Inspection on 04/04/07 for Abbotts Barton

This inspection was carried out on 4th April 2007.

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 7 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 17/10/06

Abbotts Barton 20/09/05

Abbotts Barton 21/06/05

Abbotts Barton 07/12/04

Abbotts Barton 18/02/04

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Thorndene

Insight - Eastchurch

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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 Joseph Croft Unannounced Inspection 4th April 2007 10:00 Abbotts Barton DS0000013482.V333109.R02.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.V333109.R02.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.V333109.R02.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.V333109.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th October 2006 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. The weekly fees for the home are £61.95. Abbotts Barton DS0000013482.V333109.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) undertook an unannounced site visit on the 4th April 2007 using the new ‘Inspecting for Better Lives’ (IBL) process. This visit was undertaken by Regulation Inspector Mr Joe Croft and took over six hours, commencing at 10:00 and concluding at 16:30. On arrival at the home the Inspector was made aware of the registered manager’s absence; she was away on sick leave, however, the manager arrived at the home approximately one hour later and assisted the Inspector until 13:00 hours. The service users and all members of staff on duty made the inspector welcome. The inspection process included a tour of the premises and sampling of residents’ care plans and risk assessments. Other documents sampled included the staff duty rota, menu, residents’ monies, policies and procedures and records of medication. The Inspector had discussions with the manager and two members of staff on duty. The Inspector also had discussions with four residents and he observed staff interaction with them. Feedback from residents was complimentary about the home and the care they receive from the staff. Both residents and staff were complimentary about the manager of the home. The Inspector had a discussion with a visiting professional during the site visit. The inspector would like to thank the manager, staff and residents for their cooperation during this visit. What the service does well: What has improved since the last inspection? The home has a “Moving in Policy” dated June 2005. This describes the procedures to be followed for admissions to the home that include obtaining an assessment of needs and introduction visits to the home, including overnight and weekend visits. The home has a Welmede Complaints Policy and Procedure that includes time scales for responding to complaints. This document had been reviewed in February 2005. There is an appropriate complaints leaflet for residents that Abbotts Barton DS0000013482.V333109.R02.S.doc Version 5.2 Page 6 include pictures and symbols, and copies of these are kept in the entrance to the home and in the Service Users’ Guide. Staff are attending mandatory training. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Abbotts Barton DS0000013482.V333109.R02.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Abbotts Barton DS0000013482.V333109.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2 was assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The policy and procedure for pre-admission assessments ensure prospective residents needs and aspirations are identified prior to moving into the home. EVIDENCE: The manager informed the Inspector that current residents have been with the company for a long period of time, and pre- admission assessments had been archived. There had been no recent admissions to the home. The home has a “Moving in Policy” dated June 2005. This describes the procedures to be followed for admissions to the home that include obtaining an assessment of needs and introduction visits to the home, including overnight and weekend visits. This provides prospective residents with the opportunity to meet the staff, residents and view the bedroom they will live in. Abbotts Barton DS0000013482.V333109.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 9 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has care plans and risk assessments in place, however, care plans must be reviewed on a regular basis to reflect the changing needs of residents. EVIDENCE: Three care plans were sampled as part of the case tracking process. Care plans sampled included information in regard to religion, social skills, independence, work, physical health, weekly activities and communication. Residents had signed the care plans sampled. The home has produced Person Centre Plans for residents that used photographs and symbols to help them convey their likes, dislikes, activities they enjoy, favourite foods and activities. During discussions, some residents informed the Inspector they knew about the care plan, but could not remember the contents. One resident informed the Inspector that he had been provided with a Person Centre Plan to keep in his bedroom, but he keeps losing things, so could not remember where it was. Dates of reviews were evidenced in two of the care plans sampled, however, one care plan provided no evidence of reviews. The manager informed the inspector that it had recently been reviewed, but could not provide an explanation as to why this had not been recorded. The key worker explained Abbotts Barton DS0000013482.V333109.R02.S.doc Version 5.2 Page 10 that he knew the assessed needs of the resident, and maintains daily records. A requirement has been made that dates of reviews of care plans are clearly written, to ensure the changing needs of residents are being met. Staff informed the Inspector that they encourage residents to make choices about their lives, the activities they like to do and the food they like to eat. Residents spoken to stated they make choices in regard to their daily lives. Risk assessments were evidenced in the care plans sampled, and had been reviewed. Residents have individual bank accounts, and the home holds small amounts of money for each resident. Records sampled on the day of the site visit were appropriately maintained. Two members of staff and the resident sign the records of financial transactions, and monies are checked during each hand over period. Abbotts Barton DS0000013482.V333109.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15, 16 and 17 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff in the home encourages residents to participate in a range of activities both within the home and the local community. A healthy and balanced diet is provided for residents. EVIDENCE: Residents are encouraged and supported to be as independent as they are able to be. Activities included attending day centres, leisure activities, shopping, restaurants and pubs. One activity observed by the Inspector was the visit by a person providing reflexology. This person informed the Inspector that in their opinion the residents receive excellent care from the home, are always immaculately dressed, and the home is kept clean and tidy. During discussions residents informed the Inspector that they enjoy the activities they do both in the home and at the day centres, and they can choose whether to partake in them or not. Staff informed the Inspector that residents are able to make choices in regard to activities they partake in, and are supported when required. Records of activities are maintained in residents’ care files. Abbotts Barton DS0000013482.V333109.R02.S.doc Version 5.2 Page 12 Two residents are currently in part time employment. Family and friends are encouraged to visit the home, and residents can meet with them in the privacy of their bedrooms. Residents are supported to undertake household chores that include cleaning their bedrooms, sorting their laundry and helping with household chores. Staff informed the Inspector that they promote residents’ privacy and dignity through treating them as individuals, promoting their independence and knocking on bedroom doors. This was confirmed during discussions with residents and observations during the site visit. During discussions, staff informed the Inspector that the main religions of residents are that of Roman Catholic and Church of England. Only one resident occasionally attends the local church, others choose not to practice their religion, however, staff stated residents would be supported to practice the religion of their choosing. An advertisement in regard to “Cultural Awareness Training” was posted on the notice board in the office. Staff informed the Inspector that it is hoped all staff could attend this. Residents and staff informed the inspector that residents choose the week’s menu every Thursday. The menu viewed during the site visit included meat, fish, pasta and fresh vegetables. Fresh fruit was available on the dining room table. Staff undertake the cooking duties, and the training matrix maintained by the home provided evidence that staff are receiving training in regard to food hygiene. Residents and staff stated that the food is always good. Abbotts Barton DS0000013482.V333109.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 and 20 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Physical and health care is offered in such a way as to promote residents’ independence. Residents are protected by the home’s storage, administration and recording of medication procedures. EVIDENCE: During discussions staff stated that residents do not require support with their personal care, however, if this became necessary then it would be provided in the privacy of their bedrooms. Key workers offer advice to residents in regard to personal hygiene. Residents are able to choose the time they go to bed and get up in the morning, the clothes they wish to wear and their hairstyles. Care plans sampled evidenced residents are registered with the local GP practice, and attend the Dentist, Optician, Psychiatrists, and Speech Therapist. Residents have access to all National Health Services. Records of appointments and annual check ups are recorded in the daily records, and monthly monitoring of weights are maintained. The home uses the blister packs that are provided by the local pharmacy, and Medical Administration Record sheets (MARs) for the recording of medicines. Abbotts Barton DS0000013482.V333109.R02.S.doc Version 5.2 Page 14 The home maintains records of medicines received and returned to the Pharmacist. Medicines are appropriately stored in a locked metal medicine cabinet. The MAR records for residents who were part of the case tracking process were accurately maintained. The manager informed the Inspector that no current resident self-administers medication or is taking a prescribed controlled drug. The manager informed the Inspector that she has completed the “Train the Trainer” course, and provides in-house training to staff on the administration of medicines. The manager stated that only the staff that have received this training administer medication. Abbotts Barton DS0000013482.V333109.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23 were assessed. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home has a complaints system to enable residents and their families to raise concerns. Staff require training in Protection of Vulnerable Adults to ensure residents are fully protected from abuse. EVIDENCE: The home has a Welmede Complaints Policy and Procedure that includes time scales for responding to complaints. This document had been reviewed in February 2005. There is an appropriate complaints leaflet for residents that include pictures and symbols, and copies of these are kept in the entrance to the home and in the Service Users’ Guide. Inspection of the complaints book indicated the home had not received any complaints. Residents informed the Inspector that they would talk to the manager if they felt unhappy or wanted to make a complaint. The manager located a ‘Dealing with Abuse’ policy that had been produced by Welmede in December 2002. This policy must be reviewed to ensure it is written within the guidelines of the recent Surrey Multi-Agency Procedures of the Protection of Vulnerable Adults. During discussions staff were able to give an account of who they would report suspicions of abuse to. Staff were not aware of a Whistle Blowing Policy, and informed the Inspector they had not received training in regard to the Protection of Vulnerable Adults. The manager informed the Inspector that she and the deputy manager had attended the Surrey Multi – Agency Protection of Vulnerable Adults training. Information provided to the Inspector indicated that one member of staff had received training during a previous employment Abbotts Barton DS0000013482.V333109.R02.S.doc Version 5.2 Page 16 in 2005, and two staff had attended training in 2002. The requirement made at the last inspection in regard to all staff receiving training in this area of their work has not been met. This requirement will be carried over and must be complied with. The manager located a ‘Staff Concerns’ Policy that had been produced by North Surrey Primary Care Trust on the 28th June 2002. Abbotts Barton DS0000013482.V333109.R02.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): Standards 24 and 30 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides adequate communal and individual living space making it a comfortable place to live, however, identified areas require attention. EVIDENCE: A tour of the premises was undertaken. Requirements made at the previous inspection in regard to the environment have not been complied with. The ground floor shared areas are spacious and comfortable. Residents had unrestricted access to the communal areas, and a well-maintained large garden. At the time of the inspection the home was clean, tidy and free from offensive odours. Residents’ have keys to their bedrooms, which they choose to keep locked when they are attending external activities. Residents informed the Inspector they like their bedrooms. Bedrooms were appropriately furnished, however, identified areas require attention to the décor. It was observed in bedroom three that a light over the bed was broken, and masking tape had been used to cover the electrical wires. The manager of the Abbotts Barton DS0000013482.V333109.R02.S.doc Version 5.2 Page 18 home was strongly advised to ensure this fitting was made safe before the Inspector left the premises. An electrician arrived and disconnected the light fitting during this site visit. One bedroom had the cover of a drawer missing; the wall mirror in another identified bedroom was not fixed to the wall. The manager informed the Inspector that the bathroom and bedrooms identified during the last inspection to be decorated had been reported to the organisation, and are waiting confirmation of a start date. The ground floor corridor has had the height of the handrails adjusted to meet the needs of residents, however, the holes of the previous site for the handrails remain in the walls. The walls and ceilings have cracks that require attention. Requirements in regard to the environment have been made. Abbotts Barton DS0000013482.V333109.R02.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): Standards 32, 34, 35 and 36 were assessed. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The staff team supports residents to ensure their needs are met. Residents are not supported and protected by the home’s recruitment policy and procedures. EVIDENCE: The staff team is made up of male and female staff. The duty rota was viewed and evidenced there are a minimum of three staff on each shift, and two waking night staff. Staffs are responsible for the cooking duties and helping the service users with the domestic duties around the home. During discussions staff informed the Inspector that, in their opinion, there are enough staff on duty each shift to cater for the needs of the six residents currently living in the home. Residents stated there are always staff on duty to help you and do activities with. The manager informed the Inspector that there are currently five staff who have achieved NVQ level 2 and 3, one member of staff holds the assessors award and is currently undertaking the NVQ level 4. The home has recently recruited a further two members of staff who will undertake NVQ training upon completion of their induction. The manager stated staff have attended in-house training that has included mental health issues, medication training, the role of the ‘shift leader’ and Abbotts Barton DS0000013482.V333109.R02.S.doc Version 5.2 Page 20 autism awareness. However, there were no certificates to evidence the training staff had received in their training files, or of induction training undertaken by staff. A requirement has been made that evidence and records of training undertaken by staff, including induction, are maintained in the care home. The manager could not locate the Recruitment Policy and Procedure for the home. The Inspector was not able to view the recruitment files of the three most recently employed members of staff as the manager stated the organisation had not forwarded these to the home. Recruitment files sampled, with the exception of one, contained an application form, written references and Criminal Record Bureau checks. One recruitment file did not contain a Criminal Record Bureau reference number. A requirement in regard to these issues has been made continuously since 11/06/05. All records specified in Schedule 4 of The Care Home Regulations 2001, as amended, must be maintained in the home for each member of staff. This requirement will be carried over and must be complied with. The manager informed the Inspector that she undertakes formal one to one staff supervision, however, records of these could not be evidenced. A recommendation has been made that records of formal one to one supervision meetings should be maintained. Abbotts Barton DS0000013482.V333109.R02.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): Standards 37, 39, 40 and 42 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There was evidence of areas of good management and practice within the home; however, issues in regard to training and record keeping must be addressed to ensure the safety and welfare of the residents is maintained. EVIDENCE: The registered manager informed the Inspector that she has many years experience in caring for adults, and had worked at the previous care home since 2002, as an assistant manager, deputy manager and then the manager before transferring the home to Abbots Barton. The manager is a qualified RMN and completed the Registered Managers Award (RMA) in July 2006. Other training undertaken includes Protection of Vulnerable Adults, Autism Awareness, Drugs Competencies, Knowledge Skills Framework and Risk Management. The manager informed the Inspector she has attended training with the Nursing and Midwifery Council (NMC) code of conduct, and is able to provide in-house training to staff in regard to the administration of medication. Abbotts Barton DS0000013482.V333109.R02.S.doc Version 5.2 Page 22 The manager must attend to the requirements made in this report in regard to record keeping. The manager informed the Inspector that she had devised an annual questionnaire for residents, their families and other associated professionals to ascertain their views on the care provided. However, these could not be evidenced as they are held on the home’s computer, which has been out of action for the last three months. This was a requirement made in the previous report, and will be carried over. The home holds residents meetings where topics discussed include meals, activities and choices. The home has a variety of Policies and Procedures. Some policies sampled during this site visit were dated 2002, and had not been reviewed since. It is strongly recommended that a review of all the Policies and Procedures be undertaken to ensure they are relevant and up to date to ensure the safety of residents. The manager informed the Inspector that previous records of training were out of date. The home had a training matrix in place to evidence that refresher mandatory training had commenced for staff working at the home; however, certificates were not held on staff files to evidence these. The matrix shown to the Inspector indicated that seven staff had attended training in first aid and six had attended training in food hygiene. The manager stated that other dates are being booked as and when dates become available. The home has a Health and Safety manual dated 2005, which also includes policies and procedures in regard to Infection Control, Fire, Manual Handling and Legionella. Sampling of documented records demonstrated that health and safety checks are routinely carried out at the home. All equipment examined on the day was properly maintained. Records indicated that fire drills, fire alarm, water temperature and fridge and freezer recordings were regularly checked, Control Of Substances Hazardous to Health (COSHH) risk assessments and the Environmental Health report were viewed. The Employers’ Liability Insurance certificate displayed at the home had expired at the end of March 2007. The manager stated she would contact the organisation to request a copy of the current certificate. Abbotts Barton DS0000013482.V333109.R02.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 3 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 3 STAFFING Standard No Score 31 X 32 3 33 X 34 1 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 2 X 3 X Abbotts Barton DS0000013482.V333109.R02.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 YA6 Regulation 15 (2) (b) Requirement Timescale for action 04/05/07 2. YA23 13 (6) Dates of reviews of care plans must be clearly written, to ensure the changing needs of residents are being met. 04/06/07 All care workers must receive training in the procedures for responding to suspicion or evidence of abuse or neglect, including whistle blowing, to ensure the safety and protection of residents. This requirement has been carried over from the previous inspection and must be complied with. The Protection of Vulnerable Adults Policy and Procedure must be reviewed to ensure it is written in line with the recent Surrey Multi-Agency guidelines on the Protection of Vulnerable Adults. The Registered Person must forward to the Commission For Social Care Inspection an action plan with timescales of how the identified issues in regard to the environment of the home are to be achieved. DS0000013482.V333109.R02.S.doc 3. YA23 13 (6) 04/05/07 4. YA24 23 (2) (b) (d) 04/05/07 Abbotts Barton Version 5.2 Page 25 5. YA34 17(2) All records as specified in 04/05/07 Schedule 4 of the Care Homes Regulations (as amended) 2001, must be maintained for each member of staff working at the care home. This requirement has been carried over from the previous inspection and must be complied with. 6. YA35 18 (1) (c) (i) Sch 4 (6) (g) Evidence and records of training undertaken by staff, including induction, must be maintained in the care home. 04/05/07 7. YA39 24 This requirement has been carried over from the previous inspection and must be complied with. 04/05/07 To develop an annual questionnaire for residents, their families and other associated professionals to ascertain their views on the care provided. This requirement has been carried over from the previous inspection and must be complied with. 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 YA40 YA36 Good Practice Recommendations It is strongly recommended that a review of all the Policies and Procedures be undertaken to ensure they are relevant and up to date to ensure the safety of residents. Records of formal one to one staff supervision should be maintained in the care home. DS0000013482.V333109.R02.S.doc Version 5.2 Page 26 Abbotts Barton 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.V333109.R02.S.doc Version 5.2 Page 27 - 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. 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