Inspection on 17/10/06 for Abbotts Barton

This inspection was carried out on 17th October 2006.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Abbotts Barton 04/10/07

Abbotts Barton 04/04/07

Abbotts Barton 20/09/05

Abbotts Barton 21/06/05

Abbotts Barton 07/12/04

Abbotts Barton 18/02/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

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Seabourne House

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Dovedale Court

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

CARE HOME ADULTS 18-65 Abbotts Barton 3 Abbey Gardens Chertsey Surrey KT16 8RQ Lead Inspector Mavis Clahar Key Unannounced Inspection 17th October 2006 10:00 Abbotts Barton DS0000013482.V316101.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Abbotts Barton DS0000013482.V316101.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Abbotts Barton DS0000013482.V316101.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbotts Barton Address 3 Abbey Gardens Chertsey Surrey KT16 8RQ 01932 569455 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) Welmede Housing Association Ltd Mrs Kathleen Murphy Care Home 6 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (1) of places Abbotts Barton DS0000013482.V316101.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th September 2005 Brief Description of the Service: Abbey Gardens is a detached house, providing accommodation and care to six people with learning disabilities. The home has six single bedrooms, five on the first floor, and one on the ground floor with en-suite facilities. Welmede Housing Association manages the home and has a contractual arrangement with the North Surrey Primary Care Trust to provide staff. The home is situated in a quiet residential road in Chertsey, a short distance from the town centre, which has a range of shops, a supermarket, church and several pubs/restaurants. The home has its own transport. Abbotts Barton DS0000013482.V316101.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit, which forms part of the home’s first key inspection to be undertaken by the Commission for Social Care Inspection was undertaken by Mrs Mavis Clahar on the 17th October 2006 and lasted for six and one half hours; commencing at 08:45 and concluding at 15:20 hours. On arrival at the home the inspector was made aware of the registered manager’s absence; she was away on annual leave. The service users and all members of staff on duty made the inspector welcome. The first part of the visit was spent explaining the new inspection processes to the deputy manager. A brief time was spent speaking to the service users who were on their way out to attend their booked daily activities and to the staff accompanying them. During this discussion one service user who was not leaving the home on the day of inspection invited the inspector to “come and see my garden”, this visit lengthened into a tour of the gardens and the home as another service user invited the inspector to look at his antiques he bought in the town and kept in his bedroom. The garden is laid out in an attractive style, which suits the service users. One service user told the inspector he enjoyed gardening and he and his key worker whom he identified as the deputy manager had cleared a spot in the garden, which he called his own. In this patch the service user had constructed an arbour, which contained two chairs, planted some flowering plants and the established shrubs made this quite a secluded spot. The inspector praised the service user for his obvious hard work and thanked him for his thoughtfulness in sharing his project with her. The deputy manager informed the inspector that the service user uses the arbour as a place to relax and to have some quiet time. The garden is safe with one gate, which is kept locked A tour of the home was undertaken and this revealed that although the home was clean and tidy it appeared tired. The home would benefit from a complete redecoration programme, starting with the bathroom, which is in need of urgent redecoration; followed by the bedrooms. It was obvious that the current service users who are all male did not choose the décor in the bedrooms as some of the bedrooms are decorated with pink flowery wallpaper. It was observed that service users were able to personalise their bedrooms, which were odour free, with family photographs and their own personal belongings. It was also noted that service users clothing was neatly folded and stored The third part of the visit was sampling service users records, sampling policies and records and speaking with service users and care workers. It was found that service users records were up to date and in good order. However, many policies and records were missing or non-existed. A number of requirements Abbotts Barton DS0000013482.V316101.R01.S.doc Version 5.2 Page 6 were issued on this visit. Please refer to the body of the report and to the statutory requirements page for more information. On the day of the visit there were no visitors to the home. The inspector would like to thank all the service users, relatives and visiting professionals who completed the questionnaire; service users and care workers who spent time speaking with the inspector, and for providing liquid refreshment on the day. What the service does well: What has improved since the last inspection? What they could do better: The registered manager must ensure that statutory requirements are actioned within the agreed time scale. Abbotts Barton DS0000013482.V316101.R01.S.doc Version 5.2 Page 7 Ensure the home’s complaints policy is available to relatives and visitors to the home Ensure care workers are trained to do the job they are asked to do including Abuse training Management of records needed for inspection by Commission for Social Care Inspection are to be kept and made available. 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. Abbotts Barton DS0000013482.V316101.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Abbotts Barton DS0000013482.V316101.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is (adequate). This judgement has been made using available evidence including a visit to this service. There is no new admission to the home for a long time. However, current service users documentation indicated that service users needs were assessed prior to moving into the home. EVIDENCE: Service users have been with the company for a long period of time. There has been no recent admission to the home. Random selection of service users files indicated assessment of needs was carried out prior to the service user being admitted into the home. In discussion with Service users they told the inspector that they liked living at this new home. The deputy manager said no new admission has been added to the home and that the home is now full. However, he was knowledgeable about the requirements for admission to the home even though there were no policies on admission and or referral available for inspection. A requirement was issued on this standard. Abbotts Barton DS0000013482.V316101.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6 7 9. Quality in this outcome area is (good). This judgement has been made using available evidence including a visit to this service. Service users assessed needs are and personal goals are recorded in their care plans. It was not possible to obtain sufficient information from the service users to make a judgement that they know about this documentation. Service users are consulted on, and participate in all aspects of life in the home. Information about service users is kept in confidence and their personal records are stored securely. EVIDENCE: The deputy manager said service users are aware of their care plans contents, as they are fully (as much as is possible) involved in the development of the care plans. Service users were not really able to discuss their care plans. However, documented evidence showed that they were present and were involved in the discussions regarding the contents of their care plans. Abbotts Barton DS0000013482.V316101.R01.S.doc Version 5.2 Page 11 Random sampling of care plans contained information on personal goals, lifestyles, choices, health needs and personal activities. One service user informed the inspector that they are consulted on menu planning; this service user planned today’s lunch menu, and every day another service user will choose the lunch. He further said that they have a choice in deciding on daily activities such as bowling, therapeutic sessions at the day centre, and that they are enabled to choose their own clothing with the help of their key worker. Taking risks is part of the service users daily lives. The inspector reviewed various risk assessments in place for the service users. Service users spoken to said they were involved in all aspects of life in the home. One service user told the inspector he is able to walk into town where he visits the antique shops. He said he really loves going into these shops and sometimes he will buy something. He was very pleased to show his bedroom, which contained some of his special purchases to the inspector It was observed that service users personal records were kept in a locked cupboard. The deputy manager informed the inspector that both himself and the manager have access to the keys. Abbotts Barton DS0000013482.V316101.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 15 16 17. Quality in this outcome area is (good). This judgement has been made using available evidence including a visit to this service. Service user are encouraged and enabled to become involved in meaningful daytime activities of their own choice and according to their individual interests and capability. They have been fully involved in the planning of their lifestyle and quality of life. They can access and enjoy the opportunities available in their local community such as local leisure facilities, the local pubs and parks. The service is committed to the principles of inclusion and promotes, and fosters good relationships with neighbours and other members of the community. Where possible service users are involved in the domestic routines of the home, they take responsibility for their own room, menu planning, and participates in cooking meals, making sure they are able to enjoy the food they prefer and like. The menu is varied and sometimes includes unfamiliar foods that encourage service s users to try something different and new. EVIDENCE: Abbotts Barton DS0000013482.V316101.R01.S.doc Version 5.2 Page 13 All service users have been away on summer holidays this year. Some service users attend the day centre for therapeutic sessions to include reflexology, reading and writing, art work, fishing leaflet dropping in the local community; and pottery; whilst others go bowling in Woking. Service users are involved in trampoline, days out to interesting places, rambling, visiting the pubs and cinemas and having meals out. Service users participate in house shopping and one said they do not go shopping often enough. The deputy manager said this statement could be true, but service users visit the local café and they access their finances at the bank. The town centre is within walking distance and they are encouraged to walk to the shops for their personal cigarettes and tobacco. One service user told the inspector he loves walking to the antique shops in the town centre where he spends a lot of his money. Service users are encouraged to maintain their friendships outside of the home. They attend Welmede open day and all service users were issued with a certificate to mark their good work in participating in the move from their old home. Contact with families is encouraged and if families are unable to visit then arrangements are made for the service user to visit their families. Service users are encouraged to remember families and friends special days. One of the service users is capable and he always exercises his right to vote at elections. It was observed that care workers always knock on services users doors and ask permission to enter prior to going into service users bedrooms. It was also observed that service users bedroom doors are kept locked. Service users have keys for their bedrooms. The menu was reviewed and was found to offer varied and appetising dishes. It was noted that service users wishes and likes and dislikes were taken into consideration when planning the menu. All service users are involved and a record of this is kept. Today’s lunch was Egg mayo roll chosen by one service user. The inspector did not sample the meal but service users said it was very nice. There was a good amount of fresh fruit available for dessert. Abbotts Barton DS0000013482.V316101.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18 19 20. Quality in this outcome area is (good). This judgement has been made using available evidence including a visit to this service. Care workers understand the key principle of giving personal care and support and are responsive to the varied and individual requirements of the service users. Personal care is offered in the way the service user prefers. Service users have access to health and remedial services. Care workers ensures that those service users who are fit and well are encouraged and enabled to be independent, have regular appointments and visit local health care services. There are no service user currently risk assessed as capable to administer their medication. EVIDENCE: The home operates the key worker system. None of the service users at this home has expressed a preference for gender specific carer. It was observed that the care plans included clear guidelines of support each service users requires with their personal care. Physical and emotional needs of the service users are also detailed in the care plans. Care workers stated that personal Abbotts Barton DS0000013482.V316101.R01.S.doc Version 5.2 Page 15 care is provided in private with respect at all times, and that the service user would let them know if they are not happy with the way they are being treated, All service users are registered with a General Practitioner and have access to physiologist, psychiatrists, speech therapist and occupational therapist. Service users access this service if and when they are required. None of the service users at this home is risked assessed as capable to administer their medication. All medication is administered by care workers trained and assessed as capable to do so. Abbotts Barton DS0000013482.V316101.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 23. Quality in this outcome area is (poor). This judgement has been made using available evidence including a visit to this service. The home does not have a complaints policy and there was no evidence of one being advertised within the home. Care workers knowledge on safeguarding service users was not up to date and the home does not have a policy on whistle blowing. EVIDENCE: The home has not received any complaints since re registration. However, service users indicated they knew how to and to whom they would complain if they needed to. There is no documented indication to the visitor of the home on how to complain. The homes’ complaint policy and procedure could not be found on the day of the visit. A Requirement was issued on this standard. The home had a copy of the Surrey Adult protection policy, and in discussion with care worker it was apparent they have had training in this area of care, but lacked knowledge on up to date information in areas such as professional abuse and whistle blowing. The provider data set received at CSCI indicated that the home does not have a Whistle blowing policy. Requirements were issued on this standard. Discussion was held with the deputy manager for the need to have refresher courses available to keep staff up to date. Abbotts Barton DS0000013482.V316101.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 30. Quality in this outcome area is (adequate). This judgement has been made using available evidence including a visit to this service. In general, the bedrooms and bathroom needs redecorating. The decoration reflects the preferences or convenience of the provider rather than the service users. However, the home was mostly clean and tidy and the gardens were pleasant. EVIDENCE: A tour of the premises indicated that the home is clean and tidy. One service user showed the inspector his bedroom, which was very clean. All his clothing were neatly folded and put away. One bedroom has an en-suite shower, and there is one bathroom for the other five service users. This bathroom is in need of redecoration. There is mould growing along the tiles situated on top of the bath. A requirement was issued on this standard. It was observed that service users were encouraged and enabled to personalise their bedrooms with family photographs and other pictures, and ornaments they treasured and hold dear. Abbotts Barton DS0000013482.V316101.R01.S.doc Version 5.2 Page 18 The home was clean and tidy. The garden is well stocked and looked after. One service user showed the inspector his own patch of ground, which he cultivates with the help of his key worker. The decoration in some bedrooms is totally unsuitable for male service users and it was recommended that these bedrooms be the first to be redecorated. It was observed that waste was securely disposed of and there were no offensive odours in the home. Service users and care workers were observed to be relaxed in the home. Abbotts Barton DS0000013482.V316101.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32 34 35 36. Quality in this outcome area is (poor). This judgement has been made using available evidence including a visit to this service. Service users’ individual and joint needs are not met by appropriately trained staff. There is no comprehensive training plan and much of the training is out of date. There are no reliable records to show staff had up to date training, and or staff supervision has been undertaken EVIDENCE: The deputy manager was unable to find any information regarding care workers files that was up to date, and the home’s recruitment policy could not be found. ‘Requirement issued on this standard on 11/04/05 to be actioned by 11/06/05 is still outstanding. Therefore this standard was assessed as not met. In discussion with the deputy manager it became apparent only two of the twelve staff has National Vocational Qualification Level2 (NVQ L2). The deputy manager has completed D32/3. Assessors course. He has also completed NVQL3 in Management. The manager is away on annual leave, but the deputy manager informed the manager that the registered manager has completed the Registered Managers Award (RMA) course. The home has failed to meet Abbotts Barton DS0000013482.V316101.R01.S.doc Version 5.2 Page 20 the criteria for 50 of care staff to be trained to at least NVQ L2 and above by 2005. A requirement has been issued on this standard. There was no evidence to show that care workers are been supervised or supported in their role as carers for the current service users living in the home. A requirement was issued on this standard. The information reviewed in the training record kept by the home was insufficient to give a clear indication that care workers are trained to do their job; and there were no records available to indicate care workers are being supervised. A requirement was issued on this standard. In discussion with care workers it became apparent that they have had training on the job, but have not had regular up to date refresher courses. Only one care worker said she had completed the NVQ L2 and that was a long time ago she said. Abbotts Barton DS0000013482.V316101.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37 39 41 42. Quality in this outcome area is (poor). This judgement has been made using available evidence including a visit to this service. Training, development and supervision of staff is inconsistent and in many cases lacking. Policies are reviewed and kept up to date but Quality assurance monitoring is not regarded or implemented as a core management tool. The home is drifting and lacks purpose and direction EVIDENCE: The registered manager is on annual leave, but the deputy informed the inspector that the manager has completed the Registered Managers Award course. Lack of documented records indicated the home is not well run for the benefit of the service users. The deputy manager is very new in post and is not aware of any Quality Assurance processes that are in place. The Provider data set received at CSCI Abbotts Barton DS0000013482.V316101.R01.S.doc Version 5.2 Page 22 on the 31/07/06 indicated the home had quality assurance system in place, but no evidence could be found to support this statement. In discussion with care workers and service users it was apparent they are happy in their home. Due to the mental frailty of these service users they are unable to say how confident they were that their views are listened to and there was no evidence available to demonstrate that their views are acted upon. It was difficult to measure how confident service users were that their views underpin all selfmonitoring, review and development by the home. Documented evidence from service users/care workers meetings was not available. A requirement was issued on this standard. However, the deputy manager informed the inspector that service users and care workers opinions were listened to and acted upon, and service users supported this during discussion. Service users are encouraged and supported to make choices even when these choices might involve some degree of risks, for which appropriate risk assessment is completed. Service users records were in good order, up to date and kept secured. However, care workers records and records relating to the efficient running of the home and for the protection of service users were not up to date and in some instances not present. Review of service users care plans and daily notes revealed that each service user is allocated a key worker. In discussion with service users it was apparent they knew who their main worker was. Service users said their key worker accompanies them when they go out on social occasions. Each service user is registered with the local GP practice, which they access as required. Chiropody service and dental service is also accessed as required. Service users have access to the wider primary health care services and the deputy manager is aware of whom to contact if the need arises. The manager ensures that at all times the health, welfare and safety of the service user and care staff are promoted and protected by having suitable numbers of care workers on duty at all times to meet the needs of the service users and this was evidenced by the staff roter. Fire fighting equipments were observed serviced at regular intervals and the central heating system and all electrical tests were carried out. The home has developed a very good Control of Substances Hazardous to Health Regulations (COSHH) 1999 folder. This folder contains information from the manufacturers on substances used in the home, such as side effects and what to do if an accident occurs. Consequently the care workers are advised that only substances logged in the COSHH folder will be used at the home. Abbotts Barton DS0000013482.V316101.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 1 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 1 33 X 34 1 35 1 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 1 X 1 3 x Abbotts Barton DS0000013482.V316101.R01.S.doc Version 5.2 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 YA39 Regulation 24 Requirement The manager must develop an annual questionnaire for residents, their families and other associated professionals to ascertain their views on the care provided. This requirement is still out standing as of 17/10/06. The registered person shall not provide accommodation to a service user at the care home unless, the needs of the service user has been assessed by a suitable qualified or suitably trained person. The manager must produce an admission policy, which includes a referral policy by which service users are assessed prior to becoming a resident of the home. The registered person shall supply a written copy of the complaints procedure to every service user and to any person acting on behalf of a service user if that person so wishes. The registered manager must DS0000013482.V316101.R01.S.doc Timescale for action 31/01/07 2 YA2 14(a) 31/01/07 3 YA22 22(5) 31/01/07 Abbotts Barton Version 5.2 Page 25 4 YA23 18 5 YA24 13 (3) 6 YA30 23 (2)(d) 7 YA32 18 (a) make available an accessible copy of the complaints procedure for relatives/visitors to the home The registered manager must ensure that the persons employed to work at the care home receive training appropriate to the work they are to perform. Care workers must receive training in procedures for responding to suspicion or evidence of abuse or neglect, including whistle blowing to ensure the safety and protection of service users. The registered manager shall make suitable arrangements to prevent infection, toxic conditions and the spread of infection at the home. The bathroom must be redecorated and kept clean, safe, and in good decorative order including the tiles and surroundings of the bath. The registered manager must ensure that all parts of the care home are kept clean and reasonably decorated. All bedrooms should be redecorated ensuring service users views are asked and acted upon. The registered manager must ensure that at all times suitably qualified, competent and experienced persons are working at the home. The manager must ensure that at least 50 of care staff on duty at any time over a twentyfour hour period have or are in the process of obtaining a National Vocational Qualification in Care of Level 2 or above. DS0000013482.V316101.R01.S.doc 31/01/07 31/01/07 28/02/07 31/01/07 Abbotts Barton Version 5.2 Page 26 8 YA34 17(2) 9 YA35 YA41 10 YA36 All records as specified in 31/12/06 Schedule 4 of the Care Homes Regulations (as amended) 2001, must be maintained in the home, including Criminal Record Bureau (CRB) and Protection of Vulnerable Adults (POVA) checks. This requirement was issued on 11/04/05 to be actioned by 11/06/05 and was not met. 17(3)(a)(b) The registered manager 31/01/07 must ensure that records are kept up to date and are at all times available for inspection in the care home by any person authorise by the Commission for Social Care Inspection to enter and inspect the care home. The registered person must ensure that there is a record of staff training and development programme which meets Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of the service users living at the home. 2(a) The registered manager 31/01/07 must ensure that all persons working at the care home are appropriately supervised. The manager must ensure all staff working at the care home receives regular supervision at least six times per year and these meetings must be recorded. Abbotts Barton DS0000013482.V316101.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA30 YA18 Good Practice Recommendations It is recommended that the pink bedroom occupied by a male service user should be the first bedroom to be decorated. The registered manager should seek the help and advice of the continence advisor regarding service users who need this care. Abbotts Barton DS0000013482.V316101.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Abbotts Barton DS0000013482.V316101.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!