Inspection on 20/09/05 for Abbotts Barton

This inspection was carried out on 20th September 2005.

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

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

Other inspections for this house

Abbotts Barton 04/10/07

Abbotts Barton 04/04/07

Abbotts Barton 17/10/06

Abbotts Barton 21/06/05

Abbotts Barton 07/12/04

Abbotts Barton 18/02/04

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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 Abbey Gardens (3) 3 Abbey Gardens Chertsey Surrey KT16 0PT Lead Inspector Joseph Croft Unannounced 20 September 2005, 10:00 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. Abbey Gardens (3) H58 s13482 Abbey Gardens v248391 200905 Stage 2.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Abbey Gardens (3) Address 3 Abbey Gardens, Chertsey, Surrey, KT16 0PT 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) 01932 569455 Welmede Housing Association Ltd Ms R M Flint Care Home 6 Category(ies) of DE Dementia, 1 registration, with number LD Learning disability, 6 of places Abbey Gardens (3) H58 s13482 Abbey Gardens v248391 200905 Stage 2.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 3 The age/age range of the persons to be accommodated will be: UNDER 65 YEARS OF AGE 4 Of the six Service Users with Learning Disability (LD), one may also fall within the category of dementia (DE). Date of last inspection 14 June 2004 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. Abbey Gardens (3) H58 s13482 Abbey Gardens v248391 200905 Stage 2.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second unannounced inspection of the year 2005 – 2006. It will be necessary to view both inspection reports for 2005 – 2006 to obtain a full understanding of the extent to which the home meets The National Minimum Standards for Younger Adults. The duration of the inspection was four hours. In depth discussions took place with the manager, and other staff were spoken to during the course of their duties. Residents’ communication and levels of understanding were limited, but some were able to communicate through pointing, showing pictures, use of Makaton and limited language. Lunch was taken with the residents and staff; this was a friendly, relaxed occasion, with staff and residents communicating with one another. One of the topics discussed was the impending move from Abbey Gardens to Amis Avenue in November 2005. Residents conveyed they had visited the new premises on several occasions, and had chosen the colour of paint and furnishings for their bedrooms. Family members had also made a visit to the new premises. Risk assessments, health records, medication, health and safety and policies and procedures were sampled during the inspection process. These were found to be comprehensive and reviewed on a regular basis. Three requirements have been made during this inspection. No recommendations were made. What the service does well: Staff in the home were observed to interact with residents, displaying respect and a caring attitude. Staff on duty were observed communicating with residents through their preferred methods of communication. The home was again found to be welcoming, clean, tidy and free from clutter. Medicines are appropriately stored and accurate records are maintained. Abbey Gardens (3) H58 s13482 Abbey Gardens v248391 200905 Stage 2.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Abbey Gardens (3) H58 s13482 Abbey Gardens v248391 200905 Stage 2.doc Version 1.40 Page 7 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 Abbey Gardens (3) H58 s13482 Abbey Gardens v248391 200905 Stage 2.doc Version 1.40 Page 8 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) EVIDENCE: These key Standards were assessed at the previous inspection. Abbey Gardens (3) H58 s13482 Abbey Gardens v248391 200905 Stage 2.doc Version 1.40 Page 9 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) 9 The home has regard to enable residents to take risks with support from the home’s staff. EVIDENCE: Care plans sampled evidenced comprehensive written risk assessments for residents to enable them to live as much an independent lifestyle as possible. Risk assessments included behaviour, friendships, mobility, epilepsy, sleeping, road safety, self harm, leisure activities and falls. Risk assessments included information of the action to be taken when a resident is exposed to a risk. Risk assessments sampled evidenced that these were reviewed. It was evident during staff discussions that they were aware of the risks for residents. Staff stated they could access residents’ risk assessments, and they update them as and when needed. The manager has written generic risk assessments for the home, and includes risk for activities in the garden, manual handling, windows, use of laundry and appliances used in the home. Abbey Gardens (3) H58 s13482 Abbey Gardens v248391 200905 Stage 2.doc Version 1.40 Page 10 Abbey Gardens (3) H58 s13482 Abbey Gardens v248391 200905 Stage 2.doc Version 1.40 Page 11 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) 15 and 16 Residents maintain contact with family, relatives and significant others, and their rights, privacy and responsibilities are taken into account in their daily lives. EVIDENCE: The manager stated family and friends are able to visit the home at any reasonable time, and as long as the resident wishes to see them. Records of these visits are maintained in the home’s daily report book. These were evidenced at the time of the inspection. Residents conveyed to the inspector that their family do visit them. One resident, with staff support, communicated that he had recently been with his family to visit the new care home at Amis Avenue. Residents attend church services, Adult Education Centres, theatres, restaurants and shops in the local community. Evidence of this was viewed. The manager stated this gives residents the opportunity to meet other people Abbey Gardens (3) H58 s13482 Abbey Gardens v248391 200905 Stage 2.doc Version 1.40 Page 12 who do not have their disability. The manager stated that staff working at the local supermarket have learnt some Makaton signs, and are able to communicate with residents. Currently, no resident has developed intimate relationships with people of their choice. The manager stated that staff would support residents if they were to develop these kinds of relationships. Each resident has a list of routines for maintaining the cleanliness in their bedrooms. One resident insisted the inspector viewed the list of jobs he keeps on his bedroom wall. Residents have routine jobs they like to conduct in the home such as laying the tables, clearing their own plates and cutlery. The inspector had lunch with the residents and staff where these routines were observed. Staff and residents address each by their Christian names. Staff were observed to be appropriately interacting with the residents, treating them with respect, care and sharing in the residents’ sense of humour. During discussions, staff stated they always knock on residents’ bedroom doors and wait to be invited in. The only exception to this would be if they had a health concern. The manager stated that keys for bedroom doors had been offered to residents, but they choose not have them. Residents were observed to have unrestricted access to all communal parts of the home. Abbey Gardens (3) H58 s13482 Abbey Gardens v248391 200905 Stage 2.doc Version 1.40 Page 13 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) 19 and 20 The residents’ physical, emotional and health needs are being met. EVIDENCE: Residents’ health plans sampled evidenced that individual health needs are being met. Health plans included records of diet, hearing, sight, weight, communication, dentist, GP and personal hygiene. All appointments with medical professionals are maintained in the daily record book, and changes to medication and treatment made by the GP are recorded in the significant changes book. These records were evidenced. Risk assessments were in place for residents who are epileptic. Residents have regular check ups with the appropriate professionals; these records were evidenced. The homes’ records of medication were sampled and evidenced that accurate records are maintained. The home continues to use individual drug sheets for residents. The manager stated that the home would commence using the MAR sheets when they have moved to the new home in November. The manager stated that no resident self medicates, and no resident is currently prescribed Controlled Drugs. Abbey Gardens (3) H58 s13482 Abbey Gardens v248391 200905 Stage 2.doc Version 1.40 Page 14 Whilst accurate records were evidenced, a requirement has been made that all records and health and care plans must be maintained in one file. This would make it easier to monitor the residents’ wellbeing as a whole. The manager stated the home uses the local Lloyds pharmacist for training in medication. Training records evidenced this training had been undertaken in April 2005. Samples of staff signatures were evidenced. Evidence was also viewed of staff training in basic First Aid. The medication cabinet was viewed. Medicines were appropriately stored, and had clear written directions for use. The home had a Welmede Housing Association Policy on the ‘Control and Administration of Medication in Care Homes’ that was dated May 2004. Abbey Gardens (3) H58 s13482 Abbey Gardens v248391 200905 Stage 2.doc Version 1.40 Page 15 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) EVIDENCE: These key Standards were assessed at the previous inspection. Abbey Gardens (3) H58 s13482 Abbey Gardens v248391 200905 Stage 2.doc Version 1.40 Page 16 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) EVIDENCE: These key Standards were assessed at the previous inspection. Abbey Gardens (3) H58 s13482 Abbey Gardens v248391 200905 Stage 2.doc Version 1.40 Page 17 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) EVIDENCE: These key Standards were assessed at the previous inspection. Abbey Gardens (3) H58 s13482 Abbey Gardens v248391 200905 Stage 2.doc Version 1.40 Page 18 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) 42 The home has regard for the health, safety and welfare of residents in the home. EVIDENCE: Evidence of mandatory training for staff was viewed. The exception to this was the two members who have been absent through long-term sick leave. However, the manager stated this would be addressed when they returned to full duties. During discussions staff stated they had attended mandatory training. The home safely stores all COSHH substances in a locked cupboard, and maintains a register of hazardous substances kept in the home. Evidence of annual maintenance on the boiler, electrical equipment, fire extinguishers and fire alarm systems were viewed. The last fire drill recorded was the 14th September 2005. The Surrey Fire and Rescue Service inspection Abbey Gardens (3) H58 s13482 Abbey Gardens v248391 200905 Stage 2.doc Version 1.40 Page 19 was undertaken on the 5th November 2004, no requirements were made; the report commented that fire risk assessments were satisfactory, but must be reviewed annually. The Environmental Health Officers’ report was not available at the time of the inspection. A requirement has been made for a copy of this report to be forwarded to the Commission For Social Care Inspection Surrey Local Office. Daily records of fridge, freezer and cooking temperatures were evidenced. Weekly records of water testing were evidenced. Legionella testing was undertaken on 25th November 2004. Abbey Gardens (3) H58 s13482 Abbey Gardens v248391 200905 Stage 2.doc Version 1.40 Page 20 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 x x x x x Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x x x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x x Standard No 11 12 13 14 15 16 17 x x x x 3 3 x Standard No 31 32 33 34 35 36 Score x x x x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Abbey Gardens (3) Score x 2 3 x Standard No 37 38 39 40 41 42 43 Score x x x x x 3 x H58 s13482 Abbey Gardens v248391 200905 Stage 2.doc Version 1.40 Page 21 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. 2. Standard 19 39 Regulation 17 (1) 24 Requirement All information relating to the care of residents must be kept together in one file. The manager must develop an annual questionnaire for residents, their families and other associated professionals to ascertain their views on the care provided. This was a requirement from the previous inspection and must now be complied with. The manager must forward a copy of the EHO report to the Commission For Social Care Inspection Surrey Local Office Timescale for action 20/10/05 20/10/05 3. 42 23 (5) 04/10/05 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 Good Practice Recommendations Abbey Gardens (3) H58 s13482 Abbey Gardens v248391 200905 Stage 2.doc Version 1.40 Page 22 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Abbey Gardens (3) H58 s13482 Abbey Gardens v248391 200905 Stage 2.doc Version 1.40 Page 23 - 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. 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