home is far more detailed). Staff rotas show the capacity / skill mix in which the staff are employed. Examination of the personnel files of four staff evidences the improvement in the home’s recruitment policy and practice. This now involves application form, two written references, a Criminal Records Bureau check and a check against the POVA (Protection of Vulnerable Adults) list, which is a list of people considered unsuitable for care work. The home currently employs twenty (all female) care staff. Three of these have National Vocational Qualification Level 2 or above. A further eleven are working towards NVQ 2. The home therefore currently has only 15 qualified staff. However, when those currently working towards their qualification have finished, the home will have 70 qualified staff, exceeding the required 50 . Housekeeping and catering staff are dedicated to providing the highest standards to ensure that people live in a clean and hygienic environment and that their nutritional needs and preferences are met. These staff are also undertaking NVQ training in their field. An NVQ Assessor was visiting the home at the time of the inspection visit and kindly told us of his work to ensure the high standards of the home’s catering. The owner (himself City and Guilds qualified) and the registered manager (NVQ 4 and Registered Managers Award) are keen to develop staff supervision and appraisal, which was previously in an embryonic stage. Only a few members of staff have so far benefited from the new system of supervision and appraisal which the manager proposes to introduce to all twenty staff. Abbeywood House DS0000018311.V342814.R01.S.doc Version 5.2 Page 21 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, 37, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a home which is run in their best interests. The owner, manager and staff team together provide a comfortable home where the health, safety and welfare of people who live there are promoted and protected. EVIDENCE: The manager writes in the Annual Quality Assurance Assessment that: “The hands-on owner and registered manager are experienced and qualified and for the job they are doing. Policies , procedures and practices are now being reviewed and improved. The home does not act as Power of attorney, agent or appointee for any residents. The home will assist residents with their personal Abbeywood House DS0000018311.V342814.R01.S.doc Version 5.2 Page 22 spending money if requested to do so. All accidents and injuries are recoded and reported.” The qualified owner promoted an existing staff member to the position of registered manager about two years ago. Since then they have together been tackling in their order of priority the many tasks that are required to update the home. The first priority has been the ten-bed extension which has enhanced the facilities of the home. Since the last inspection the manager has been taking more and more responsibility for the administration of the home, and updating and improving documentation, policies and procedures. These include staff recruitment, induction, supervision and appraisal, and client assessment and care planning documentation. These have all improved, though staff supervision needs to take place as per the standard. It is again recommended that the owner and manager clarify and put in writing their respective roles and responsibilities to ensure effective and efficient management of the home. Abbeywood House DS0000018311.V342814.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 X 18 3 3 3 3 X 3 3 3 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 3 2 3 X X 2 2 3 Abbeywood House DS0000018311.V342814.R01.S.doc Version 5.2 Page 24 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 OP36 Regulation Reg 18 (2) Requirement The registered person shall ensure that persons working at the care home receive appropriate induction, supervision and appraisal. This requirement was made at the last inspection. Timescale for action 27/12/07 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 OP32 Good Practice Recommendations It is recommended that the owner and manager clarify and write down their respective roles and responsibilities to ensure effective and efficient management of the home. Abbeywood House DS0000018311.V342814.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Abbeywood House DS0000018311.V342814.R01.S.doc Version 5.2 Page 26 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!