Inspection on 17/05/07 for Abbotts Lodge

This inspection was carried out on 17th May 2007.

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

The inspector 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 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Abbotts Lodge 18/05/06

Abbotts Lodge 30/11/05

Abbotts Lodge 05/05/05

Abbotts Lodge 07/10/04

Abbotts Lodge 17/05/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Abbotts Lodge 56 Abbotts Road Cheam Surrey SM3 9TA Lead Inspector Peter Stanley Key Unannounced Inspection 17th May 2007 9:30am Abbotts Lodge DS0000007166.V339665.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 Lodge DS0000007166.V339665.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 Lodge DS0000007166.V339665.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbotts Lodge Address 56 Abbotts Road Cheam Surrey SM3 9TA 020 8395 9052 020 8286 4067 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) Mr Mohamad Hoozeer Mrs Bibi Mahazabine Hoozeer Mr Mohamad Hoozeer Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Abbotts Lodge DS0000007166.V339665.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. A variation has been granted to allow one specified service user in the Learning Disabilty (LD) and Dementia (DE) categories to be accommodated until such time as the needs of the person can no longer be met or until such time as the placement ceases. No further admissions of service users outside of the Learning Disability (LD) category may be made. Care staff in the home must undertake training relating to the care and support needs of adults who have dementia. 18th May 2006 2. 3. Date of last inspection Brief Description of the Service: Abbotts Lodge is registered with the Commission For Social Care Inspection (CSCI) as a care home providing care for up to six adults with learning disabilities. The homes Statement of Purpose indicates that it is for adults between 20 and 60 years of age and who have a degree of independence. The premises are situated off the Sutton/Cheam by-pass (A217). There are local shops and a bus route passes nearby. The home itself is a traditional, domestic family home converted to provide care home facilities. It remains a family home in appearance and given the small number of service users it retains a family atmosphere. There are four single and one double bedroom. One single room on the ground floor has an ensuite toilet and shower. There are the usual care home facilities, these being bathroom, toilets on each floor, a small kitchen, and small laundry area. There is a large store in the rear garden. The home has no office but for a small care home of this size the office arrangements are acceptable. Abbotts Lodge DS0000007166.V339665.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted over one day, and involved extensive discussion with the registered provider and manager, Mr Hoozeer. The inspector had a group discussion with four of the home’s five residents, and spoke individually to three residents. Three questionnaires were returned. Since the last inspection, one of the home’s residents has transferred to another home. This was due to a significant increase in the person’s dependency levels, which the home was no longer able to meet. The inspector had wide-ranging discussion regarding the home, and examined both service user and staff records. These included residents’ health action plans, activity programmes, care plans and risk assessments Staff records examined included staff rotas, supervision, appraisal and training records. Recruitment records and criminal records checks were examined and found to be satisfactory- there has been one new staff member recruited since the last inspection. The inspector looked at documentation relating to the day-to-day running and management of the home. This included quality assurance questionnaires and records, policies and procedures and records relating to the logging of any accidents, incidents or complaints (none being recorded). Documentation relating to health and safety including the home’s risk assessments, servicing and maintenance certification, were also examined. All documentation examined was satisfactory and well maintained and in compliance with the national minimum care standards. Feedback from residents indicates that the home provides a homely environment, that residents feel very settled and well supported, and that they are being offered a range of opportunities with which to develop their interests and social life. There is evidence from feedback at reviews that residents’ rights are being respected, and that the home is providing an enabling and inclusive home environment. Of 12 requirements from the previous inspection 9 have now been met and 3 remain outstanding. There are, however, some concerns that have resulted in a number of new requirements. From this inspection there are a further 7 requirements. 3 requirements relate to health and safety issues, a key area. These include the need for up-to-date staff training in both fire safety and health and safety. There is also a requirement for statutory annual care reviews to be arranged for three residents, these having become several months overdue. The inspector would like to extend his thanks to the registered provider, Mr Hoozeer, for his assistance in helping to facilitate this inspection. He would also like to extend his thanks to both staff and residents for their contributions. What the service does well: Abbotts Lodge DS0000007166.V339665.R01.S.doc Version 5.2 Page 6 Prospective residents are being provided with the information they require, to make an informed choice, as to whether the home is likely to be suitable in meeting their needs. Prospective residents are being provided with the opportunity to visit the home, and stay overnight, before deciding whether the home is likely to meet their needs. Residents admitted to the home have been fully assessed and know that their individual needs will be met. Residents are having their health, personal and social care needs and goals set out in an individual plan of care, and are fully involved in the care planning process. Residents are enabled to participate fully in decisions that affect them and their day-to-day lives in the home. Residents are encouraged and supported to develop an independent lifestyle, with risk assessments being carried out for activities that involve responsible risk-taking. Residents are being assessed regarding potential risks to their health and safety, and are enabled to take responsible risks wherever possible. The health, personal, and social care needs of residents are being met, and their privacy respected. Residents are being protected by the home’s medication policy and procedures, and by the provision of accredited medication training for all care staff. Issues relating to bereavement and loss are being handled with respect, and in accordance with individuals’ wishes. The home has an appropriate and well-publicised complaints policy and procedure in place. Residents and their relatives/friends are encouraged to raise any concerns that they may have. The home’s policies, procedures and practice indicate that residents are being protected from abuse and are living in a safe environment. Residents live in a safe, hygienic and well-maintained environment with access to appropriate and sufficient communal facilities. Residents’ rooms are safe, comfortable and pleasantly decorated, being suited to their individual needs. Abbotts Lodge DS0000007166.V339665.R01.S.doc Version 5.2 Page 7 Generally, residents are having their needs well met by an effective, appropriately trained and qualified staff group. Residents are being protected by the home’s recruitment policy and procedures. Generally, residents can be assured that their needs are being safeguarded, through staff being appropriately supported and supervised on a regular basis. Residents are living in a home that is generally being well managed and run in their best interests, and which provides an open, positive and inclusive atmosphere. The home is able to demonstrate that it is obtaining widespread feedback regarding the extent to which the home is supporting residents and meeting its aims and objectives. The rights and best interests of service users are being safeguarded by the home’s record keeping policies and procedures. What has improved since the last inspection? What they could do better: The Statement of Purpose and the Service Users Guide must be reviewed so as to provide residents and their relatives with up-to-date information. Statutory care reviews must be held every 12 months for all residents. Abbotts Lodge DS0000007166.V339665.R01.S.doc Version 5.2 Page 8 The registered manager must obtain the views of relatives, friends, professionals and other stakeholders, regarding the quality of care and support services provided by the home. All policies and procedures must be reviewed and updated at least annually. The health and safety of residents must be fully safeguarded with up-to-date staff fire safety and health & safety training. 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 Lodge DS0000007166.V339665.R01.S.doc Version 5.2 Page 9 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 Lodge DS0000007166.V339665.R01.S.doc Version 5.2 Page 10 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): 1 to 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are being provided with the information they require, to make an informed choice, as to whether the home is likely to be suitable in meeting their needs. Prospective residents are being provided with the opportunity to visit the home, and stay overnight, before deciding whether the home is likely to meet their needs. Residents admitted to the home have been fully assessed and know that their individual needs will be met. EVIDENCE: Prospective residents are being provided with the information they need to make an informed choice. The home has a Statement of Purpose and a Service User Guide. These provide the information listed in the Regulations and Abbotts Lodge DS0000007166.V339665.R01.S.doc Version 5.2 Page 11 National Minimum Standards. The Service Users Guide is produced in a pictorial format making it more comprehensible for service users. Both the Statement of Purpose and the Service Users Guide need, however, to be reviewed and updated, having last been reviewed on 20/12/05 and 13/1/06 respectively. A requirement applies. Following referral, care management assessments, risk assessments and care plans are obtained from the referring agency. The home then completes its own detailed assessment (based on functional performance). The risk assessment format provides a generic assessment of risk and includes assessment of vulnerability, risk-taking, aggression and verbal abuse. This assessment document ensures that all aspects of prospective service users needs are assessed, including all those matters listed in the NMS No.2. The assessment documents are kept with the care plans and service user plans in the service user files. The registered provider/manager, Mr Hoozeer, has outlined the process for any individual who has been referred and assessed, and for whom there is the prospect of a possible placement. He/she is invited to visit the home, to meet residents and staff, and to spend some time looking round and getting the feel of the home. This can then be followed up with an overnight stay before a decision is made, involving consultation with the resident, their nearest relative, and the care manager. Should the admission proceed, then there is a two to three month trial period, prior to an initial review meeting, to decide whether the placement is meeting the person’s needs and is to become permanent. Assessment reports are obtained from psychiatrists and psychologists, with advice being sought as and when required. Feedback from relatives, care managers, and other professionals, from visits and reviews, indicates that there has been positive feedback regarding the home’s capacity to meet individuals’ assessed needs, and in helping to facilitate their independence and personal development. Since the last inspection staff have undertaken specific training relating to work with residents who have learning difficulties, and who present challenging behaviour. Each resident has a contract provided by the Local Authority. Each resident is also given the home’s own contract, which details conditions of residence and the services to be provided by the home. This has been produced in a pictorial form so as to aid service users’ understanding of its contents. Abbotts Lodge DS0000007166.V339665.R01.S.doc Version 5.2 Page 12 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 to 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are having their health, personal and social care needs and goals set out in an individual plan of care, and are fully involved in the care planning process. Residents are enabled to participate fully in decisions that affect them and their day-to-day lives in the home. Residents are encouraged and supported to develop an independent lifestyle, with risk assessments being carried out for activities that involve responsible risk-taking. Residents are being assessed regarding potential risks to their health and safety, and are enabled to take responsible risks wherever possible. EVIDENCE: Abbotts Lodge DS0000007166.V339665.R01.S.doc Version 5.2 Page 13 The home currently has five residents with mild to moderate learning difficulties, one of whom is autistic. One resident, whose needs had significantly changed, has recently transferred to another home. The residents spoke with the inspector, both individually and in a group. Views indicated that the residents like the home, that they feel well supported by staff, and that the home is providing a safe, secure and enabling environment. Based on the inspection of a wide range of documentation including care plans, activity programmes, the feedback from reviews, and the views expressed by residents, the home would appear to be meeting their individual and collective needs. The home has a very homely and caring atmosphere, this being reflected in the attitudes of residents and staff. Each resident who lives in the home has their care plan reviewed at least once every six months, these being updated to reflect any changing needs. This is in accordance with Standard 6.10. The Plan is reviewed with each individual, his/her relative(s)/ representatives and any significant professionals including the care manager and day centre key worker. All care plans were last reviewed in March 2007. The home has introduced a new care plan format. This provides a more detailed breakdown of service users’ needs and goals and the actions required to meet these. Care Plans include a list of clients’ likes and dislikes. These documents are checked frequently to ensure they remain up to date and relevant, and the manager ensures that each resident has been given a copy of these. A statutory 12 monthly care management review is arranged for each resident. The inspector examined residents’ files. This evidenced that statutory 12monthly care management reviews for three residents were overdue, and had not been held since the first quarter (Jan-March) of 2006. The reviews for the other two residents had been held in March and April 2007. A care management review must, without further delay, be arranged for the three residents (PH, LM and ES) who have not, as yet, had their review. A requirement applies. The inspector spoke to residents regarding their participation in day-to-day routines and activities. This indicated that individuals feel able to make decisions about their day-to-day lives, including their participation in daily routines and activities, and that that they feel well supported by staff and consulted regarding any decisions that affect them. Residents are encouraged to be as independent as possible in their day-to-day living and, with the support of their key workers, to be fully involved in making decisions relating to their daily recreation and activities. Abbotts Lodge DS0000007166.V339665.R01.S.doc Version 5.2 Page 14 Care plans and review notes evidence that residents are able to make choices in their day-to-day routines and activities, and are consulted regarding decisions that affect them. Residents are consulted in a variety of ways during their stay in the home. This includes service user meetings, key-worker meetings, care reviews and through questionnaires completed for quality assurance purposes. Service User meetings are held on a regular, monthly basis. Notes examined indicate that there is open discussion of issues relating to the home, and regarding issues that affect their welfare and interests. There is evidence that residents are being supported to take risks in developing independent skills and abilities. Residents participate in a wide range of activities and are encouraged to access local recreational and shopping facilities. The home completes a wide range of risk assessments covering various aspects of risk and daily living. These are being updated in line with annual review, and more frequently if the need arises. Abbotts Lodge DS0000007166.V339665.R01.S.doc Version 5.2 Page 15 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): 11 to 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are being enabled to participate fully, and to exercise choice and control, in their daily routines and activities. Residents are being encouraged to maintain contact with their family and friends, and to maintain links with the local community. Residents’ rights and responsibilities are being respected and recognised in their day-to-day lives. Residents are being offered a healthy diet, in pleasant surroundings, and are able to exercise choice and flexibility with meal arrangements. EVIDENCE: Abbotts Lodge DS0000007166.V339665.R01.S.doc Version 5.2 Page 16 The philosophy of the home, as indicated in the home’s Statement of Purpose, is to promote independence and enable residents to develop a wide range of social and independent living skills. Activity programmes and care plans evidence that residents are being provided with opportunities for personal and social development. This includes regular attendance, by 4 residents at a local day centre in Sutton, where there is a varied programme of activities. The day centre is, however, scheduled for closure within the next few months, and alternative provision is being planned. One resident, who enjoys gardening, works in a garden centre 4 days a week, while another resident works part-time in a cafeteria for 2 half days a week. Both residents indicated that they derive considerable satisfaction and enjoyment from their involvement in these work activities. One resident is developing his interests in painting and computers, while another resident attends a Literacy evening class provided by the Local Authority for adults with special needs. Other classes, which include arts and crafts, pottery, cookery, self-advocacy, and developing independent living skills, are available but are not currently being accessed by any of the residents. Residents also have the opportunity to attend a mini-gym and participate in physical activities at a local leisure centre. Two of the residents attend a local bowling centre in Sutton. Within the home residents are being encouraged to participate and to develop domestic living skills, such as cleaning and keeping their room tidy, cooking (under supervision), setting table, and helping to maintain the garden. There are also opportunities for residents to participate in the local community, to go shopping, attend church and church events, and visit leisure centres. Three service users regularly attend the Gateway Club every Thursday evening where there is the opportunity for social contact with other users and activities including snooker, pool and other games. Occasional discos and other events are also arranged. Residents occasionally go to a local cinema or theatre, and other trips out are arranged. Residents maintain regular contact with residents at a small sister home, and participate in joint events and outings from time to time. A Christmas party was organised. Outings have included a day outing to Hastings and a trip to Heathrow. Residents spoke enthusiastically about their holiday in the Isle of Wight last July, where they stayed at a holiday centre. A holiday is being planned in Great Yarmouth in July 2007. The home has its own transport that it uses for day trips and holidays. Abbotts Lodge DS0000007166.V339665.R01.S.doc Version 5.2 Page 17 The home encourages residents to maintain their family links and friendships both inside and outside of the home. Residents are able to see visitors in the privacy of their own rooms, or to go out and stay with family for day or weekend visits. Feedback and review notes indicate that the home is positively regarded and that friends and relatives are consulted and encouraged to maintain their contact. Two residents were able to take holidays with family in 2006, one to Cornwall and the other to visit relatives in Canada. Residents expressed positive views about the support provided by staff and the opportunities offered for accessing activities. Generally, individuals felt that they were able to exercise a fair degree of choice in their day-to-day lives, and that there was sufficient flexibility in their daily routines with which to develop their interests and social contacts. Residents again expressed their satisfaction with the food provided. Individuals can, if they wish, assist with preparing sandwiches and light snacks, and to help with laying the table. Residents are encouraged to identify their food and drink preferences, these being noted in their files. Meals can be taken at flexible times to fit in with service users’ preferences and social/recreational commitments. Meals are eaten in an attractive dining area in the conservatory extension. The inspector looked at menus over a four-week period. These offer a balanced, nutritious and varied range of food. The home is providing more salad and fresh vegetables in the diet. One resident, who is a vegetarian, is provided with vegetarian or fish options. The kitchen area presented as clean and homely, with staff having undertaken training in food hygiene. Regular checks on fridge/freezer and oven temperatures are being maintained. Abbotts Lodge DS0000007166.V339665.R01.S.doc Version 5.2 Page 18 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 to 21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health, personal and social care needs of residents are being fully met, and their privacy respected. Residents are being protected by the home’s medication policy and procedures, and by the provision of accredited medication training for all care staff. Issues relating to bereavement and loss are being handled with respect, and in accordance with individuals’ wishes. EVIDENCE: Abbotts Lodge DS0000007166.V339665.R01.S.doc Version 5.2 Page 19 The home has a friendly, homely feel with a small staff team, which works in shifts of two with the five residents. Staff observed on the inspection presented as caring and supportive towards the service users, and to be interacting in a positive way. The key worker system provides the opportunity for 1 to 1 support. As detailed in residents’ assessments and care plans, there is a varied range of personal support needs that are being presented. The support offered is provided according to individuals’ needs, wishes and goals. Inspection of care plans, together with observation and feedback provided from reviews, indicates that staff are enabling in promoting independence and are meeting individuals’ wishes and needs. Residents are encouraged to maintain responsibility for their own personal care, hygiene and appearance, with encouragement, prompting or assistance being given where this is required. The inspector spoke individually with three residents. Feedback indicated that both personal and social care needs are being well met, and that their privacy and independence is being respected. Information recorded in daily notes and service user plans indicate that residents’ needs are being well monitored and recorded. The healthcare needs of residents are being met in this home. Records indicate that there is regular contact with health care professionals, four residents being registered with a local GP practice. One resident has retained his own GP in accordance with his wishes. There are occasional visits from a Psychiatrist, and periodic 3-monthly contact from a chiropodist. There are also annual dental checks and optician visits to test residents’ eyesight every two years (last visit recorded on 13.10.06). There is monitoring of residents’ weight, with weight charts being maintained, and, where appropriate, residents are assisted to manage their weight through a “healthy eating” program. The home has an appropriate medication policy and procedures in place. The home uses the Monitored Dosage System for administering medication. All but one new staff member have undertaken accredited medication training. A separate record is being maintained for all receipts and disposals of medication. The inspector examined medication records for the three residents who are presently taking medication. None have been assessed as being able to selfadminister. The home maintains MAR sheets for administering medication. These were checked and found to be in order. The inspector recommends that a front sheet is included for each resident’s medication records, to include the name, date of birth and a photograph of the individual. This would assist in ensuring that the medication detailed is being administered to the right person. Abbotts Lodge DS0000007166.V339665.R01.S.doc Version 5.2 Page 20 The home received an annual pharmacy inspection on 14/07/06, no concerns being recorded. A requirement was made at the last inspection for a section to be included on homely remedies in the home’s medication policy does not currently include a section. Whilst a policy has now been evidenced (dated February 2002) this is out-of-date and must be reviewed and updated, and included as a section in the home’s medication policy. A requirement applies. Whilst there have been no deaths of service users since the home was opened in 1996 a number of family members close to service users have died and the home has evidently provided appropriate support to bereaved service users. This has also provided the opportunity for staff to support residents in their understanding of serious illness and death. The wishes of each resident regarding the eventuality of their terminal illness or death does, however, need to be recorded. This should ideally involve the nearest relative, or an advocate. A recommendation applies. There is a long outstanding requirement from the last inspection, for all staff to receive training in loss and bereavement, which remains to be met. Some staff have previously received training, but this needs to be extended to all staff. The inspector was advised that training in bereavement and loss has now been arranged (with LB Sutton) for 12 June 2007. This will need to be evidenced on the next inspection. Abbotts Lodge DS0000007166.V339665.R01.S.doc Version 5.2 Page 21 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an appropriate and well-publicised complaints policy and procedure in place. Residents and their relatives/friends are encouraged to raise any concerns that they may have. The home’s policies, procedures and practice indicate that residents are being protected from abuse and are living in a safe environment. EVIDENCE: Any complaints or concerns are detailed in a complaints log. No complaints have been recorded since the last inspection on 17/05/07. The complaints procedures and information given to residents and their relatives is up to date, and comprehensive, providing details as to how, and to whom they should complain. Residents are assisted to understand the complaints procedure, with access to their care manager being arranged should grounds for making a complaint against the home arise. Independent advocacy, and/or support with communication, can be arranged if this is required. No allegations of abuse have been recorded since the last inspection. The home has a whistle-blowing policy, and a copy of the Local Authority’s Protection from Abuse policy, which has been integrated into the home’s procedures manual. All staff are expected to be familiar with these policies. Abbotts Lodge DS0000007166.V339665.R01.S.doc Version 5.2 Page 22 The registered manager has confirmed that all staff are being provided with a summary of the home’s procedures for the protection of vulnerable adults. All staff members have completed Sutton’s multi-agency Adult Protection training. The inspector spoke to residents regarding their day-to-day lives in the home. Feedback indicated that residents feel safe and secure, and have trusting relationships with staff. The inspector observed that staff interacted in a positive and respectful way with residents, and that there was a good family atmosphere in the home. No concerns were identified. Abbotts Lodge DS0000007166.V339665.R01.S.doc Version 5.2 Page 23 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a safe, hygienic and well-maintained environment with access to appropriate and sufficient communal facilities. Residents’ rooms are safe, comfortable and pleasantly decorated, being suited to their individual needs. EVIDENCE: The inspector completed a tour of the premises, no health and safety concerns being identified. The home presents as clean, hygienic and comfortable throughout, and to be meeting the needs of the home’s residents. Residents presented as settled and comfortable in their surroundings, and the environment was observed to have a very ‘homely’ feel. Abbotts Lodge DS0000007166.V339665.R01.S.doc Version 5.2 Page 24 This is a small home is an ordinary domestic dwelling that has been enlarged to provide care for up to six residents. The home is generally well maintained, and is in a good decorative state, with residents having access to safe and comfortable facilities. Double-glazing has recently been fitted to the bathroom, toilet and landing windows, helping to create a quieter environment. The lounge and adjoining conservatory have had new light coloured wooden flooring laid down, and a new roof, creating an extended dining and living area. The residents in this home are younger adults between 25 and 55 years of age and are reasonably mobile. The inspector spoke with residents, and observed them in their setting. Views expressed to the inspector indicated that individuals feel settled and happy with their environment, and that their rooms and the facilities provided are meeting their needs. Residents assist in various ways with practical domestic tasks, helping to keep their rooms clean and tidy, and in helping to look after their home. There are four single bedrooms, and one double bedroom, which is now being occupied by one resident. Each bedroom is decorated according to the individual’s choice and includes the required furniture and fittings. Two residents showed me their rooms which were both pleasantly decorated and arranged, and which reflected their individual identities. The quality of décor, furnishings and facilities throughout the home is generally of a high standard, and is homely in character. Given that the provider has no plans to fill the vacancy, the inspector recommends that the double room be rearranged so as to provide a small living area and a more pleasant layout for the current resident. The home has two toilets for residents, plus a toilet for the use of kitchen staff. There is a shower and a bathroom, while one single room has ensuite facilities. All these facilities have suitable locks and afford service users privacy. The home’s bathroom and toilet facilities appear to be meeting the current service users needs. The home has a small laundry that is adequate for the purpose. Apart from emergency call systems, bath seats and rails, the current residents do not require any specialist adaptations or aids, and are able to move freely around the premises, including the ground and first floors, and the front and rear gardens. There is a pleasant garden to the rear of the house that residents can easily access from the dining area. There is a small patio with garden furniture where residents can sit and enjoy the garden. Abbotts Lodge DS0000007166.V339665.R01.S.doc Version 5.2 Page 25 Abbotts Lodge DS0000007166.V339665.R01.S.doc Version 5.2 Page 26 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): 31 to 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Generally, residents are having their needs well met by an effective, appropriately trained and qualified staff group. Residents are being protected by the home’s recruitment policy and procedures. Generally, residents can be assured that their needs are being safeguarded, through staff being appropriately supported and supervised on a regular basis. EVIDENCE: The home has an induction programme in place, which new staff members must complete over their first six weeks of working in the home. An induction checklist to evidence the induction training that each new staff member undertakes has been put in place. A recently recruited staff member was evidenced to have completed their induction programme. Abbotts Lodge DS0000007166.V339665.R01.S.doc Version 5.2 Page 27 Staff are evidenced to have obtained relevant qualifications, skills and experience with which to deliver the services and care that the home aims to provide. Five of the eight care staff employed have obtained their NVQ Level 2, while one staff member has an NVQ Level 3. The figure exceeds the 50 target set in Standard 32.6, representing approximately 75 of the staff group. The home is evidenced to have the numbers and skill mix of staff on duty with which to meet the needs of the residents. The duty rota was examined and evidenced to include two on at all times during the day on weekdays when residents are around- apart from 9am to 3 pm when residents attend their day centre or work setting. 2 staff are on duty at all times at weekends, and there is 1 staff member on a sleep-in basis for overnight x7. The home has a stable and appropriately qualified staff group and does not tend to use temporary or agency staff. The staff group comprises of individuals from both genders and from differing ethnic and cultural backgrounds. The inspector spoke to staff on duty. This indicated that staff are generally feeling well supported in their role and that their training and development needs are being met. Staff were observed to be caring and enabling in their interaction with residents, and demonstrated good communication and interpersonal skills. Interactions observed between staff and residents on this, and previous inspections, are generally very positive, with individual residents indicating that they feel well supported and enabled by staff to develop their daily living skills. Staff were evidenced to be undertaking relevant training, including a recent course in learning disabilities and challenging behaviour. All staff are scheduled to attend training in Person Centred Planning in July and August 2007. There is an ongoing staff training programme. During the last year staff have also received training in dementia awareness, adult protection, infection control, and food hygiene. There has also been past training in autism awareness. Staff have also undertaken accredited medication training. Training in bereavement and loss is planned for 12.6.07. The home has satisfactory recruitment policy and procedures in place. These are based upon sound equal opportunity principles, and with the safety and well being of service users in mind. One staff member has been recruited since the last inspection on 18.5.06. The staff file was inspected; this evidenced an up-to-date CRB check, and the completion of all necessary recruitment and identity checks. Following a requirement from the last inspection, The inspector examined a sample of staff supervision files. This evidenced that staff are receiving regular two-monthly one-to-one supervision. The Abbotts Lodge DS0000007166.V339665.R01.S.doc Version 5.2 Page 28 supervision format has been revised so as to provide a fuller record of the issues raised and actions/decisions agreed. A requirement in respect of staff appraisal has not, as yet, been met. Whilst the registered provider/manager was evidenced to be holding appraisals with staff, these should provide full information regarding personal, training and development objectives. The appraisal must review a staff member’s performance against their job description, and agree development and learning objectives for the year ahead. An appraisal preparation form, for each staff member to self-evaluate their own performance and training/development needs, also needs to be completed prior to the appraisal session taking place. Abbotts Lodge DS0000007166.V339665.R01.S.doc Version 5.2 Page 29 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 to 43 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are living in a home that is generally being well managed and run in their best interests, and which provides an open, positive and inclusive atmosphere. The home is able to demonstrate that it is obtaining widespread feedback regarding the extent to which the home is supporting residents and meeting its aims and objectives. The rights and best interests of residents are being safeguarded by the home’s record keeping policies and procedures. Generally, the health, safety and welfare of residents are being appropriately protected. However, some concerns were identified. Abbotts Lodge DS0000007166.V339665.R01.S.doc Version 5.2 Page 30 EVIDENCE: The registered provider and manager, Mr Hoozeer, has had 13 years experience in caring for adults with learning difficulties including several years at senior level. He has a Nursing qualification, and has a level 4 NVQ Management qualification. The home has been registered in his name since 1996. The evidence from this inspection indicates that the home is being managed in a caring, competent and professional way. The atmosphere in this small group home is evidenced as being open, positive and inclusive. Feedback from residents indicates that they like the home, that it is being managed in a way that meets their needs, and that they are consulted and involved in making decisions that affect their day-to-day living and routines. Staff have indicated that they like working in the home, that they feel supported in carrying out their duties, and that they are being provided with relevant training. No concerns were expressed. Feedback is being obtained regarding the extent to which the home is supporting residents and meeting its aims and objectives. A questionnaire designed for residents has been improved so as to make it more comprehensible and easier to complete. A questionnaire has been designed for relatives but has yet to be sent out. The inspector was advised that a questionnaire is currently being designed for professionals and care managers to complete. A requirement applies. A development plan, which provides feedback from surveys and other sources, and identifies priorities and objectives, is presently being prepared for 200607. A plan has been completed for 2005-06. The rights and best interests of residents are being safeguarded by the home’s record keeping, with generally comprehensive, up to date and accurate records being maintained. Staff and service user files were found to be generally satisfactory and well maintained. The home has a comprehensive range of policies and procedures. These do not, however, evidence the date of their last review. The registered provider is reminded that all policies and procedures must be reviewed and updated at least annually. A checklist, indicating the date when each was last reviewed must also be put in place. A requirement applies. The inspector completed health and safety checks with updated certification having been provided for fire inspection, and the emergency call system (30/4/07), gas (14/3/07), electrical installation (11/11/05) and portable electrical appliances (29/11/06), and environmental health. Fire alarm checks, Abbotts Lodge DS0000007166.V339665.R01.S.doc Version 5.2 Page 31 are being completed weekly, with monthly checks of emergency lighting and call systems. Fire drills are being carried out monthly, most recently on 18/4/07. There are daily fridge/freezer checks. Risk assessments for the home, for both Fire and Health & Safety, were last updated in Feb-March 2007. The inspection of the home’s water supply and test for legionella is overdue, this last having been certified on 9/3/06. A requirement applies. The inspector also noticed that the home’s hot water temperature checks are not being completed on a regular weekly basis, having gone over 2 weeks on occasion. This is a potential health and safety risk. A requirement applies. Updated training that was planned for fire safety and health & safety in 2006 has not taken place. This must be arranged as a priority; a requirement applies. Abbotts Lodge DS0000007166.V339665.R01.S.doc Version 5.2 Page 32 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 2 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 3 LIFESTYLES Standard No Score 11 3 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 2 3 3 3 3 2 3 X Abbotts Lodge DS0000007166.V339665.R01.S.doc Version 5.2 Page 33 Are there any outstanding requirements from the last inspection? Yes 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 YA1 Regulation 6(a) & (b) Requirement Information. The Statement of Purpose and the Service Users Guide must be reviewed so as to provide residents and their relatives with up-todate information. 2 YA6 14(2)(a) & (b) Care management reviews. A statutory, care management review must, without further delay, be arranged for the three residents (PH, LM and ES) who have not, as yet, had their annual review. This is to ensure that the home is fully meeting each resident’s needs, and that this is reflected in their care plan. 3 YA20 13(2) Medication The home’s medication policy must include a Abbotts Lodge DS0000007166.V339665.R01.S.doc Version 5.2 Page 34 Timescale for action 31/10/07 30/06/07 30/09/07 section covering the storage and administration of homely remedies. Whilst a policy has now been evidenced, this dates from February 2002, and must be reviewed and updated, and included as a section in the home’s medication policy. This is necessary in order to ensure the safety of any resident who may be in receipt of a homely remedy. Requirement not met from previous inspection. Timescale extended. 4 YA21 12(1)(a)18(1)(c)(i) Training in bereavement and loss. The registered manager must ensure that staff undertake training in loss and bereavement. This is to assist staff to provide residents with appropriate support when bereavement or loss occurs. The inspector was advised that training in bereavement and loss has been arranged (with LB Sutton) for 12 June 2007. Requirement not met from previous inspection. Timescale extended. 5 YA36 12(1)(a)(b), 18(2) Staff appraisals must provide full information 31/12/07 30/06/07 Abbotts Lodge DS0000007166.V339665.R01.S.doc Version 5.2 Page 35 regarding personal, training and development objectives for the year ahead. A pre-appraisal preparation form must be developed, and completed by the appraisee prior to the appraisal meeting. This should enable the appraisee to identify his/her strengths and weaknesses, and those areas where he/she feels that support and training are required. Requirement not met from previous inspection. Timescale extended. 6 YA39 24(1)(a)(b) 21(3) Quality assurance. The registered manager must obtain the views of relatives, friends, professionals and other stakeholders, regarding the quality of care and support services provided by the home. Requirement not met from previous inspection. Timescale extended. 7 YA41 12(1)(a) Policies and Procedures. All policies and procedures must be reviewed and updated at least annually. A checklist, indicating the date when each was last reviewed, must also be put in place. 30/09/07 30/09/07 Abbotts Lodge DS0000007166.V339665.R01.S.doc Version 5.2 Page 36 The regular review of policies and procedures is essential in ensuring that residents are being fully and appropriately safeguarded. 8 YA42 13(4)(a) & (c) Health and safety. The inspection of the home’s water supply and test for legionella is overdue, and must be recertified without further delay. A copy of the new inspection certificate must be forwarded to the CSCI, Croydon office. 9 YA42 13(4)(a) & (c) Health and safety. The home’s hot water temperature checks must be completed on a regular weekly basis. Without regular testing, residents are being placed at risk. 10 YA42 13(4)(a) & (c)13(6), 18(1)(a) & (c) Health and safety. Updated staff training in fire safety, and health & safety, must be arranged as a priority. 30/09/07 31/05/07 30/09/07 Abbotts Lodge DS0000007166.V339665.R01.S.doc Version 5.2 Page 37 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 YA20 Good Practice Recommendations The inspector recommends that a front sheet is included for each resident’s medication records, to include the name, date of birth and a photograph of the individual. This would assist in ensuring that the medication detailed is being administered to the right person. The wish of each resident regarding the eventuality of their terminal illness or death needs to be recorded. This should ideally involve the nearest relative, or an advocate. The double bedroom should be rearranged to provide a small living area and more pleasant layout for the present sole resident. The supervision format should be revised so as to provide an agenda, and more space for each item discussed. The supervision record should be signed and dated at the bottom of the record sheet rather than for each item discussed as at present. 2 YA21 3 YA25 4 YA36 Abbotts Lodge DS0000007166.V339665.R01.S.doc Version 5.2 Page 38 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Lodge DS0000007166.V339665.R01.S.doc Version 5.2 Page 39 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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