Inspection on 06/03/08 for Abbi Lodge

This inspection was carried out on 6th March 2008.

CSCI found this care home to be providing an Excellent service.

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

Abbi Lodge 16/10/06

Abbi Lodge 10/01/06

Abbi Lodge 10/11/04

Abbi Lodge 14/04/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Abbi Lodge 13 Clifton Road Weston Super Mare North Somerset BS23 1BJ Lead Inspector Patricia Hellier Unannounced Inspection 6th March 2008 08:30 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 Abbi Lodge DS0000008144.V359626.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. Abbi Lodge DS0000008144.V359626.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbi Lodge Address 13 Clifton Road Weston Super Mare North Somerset BS23 1BJ 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) 01934 642251 Mrs Lorraine Mutch Mrs Lorraine Mutch Care Home 7 Category(ies) of Old age, not falling within any other category registration, with number (7) of places Abbi Lodge DS0000008144.V359626.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. May accommodate older persons (category OP) who require personal care only. May accommodate up to 7 persons of either sex. Date of last inspection 16th October 2006 Brief Description of the Service: Abbi Lodge is a small residential care home registered for seven older persons. The accommodation in this home is on two floors with a stair lift for easy access to the first floor. All rooms have vanity units and are well decorated to residents tastes. It is on a quiet residential road not far from the sea front with local shops and amenities within reasonable walking distance. The building is an older property and its decoration and furnishings give it a strong sense of the house being a family home. Dedicated sitting areas at the front, and a well kept garden at the back, of the property allow for good weather activities outside. Garden furniture is provided. Provision is made within the home for a variety of activities and outings, which also enable close links with the local community to be maintained. The provider makes information available through a brochure about the home. CSCI reports are available to read on request. The fees are £365.65 per week with additional charges being made for hairdressing, chiropody, and newspapers. This information was provided in March 2008. Abbi Lodge DS0000008144.V359626.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 star. This means the people who use this service experience excellent quality outcomes. This key inspection took place over 5.5 hours on one day. The manager/provider was not present, however the deputy manager was very efficient and helpful. Since the last key inspection a Random inspection was undertaken in July 2007 to ensure that requirements made had been met. These had been met and one requirement was made in regard of recruitment practices to ensure the safety of residents. Before the inspection the information about the home was received from the file held in the office, surveys received from 7 people who use the service; 7 relatives and 5 staff. The last two inspection reports were reviewed together with the completed Annual Quality Assurance Assessment (AQAA) form, from the provider. We (The Commission) also reviewed all correspondence and regulatory activity since the last inspection. The accumulated evidence for this report comes from the above and also fieldwork that included discussions with 6 residents, and 3 staff; observation of practices, and review of documents relating to care, recruitment and health and safety. All 7 of the resident surveys sent were returned. This is a high return rate and reflected the residents’ contentment with the home, and the positive outcomes they experience. All were satisfied with the care they received and said the home is clean and fresh. All but one said there were activities they could take part in. The overall comment from all residents was summed up in this comment “Abbi Lodge answers to one word excellence in every way”. Other comments from residents were “the staff are friendly and kind”, “I am very happy here”; “they are all wonderful”. All 7 of the relative surveys sent were returned, and all felt that their relatives were well cared for by competent staff. Comments from relatives were “the staff provide professional and friendly care and I have every confidence in them”; “care is provided in a respectful person centred and family orientated way”. All relatives felt they were kept up to date with important issues. All said they did not feel the home could improve in any way, with 2 saying “it does a smashing job in a very professional way”. Abbi Lodge DS0000008144.V359626.R01.S.doc Version 5.2 Page 6 All residents and staff spoken with told us that the home was lovely and the staff very kind. Comments received were “it is very homely and comfortable”; “it’s a good staff team and they provide care that takes account of residents wishes and preferences”. What the service does well: What has improved since the last inspection? All outstanding requirements from the last inspection have been met. Since the last inspection the management of medicines has been reviewed and a new system implemented for the safety of residents. Recruitment practices have been amended to ensure that all required safeguards are undertaken prior to the employment of new staff fro the safety of residents. At the random inspection it was seen that the quality assurance system has now been formalised with the analysis of the results, and a report giving feedback to residents had been displayed and shared at the recent residents/relatives meeting. A copy had also been supplied to the Commission. The home have now accessed advice on fire safety and fitted electrically operated fire door releases, which are activated when the fire alarm is sounded. These have replaced the door wedges for the safety of residents. A qualified electrician has inspected the electrical wiring of the home and a certificate of safety has been issued, to evidence safety of the system for residents. Abbi Lodge DS0000008144.V359626.R01.S.doc Version 5.2 Page 7 Since the last inspection, the home have reviewed the management of risks both environmental and personal, with clear risk assessments having been undertaken and actions identified to minimise risks, for residents’ safety. 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. Abbi Lodge DS0000008144.V359626.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 Abbi Lodge DS0000008144.V359626.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): 1,2,3,4,5 (6 N/A) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information about the home is comprehensive and provided in a variety of formats to ensure prospective residents and their families can make an informed choice. Visits to the home to support this choice process, are encouraged. The home’s assessment process is thorough and person centred to ensure the home can meet the needs of prospective residents’ needs. EVIDENCE: Prospective residents and their relatives are provided with an information booklet about the home. This contains the Statement of Purpose, Service User Guide and brochure about the home and a copy of the last inspection report. The Statement of Purpose and Service User Guide need updating to include current information. Not all required information is contained within these documents. These documents can be made available in large print. Abbi Lodge DS0000008144.V359626.R01.S.doc Version 5.2 Page 10 The most recent resident to move into the home, and their relatives, told us they felt they had received plenty of information on which to make their choice. One person who is relatively new to the home said, “ I really enjoyed coming for lunch, and the day, before coming to stay. It helped me settle in”. Contracts, or Terms and Conditions documents, for the three residents case tracked were inspected and they all clearly stated the fees to be paid; showing a breakdown of what is to be paid to make up the weekly rate and by whom, thus providing clarity for residents and their relatives. There is nothing in the contractual agreement regarding fees in the case of death. When talking to these three residents only one was aware they had a contractual agreement two were not. One said “I leave that side of things to my son” .In feedback from the surveys all respondents stated they were aware they had received a contract. Care needs are well met through a full assessment process as evidenced in the three care plans inspected. The assessment information is clearly documented in all aspects of physical, mental, social and emotional needs providing staff with a good knowledge base from which to provide person centred care. A plan of care to meet the new residents’ needs is developed from the assessment information. The assessment includes all the elements listed in the standard. Not all assessment records had been completed with the same attention to detail. In one assessment and care plan there was no evidence of resident or involvement although they told us it had been discussed with them. Staff completing the forms had not signed them for accountability purposes. This is recommended. The assessments seen contained the key details for person centred care, however the outcome of the assessment is not clearly documented to state whether the home can meet the assessed needs. Residents spoken with told us “ staff are very kind and know what I need”. Staff when interviewed were able to provide us with full and clear information about the needs, personality and preferences of the individuals. Care practices observed showed that staff were fully aware of the residents needs as stated in their assessments. The home does not provide Intermediate Care. Abbi Lodge DS0000008144.V359626.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 excellent. This judgement has been made using available evidence including a visit to this service. Residents benefit from care plans that are well formulated and give clear information to enable staff to meet residents’ health and social care needs. Risks to residents are fully assessed and actions to minimise these planned, for the safeguarding of residents. Respect and dignity are well maintained by kind and caring staff. EVIDENCE: Individual records are kept for each of the residents, which include a social history. Three care plans were inspected and all reflected clearly current identified health and social care needs. All of these records showed clear evidence of Interprofessional working with other Health Care Professionals to provide full, holistic, care to residents. Visits by the dentist, chiropodist and optician were recorded in all of the care plans. All care plans contained an ‘Emergency medical information sheet’, which contained key personal, health and social care information for supply to Abbi Lodge DS0000008144.V359626.R01.S.doc Version 5.2 Page 12 other key professionals involved in the care of the resident, e.g. on admission to hospital. One care plan had excellent records of how a resident’s deteriorating health situation and psychological response had been handled. These good practices are to be commended. Evidence was seen that social and psychological needs are well met. Residents were observed through the morning undertaking activities of their choice, facilitated by the staff. Observation of interactions showed staff were aware of the resident’s current health and psychological condition, and used appropriate interventions for their well being. Clear actions to meet identified needs were recorded and regular evaluation noted. Documentary evidence of relative and resident involvement was not present in two of the three care plans, however residents and relatives told us they are involved in the discussions regarding their care needs. Not all records had been signed and dated by the person completing them for accountability purposes. This attention to detail in record keeping is recommend for the protection of residents. . All care plans contained personal risk assessments, with the outcomes being used to inform the provision of care. Other environmental risk assessments were present as necessary, to ensure the safety of the resident while promoting independence as able. Daily records were up to date and written in a respectful manner. Detailed conversations with six of the residents confirmed an excellent standard of care. Comments made were – “the home is excellent, no improvements needed”, “staff are always kind and approachable – nothing is too much bother”; “I’m very happy here”; “you can have a laugh with the staff they are very good”. All relatives who responded to the surveys said they were “completely satisfied with the care provision of the home”. Care practices observed showed caring interactions and good communication skills from staff. Choices and preferences were observed being discussed and offered. One resident said ‘they always do things the way I like’. The management of medicines is satisfactory and the home has a policy for the receipt, recording and storage of medication. The staff were clearly able to describe the process and policy, thus demonstrating that the policy is adhered to for the protection of residents from the mishandling of medications. Good practice was observed, in the dispensing and disposal of medication, during the morning period. Medication Record Sheets (MAR) showed no gaps thus providing accurate records in the best interests of residents. The medications cupboard was locked and temperatures recorded had been within the recommended limits providing safe storage of medicines. Abbi Lodge DS0000008144.V359626.R01.S.doc Version 5.2 Page 13 All residents spoken with felt that kind and caring staff respected their dignity and privacy. One resident stating “they always knock on the door”; and another said, “they are always polite and ask what I would like”. Staff were observed encouraging and supporting residents to be as independent as able, while supporting their needs. The home has an Equality and Diversity policy, and an Equal Opportunities policy, which recognises the cultural and social needs and differences that are present in society. In the AQAA returned the manager told us “our policy is reviewed on a regular basis to promote this”. Both management and staff demonstrated clear knowledge and desire to meet cultural and diversity needs as and when they should arise. Residents spoken with, and staff interviewed, spoke of the homely atmosphere and family orientated approach to the management of the home. Abbi Lodge DS0000008144.V359626.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Social activities and meals are both well managed, creative and provide daily variation and interest for people living in the home. Residents’ right to choice and control over their lives is well respected, and encouraged, helping residents to maintain independence. Friendly staff always welcomes relatives and visitors. EVIDENCE: Residents are encouraged to undertake daily activities they enjoy, both inside and out of the home. For those wishing to access community activities transport is provided. In the AQAA we are told “a disabled parking badge has been obtained and a disabled parking space outside the home has enabled better transport facilities, for residents to access the local community”. Most of the residents are happy with their own ‘in house’ activity and keep themselves alert by watching the news and quiz shows. They take part in the daily running of the home as they wish. Residents and relatives meetings are held regularly. Minutes of these meetings were seen, showing their involvement and actions taken in response to suggestions. Residents spoke of their involvement in choosing the new décor for the lounge. Abbi Lodge DS0000008144.V359626.R01.S.doc Version 5.2 Page 15 All residents enjoy meeting in the lounge and said they have “many stimulating and enjoyable conversations”. One resident enjoys gardening and was seen taking an active part in keeping the garden looking nice. In the AQAA we are told that “new garden furniture has been obtained, and increased bulbs and plants have enhanced the garden”. Two residents told us “the garden is lovely to sit in, in the summer”. Spiritual needs are catered for and local religious leaders visit regularly, and as requested. Residents told us they can see their visitors at any time. Relatives were seen popping in during the course of the inspection and being welcomed by staff. One relative said, “I feel quite happy coming here and the staff are very good to me”. Choice and preference is well respected. There was evidence of a good rapport between residents and staff, with lots of laughter and encouragement. Care records contained clear information about their likes and dislikes and residents’ preferred daily routine. The kitchen is clean, tidy and well organised demonstrating good standards of hygiene for the safety of residents. The dining room is homely and tables well presented ensuring residents can eat in a convivial atmosphere. All residents said they liked the meals and felt that they provided a good balanced diet. The lunch served during the inspection looked appetising and well presented. All residents spoken with about the food said ‘it is good’. Many said they “ like the meals, and the choices offered”. Feedback from the relative’s surveys and six residents spoken with said, “the food is nice and we have what we like”. Since the last inspection the home have received a visit from Environmental Health (Food) who were satisfied with the standard of provision. Abbi Lodge DS0000008144.V359626.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are confident that they are listened to and their requests acted upon. Knowledgeable and competent staff protect residents. EVIDENCE: The home has a comprehensive complaints procedure and all residents receive a copy on admission. The policy needs updating to include the current CSCI details for resident and relatives information. All relatives and residents spoken with were aware of the complaints policy. All residents stated that if they were not happy about anything they would speak to the manager or a member of staff. Staff and residents spoken to, say the manager is very approachable and understanding and they would feel able to “air any grumbles to her”. One service user said ‘I’ve nothing to complain about, it’s a lovely home”. Another resident said, “ the manager is always available if things aren’t quite right”. Residents also spoke of Residents’ / Relatives Meetings where a variety of issues relating to the home are discussed. Minutes of these were seen indicating that all residents have their say. A system for keeping clear records of complaints received with actions taken and outcomes is available should any complaints be received. Abbi Lodge DS0000008144.V359626.R01.S.doc Version 5.2 Page 17 In the AQAA we are told, “there have been no complaints in the last 12 months” and “written records are kept up to date”. The home has a copy of the North Somerset ‘No Secrets’ Guide and a comprehensive policy and procedure for responding to allegations of abuse to safeguard residents. . The home also has a Whislteblowing policy and staff said they would report any concerns to the manager. Staff said they had never seen any signs of abuse in the home and demonstrated a good understanding of what abuse is. Staff have received training in the recognition and handling of abusive situations for the protection of residents. All residents spoken with said ‘the staff are very kind’; ‘they take time to help me’; ‘I can’t fault them’. Abbi Lodge DS0000008144.V359626.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 21,22,23,24,25,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with homely, safe and comfortable surroundings. Outdoor space is attractive and accessible for residents to enjoy. The home has suitable equipment to meet residents’ needs and maximise their independence. Robust Infection Control practices are followed protecting residents from the potential of cross infection. EVIDENCE: The property is well maintained, with homely and comfortable communal spaces. The living accommodation is well decorated, with décor, fixtures and fittings being in excellent order, thus providing residents with a pleasant home. Residents’ rooms are personalised and comfortable to suit individual’s needs and choices. All rooms are provided with vanity units for residents’ privacy and convenience. Abbi Lodge DS0000008144.V359626.R01.S.doc Version 5.2 Page 19 Maintenance and refurbishment plans and records are kept, to ensure the homes’ environment is maintained at a high standard. The provider ensures that all breakdowns in equipment and the general safety of the building are dealt with promptly, to ensure the safety of residents. In the AQAA we are told, “all equipment is serviced on a regular basis and written records kept to show service history” for the safety of residents. We are also told that a number of improvements have been made to the home to ensure comfort and safety for residents. The home has grab rails situated at relevant points and a stair lift that is easily used to assist resident mobility, and aid independence within the home. All resident rooms are provided with a lockable space for securing personal possessions, if desired, and door locks that are accessible to staff in an emergency. There are sufficient bathrooms and lavatories suitably situated to ensure availability and privacy for residents. The home was clean and free from offensive odours throughout, on the day of inspection. The laundry facilities were well organised providing residents with a satisfactory service. Staff interviewed and observed demonstrated good understanding of Infection Control procedures and practices and maintained a clean and hygienic environment. Training records inspected did not show evidence of staff having received infection control training in the last 12 months, which may potentially puts residents at risk of cross infection, from staff who do not have good knowledge or practice in this area. Staff interviewed said they had received training and had good knowledge of infection control practices. There have been no outbreaks of infection in the home in the last year. The home has good facilities for ensuring that staff can maintain good hand washing practices, between caring for residents to prevent the spread of infection. Abbi Lodge DS0000008144.V359626.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s staffing levels are sufficient to manage the care needs of residents. The procedures for the recruitment of staff are robust and provide the safeguards required for residents’ protection. Staff may not have the necessary training and competence to meet resident’s needs. EVIDENCE: Staff went about their duties in an unhurried manner and were observed spending time talking with residents. Residents reported, “staff make time for a chat when they can.” Staff approached residents with directness, openness and consideration. Each of the resident’s with whom the inspector spoke said, “the staff are very good”. One member of staff was observed helping a resident with memory loss to find her way, and to feel comfortable and settled with the company she wanted. The member of staff gently engaged the resident in conversation and helped her to re-orientate herself and understand where she was. Copies of two weeks staffing rosters were seen and these showed there to be satisfactory numbers of staff on duty to meet residents needs. Comments from residents were, “staff are there when you need them, day or night”. Staff when interviewed said that they “are kept busy, but still have time to chat with the residents”. Staff and residents feel that the current staffing arrangements Abbi Lodge DS0000008144.V359626.R01.S.doc Version 5.2 Page 21 are satisfactory to meet residents’ needs. In the AQAA we are told, “ staffing levels are sufficient to meet residents needs”. Recruitment procedures are robust and both files inspected contained the required documentation ensuring that all the necessary safeguards had been completed prior to employment at the home. Newly appointed staff confirmed they had completed an induction programme and evidence of this was seen for all staff in their personnel files. This ensures that all staff are provided with the necessary skills and knowledge, for their level of employment in the home, to safely meet residents needs. The home tells us they provide training in the key required areas of practice for the safety and protection of residents. However it was not possible to evidence this in staff files and few records of training provided are kept. Staff when interviewed said they had “received some training in the last year”, but were unsure they had attended all the key required areas in the last 12 months. Key required areas of training, and evidence of this, are required to ensure that staff have the necessary skills and knowledge to meet residents needs. Abbi Lodge DS0000008144.V359626.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The manager provides clear leadership and guidance to staff to ensure residents receive consistent care in a safe environment, where Health and safety issues are monitored Quality assurance processes in the home are formal demonstrating that the home consults with residents, families and visiting professionals. Residents’ monies are handled safely. EVIDENCE: The manager / provider gives clear leadership, guidance and direction to staff. Residents feel she is approachable, available, and seeks to ensure all their needs are met. Two residents said, “she can’t do enough”; “she is always helping”. Staff interviewed stated that they felt “well supported by an approachable manager”. In the AQAA we are told “the home is a small friendly Abbi Lodge DS0000008144.V359626.R01.S.doc Version 5.2 Page 23 home run in the best interests of the residents. Residents are at the forefront of our philosophy.” A formal quality assurance tool was available for inspection in order to demonstrate that the home consults with residents, and that comments from them are acted upon. Residents and relatives told us they can “always have their say, and the manager listens”. Residents said they are always encouraged to express their views and “to air any grumbles”. One resident said, “the manager is very proactive and helpful in many ways”. The results of the last quality assurance review were seen and demonstrated that all residents and relatives felt they were listened to, and the home run in their best interests. Feedback from surveys we sent out supported this report. With residents and staff telling us “Abbi Lodge is excellent in every way”. Residents’ pocket monies held by the home were inspected and found to be accurate and to have clear records with two signatures for any transactions. Thus providing good safeguards for resident’s monies. Supervision for staff is provided both formally, and informally at hand over times and other times, when the staff discuss resident’s care needs and how best to meet them. Records seen showed evidence that care practices for residents and training needs were discussed. Staff interviewed said, “supervision does take place regularly and when needed”. Records in two personnel files inspected showed that issues relating to resident care, personal and professional development had been discussed and actions planned to address issues raised. Records inspected indicated regular safety and fire checks are carried out. The home has a fire risk assessment, and was aware on the day of inspection that two doors above the stairwell did not fit flush to frame for residents’ protection. They told us they were expecting the maintenance man to call that day. All staff spoken to told us they had received “regular fire instruction, and drills” had taken place. Records of staff attendance at fire training did not support the staff’s comment that regular training had been provided. The manager told us the records were not accurate, as discussed in the previous section of this report about training. Accurate records must be kept to demonstrate staff have been given the knowledge and skills to safely deal with any fire emergencies in the home. A number of staff have received First Aid training to ensure all emergencies can be dealt with safely. Records indicating regular maintenance to gas and water systems were seen, together with servicing records for all equipment, demonstrating the safety of all systems for the protection of residents. In the AQAA we are told Abbi Lodge DS0000008144.V359626.R01.S.doc Version 5.2 Page 24 “thermostatic valves have been fitted to all hot water outlets in bathrooms”. On the day of inspection, the hot water outlet in the downstairs bathroom recorded the temperature at 48°C, but there was a sign stating hot water, beware. It is recommend that these outlets are monitored regularly and records kept to evidence safe practice for the benefit of residents. Abbi Lodge DS0000008144.V359626.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 4 4 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 4 3 3 4 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 3 X 3 3 X 3 Abbi Lodge DS0000008144.V359626.R01.S.doc Version 5.2 Page 26 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. 1. Standard OP1 Regulation 4.1 (c) Requirement The registered person to ensure that the all the elements listed in Schedule 1 are contained in the Statement of Purpose to ensure residents have comprehensive information The registered person to ensure that staff receive training necessary to the job, and can evidence it. Timescale for action 30/04/08 2. OP30 18.1(c) (i) 31/05/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP7 OP16 OP38 Good Practice Recommendations To ensure that all records are signed and dated by the person making the entry for accountability purposes. To amend the Complaints policy to include the current CSCI details, for resident and relative information. To make regular checks on the temperature of hot water from outlets that are thermostatically controlled, to ensure risks are minimised. Abbi Lodge DS0000008144.V359626.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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