Inspection on 16/08/05 for Abbotsford

This inspection was carried out on 16th August 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Abbotsford 15/08/07

Abbotsford 04/09/06

Abbotsford 06/02/06

Abbotsford 07/02/05

Abbotsford 18/10/04

Abbotsford 22/03/04

Abbotsford 01/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Abbotsford 7 Bracken Road Southbourne Bournemouth Dorset BH6 3TB Lead Inspector Stephanie Omosevwerha Unannounced 16 August 2005 16:30 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 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Abbotsford D55 S4002 Abbotsford V245246 160805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Abbotsford Address 7 Bracken Road Southbourne Bournemouth Dorset BH6 3TB 01202 417847 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) The Stable Family Home Trust Mr Mark Wells CRH PC - Care Home Only 8 Category(ies) of LD Learning disability (8) registration, with number of places Abbotsford D55 S4002 Abbotsford V245246 160805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection 7 February 2005 Brief Description of the Service: The registered service provider is The Stable Family Home Trust [S.F.H.T] a registered charity that provides residential care, a day service and related services for adults with learning disabilities. The day and residential services are interdependent with support from specialist staff at the day service being available to the staff and service users in residential care services to provide training, guidance and help with among other things, issues such as employment; risk assessments and personal relationships. The home is located in the residential area of Southbourne, within walking distance of the local amenities and cliff top. Local amenities include shops, a post office and places of worship. Public transport is readily available and Bournemouth town centre a ten-minute bus ride away. The accommodation provides for up to eight people in a detached house converted for use as a residential care home. Bedrooms are located on the ground, first and second floors of the premises. The home is centrally heated and all users have single rooms, en suite facilities and the use of a lounge and dining room. There is a small garden area to the side of the property and a garden and patio area to the rear. Abbotsford D55 S4002 Abbotsford V245246 160805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced inspection of the home and took place during the evening between 16.30 and 19.30. It was carried out as part of the planned inspection programme for care homes undertaken by CSCI and to address the requirements and recommendations made at the previous inspection. The manager was available for the first hour of the inspection and the inspector had the opportunity to look at some records and documentation e.g. staff files and medication records. The rest of the inspection was spent talking to the service users both on an individual and collective basis. The inspector was also able to speak to 2 members of care staff. All communal areas of the home were viewed and 6 residents were happy to show the inspector their bedrooms. The inspection took into account previous information sent to the inspector by the responsible individual including copies of a draft statement of purpose, service user guide and contracts and policies and procedures including the complaints procedure. The inspector receives regular monthly reports from the responsible individual about this service that are available to provide additional information for the inspection. What the service does well: Abbotsford has a relaxed atmosphere in which service users rights and choices are respected. There are excellent opportunities to develop independent living skills and service users felt their goals and aspirations were being listened to and their plans reflected any changes e.g. one service user was working towards moving onto more independent living and had been provided with a kitchen area in his room and his own shopping budget. Services users comments referred to this e.g. “my life has grown bigger”. They also said “its good at Abbotsford” and “I love it here”. Service users benefit from a competent staff team who work in a person centred way focusing on service users needs. Staff morale is good resulting in an enthusiastic workforce that committed to improving service users quality of life. Abbotsford offers comfortable, spacious accommodation and service users have an obvious pride in the rooms, which they were happy to show to the inspector. All rooms have ensuite facilities offering them maximum personal privacy. The home is ideally situated in the local community and service users regularly visit the local shops and amenities. Abbotsford D55 S4002 Abbotsford V245246 160805 Stage 4.doc Version 1.40 Page 6 Visitors are welcomed into the home and personal relationships are supported which greatly enhances service users social lives and family ties. Service users said they had plenty of opportunities to pursue leisure activities and hobbies and an excellent range of holiday choices is provided by the organisation. What has improved since the last inspection? What they could do better: The finishing touches need to be put into place now so that the information, which has been produced in draft format, can be sent out to its intended audience e.g. statement of purpose, service user guide and service user contracts. There are still some outstanding policies and procedures, however, it is appreciated that these are being prioritised and produced as quickly as possible. The home needs to produce an annual development plan to measure its success in achieving its aims and objectives as set out in the statement of purpose. There are still some staffing records that are not available in the home. An agreement now needs to be set up with CSCI concerning access to these as specified in the revised CRB guidance. The home is still not fully staffed during the day between the hours of 9.00 am to 5.00pm (Mondays to Fridays) and whilst this is clearly specified in service users’ contracts it does restrict service Abbotsford D55 S4002 Abbotsford V245246 160805 Stage 4.doc Version 1.40 Page 7 users choice and access to the home during these periods. The organisation may wish to review their staffing levels/fee structure in the future to facilitate working in a person centred way promoting peoples’ choices of what they do during the day. 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. Abbotsford D55 S4002 Abbotsford V245246 160805 Stage 4.doc Version 1.40 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Abbotsford D55 S4002 Abbotsford V245246 160805 Stage 4.doc Version 1.40 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 and 5. Much better information about the organisation and the range of services offered has now been produced in draft format. Once these have been implemented service users and their representatives will have a comprehensive guide enabling them to make an informed decision about admission to the home. Residents living in the home have been encouraged to make a significant contribution to the guide meaning this is based on service users actual experiences of the home. New contracts have now been devised and these need to be distributed to service users so they are fully aware of the terms of residency. EVIDENCE: The inspector saw a copy of the draft Statement of Purpose, draft Service User Guide and draft Contract, which was sent to the inspector prior to the inspection by the Responsible Individual. The Statement of Purpose was comprehensive and included all the information required by regulation. The Statement of Purpose has been designed corporately so all the information is consistent between all the care homes owned by SFHT. This now needs to be fully personalised to include the details specific to each home e.g. number of rooms, ensuite facilities and staffing details and qualifications. Once this has been implemented the standard will have been fully met. Abbotsford D55 S4002 Abbotsford V245246 160805 Stage 4.doc Version 1.40 Page 10 The manager confirmed that a management meeting is held every fortnight, which facilitates consistency enabling things to be produced on a corporate level e.g. induction of new staff and risk assessments. The Service User Guide was written in simple language providing a useful guide about living in the home. When it is finished it will also contain pictures enhancing its accessibility. Service Users told the inspector they had been consulted about the service users guide and had come up with ideas. Some of the quotes they wished to appear included “wonderful living here”, “more independence”, “my life has grown bigger” and “it’s good at Abbotsford”. Once work on this has been completed it is anticipated that the Service User guide will exceed the minimum standards required by regulation. A contract has been set up that specifies the terms and conditions of residency in straightforward language. It clearly sets out both parties’ responsibilities. It is recommended that the contract includes details of the fees charged and who they are payable by, particularly the amount the service user contributes to their fees. This now needs to be implemented and signed by service users with support if appropriate to fully meet the standard. Abbotsford D55 S4002 Abbotsford V245246 160805 Stage 4.doc Version 1.40 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 and 8. Staff recognised and supported service users rights to make decisions giving residents choice and control in their daily lives. Service users have opportunities to participate in the life of the home and the organisation enabling them to make significant contributions to service developments. EVIDENCE: Discussion with residents indicated they felt they had more opportunities to increase their independence and this included many examples of how they were able to make decisions about their lives, e.g. “I can do what I want in the evening”, “I can make a drink at night and take it up to bed with me” and “I have my own shopping budget, I make a shopping list and go shopping”. Observation during the evening confirmed service users were encouraged to make decisions such as making their own evening meal (with support if appropriate), choosing when to eat and where to eat and deciding what to do during the evening. Staff spoken with also saw it as part of their role to encourage service users to make their own decisions and said, “We are here mainly to support what they want to do”. Information about advocacy was available in the home and various services and helplines were displayed on noticeboards around the home. One service Abbotsford D55 S4002 Abbotsford V245246 160805 Stage 4.doc Version 1.40 Page 12 user told the inspector he was a member of a local self advocacy group and enjoyed being involved with it. Service users have been given opportunities to become more involved in the life of the home. A regular residents’ meeting is held in the home and the inspector observed that the minutes of these were clearly displayed so all residents could view them and contribute to the next meetings agenda. The registered manager told the inspector there was now much more emphasis on working in a person centred way in the organisation and this had resulted in service users being able to make significant contributions to service development. For instance they had been involved in the setting up of the new service user guide, they had been involved in interviewing prospective new members of staff and they had also been involved in the redecorating of the lounge and confirmed they had chosen the colours. Abbotsford D55 S4002 Abbotsford V245246 160805 Stage 4.doc Version 1.40 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15 and 17. The home has adopted a more person centred approach to provision of daytime activities offering service users more choice about what they do during the day. Links with the local community are good and service users are able to pursue their individual interests and hobbies including an extended range of annual holidays they can choose from. The home makes visitors feel welcome and offers service users excellent support with their personal relationships enabling them to develop healthy social lives and maintain strong family ties. The home offers maximum choice and flexibility over meal times promoting service user’s individuality and independence. EVIDENCE: The SFHT has it’s own integrated day service that most service users attend. Since the last inspection there was evidence that there was more flexibility about what service users wanted to do during the day. The manager told the Abbotsford D55 S4002 Abbotsford V245246 160805 Stage 4.doc Version 1.40 Page 14 inspector that 2 residents now received extra funding for additional support so they could pursue their activities of choice e.g. gardening and horse riding. One service user had stayed home for the past few days from the day service whilst his room had been re-decorated and had been able to help with the redecoration. Another service user told the inspector about his work experience which he clearly enjoyed. Service users also told the inspector they were able to access the local community including shops, banks, pubs, cinema and leisure centres. The home has good access to public transport and one service users said he was currently being supported to catch the train to his work placement. Service users were happy with the range of leisure pursuits available. A member of staff said residents were able to discuss ideas for outings at resident’s meetings for example several service users had expressed an interest in attending a local steam fair. Service users told the inspector that they often take trips to the local shopping centre and walk to the local beaches. They were hoping to hold a garage sale to raise money to convert the home’s garage. Service users were able to pursue individual interests inside the home and these included watching TV, listening to music, playing on the computer, playing the keyboard and reading. Observation throughout the evening showed service users were able to use the communal areas of the home freely or enjoy some privacy in their bedrooms. Service users are offered a choice of holidays by the organisation and are able to go with service users from the other care homes to extend the choice and flexibility e.g. one resident was looking forward to a holiday in Florida and was joining a party of three other service users from other homes within the organisation. Staff confirmed visitors were welcomed into the home. One service user said her boyfriend was going to visit her on the evening of the inspection. Family contact was promoted and service users were able to regular contact their families and visit them. A member of staff said she also supported one service user to have contact with their family who lived further away by supporting them on the journey. The inspection took place in the evening and all service users were supported to prepare their evening meal. Most service users have a cooked lunch during the day at the day service so make snacks during the evening, however, cooked meals are also available. Observation during the inspection showed the evening meals were chosen individually to each residents taste and included pie and chips, omelette, salad, soup and ravioli on toast. Residents could also choose to eat in their rooms, the lounge or the dining room. One resident had had a small kitchen area put in his room including a work surface, toaster, bread bin and mini fridge. He also had a kettle and was able to make Abbotsford D55 S4002 Abbotsford V245246 160805 Stage 4.doc Version 1.40 Page 15 his own drinks and snacks and part of a plan to work towards more independent living. He told the inspector he now had his own shopping budget and was able to buy his weekly food himself. Service users could also make their own drinks when they wanted and fresh fruit was observed to be available in a bowl in the dining room. Abbotsford D55 S4002 Abbotsford V245246 160805 Stage 4.doc Version 1.40 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 20. The systems for managing medication are satisfactory and staff are familiar with the procedures for administration ensuring service users medication needs are met. EVIDENCE: The home has a written policy and procedure concerned with the management and administration of medication. Records were checked and currently only half of the residents are taking prescribed medication. Details were available of all current medication and the numbers of tablets received from the pharmacist are now recorded to facilitate monitoring of medication in the home. The member of staff on duty gives out medication once they have been signed off as competent to administer medication, any new staff are supervised. Staff then sign to say they have witnessed the service user taking the medication and records were checked and found to be up-to-date and accurate. One service user was managing some of their own medication and this was based on a recorded risk assessment. Members of staff confirmed they had undertaken training in the management of medication and were fully aware of the procedures for administration in the home. Abbotsford D55 S4002 Abbotsford V245246 160805 Stage 4.doc Version 1.40 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22. There is an ethos of openness throughout the organisation and service users were confident about how to raise complaints feeling their views would be listened to and acted upon. EVIDENCE: The responsible individual sent the fully up-dated complaints policy and procedure to the inspector prior to the inspection. The policy is clear offering comprehensive guidance to staff about dealing with minor complaints and more serious ones. There is a clear line of accountability throughout the organisation and information is given about other agencies that can be approached including CSCI. An accessible format has been developed for service users called “Making things better”. This includes a simple written format and symbols to explain the procedure and a form that the service user can complete with appropriate support if necessary e.g. an advocate. Service users confirmed they were fully aware of the procedure and how to use it. The also were confident that any issues/problems raised would be resolved by the organisation, although they did know they could talk to other agencies such as social services and CSCI if necessary. It was noticeable that the organisation encourages an ethos of openness and “welcome complaints as they can bring something wrong with the service to our attention and enable us to improve what we do”. The home has a separate complaints procedure for anyone other than service users. Abbotsford D55 S4002 Abbotsford V245246 160805 Stage 4.doc Version 1.40 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24. Recent investment has improved the appearance of the home, which provides service users with a comfortable and homely environment. EVIDENCE: The inspector completed a tour of all communal areas of the home including the lounge, dining room, kitchen and laundry home. A total of 6 residents’ bedrooms were also viewed. Since the last inspection the lounge had been redecorated and a new TV purchased. The damp in the kitchen had been made good and redecorated. One resident showed the inspector his bedroom that had been redecorated and new furniture purchased, another resident showed the inspector a new kitchen area that had been fitted into his bedroom to help him increase his independent living skills. This included a work surface, toaster, bread bin, mini fridge and kettle. Residents said they liked their rooms and were happy to show them off to the inspector. All bedrooms were seen to be individual personalised with plenty of space for the occupants’ personal possessions. Residents told the inspector they had been involved in choosing the colours and redecorating the lounge. Abbotsford D55 S4002 Abbotsford V245246 160805 Stage 4.doc Version 1.40 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33 and 34. Staff are clear about their roles and work in a person centred way promoting service users choices in the home. There are sufficient staff on duty, although the current residential fee does not include support during the daytime (Mondays-Fridays). Some flexibility has been introduced, however, to promote service users choice in being able to stay home during the day. The home operates a recruitment procedure that encourages service users full participation. An agreement needs to be set up with CSCI about future access to personnel records to ensure appropriate vetting of staff is carried out. EVIDENCE: The manager told the inspector the home now employs 5 members of care staff. A sample of one member of staff’s file was observed and this provided evidence of past experience, qualifications and training included the home’s own induction training that had been carried out, supervision notes and an appraisal/probationary form after the person had satisfactorily completed this period. There are still records held at the organisations HR department that are not always available in the home e.g. CRB checks and references. An agreement now needs to be set up with the organisation about future availability of records as specified in the revised CRB guidance. Abbotsford D55 S4002 Abbotsford V245246 160805 Stage 4.doc Version 1.40 Page 20 Service users told the inspector they had been involved on the interview panel for prospective new members of staff and had been able to help devise questions to ask them. There is still an outstanding recommendation for an updated policy and procedure to be produced on the recruitment of staff. Discussion with staff during the inspection evidenced they had been given job descriptions and they were aware of their roles in the home. They said that they had regular meetings and discussed current issues such as working in a person centred way to promote service users choice and support their goals and aspirations. Examples observed during the inspection including supporting service users to make their own evening meals and allowing service users to make their own choices about evening activities. There were 2 staff working throughout the evening. The current rota shows that there is one staff on duty from 7.00 am – 9.00 am and two staff from 5.00 pm – 10.00 pm and one member of staff sleeping in. At the weekend there are 2 staff working from 7.00 am until 10.00 pm. The current contract specifies that residential fees do not cover support during the daytime from Mondays-Fridays, however, the manager said there is now more flexibility to promote service users choice, e.g. one service user had stayed home the last few days whilst his room was being decorated. The SFHT may wish to review their staffing levels/fee structures, however, to facilitate service users spending time in the home during the day. Service users confirmed that staff were approachable and described them as “alright” and “nice”. Observation of practice indicated a high level of interaction between staff and service users and it was clear positive relationships had been formed. Abbotsford D55 S4002 Abbotsford V245246 160805 Stage 4.doc Version 1.40 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39. The Director of the SFHT has a clear development plan and vision for the organisation, which has promoted a better sense of corporate identity enabling the service to evolve and develop based on the views of service users. An individual plan now needs to be set up for the home to measure it’s success in achieving the aims and objectives as set out in the statement of purpose. EVIDENCE: There has been some progress in setting up a quality monitoring programme in the home. Questionnaires have been designed for service users on a variety of issues concerning the home e.g. food and drink, staffing. Discussion with service users evidenced that their views were regularly sought and they had been involved in a variety of ways in service development such as the development of a service user guide, staff recruitment and redecoration of the home. The organisation has made a commitment to working in a person centred way focusing on individual’s wants, needs and aspirations and there was evidence Abbotsford D55 S4002 Abbotsford V245246 160805 Stage 4.doc Version 1.40 Page 22 that this had brought about changes e.g. a more flexible approach to day care and supporting service users to gain more daily living skills to enable them to move onto more independent living. The organisation is also reviewing its policies and procedures to provide consistency and promote a corporate identity in line with current legislation and best practice guidelines. The Responsible Individual now undertakes regular monthly visits and CSCI is provided with copies of the reports. There is now a business plan in place for the organisation, however, an annual plan now needs to be developed for the home in order that the success in achieving the aims and objectives set out in the Statement of Purpose can be measured. Abbotsford D55 S4002 Abbotsford V245246 160805 Stage 4.doc Version 1.40 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 x x x 2 Standard No 22 23 ENVIRONMENT Score 4 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x 3 4 x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x x Standard No 11 12 13 14 15 16 17 x 3 3 4 3 x 4 Standard No 31 32 33 34 35 36 Score 3 x 3 2 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Abbotsford Score x x 3 x Standard No 37 38 39 40 41 42 43 Score x x 2 x x x x D55 S4002 Abbotsford V245246 160805 Stage 4.doc Version 1.40 Page 24 Yes Are there any outstanding requirements from the last inspection? 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 1 Regulation 4 Requirement A draft corporate Statement of Purpose has now been produced. This needs to be personalised to include specific details related to Abbotsford. A draft Service User Guide has now been produced. The homes details and pictures now need to be included to produce a final version that can be given out to service users. The SFHT must set up an agreement with CSCI regarding future access to personnel records as specified in the revised CRB guidance. The registered provider must develop an annual plan for the home in order that the success in achieving the aims and objectives set out in the Statement of Purpose can be measured. Timescale for action 1 December 2005 2. 1 5 1 December 2005 3. 34 19 1 December 2005 4. 39 24 1 June 2006 Abbotsford D55 S4002 Abbotsford V245246 160805 Stage 4.doc Version 1.40 Page 25 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 5 Good Practice Recommendations It is recommended that the draft contract includes details of service users contributions to their fees and that the contract is distributed to service users so they are clear about the terms and conditions of their residency. It is recommended that the registered provider review staffing levels/fee structure to facilitate more service users spending time in the home during the day whether this is necessary because of illness or through personal choice. It is recommended that the registered provider should produce a written policy and procedure concerned with the recruitment of staff. It is recommended that the registered provider should produce written policies and procedures for all the topics set out in Appendix 2 to the National Minimum Standards (2nd Edition). This standard was not assessed on this occasion but carried forward from the previous inspection. 2. 33 3. 4. 34 40 Abbotsford D55 S4002 Abbotsford V245246 160805 Stage 4.doc Version 1.40 Page 26 Commission for Social Care Inspection Unit 4 New Fiels Business Park Stinsford Road Poole Dorset BH17 0NF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Abbotsford D55 S4002 Abbotsford V245246 160805 Stage 4.doc Version 1.40 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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