Inspection on 01/11/07 for Abbotsbury

This inspection was carried out on 1st November 2007.

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

The inspector 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

Abbotsbury 17/05/07

Abbotsbury 22/02/07

Abbotsbury 02/05/06

Abbotsbury 09/11/05

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 06/02/2009.

CARE HOMES FOR OLDER PEOPLE Abbotsbury 25 Park Road Southport Merseyside PR9 9JL Lead Inspector Elaine Stoddart Key Unannounced Inspection 1st November 2007 09:30 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 Abbotsbury DS0000065441.V351546.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. Abbotsbury DS0000065441.V351546.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbotsbury Address 25 Park Road Southport Merseyside PR9 9JL 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) 01704 537117 0870 762 8881 Ramos Healthcare Limited vacant post Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Abbotsbury DS0000065441.V351546.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service must employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 17th May 2007 Date of last inspection Brief Description of the Service: Abbottsbury is a care home providing accommodation for up 21 older people who need personal care and support. Ramos Health Care own the home. The manager Carole Dacre is yet to be registered with the Commission. The home is situated in a quiet residential area not too far from the centre of Southport and its amenities. It is within easy reach of the local park and public transport. The home is a large detached 3-storey building with 19 single rooms and 1 double. All rooms now have single occupancy There is a large well-kept garden to the rear and side of the property and parking at the front. The home is well maintained internally and externally with good quality furniture and fittings. There is a passenger lift servicing all floors. Equipment is available to assist those residents with a disability. A call bell system is available throughout. The current rate of charges is £365.00 per week. Abbotsbury DS0000065441.V351546.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A site visit took place as part of the unannounced inspection. It was conducted over one day for a duration of approximately nine hours. Nineteen residents were accommodated at this time. A partial tour of the premises took place and a number of care, staff and health and safety records were viewed. Discussion took place with nine residents, three staff, the manager Carole Dacre, a representative of Ramos Health Care, Audrey Tan and a visiting relative. During the inspection three residents were case tracked (their care files were examined and their views of the service were obtained). This process was not carried out to the detriment of other residents who also took part in the inspection process. All the key standards were inspected and also previous requirements and recommendations from the last inspection in May 2007 were discussed. Satisfaction survey forms “Have Your Say About …” were distributed to all of the residents, relatives, staff and health care professionals prior to the site visit. Only three surveys were received back to the commission. Comments from the surveys received and those people spoken with on the day are included in this report. An AQAA (annual quality assurance assessment) was completed by the manager prior to the site visit. The AQAA comprises of two self-questionnaires that focus on the outcomes for people. The self-assessment provides information as to how the manager and staff are meeting the needs of the current residents and a data set that gives basic facts and figures about the service, including staff numbers and training. What the service does well: The home provides clean and comfortable accommodation. There was a pleasant atmosphere and residents, visiting relatives and staff were observed to interact well. Since the last visit five new residents have been admitted and Abbotsbury DS0000065441.V351546.R01.S.doc Version 5.2 Page 6 confirmed that they were provided with information on the service provided, had an opportunity to visit prior to their admission and were supported by the staff to settle in. Residents spoken with confirmed that they enjoyed the meals provided and are very satisfied with their rooms. Positive comments were obtained from residents and a relative spoken with regarding the caring, pleasant and courteous staff. Positive comments were also received on the ‘open’ and approachable manner of the manager. Comments received from residents and a relative spoken with include: “I have settled in very well. The staff are lovely and the food is very good”. Resident. “I am very happy here and have settled in very well. I came to look around before moving in”. Resident. “Very comfortable here. I am very pleased. The staff are very caring and courteous and I have settled in nicely. I came with my daughter to have a look around before I moved in”. Resident. “I am very happy with my Mothers care. I call each week and the staff are all very good to her”. Relative. What has improved since the last inspection? Since the last visit the manager has made progress to meet the requirements. Five new residents have been admitted and this has improved the financial viability of the service. All vacant rooms have been refurbished prior to new residents being admitted and one room has an en suite facility. New dining room furniture has been purchased. Double rooms now have single occupancy. Abbotsbury DS0000065441.V351546.R01.S.doc Version 5.2 Page 7 What they could do better: Viewing of assessments and care plans for three new residents showed admission details had been obtained and care plans were in the process of being developed. The manager should complete more detailed assessments and these should be used to form the basis of the plan of care for the residents to demonstrate that the service can meet their needs. The care plan should provide information for the staff on the tasks to undertake to meet the residents’ needs. The manager must ensure that individual residents risk assessments are completed during the admission process to ensure the personal safety of the residents. The manager must ensure that moving and handling risk assessments are recorded to safeguard staff and residents. Selfmedication risk assessments must be obtained for those residents who wish to self medicate and photo identification of the resident put on file. It is strongly recommended that the manager be provided with more management time to enable her to keep records, the staff training programme, staff meetings and supervision up to date. This was discussed with both the manager, Carole Dacre and Audrey Tan during the visit. It is strongly recommended that the staffing levels be reviewed at core times, such as lunchtime, to ensure that sufficient cover is provided to meet the residents needs. All residents should be provided with the choice of having a key to their room for privacy and records made to show this. It is strongly recommended that the manager consult with the fire authority regarding safe access to the property and protection of the residents and staff. The manager must ensure that the training programme is brought up to date for all staff employed to ensure they have the skills to carry out their roles in a safe manner. National Vocational Qualifications training for staff should continue so that 50 of the care staff obtain an NVQ qualification in care. A full induction programme should be provided to all staff to enable them to meet the needs of the residents. The manager should complete her application for registered manager. Emergency lighting (monthly) and fire alarm checks (weekly) must be completed and records made. This is to ensure the safety of the residents accommodated. The service should provide an extension to the ramped access at the front entrance to include the two steps. Risk assessments must be recorded for those residents who use wheelchairs via the front entrance. Abbotsbury DS0000065441.V351546.R01.S.doc Version 5.2 Page 8 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. Abbotsbury DS0000065441.V351546.R01.S.doc Version 5.2 Page 9 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 Abbotsbury DS0000065441.V351546.R01.S.doc Version 5.2 Page 10 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): Standards 1,2,3,5,6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are provided with information on the service and have the opportunity to visit the home. Contracts are in place for residents. Some assessments failed to be completed in sufficient detail to demonstrate the needs of the residents. Standard 6 is not provided. EVIDENCE: Since the last visit five new residents have moved in to the home. Nineteen residents are now accommodated. This has improved the financial position of the service as vacancies have now been filled. The statement of purpose and service user guide has recently been updated and is available for residents and prospective residents and is displayed in the entrance hall. A copy of the most recent inspection report is also available for visitors and residents to view. The Abbotsbury DS0000065441.V351546.R01.S.doc Version 5.2 Page 11 four new residents were spoken with and confirmed they had visited prior to admission, settled in well and are very happy with the care and support provided. The new residents were observed to be relaxed and comfortable in their surroundings and chatted with other residents and staff. Comments include: “I have settled in very well. The staff are lovely and the food is very good”. “I am very happy here and have settled in very well. I came to look around before moving in”. “Very comfortable here. I am very pleased. The staff are very caring and courteous and I have settled in nicely. I came with my daughter to have a look around before I moved in”. Assessment details were viewed for three new residents and some were found to contain detailed information on the following - communication needs, health care, mobility, religion, medication and personal care. Assessments were viewed from other professionals (Care manager) whose local authority is funding the placement. Some assessments are still in the process of being completed as the residents have recently moved in. It was recommended to the manager during the visit that these be brought up to date and records put in place to demonstrate the care needs. Residents who have lived at the home for some time are provided with contracts of terms and conditions and are signed by the resident/or their relative. The new residents have yet to receive a contract as they are still within their assessment period. Standard 6 was not assessed, as the service does not provide intermediate care. Abbotsbury DS0000065441.V351546.R01.S.doc Version 5.2 Page 12 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): Standards 7,8,9,10,11. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some care plans failed to be in place to identify residents care needs. The lack of risk assessments put residents at risk. Residents’ rights to privacy are upheld. Medication is administered safely and staff are trained. EVIDENCE: Three care plans for new residents were viewed and failed to demonstrate the individual care needs of each resident and record the action to be taken by care staff to ensure all aspects of the residents needs are met. The manager confirmed that these are in the process of being brought up to date. Care plans were in place for residents who have been accommodated for some time. Staff spoken with confirmed they are aware of the residents needs, as Abbotsbury DS0000065441.V351546.R01.S.doc Version 5.2 Page 13 information has been provided during handovers and by daily records. Care plans need to be reviewed monthly or before if there is a need. All health care visits are recorded and residents spoken with confirmed they have regular contact with an optician and GP were needed. Residents spoken with confirmed their health care needs are being met. A resident’s emergency file has been developed to ensure that should they be admitted to hospital the correct information goes with them, such as medication and care needs. All personal care given is recorded and weights are completed monthly. Comments include: “I attend the chiropodist, optician and dentist regularly”. Up to date medication records were found. The manager undertakes monthly audits to ensure the staff are following the correct procedures. However, records showed the last audit was completed in August 2007. The manager confirmed due to shortage of management time over the last two months she hasn’t had time to keep records up to date. A strong recommendation has been made to provide more management time to enable records to be kept up to date. Risk assessment for self-administration must be recorded for residents who wish to self medicate to ensure that residents are supported to do this safely. Photo identification should be available for all residents on their medication records. These were discussed with the manager at the time of the visit. Sample signatures for staff who administer are in place and only those staff who are trained administer. Training records showed seven care staff have received medication training in February 2007. Staff confirmed they are not allowed to administer meds without the training. The manager records all receipts and returns of medication. Medication policies and procedures are in place for safe handling of medication. Residents spoken with said they are treated with dignity and respect at all times and staff were observed to knock on rooms prior to entering. Staff were seen to interact positively with the residents and a pleasant atmosphere was present throughout the day. Abbotsbury DS0000065441.V351546.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): Standards 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. The daily life and routine in the home is flexible to suit individual needs. Residents have an appealing balanced diet are able to maintain contact with family and friends. EVIDENCE: An activity programme is in place and includes quizzes, word search and gentle exercise. An activities organiser attends Tuesday and Thursdays. A quiz was taking place during the site visit. A number of residents attended and were seen to enjoy the session. When time allows the staff work with residents individually doing jigsaws and sit and chat. A BBQ was held in the summer and visits are made by the ‘Land girls’ to entertain the residents. Daily reports record the activities the residents have taken part in. Some residents do not wish to attend and their wishes are respected. Comments include: “I don’t like to take part in the activities and that is my choice”. Abbotsbury DS0000065441.V351546.R01.S.doc Version 5.2 Page 15 Meals are provided at set times, however residents spoken with and observation made during the visit confirmed that residents have the choice to have their meals in the dining area or within the privacy of their own rooms. The main meal of the day is served at lunchtime and consisted of a threecourse meal of soup, lamb stew, fresh vegetables and rice pudding. There is a menu board to record the daily menu. The site visit covered both lunchtime and the tea time periods and residents were observed to be offered alternatives meals if they wished. Discussion with the cook confirmed that special diets are catered for and stocks evidenced food was in plentiful supply. Discussion took place with the manager regarding the staffing levels during core times, such as meal times. It was observed during the main meal that although three care staff were on the duty only one care staff was available to assist residents into the dining area and residents who required support with feeding. This should be conducted in a discreet and sensitive manner. The manager was assisting a resident who required support in her own room and the other carer was off site. It is recommended that a review of staffing levels during meal time periods is made to ensure mealtimes are unhurried and residents are supported at all times. Sufficient staff were on duty during the tea time session. Residents spoken with confirmed their satisfaction with the meals and alternatives provided and said they have a choice of where they wish to eat their meals. Comments from residents include: “I complimented the cook on the lunch today it was lovely.” “The food is very nice. I like to eat my meals in my own room and they allow me to do this. You get too much”. “The meal today was exceptional. There is always a choice and alternatives”. Throughout the day the residents were observed to be relaxed and comfortable in their environment. Several residents sat in the two lounges and chatted, watched TV or took part in the activities. Those residents who wished to stay in their own rooms were able to do so and staff responded to call bell assistance if needed. Some residents have keys to their rooms and records should show that this choice has been given to them. One resident has recently had a key fitted to his room and was very pleased. Residents spoken with commented on the daily routines: “I visit my friends’ daily and my family visit me and are very pleased”. Abbotsbury DS0000065441.V351546.R01.S.doc Version 5.2 Page 16 “I have visitors call to see me often. I can get up and go to bed when I want to. I would like a key to my room and Audrey (owner) said she would sort it out”. (This was discussed with the manager during the visit). Some residents are able to go out independently and were observed to do this. Some residents received visitors in the home or were taken out by their families for lunch. Visitors were observed to be made welcome and sat in the lounge area, chatting to staff and residents. A relative interviewed said: “I am very happy with my mother’s care. I call each week and the staff are all very good to her”. The manager keeps a record of pocket money allowances and the residents’ sign if they are able to. Receipts are kept for all transactions made. Families/or friends manage some residents’ monies and they have their own separate accounts. Residents spoken with commented: “My friend deals with my finances but I always sign for my pocket monies”. Abbotsbury DS0000065441.V351546.R01.S.doc Version 5.2 Page 17 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): Standards 16,18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are aware of how to make a complaint. An abuse policy and procedure is in place to protect the residents. EVIDENCE: Over the last twelve months three complaints have been received and the service has dealt with them through their complaints procedures. Information on how to complain is made available to both residents and visitors. Leaflets are displayed in the entrance hall and available in the statement of purpose. Policies and procedures are in place and available to staff for reference. Both residents and a visitor spoken with confirmed they know how to complain and provided the following comments: “If I wasn’t happy with anything I would be able to talk to the staff they are very approachable”. Relative. “I asked for a bigger room and Carole sorted it for me” Resident. The whistle blowing policy is available to staff. The staff spoken with demonstrated their awareness of the ‘Safeguarding Adults’ procedures and Abbotsbury DS0000065441.V351546.R01.S.doc Version 5.2 Page 18 expressed they would not hesitate to alert any concerns. Records showed five staff had received Abuse training and it is recommended that this continue for all the staff employed. The service has had an experience of dealing with ‘Safeguarding Adults’ referral since the last visit and this was dealt with using the policies and procedures in place and notification to the required authorities was made. Abbotsbury DS0000065441.V351546.R01.S.doc Version 5.2 Page 19 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): Standards 19,20,21,22,23,24,25,26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents live in a safe, well maintained, clean and hygienic environment. EVIDENCE: The service provides communal areas consisting of two lounges and one dining room. All private rooms are now of single occupancy and contain residents own personal possessions. A full tour of the premises was made. Rooms were found to be attractively furnished and clean. Residents spoken with provided positive comments on the accommodation. As stated in above section (Standards 12 to 15) records should show that residents have been given a choice to have a lock fitted to their rooms if they wish. Comments include: Abbotsbury DS0000065441.V351546.R01.S.doc Version 5.2 Page 20 “Very comfortable here. I am very pleased”. “My room is lovely. It is too good to be true”. Sufficient bathrooms and toilets are provided and adaptations are in place for those residents with disabilities. Since the last visit the following improvements have been made – an en suite has been fitted in one room. Rooms decorated prior to new admissions. New furniture has been purchased for the dining room. The maintenance programme includes ongoing refurbishment and replacement of communal carpets. The maintenance person has left since the last inspection and the owner aims to appoint a new maintenance person as soon as possible. The front access to the home is accessible by a ramp, with the exception of two steps at the doorway. This was discussed with the owner who is planning to add a conservatory at the side of the home and improve the ramp access. Risk assessments should be provided for those residents who access the exterior via wheelchairs. These will identify risks and provide a safe access. The last Occupational Therapist report was made on the premises on 12/11/04 and recommendations made. The front entrance is locked at all times and staff keys are made available for access. The rear door has a coded keypad. The owner explained that these have been put in place to ensure the safety of the residents. Concerns were raised with the manager and owner regarding access should a fire occur and it was strongly recommended that they consult with the fire department on this. A fire risk assessment was completed in February 2007. There is parking for visitors at the front entrance and a garden for residents use at the side of the home. It is recommended that paper towels systems are put in pace in communal areas and the laundry to prevent cross infection. Abbotsbury DS0000065441.V351546.R01.S.doc Version 5.2 Page 21 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): Standards 27,28,29,30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service must ensure that all staff receive the training required to carry out their roles safely. The service should aim to meet 50 of the staff qualified in NVQ. EVIDENCE: Since the last inspection the service has improved its recruitment and selection procedures. One new staff file viewed showed that a protection of vulnerable adults (POVA) first check had been completed and two written references are in place. The induction process needs to be improved in line with ‘Skills for care’. This was confirmed by the manager, in the AQAA received, as in need of improving. The manager confirmed that induction training is to take place with all staff. Staff training records showed that some training has been provided, however there are many courses that need updating. Statutory training is yet to be to provided for the new staff employed and this includes manual handling, food hygiene and health and safety. Lack of up to date training for staff can put residents at risk. Staff and the manager spoken with confirmed that the training was incomplete. A requirement has been made to ensure the training is brought up to date to equip the staff with the skills to carry out their roles. Abbotsbury DS0000065441.V351546.R01.S.doc Version 5.2 Page 22 Staff who administer medication have been trained to do this safely. Discussion with the manager and training plan showed manual handling training is booked for February 2008 and health and safety is booked for March 2008.The manager confirmed that training courses have been arranged and staff either failed to attend or couldn’t attend due to work commitments. Staff recently attended a course on managing challenging behaviour August 2007. The manager is qualified in national vocational qualification (NVQ) Level 4. Seven staff are enrolled on NVQ Level 2/3 courses and the deputy manager is taking NVQ Level 4. The NVQ assessor was present during the morning of the visit and confirmed the enrolment of the staff on the courses. Three care staff (including the manager) plus the cook was on duty during the visit. The staff duty rota confirmed those on duty. Discussion took place with the manager and owner regarding sufficient levels of staff to be on duty during core times i.e. lunch. This is to enable residents to have their meals in an unhurried atmosphere and those who require assistance with feeding are supported individually in a discreet manner. Two waking night staff cover the evening period. The staff were observed to be polite and courteous at all times with the residents. Residents and a relative spoken with provided positive comments on the care and support provided. These include: “The staff are very good”. “The staff are very caring and courteous”. “I am happy with all the care staff”. “The staff are very friendly and helpful”. (Residents). “I am very happy with my Mothers care. I call each week and the staff are all very good to her” (Relative) Abbotsbury DS0000065441.V351546.R01.S.doc Version 5.2 Page 23 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): Standards 31,32,33,35,38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Inadequate management time has affected the overall management of the service and the lack of sufficient training for staff and up to date record keeping puts residents at risk. EVIDENCE: The manager is qualified in NVQ Level 4 and has many years experience of working with elderly people. The manager is in the process of completing her application to CSCI to become registered manager. The manager provides an open and inclusive atmosphere. Since the last visit Carole, the manager has been included in the care staff rota of three staff per shift and this has resulted in a reduction in her management time, affected management of the service and maintaining up to date records. This has also had an impact on her staff management as no staff supervision or staff meetings have taken place since Abbotsbury DS0000065441.V351546.R01.S.doc Version 5.2 Page 24 the last inspection. Staff training must be brought up to date to ensure the staff can meet the needs of the residents safely. Training records viewed and staff and management spoken with confirmed this. Carole has developed a training programme, which identifies training needs and ‘gaps’ in training. This is noted within the staffing section of this report and a requirement made. These issues were discussed with both the manager and the owner who agreed that more management time should be allowed. Since the last inspection manager has made improvements to meet the requirements of the last inspection. All policies and procedures have now been reviewed and are available for staff to view. Quality assurance surveys have been conducted and the results are displayed in the entrance for visitors and residents to view. A summary showed 91.57 of residents are satisfied with the service provided. Since the last visit five new residents have been admitted. Discussion with the owner confirmed that this has improved the financial viability of the service. Residents spoken with provided positive comments on the management of the service. These include: “Carol the manager is lovely”. “I think a lot about Carol the manager you can really talk to her”. All certificates for services, such as gas and electricity, are up to date. Health and safety audits are conducted every three months on the environment. Emergency lighting and fire alarm records viewed showed the last record was completed on 10/7/07. These should be completed weekly for safety and emergency lighting monthly. This was brought to the attention of the manager during the visit who agreed to ensure these are completed at the correct periods. Fire training for staff has taken place and recorded in March 2007. All accidents and injuries are recorded. Risk assessments are in place for safe working practices and are available for staff to view. Resident’s handle their own finances were possible and records are kept of all transactions made for personal allowances. Finances for three residents were viewed and showed that a balance of accounts is made. Abbotsbury DS0000065441.V351546.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 3 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 3 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 3 3 3 3 3 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X 3 2 X 2 Abbotsbury DS0000065441.V351546.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 OP27 Regulation 18 Requirement The responsible person shall ensure that the statutory training programme for all care staff is brought up to date to ensure that residents are needs are met safely. The responsible person shall ensure that risk assessments are provided to provide a safe system of moving and handling and ensure the personal safety to the residents accommodated. The responsible person shall ensure that a risk assessment is in place for those residents who wish to administer their own medication. Timescale for action 28/02/08 2 OP8 13 30/11/07 3 OP9 13 30/11/07 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 OP3 Good Practice Recommendations The manager should provide more detailed assessments of DS0000065441.V351546.R01.S.doc Version 5.2 Page 27 Abbotsbury 2 OP7 3 4 5 6 7 8 9 10 11 OP27 OP27 OP28 OP36 OP26 OP33 OP31 OP30 OP33 need for the new residents accommodated. The manager should provide detailed care plans for the new residents accommodated, which outline care needs and action to be taken by the care staff to meet those needs. The manager should provide additional staff on duty at peak times, such as lunchtime, to meet the individual needs of the residents. The manager should provide a full induction programme for all care staff in line with ‘skills for care’. The staff programme of NVQ training should continue to achieve 50 of staff with a qualification in care. The manager should provide regular staff supervision and staff meetings. Paper towels should be provided in communal areas to avoid cross infection. The manager should arrange resident/relative meetings to keep them involved with the changes and developments. The manager should make an application to CSCI to be appointed as the registered manager. Abuse training should be provided to all care staff. The provider should conduct regulation 26 visits and complete a report on the quality of the service and a record of this report made accessible for the inspector to view. A photo identification of each resident should be available on medication records. The manager is strongly recommended to consult with the fire department regarding safe access to both the front and rear entrances in the event of a fire. Records of emergency lighting and fire alarm tests should be recorded in line with the guidance from the fire authority. (Discussed with the manager during the inspection and agreed). All residents should be provided with the choice of having a key to their room and records made to show this. It is strongly recommended that risk assessments be conducted for those residents who use a wheelchair to access the front entrance. DS0000065441.V351546.R01.S.doc Version 5.2 Page 28 12 13 14 OP9 OP38 OP38 15 16 OP10 OP22 Abbotsbury Abbotsbury DS0000065441.V351546.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Merseyside Area Office 2nd Floor South Wing Burlington House Crosby Road North Liverpool L22 0LG 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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